Respiratory Medicine
What this domain tests
Asthma and COPD care in the community, inhaler technique, exacerbation management, and the respiratory red flags that demand urgent referral.
Core rules
- Asthma: confirm and control. Objective confirmation (spirometry with reversibility, or peak flow variability) before a lifelong label. Assess control on symptom frequency, night waking, reliever use and activity. Reliever overuse - more than two canisters a year - signals risk and should prompt a review.
- Anti-inflammatory reliever therapy. For most adults, a low-dose inhaled corticosteroid/formoterol inhaler used as needed, with or without maintenance, reduces exacerbations compared with a short-acting beta-agonist alone.
- COPD. Post-bronchodilator spirometry showing a ratio below 0.70 confirms obstruction; severity from FEV₁. Core interventions are smoking cessation, vaccination, pulmonary rehabilitation and a short-acting bronchodilator; long-acting agents for persistent symptoms. Avoid inhaled steroids unless there is an asthma component or frequent exacerbations.
- Exacerbations. Increase reliever, start oral prednisolone in a moderate/severe asthma attack, and give antibiotics only for increased sputum purulence with other signs. Use CRB-65 to site community-acquired pneumonia.
- Red flags. Haemoptysis, unexplained weight loss, hoarseness, unilateral pleuritic pain, a non-resolving shadow, or a patient who cannot complete a sentence - urgent assessment or chest X-ray.
Worked example
A 24-year-old uses a salbutamol inhaler four times a week and wakes twice a month. Spirometry shows 14% reversibility. You switch to an inhaled corticosteroid/formoterol reliever, check and correct technique with teach-back, provide a written action plan, and review in six weeks. The reasoning: reliever frequency is both a control marker and a risk marker.
Traps
- Diagnosing asthma or COPD without spirometry.
- Missing poor inhaler technique, which mimics treatment failure.
- Using antibiotics for every exacerbation.
- Ignoring the asthmatic who has been prescribed three relievers in a year.