Overview
This is the introductory lecture for the Respiratory block module (ELM 2, 15 July - 22 August 2025, convened by Prof Ivan Sammut). It sets out the module’s learning objectives, how content is split across the core block elements (Anatomy, Physiology, Medicine) and the attached vertical modules (Pathology, Clinical Pharmacology, Immunology & Infection), the terminology used for respiratory drug classes, the GINA 2024 stepwise approach to asthma management, and how the module is assessed through integrated clinical cases and a respiratory workshop.
Module objectives
By the end of the module you should be able to:
- Describe the anatomy of the upper and lower airways, associated auxiliary structures and the pulmonary circulation.
- Describe the mechanics and chemical/neuronal control of ventilation, and the regulation of gas exchange and gas carriage.
- Explain the immunological processes and inflammatory mediators underpinning the pathogenesis of bronchospastic and inflammatory lung diseases.
- Identify the common microbial organisms causing respiratory disease and describe their associated clinical presentations.
- Interpret lung function tests and basic radiological investigations in respiratory disease.
- Explain the mechanisms of action of drugs used in Asthma / chronic obstructive respiratory disease and in Cystic fibrosis, including:
- the value of combination drug therapy and its potential for adverse effects.
- drug algorithms for asthma management, and the advantages/disadvantages of inhalation versus oral routes.
- Explain the mechanisms of action of drugs used to treat core respiratory infections (pneumonia, Yours/Medwiki/Vertical modules/Infection and Immunity/Reference/Diseases/Tuberculosis).
Content delivered by discipline
- Anatomy, Physiology and Medicine (block elements): anatomical/mechanical aspects of the upper and lower respiratory airways, microanatomy of the respiratory airways, imaging of the chest, principles of physics and mechanics of respiration, lung function assessment, gas exchange and gas transport, control of breathing.
- Anatomy labs: upper airways, respiratory histology, lower respiratory tract.
- Physiology labs: spirometry, alveolar gases and ventilatory drive, lung function tests and arterial blood gases.
- Pathology (vertical module, tutorial-based): hypersensitivity; obstructive lung disease (asthma, COPD); restrictive lung disease (tuberculosis, pneumonia, pulmonary neoplasia); history and examination of the respiratory system.
- Immunology & Infection (vertical module): allergic/hypersensitivity responses and viral/bacterial respiratory pathogens, covering an introduction to antibiotics, lower respiratory tract infections, antimicrobial pharmacology, biofilms and cystic fibrosis, and tuberculosis identification and treatment. Laboratories: antimicrobials, respiratory pathogens, tuberculosis.
- Clinical Pharmacology (vertical module): 4 lectures on drug action and therapeutic management for asthma, COPD and cystic fibrosis, covering drug targets in obstructive respiratory disease; preventers/anti-inflammatories (corticosteroids, leukotriene antagonists); bronchodilators (β2 agonists — SABAs and LABAs, muscarinic receptor blockers, leukotriene antagonists); and antihistamines for allergic reactions (loratadine, promethazine). An inhaler delivery skills workshop (5th/8th August) reinforces inhalation technique to support medication adherence.
Pharmacological terminology
- Reliever: a bronchodilator used for symptom relief; can also be used prophylactically before exercise or potential allergen exposure.
- Controller: an anti-inflammatory that reduces both current symptom presentation and future risk by attenuating the underlying pathology.
- Maintenance: dosing given on a regularly scheduled frequency (e.g. twice daily, b.i.d.).
GINA 2024 stepwise asthma management (adults & adolescents 12+)
Personalised management follows a continuous cycle: Assess -> Adjust -> Review.
- Assess: confirm diagnosis if necessary; symptom control and modifiable risk factors; comorbidities; inhaler technique and adherence; patient preferences and goals.
- Adjust: treat modifiable risk factors and comorbidities; non-pharmacological strategies; asthma medications including ICS; education and skills training.
- Review: symptoms; exacerbations; side-effects; lung function; comorbidities; patient satisfaction.
Two parallel 5-step treatment tracks exist, differing in which drug is used as the reliever:
Track 1 (preferred): ICS-formoterol as both controller and reliever. Using ICS-formoterol as the reliever reduces exacerbation risk compared with a SABA reliever and is a simpler regimen.
- Steps 1-2: as-needed-only low dose ICS-formoterol.
- Step 3: low dose maintenance ICS-formoterol.
- Step 4: medium dose maintenance ICS-formoterol.
- Step 5: add-on LAMA; refer for phenotype assessment; consider high dose maintenance ICS-formoterol +/- anti-IgE, anti-IL5/5Rα, anti-IL4Rα, anti-TSLP.
- Reliever at every step: as-needed low-dose ICS-formoterol.
Track 2 (alternative): SABA-based reliever. Used when the patient is unlikely to adhere to daily controller treatment.
- Step 1: take ICS whenever SABA is taken.
- Step 2: low dose maintenance ICS.
- Step 3: low dose maintenance ICS-LABA.
- Step 4: medium/high dose maintenance ICS-LABA.
- Step 5: add-on LAMA; refer for phenotype assessment; consider high dose maintenance ICS-LABA +/- anti-IgE, anti-IL5/5Rα, anti-IL4Rα, anti-TSLP.
- Reliever at every step: as-needed ICS-SABA, or as-needed SABA alone.
Other controller options (limited indications / weaker evidence), by step:
- Step 2: low dose ICS whenever SABA taken, or daily LTRA, or add house dust mite sublingual immunotherapy (HDM SLIT).
- Step 3: medium dose ICS, or add LTRA, or add HDM SLIT.
- Step 4: add LAMA or add LTRA, or add HDM SLIT, or switch to high-dose ICS-only.
- Step 5: add azithromycin (adults) or add LTRA; as a last resort, consider adding low dose oral corticosteroids (OCS), weighing side-effects.
The slide carries footnote reference markers (an asterisk on the reliever rows and a dagger on the LTRA options) but the footnote text itself was not legible in the source, so the exact caveats those markers point to are not recorded here.
Assessment: integrated cases and workshops
- Case 10 - Shortness of Breath: interpretation of respiratory function tests; primary and secondary respiratory failure; pathophysiology of asthma; differential diagnosis of COPD; pharmacological intervention. Presented as ‘Shortness of Breath’ (asthma/COPD case) on Thursday 22 July at 3:00pm, arranged by Medicine Respiratory Specialists.
- Case 11 - Cough: causes and predisposing factors of pneumonia; pathogenesis of bronchiectasis in cystic fibrosis; genetics of cystic fibrosis; screening for disease versus carrier status.
- Respiratory Day workshop (22 August, 11am-1pm), with Dr Ben Brockway: a series of clinical scenarios, focused on dyspnoea (principles and management), plus rapid-fire MCQs.
Overarching concepts for the module
- Science concepts: anatomy of the upper/lower airways, auxiliary structures and pulmonary circulation; mechanical and chemical/neuronal control of ventilation and regulation of gas exchange/carriage; immunological processes and inflammatory mediators underpinning bronchospastic and inflammatory lung disease; receptor-signalling in smooth muscle and inflammatory cell activation; common microbial organisms causing respiratory disease.
- Clinical concepts: describing common respiratory clinical presentations; delivering bronchodilator/anti-inflammatory therapy in bronchospastic disease and antimicrobial/antifungal therapy in respiratory infection; evidence-based use of therapeutic interventions.
Self-test
- Distinguish a reliever from a controller in respiratory pharmacology, and define what “maintenance” dosing means.
- Describe the Assess-Adjust-Review cycle used in GINA 2024 personalised asthma management.
- Describe the five steps of GINA Track 1 asthma management, including what changes between steps 1-2, 3, 4 and 5.
- Distinguish GINA Track 1 from Track 2: which drug is used as the reliever in each, and in which clinical situation is Track 2 preferred?
- List the “other controller options” available at GINA steps 2 through 5.
- A patient on Track 1 has ongoing symptoms despite medium dose maintenance ICS-formoterol (step 4). According to the GINA algorithm, what should be added or considered at step 5?
- List the four attached vertical modules of the Respiratory block, and give one topic each vertical module covers.
- List the two clinical pharmacology drug classes used as bronchodilators, and name the drug class used as a preventer/anti-inflammatory.
- What two integrated cases anchor the module’s clinical teaching, and what is one learning point covered under each?
Answers
Reveal answers
- A reliever is a bronchodilator used for symptom relief (including prophylactically before exercise or allergen exposure); a controller is an anti-inflammatory that reduces both current symptoms and future risk by attenuating the underlying pathology. Maintenance dosing means the drug is taken on a regularly scheduled frequency, e.g. twice daily.
- Assess: confirm diagnosis, review symptom control and modifiable risk factors, comorbidities, inhaler technique/adherence, and patient preferences. Adjust: treat modifiable risk factors and comorbidities, apply non-pharmacological strategies, adjust asthma medications including ICS, and provide education/skills training. Review: reassess symptoms, exacerbations, side-effects, lung function, comorbidities and patient satisfaction, then repeat the cycle.
- Steps 1-2: as-needed-only low dose ICS-formoterol. Step 3: low dose maintenance ICS-formoterol. Step 4: medium dose maintenance ICS-formoterol. Step 5: add-on LAMA, refer for phenotype assessment, and consider high dose maintenance ICS-formoterol +/- anti-IgE, anti-IL5/5Rα, anti-IL4Rα or anti-TSLP. The reliever at every step is as-needed low-dose ICS-formoterol.
- Track 1 uses ICS-formoterol as both controller and reliever at every step; Track 2 uses ICS as the controller with a SABA-based reliever (ICS-SABA or SABA alone). Track 2 is the alternative to consider before committing to a SABA-reliever regimen, checked against whether the patient is likely to adhere to daily controller treatment.
- Step 2: low dose ICS whenever SABA is taken, or daily LTRA, or add HDM SLIT. Step 3: medium dose ICS, or add LTRA, or add HDM SLIT. Step 4: add LAMA or add LTRA, or add HDM SLIT, or switch to high-dose ICS-only. Step 5: add azithromycin (adults) or add LTRA, or as a last resort add low dose OCS (weighing side-effects).
- Add-on LAMA, with referral for phenotype assessment; consider high dose maintenance ICS-formoterol, +/- a biologic (anti-IgE, anti-IL5/5Rα, anti-IL4Rα or anti-TSLP).
- Pathology (obstructive/restrictive lung disease, hypersensitivity, respiratory history and examination); Clinical Pharmacology (drug management of asthma, COPD and cystic fibrosis); Immunology & Infection (respiratory pathogens, antimicrobials, tuberculosis); Public Health (named as an attached vertical module; specific topics not detailed on this slide).
- Bronchodilators: β2 agonists (SABAs and LABAs) and muscarinic receptor blockers (also leukotriene antagonists are listed among bronchodilators on the slide). Preventer/anti-inflammatory: corticosteroids (and leukotriene antagonists).
- Case 10 (Shortness of Breath): covers interpretation of respiratory function tests and the pathophysiology/differential diagnosis of asthma versus COPD. Case 11 (Cough): covers causes of pneumonia and the pathogenesis/genetics of cystic fibrosis-related bronchiectasis.