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eTG for acute COPD exacerbation says that up to 10 puff of salbutamol via MDI can be used, so increasing her dose of Ventolin to 4 when her symptoms are worse would be appropriate.

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Out of the possible options I would think ultibro would be most appropriate as the guidelines say LABA + LAMA more effecting than ICS? Not sure though. The dose doesn't match any of the resources though so doesn't make sense

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Since there is no sign of infection wouldn't the AB be the least appropriate?

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So we are left with option 1, is pneumonia an infection at the level of the alveoli?

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Thanks for this I will make sure quiz 5 questions are not randomised

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Osteoarthritis should have been osteoporosis

Vaginal thrush should have been oral thrush

Bradycardia should have been Tachycardia

That leaves option 1 as the answer

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Agree with Option 3 as answer

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Option 1: 4 puffs of salbutamol is higher than the standard dose. But it is used in some instances (e.g. when there is a COPD exacerbation). Adding a spacer will certainly improve Judy's dose delivery. Possible option considering her low FEV1, when she finds it hard to breathe, it may take more salbutamol to relieve it.

Option 2: Ultibro is a LAMA+LABA combination. Judy already has a LABA in the form of salmeterol (in Seretide). Also the AMH recommends dosing Ultibro at 1 capsule once a day and not BD as in the question.

Option 3: Symbicort contains

formoterol (LABA) and fluticasone propionate (ICS). This seems functionally the same as Seretide. Not sure if there's any evidence to suggest superiority over Seretide. Also turbohalers require patients to breathe in, may not be doable in someone with low lung function.

Option 4: It's kinda true, but I don't think we should say that outright. Smoking cessation will still improve her condition, albeit not as much as it would have if she had stopped earlier.

Other thoughts:
adding a standalone LAMA may be appropriate (e.g. Spiriva)
you can also try replacing the Seretide with Ultibro (LAMA+LABA may be better than ICS+LABA)
Smoking cessation, pulmonary rehabilitation, vaccination could be considered
Review inhaler technique

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Option 1: annual vaccination is good for this person (aboriginal w/ heart disease, he even gets it for free!)

Option 2: annual vaccination is good for this person ( Flu is more likely to cause severe illness in pregnant women than in women who are not pregnant, particularly during the second and third trimesters. So it's good that she will have the protection)

Option 3: pneumococcal vaccine (23-valent) should only be given again after >= 5 years if there is some predisposition

Option 4: pneumovax is good for this person
refer to:
https://www.nps.org.au/medical-info/medicine-finder/pneumovax-23-solution-for-injection
people with respiratory diseases and immunosuppression (from renal transplant) is at risk for infection by pneumococcus, so vaccination is appropriate for Zoe.

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FEV1 = 33% of predicted value
Admitted to hospital on COPD exacerbation

Option 1: As Judy is currently still a smoker, NRT is the number 1 disease modifying therapy for her COPD, this will probably help to reduce future exacerbations

Here are some recommendations from COPD-X:

Inhaled bronchodilators are effective for initial treatment of exacerbations.

Systemic corticosteroids reduce the severity of, and shorten recovery from exacerbations.

Exacerbations with clinical features of infection (increased volume and change in colour of sputum and/or fever) benefit from antibiotic therapy.

Option 3:  There is a lack of evidence in favour of one mode of delivery over another for bronchodilators during exacerbations of COPD (COPD-X). But changing the salbutamol from a MDI to a nebuliser may improve Judy's symptoms because there is less risk of underdosing from poor inhaler technique.

Option 4:  Oral corticosteroids hasten resolution and reduce the likelihood of relapse. 30mg for 5 days is an appropriate course. Tapering is only necessary for patients on >14 day course of corticosteroid. (COPD-X)

Option 2: At this stage, there are no indications that Judy is suffering from an infective exacerbation (or at least bacterial) of COPD. She does not show signs of infection such as increased volume and change in colour of sputum and/or fever. Antibiotics are not indicated

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Judy 66 yrs (TIME LEAPED 5 years in the past to when she was just diagnosed with COPD)

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Judy 66 yrs (TIME LEAPED 5 years in the past to when she was just diagnosed with COPD)

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FEV1 = 55% of predicted value

Looking at our COPD lecture notes:
For moderate COPD (40-59% FEV1)
Appropriate initial treatment options
- start smoking cessation
1, SABA or SAMA (as relievers)
2, LAMA or LABA
3, LAMA+LABA
4, +/- ICS (only if above options already tried)

Indacaterol = LABA (maintenance dose is appropriate)
Salbutamol = SABA (prn dose is appropriate)
Ipratropium = SAMA (prn dose is appropriate)

Using our superior deductive and time-traveling skills, we can see that the portable oxygen cylinder is both impractical and unnecessary for Judy (who wants to carry an oxygen cylinder up a hill? Not me.). There are definitely better options for use as a reliever (SABA or SAMA)

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FEV1 = 33% of predicted value
admitted on COPD exacerbation but now discharged
Seretide accuhaler (500/50)
=  salmeterol 50 mcg (LABA), fluticasone propionate 500mcg (ICS)
dose = 1 bd (max dose)

Answer = prolonged use of seretide can increase the risk of pneumonia, especially in the elderly (lower respiratory tract infection at the level of the alveoli)

refer to safety section of this NPS document
https://www.nps.org.au/radar/articles/fluticasone-propionate-with-salmeterol-xinafoate-seretide-for-chronic-obstructive-pulmonary-disease

(hey you can draw on padlet, that's cool)

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I am not Karl. How can we trust that anything is really from Karl. Can we really draw with colours? Hmm??

Note from Karl  (I am really Karl). This conversation is getting very philosophical. Plceing cartesian skepticism aside..its a good point though .. Great to see you are challenging truths and thinking critically!! In future I will comments by editing others posts and bolding my text as i have done here ..(only I have the ability to do this in padlet).

Thanks
Karl (the real Karl...honestly)