9 - Respiratory 2 Flashcards

Question

What mucoactive agents are used in CF?

Answer 1

* **rhDNase:** first-line, given via nebuliser it cleaves extracellular deoxyribonucleic acid and helps reduce viscosity and promote sputum clearance * **Hypertonic sodium chloride**: may be used alone or with rhDNase in those with inadequate response. Given via a nebuliser, it has osmotic action that hydrates airway secretions * **Mannitol dry powder for inhalation**: used in patients intolerant, ineligible or not responding to rhDNase *and* have rapidly declining lung function *and* where other osmotic agents are not appropriate. Inhaled via a handheld device

Answer 2

* **Growth chart:** measure height and weight * **O2 Sats** * **Take sputum sample:** for microbiological investigations. VERY IMPORTANT * **Spirometry:** lung function testing * **CXR** * **Physio assessment** * **Bloods:** FBC, WBC, Aspergillus

Answer 3

Colistimethate sodium

Answer 4

*Bilateral Sequential Lung Transplant* - to avoid leaving a source of infected secretions **Contraindication:** B.Cepacia infection Does not address extra-pulmonary manifestations of CF

Answer 5

**Younger:** Staph Aureus, H. influenzae, and Strep. pneumoniae **Older:** Pseudomonas aeruginosa, Aspergillosis, Burkholderia cepacia (associated with rapid progression of lung disease)

Answer 6

* ***Do nutritional assessment*** * ***Faecal elastase*** * ***High-calorie diet*** * Consider ***enteral feeding*** if not working * Take ***CREON*** to help digest fats if steatorrhea (replace pancreatic insufficiency of lipase) * ***Take Vitamin A,D, E supplements*** as these are fat soluble

Answer 7

**Faecal Elastase** tests for exocrine insufficiency

Answer 8

* **Annual LFTs** and examination * **Liver US** if abnormality * **Urseodeoxycholic Acid** if abnormal LFTs to improve biliary flow * **Transplantation** if cirrhosis. May be done alone or liver-lung, liver-pancreas * Remember abnormal LFTs could be medication side effect

Answer 9

Screened for annually from the age of 10 **_Diagnosis_** * **Continuous glucose monitoring** (CGM) * **Serial glucose testing** over several days * **Oral glucose tolerance testing** (OGTT) – if OGTT is abnormal perform CGM or serial glucose testing over several days to confirm the diagnosi*s* When diagnosed patients need ***appropriate education***. Treatment is with ***insulin***.

Answer 10

* **Abdominal pain:** recurrent bouts of colicky abdominal pain * **Palpable caecal mass** * **Abdominal distention and flatulence** * **Vomiting** Clinical findings may mimic those of [appendicitis](https://radiopaedia.org/articles/acute-appendicitis?lang=gb) or partial intestinal obstruction

Answer 11

* **AXR:** faecal loading * **CT abdomen:** signs of small bone obstruction

Answer 12

Treat in specialist CF centre * **IV fluids** * **Water-soluble (e.g. Gastrografin) orally or enterally:** First line, causes osmotic influx of water into bowel. * **Macrogol:** second line * **Surgery:** colonoscopy last line * **Prevention:** encourage fluids, regular stool softeners, optimising pancreatic enzyme replacement

Answer 13

* P.Aeruginosa * B.Cepacia

Answer 14

Regular Azithromycin

Answer 15

**Pneumothorax** Can also have haemoptysis

Answer 16

* **Psychological counselling:** often depressed and anxious * **Genetic counselling** * **Fertility counselling**

Answer 17

* **CFTR modulator**s e.g tezacaftor, ivacaftor and elexacaftor * **Gene therapy**

Answer 18

Death often from pneumonia or cor pulmonale Average life expectancy of 50

Answer 19

* Epiglottitis * Croup * Whooping cough * Diphtheria * Tonsillitis

Answer 20

* Stridor * Sore throat * Coryza * Cough * Sneezing

Answer 21

**_Aetiology_** * **Parainfluenza Virus** * Influenza * Adenovirus * Respiratory Syncytial Virus (RSV) * Diphtheria (leads to epiglottis) Can have bacterial superinfection **_Epidemiology_** * Peak incidence at 2 years * Age 6 months to 6 years most common * M\>F

Answer 22

* **Low grade fever and coryza** a few days before * “**Barking”** cough, occurring in clusters of coughing episodes * **Stridor** * **Respiratory distress** Croup starts is nasopharynx then moves to larynx that is why there is a prodrome!

Answer 23

Really important to consider epiglottis and foreign body!

Answer 24

**Westley Score** (determines treatment) * ***Mild Croup** =* occasional barking cough, no audible stridor at rest, no suprasternal or intercostal recession, child is happy and will drink, eat & play * ***Moderate Croup*** = frequent barking cough, **audible stridor at rest**, suprasternal and sternal wall retraction at rest, child is not distressed or agitated and will still show interest in its surroundings * ***Severe Croup** =* frequent barking cough, prominent inspiratory stridor at rest, marked sternal wall retractions, child will appear distressed/agitated or lethargic or restless **Red Flags:** Drowsiness, Signs of respiratory failure, tachycardia

Answer 25

CLINICAL DIAGNOSIS * **Basic Observations:** O2 Sats * **CXR:** if think foreign body, STEEPLE SIGN

Answer 26

**Dexamethasone, Oxygen, Nebulised Adrenaline** * **_All children_**_:_ single dose ***IM or IV dexamethasone***, ***anti-pyretics, oral fluids,*** regularly checking child, parent education * **_Mild (≤2)_**_:_ outpatient management * **_Moderate (3-7)_**: consider outpatient management, if no improvement or ongoing respiratory distress, consider admission and ***nebulised adrenaline.*** * **_Severe (8-11)_**_:_ ***nebulised adrenaline***, inpatient admission for observation. * **_Impending respiratory failure (≥12)_**_:_ nebulised adrenaline, urgent senior support including clinician with paediatric airway skills (e.g. Paediatric anaesthetist). PICU referral.

Answer 27

* Moderate or severe croup * Respiratory failure * Previous history of severe airway obstruction * \< 6 months of age * Immunocompromised * Have had inadequate fluid intake * Have had a poor response to initial treatment * The diagnosis is uncertain * There is significant parental anxiety

Answer 28

QUIETENING STRIDOR Indicated respiratory distress

Answer 29

* Explain **symptoms usually resolve within 48 hours** but may last for up to a week. * Explaining that croup is a **viral illness and antibiotics are not needed** * **Paracetamol or ibuprofen** can be used to control pain and fever * Ensure that the child has **fluids** * **Seek urgent medical advic**e if symptoms worsen e.g. the development of intermittent stridor at rest or if the child starts to have a high fever and heart rate (this could indicate a different diagnosis such as bacterial tracheitis). * **To call ambulance** if signs of respiratory failure

Answer 30

URTI by ***Bordetella Pertussis*** (gram negative) **Notifiable Disease** and very contagious **Children are vaccinated** at 2,3,4 months, 12 months and 3years. **Pregnant women are also vaccinated**. Immunity wanes after 5 to 10 years of vaccine

Answer 31

Usually under 3 months and then over 14 years Very mild

Answer 32

Three Stages **_Catarrhal phase (lasts 1 to 2 weeks)_** * Rhinitis * Conjunctivitis * Irritability * Sore throat * Low-grade fever * Dry cough **_Paroxysmal phase (2-8 weeks)_** * Episodes of **severe paroxysms of coughing** followed by an **inspiratory gasp,** producing the classic “whoop” sound * May have **apnea** instead of inspiratory gasp * Often **vomit** after * Occur at **night** usually * Can develop pneumothorax

Answer 33

* Ashtma * Bronchiolitis * TB * Bacterial pneumonia

Answer 34

**2 to 3 weeks of the onset of symptoms:** *Nasal swab with PCR* testing **Cough more than 2 weeks:** *anti-pertussis toxin immunoglobulin G.* *Oral fluid* of children aged *5 to 16* and in the *blood serology* of those aged *over 17 or under 5* Pertussis vaccine within the last year can produce a false positive

Answer 35

* **Inform public health** * **Supportive care** * **Prevent spread** e.g dispose tissues, hand hygiene * **Early stages (\<21 days):** macrolides e.g azithromycin, eryhromycin or co-trimoxazole * **Prophylactic antibiotics:** close contacts if they are in a vulnerable group, for example pregnant women, unvaccinated infants

Answer 36

* Vulnerable or acutely unwell patients * Under 6 months * Patients with apnoeas, cyanosis or patients with severe coughing fits

Answer 37

Absolute very high lymphocytosis

Answer 38

* Stay off until had cough for 21 days or had antibiotics for 48 hours * Cough may take up to 3 months to resolve

Answer 39

* Bronchiectasis * 100 day cough * Secondary bacterial pneumonia * Seizures * Otitits media Symptoms and complications rare if vaccinated

Answer 40

* **Cough** (typically wet and productive) * **High fever** (\> 38.5^ºC) * Poor feeding * Recessions * Tachypnoea * Tachycardia * Increased work of breathing * Lethargy * Delirium

Answer 41

* Tachypnoea * Tachycardia * Hypoxia * Hypotension (shock) * Fever * Confusion

Answer 42

**_Bacterial_** * **Streptococcus pneumonia:** most common * **Group A strep** (e.g. Streptococcus pyogenes) * **Group B strep:** pre-vaccinated infants, often contracted during birth (GBS) * **Staphylococcus aureus**. This causes typical chest xray findings of pneumatocoeles (round air filled cavities) and consolidations in multiple lobes. * **Haemophilus influenza:** affects pre-vaccinated or unvaccinated children. * **Mycoplasma pneumonia:** extra-pulmonary manifestations (e.g. erythema multiforme). **_Viral_** * **Respiratory syncytial virus** (**RSV**): most common * **Parainfluenza virus** * **Influenza virus**

Answer 43

* O2 Sats \<92% * Signs of respiratory distress

Answer 44

* **Chest Xray** if severe * **Sputum culture** for bacterial and viral PCR * If sepsis need **blood cultures** and **blood gas** for lactate

Answer 45

* PO antibiotics, usually **amoxicillin** * Add in erythromycin/azithromycin for cover against atypical bacteria * **Oxygen**

Answer 46

Investigate for underlying lung pathology or immunodeficiency * ***FBC*** to check levels of various white blood cells. * ***Chest xray*** to screen for any structural abnormality or scarring * ***Serum immunoglobulins*** * ***Immunoglobulin G*** to previous vaccines (i.e. ***pneumococcus*** and ***haemophilus***). Some patients are unable to convert ***IgM*** to ***IgG*** * ***Sweat test*** to check for CF * ***HIV test***

Answer 47

Issue with premature babies where there is **persistent hypoxia** ± difficult ventilator weaning **at 36 weeks** Mainly from barotrauma and oxygen toxicity

Answer 48

**_Early:_** * Low oxygen saturations * Increased work of breathing * Poor feeding and weight gain * Crackles and wheezes on chest auscultation * Increased susceptibility to infection (RSV Bronchiolitis) **_Late_** * Cerebral palsy * Asthma * Exercise limitation

Answer 49

**_Diagnosis_** * **Still requiring oxygen at 36 weeks** * **CXR**: hyperinflation, rounded radiolucent areas * **Sleep study** with oxygen levels **_Management_** * **Discharge home with oxygen** via nasal cannula and wean over over year * **Monthly injections of Palivizumab** to protect against RSV bronchiolitis

Answer 50

* ***Antenatal and postnatal steroids*** if \<36 weeks gestation * Using ***CPAP*** rather than intubation and ventilation when possible * Using ***caffeine*** to stimulate the respiratory effort * Not over-oxygenating with supplementary oxygen

Answer 51

* Obesity * Enlarged tonsils or adenoids * Craniofacial abnormalities * Sickle cell * Downs syndrome

Answer 52

* Snoring * Mouth breathing * Daytime somnolence * Hyperactivity or aggressive which may be misdiagnosed as ADHD * Headache * Poor growth and weight gain * Poor concentration

Answer 53

* CPAP * Treat any allergies with nasal steroids or montelukast * Tonsillectomy if enlarged * Weight loss if obese child * Jaw surgery

Answer 54

Tracheostomy

Answer 55

* The medical condition is stable and there is a stable airway with stable oxygen requirements * Nutritional intake adequate to maintain expected growth and development; * Parents understand the long term prognosis and are willing and capable of meeting the special needs of their child in the home setting.

Answer 56

***CPAP** (continuous positive airways pressure):* Pressure is delivered through- out the respiratory cycle, assisting spontaneous ventilation. It prevents airway collapse and loss of lung volume. Complications include pneumothorax, nasal trauma, feed intolerance, and reflux. Uses nasal mask or prongs ***NIPPV** (nasal intermittent positive pressure ventilation)* This combines nasal CPAP with superimposed ventilator breathing at a set pressure—it can be used as a bridge between invasive ventilation and nasal CPAP ***HFNC** (high-flow nasal cannula)* A high flow nasal cannula delivers a distend- ing positive pressure to the airways similar to CPAP

Answer 57

* Retinopathy of prematurity * Bronchopulmonary dysplasia * Intraventricular haemorrhage

Answer 58

Always record respiratory rate in observations

9 - Respiratory 2 Flashcards

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