EMQs in Clinical Medicine.pdf - Peshawar Medical College

44 Respiratory medicine
K
C
B
H
This is step 1 of the British Thoracic Society (BTS) 2003 guidelines for
the management of asthma.
A 17-year-old student complains that he has to use his salbutamol
inhaler regularly to control wheezing.
In patients who require frequent doses of inhaled bronchodilators to
control symptoms regular inhaled corticosteroids should be used.
This is a part of step 2 of the BTS 2003 guidelines for the management of
asthma in adults. Step 2 refers to regular preventer therapy and involves
the daily use of inhaled steroid at a dosage appropriate to the severity of
disease.
A 32-year-old patient taking maximum dose-inhaled therapy and
slow-release theophylline shows persistently inadequate control of
symptoms.
Although oral glucocorticoids should be avoided where possible because
of long-term adverse effects, all other therapeutic opportunities have
been exhausted in this patient.
The use of oral steroids is a part of step 5 of the BTS 2003 guidelines for
the management of asthma. A patient with such poorly controllable
asthma should be under specialist care.
A 25-year-old woman requires add-on therapy because inhaled
beclomethasone and salbutamol do not adequately combat her
symptoms.
Under the BTS 2003 guidelines there are two options for escalation of
therapy for patients not adequately controlled with a regular bronchodilator
inhaler and low-dose inhaled corticosteroids. Either a long action
agonist can be added, as is the case in this patient, or the dose of inhaled
steroid can be increased. This is step 3 of the BTS 2003 guidelines.*
17 Emergency management: respiratory distress
Answers: D K L H C
D
A 65-year-old man with long-standing COPD presents with severe
shortness of breath. He has been treated with oxygen and nebulized
bronchodilators. An hour later: PaO 2 6.0 kPa (on max. O 2 ), PaCO 2
16.0 kPa, pH 7.2.
This patient has a severe exacerbation of COPD and consequent type II
respiratory failure that has responded poorly to medical therapy.
Conventional management would involve formal intubation, ventilation
and transfer to an intensive care unit (ICU). The use of non-invasive
* British Thoracic Society (2003) Guidelines for the Management of Asthma. Thorax 2003; 58 (suppl I).