CCE-CBD-137

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are the key concerns in managing David’s bronchiectasis?

• Prompt: Discuss adherence to chest physiotherapy and sputum clearance techniques
• Prompt: Explain management of recurrent infections and antibiotic use
• Prompt: Consider prevention of further lung damage

Q2. What is your management plan for his current condition?

• Prompt: Address current infection (Pseudomonas management)
• Prompt: Consider long-term inhaled therapies and airway clearance support
• Prompt: Multidisciplinary care in rural settings

Q3. How would you support David’s concerns about specialist access and ongoing care in a rural area?

• Prompt: Discuss telehealth options and rural outreach services
• Prompt: Provide education about self-management and home-based care options
• Prompt: Coordinate with regional respiratory services

Q4. What preventive health measures would you address in this consultation?

• Prompt: Vaccinations
• Prompt: Smoking cessation reinforcement (despite past cessation)
• Prompt: Nutrition, exercise, and mental health

Q5. When would you escalate care or refer urgently?

• Prompt: Signs of acute exacerbation requiring hospital admission
• Prompt: Consideration of oxygen therapy and specialist input for advanced management
• Prompt: Indications for surgical referral (e.g., lobectomy for localised disease)

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What are the key concerns in managing David’s bronchiectasis?

Answer:

In managing David’s bronchiectasis, the focus is on minimising lung damage progression, preventing recurrent infections, and improving his quality of life. Key concerns include:

1. Adherence to Airway Clearance Techniques (ACT)

• Daily chest physiotherapy is critical to reduce mucus build-up, limiting infection risk and maintaining lung function.
• David’s poor adherence increases his risk of exacerbations and lung function decline.
• Referral to a chest physiotherapist, even via telehealth if rural services are limited, is essential.

2. Recurrent Infections

• David has Pseudomonas aeruginosa colonisation, increasing the risk of severe exacerbations and rapid disease progression.
• Chronic infection with Pseudomonas is associated with poorer prognosis; ongoing antibiotic stewardship is required.
• He requires long-term antibiotic strategies:
  • Inhaled antibiotics (e.g., nebulised tobramycin) are first-line for chronic pseudomonas colonisation.
  • Oral macrolides (azithromycin) for their anti-inflammatory and immunomodulatory effects.

3. Prevention of Further Lung Damage

• Importance of preventing exacerbations through:
  • Vaccinations (influenza, pneumococcal, COVID-19)
  • Smoking cessation (though he quit 5 years ago, ongoing reinforcement)
  • Prompt antibiotic treatment during exacerbations

4. Nutritional and General Health

• Nutritional optimisation (to maintain BMI and immunity)
• Exercise advice to maintain physical function and pulmonary capacity

5. Psychosocial Factors

• Isolation in a rural setting can lead to poor mental health outcomes.
• Assess for anxiety/depression related to chronic illness and functional decline.

Relevant guidelines: The Thoracic Society of Australia and New Zealand (TSANZ) Guidelines for Bronchiectasis Management (2015).

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Q2: What is your management plan for his current condition?

Answer:

David presents with signs of a chronic infection and functional decline in bronchiectasis. A comprehensive management plan includes:

1. Antibiotic Management

• Targeted antibiotic therapy for Pseudomonas aeruginosa.
  • If symptomatic and CRP elevated, consider oral ciprofloxacin.
  • For recurrent or chronic colonisation, consider nebulised tobramycin (requires specialist input).

2. Airway Clearance Techniques

• Re-engage him with daily chest physiotherapy:
  • Positive Expiratory Pressure (PEP) devices
  • Active Cycle of Breathing Techniques (ACBT)
  • Flutter valve devices (affordable, portable)
• Discuss access to a respiratory physiotherapist, possibly through telehealth.

3. Pharmacological Interventions

• Start long-term azithromycin (macrolide) therapy, 250 mg daily or three times weekly (requires ECG monitoring for QT prolongation).
• Short-acting bronchodilator (Salbutamol) before ACT to facilitate mucus clearance.

4. Vaccinations

• Confirm up-to-date influenza, pneumococcal, and COVID-19 vaccinations.

5. Referral and Multidisciplinary Team

• Referral to a respiratory physician for further management.
• Involve community nursing if available for monitoring.
• Social work referral if financial/transport difficulties exist.

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Q3: How would you support David’s concerns about specialist access and ongoing care in a rural area?

Answer:

1. Telehealth Options

• Arrange telehealth consultations with a respiratory specialist.
• Connect David to remote physiotherapy services for ACT education.

2. Regional Respiratory Services

• Link with local respiratory outreach services (if available).
• Investigate mobile health clinics or specialist outreach programs visiting his area.

3. Self-Management Support

• Provide clear written action plans for:
  • Exacerbation management (early antibiotic use)
  • When to seek urgent care
• Teach self-monitoring of sputum volume/colour, breathlessness, and fatigue.

4. Community Resources

• Engage chronic disease nurse coordinators (often available in rural areas).
• Encourage peer support groups (online if none locally available).

5. Transport and Financial Support

• Explore transport assistance programs for medical appointments.
• Discuss Medicare-subsidised Chronic Disease Management Plans for allied health services.

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Q4: What preventive health measures would you address in this consultation?

Answer:

1. Vaccinations

• Confirm influenza, pneumococcal, and COVID-19 vaccines are up to date.
• Zoster vaccination consideration (Shingrix) due to immunomodulatory therapy.

2. Smoking Cessation

• Reinforce ongoing abstinence from smoking.
• Offer brief intervention and resources as relapse prevention.

3. Nutrition and Weight Management

• Assess nutritional status; refer to dietitian if underweight or malnourished.
• Encourage high-protein, energy-dense diet if weight loss noted.

4. Physical Activity

• Recommend pulmonary rehabilitation exercises, even home-based, for improved endurance.

5. Mental Health

• Screen for depression/anxiety.
• Offer support/referral to mental health professionals if needed.

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Q5: When would you escalate care or refer urgently?

Answer:

1. Signs of Acute Exacerbation

• Fever, increased sputum volume or purulence, worsening dyspnoea.
• Saturations <92%, increasing respiratory rate, or signs of respiratory failure.

2. Inpatient Admission

• If oral antibiotics fail to control infection.
• IV antibiotics may be needed for severe exacerbations.
• Hospitalisation for oxygen therapy if hypoxic.

3. Respiratory Specialist Referral

• For consideration of long-term inhaled antibiotics.
• For advanced bronchiectasis workup, including suitability for lung transplantation in very advanced cases.

4. Surgical Referral

• For localised bronchiectasis with severe symptoms, surgical resection (lobectomy) may be an option.

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SUMMARY OF A COMPETENT ANSWER

• Effective communication addressing the patient’s concerns and context (rural health).
• Thorough management plan incorporating airway clearance, antibiotics, and vaccinations.
• Rural health strategies: telehealth, regional outreach, self-management education.
• Prevention focus: immunisation, smoking cessation, nutrition, and exercise.
• Clear identification of red flags and criteria for escalation of care.

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PITFALLS

• Failure to address adherence to chest physiotherapy and its importance.
• Omitting inhaled antibiotic therapy for chronic Pseudomonas infection.
• Overlooking mental health impact and psychosocial barriers in rural settings.
• Delaying specialist referral, missing opportunities for advanced therapies.
• Not considering telehealth and local community supports due to rural location.

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REFERENCES

• Thoracic Society of Australia and New Zealand (TSANZ) Bronchiectasis Guidelines 2015
• RACGP Guidelines on Management of chronic respiratory diseases
• Australian Immunisation Handbook on Immunisation Handbook

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, expectations of healthcare and the full impact of their illness experience on their lives
1.4 Communicates effectively in routine and difficult situations

2. Clinical Information Gathering and Interpretation

2.1 Gathers information from history and examination
2.2 Performs and interprets relevant investigations

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and prioritises differential diagnoses

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a management plan
4.2 Prescribes appropriate pharmacological and non-pharmacological interventions

5. Preventive and Population Health

5.1 Provides health promotion and disease prevention strategies

6. Professionalism

6.1 Demonstrates empathy and understanding of chronic disease impact

7. General Practice Systems and Regulatory Requirements

7.1 Refers to specialists appropriately and coordinates multidisciplinary care

9. Managing Uncertainty

9.1 Manages chronic disease with fluctuating symptoms

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and escalates care when deterioration occurs

12. Rural Health Context (RH)

RH1.1 Manages complex chronic disease in rural settings with limited resources

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD