Respiratory Health
Core concepts
Asthma and COPD are the workhorses. Asthma is reversible airflow obstruction with episodic symptoms; confirm with spirometry showing ≥12% and ≥200 mL improvement post-bronchodilator (or peak flow variability). Treatment is stepwise: as-needed ICS-formoterol is now preferred for mild asthma (avoid SABA-only), with escalation through ICS-LABA and consideration of biologics in severe disease. Assess control with the ACT and address triggers, adherence, and inhaler technique before stepping up.
COPD is persistent, largely fixed obstruction (FEV1/FVC <0.70 post-bronchodilator) in a smoker. Group patients by symptoms (mMRC/CAT) and exacerbation history: bronchodilators (LAMA/LABA) are the backbone; add inhaled corticosteroids when eosinophils are elevated or exacerbations persist. Smoking cessation and vaccination are the highest-value interventions; assess for home oxygen when resting PaO2 ≤55 or saturation ≤88%.
Other high-yield topics: community-acquired pneumonia severity (CURB-65) and outpatient vs. inpatient decisions; TB screening in at-risk populations; sleep apnea (STOP-BANG, confirm with sleep study); and differentiating asthma from COPD in a smoker with reversible features (asthma-COPD overlap).
Traps
- SABA-only therapy in asthma is no longer appropriate.
- A normal exam does not exclude asthma; spirometry is required.
- Antibiotics for bronchitis are almost never indicated in otherwise healthy adults.
- Don't miss occupational triggers or GERD/rhinitis contributing to poor control.
Rule of thumb
Before escalating any inhaler, check the "three A's": adherence, technique, and aggravating triggers. If those are clean and symptoms persist, then step up.