1. Respiratory Unit Questions

2. Module 1 Question
Which of the following is the commonest cause of chronic cough in persons over age 65?
A. Asthma
B. Postnasal drip
C. Gastroesophageal reflux
D. Heart Failure
E. Ace-inhibitor therapy
The correct answer is B. postnasal drip. Post nasal drip from allergic or perennial rhinitis is increasingly common with age. Allergic rhinitis is the most common of all the allergic disorders and increases in prevalence with age. This disorder may not be seasonal rather it may be present with year round symptoms.
All of the other options may cause chronic cough but are far less common than postnasal drip. Cough predominant asthma is a frequent presentation for asthma in later life. Gastroesophageal reflux is common and can sometimes present with prominent symptoms of chronic cough due to silent aspiration of gastric acid. Heart failure also may have a prominent symptom of especially nocturnal cough, but in general there should be other prominent signs and symptoms. Ace-inhibitors cause cough in roughly 15% of persons who take these medications, and cough may develop after the medication has been on the med list for a long time, not only when they are first prescribed.

3. Module 2 Question
Which of the following is the best guide to the amount of therapy a patient with COPD is likely to need in order to control symptoms?
A. Hemoglobin level
B. FEV1/FVC ratio
C. % predicted FEV1
D. Cor pulmonale by EKG
The answer is C. The percent predicted FEV1 stages the severity of COPD and assists the clinician on how much therapy is likely to be needed to control symptoms. The severity of disease is based on the FEV1 expressed as the percent of the expected based on the patient’s age. There is added as the disease becomes more severe. The FEV1/FVC is useful in the diagnosis of COPD but is not used as a guide to therapy. In COPD patients the FEV1/FVC is generally less than 70%. The hemoglobin may rise in response to hypoxia, and can be a clue to problems with oxygenation, but this would be an insensitive guide to therapy in most patients. Likewise, cor pulmonale may be seen on EKG when patient’s have severe pulmonary hypertension with advanced lung disease but this is neither specific or sensitive as a guide to therapy.

4. Module 3 Question
Which of the following is more likely to improve symptoms in older patients with asthma compared to younger asthmatics?
A. Budesonide (Pulmicort®)
B. Montelukast (Singulair ®)
C. Albuterol (Ventolin ®)
D. Ipratropium (Atrovent ®)
The answer is D. Ipratropium, an inhaled anticholinergic, is effective at improving symptoms in the presence of fixed obstruction. Because older asthmatics are much more likely to have at least an element of fixed obstruction this is an important medication for them and more likely to improve symptoms compared to younger individuals with this disease. Inhaled steroids are the basic treatment for patients of all ages whose asthma is more than intermittent. Beta 2 agonists such as albulterol appear to be efficacious regardless of age. Leukotriene modifiers have not been extensively studied in older asthmatics so there is no reason to think that they would be more likely to improve symptoms in older patients with asthma.