Chest infections

Question 1

Which infants are more likely to get bronchiolitis?

Answer 1

(Mucosal inflammation and swelling of the intrathoracic airways)
Adenovirus- bronchiolitis obliternas leading to permanent scarring
2 months-2 years (most common 1-9 months)
Premature infants who develop bronchopulmonary dysplasia
Infants with underlying lung disease (e.g. CF)
Infants with congenital heart disease
Older siblings
Nursery attendance
Passive smoking

Question 2

What is given to prevent bronchiolitis in vulnerable children?

Answer 2

IM monoclonal antibody to RSV (palivizumab) injections for high- risk premature infants

Question 3

What is the presentation of bronchiolitis?

Answer 3

Presents in winter months (November-march)
Coryzal symptoms (must include runny nose)
Feeding difficulty
Dry wheezy cough
Tachypnoea + tachycardia
Grunting
Subcostal + intercostal recession; tracheal tug; head bobbing
Hyperinflation of the chest
Fine end-inspiratory bilateral crackles (walking on snow)
High-pitched wheezes

Question 4

What are the investigations for bronchiolitis?

Answer 4

Pulse oximetry (on ALL children with suspected bronchiolitis)
Nasopharyngeal aspirate (NPA)
Chest x-ray/blood gases- only if respiratory failure is suspected

Question 5

When should you consider admitting a patient to hospital with bronchiolitis?

Answer 5

Apnoea (observed or reported by parents)
O2 sat <90% when breathing air
Inadequate oral fluid intake (50-75% of usual volume)
Severe respiratory distress: grunting, stertor/stridor, marked chest recession, RR>70
Congenital heart disease or preemie

Question 6

What is the treatment for bronchiolitis?

Answer 6

Supportive
Humified O2 delivered via nasal cannula or headbox
Monitor for apnoea
No evidence of effectiveness of nebulized bronchodilators, saline or abx
May need NG or IV fluids
Good infection control measures as RSV is highly contagious

Question 7

Which organisms cause pneumonia in infants?

Answer 7

Newborns: organisms from maternal genital tract: group B strep, Gram –ve
enterococci & bacilli
Infants & younger children: viruses such as RSV, but also Strep pneumoniae, H.influenzae (reduced incidence due to Hib immunization), B.pertussis and C.trachomatis
Children >5: Mycoplasma pneumoniae, Strep pneumoniae & Chlamydia pneumoniae
Consider M.tuberculosis at all ages

Question 8

What is the presentation of pneumonia?

Answer 8

URTI that develops into fever, cough (sputum and raised RR
Neck stiffness
Acute abdominal pain
Tachypnoea ß most sensitive clinical sign
Nasal flaring
Chest indrawing
Possible end-inspiratory coarse crackles + high pitched wheeze
Decreased O2 saturation
Absent in a young child: dullness on percussion, decreased breath sounds, bronchial
breathing

Question 9

What are the investigations for pneumonia?

Answer 9

CXR (check for pneumothorax, pleural effusion
Nasopharyngeal aspirate (viral causes)
FBC & CRP generally unhelpful

Question 10

When would you consider admitting a patient to hospital with pneumonia?

Answer 10

O2 sats <92%
Recurrent apnoea
Grunting
Inability to maintain adequate fluid/feed intake
Family can’t cope

Question 11

What is the treatment for penumonia?

Answer 11

Most can be managed at home
General supportive care: oxygen for hypoxia and analgesia if there is pain
IV fluids if necessary (dehydration & sodium balance)
Physiotherapy useless
Abx determined by child’s age and severity of disease:
Newborn: broad-spectrum IV abx
Older infants: oral amoxicillin (broader spectrum abx reserved for
complicated or unresponsive pneumonia)
Children >5yrs: oral amoxicillin or erythromycin
No advantage of IV abs in mild/moderate pneumonia
Repeat chest x-ray 4-6 weeks (evidence of lobar collapse/atelectasis)

Question 12

What are the differences between viral induced wheeze and asthma?

Answer 12

VIW: 1-5 yrs Asthma: 3+yrs
Interval symptoms: VIW (no), asthma (yes
Steroids: VIW (no), asthma (yes)
Atopy: VIW (less likely), asthma (more likely)

Question 13

What is the treatment for wheeze?

Answer 13

Supportive + the 5 Ds of acute wheeze
Depends on severity
Dilate bronchi: salbutamol, ipratropium (anticholinergic stops spasm of smooth muscle), magnesium, aminophylline
Dampen inflammation: steroids (hydrocortisone, prednisolone)
Drive respiration: aminophylline (stimulates CNS resp centre and adrenals) or caffeine in neonates
Don’t Die: NIV, rapid sequence induction, intubation, ventilation

Question 14

How is asthma treated?

Answer 14

Burst therapy: 3x neb salbutamol + 1x neb Ipratropium. Never give just ipratropium to a wheezy child. Always needs salbutamol!
IV hydrocortisone
Consider IV magnesium (poor evidence)/Aminophylline

Question 15

What are the signs of life threatening asthma?

Answer 15

33% PEV
92% sats
Cyanosis
Hypotension 
Exhaustion 
Silent chest 
Tachycardia

Question 16

What causes whooping cough?

Answer 16

Bordetella pertussis (Gram –ve). Highly contagious, epidemics every 3-4 yrs
Other causes: Mycoplasma pneumoniae, Chlamydia or adenovirus
Vaccine reduces the risk and severity of the disease, but does not guarantee protection.

Question 17

How do symptoms develop in whooping cough?

Answer 17

A week of coryza (catarrhal phase) followed by inspiratory whoop (paroxysmal phase 3 months)
Cough spasms at night- vomiting
Red or blue in face and mucus flowing during cough episode
Symptoms gradually decrease (covalescent phase) may persist for many months
In infants whoop may be absent, apnoea more common

Question 18

How does whooping cough present on examination?

Answer 18

Mucus flow from mouth and nose
Inspiratory whoop
Epistaxis (nose bleed) & subconjunctival haemorrhages can occur after vigorous
coughing

Question 19

What are the investigations for whooping cough?

Answer 19

Culture or pernasal swab

PCR (more sensitive)

Question 20

What is the treatment for whooping cough?

Answer 20

macrolides eradicate the organism, but decrease symptoms only if started during
catarrhal phase
Erythromycin 14 days (clarithromycin 7 days)

Question 21

What should all children with a persistent productive cough have?

Answer 21

CXR and tuberculin skin test or TB blood tests (interferon-gamma release assays).
Marked hilar or paratracheal lymphadenopathy is highly suggestive of TB

Question 22

What is the treatment for tuberculosis?

Answer 22

RIPE for min 6/12 (rifampicin, isoniazid, pyrazinamide, ethambutol)

Question 23

What are the causes of bronchiolitis?

Answer 23

Respiratort syncytial virus (RSV)- 80%
Other 20%:
Human metapneumovirus
Parainfluenza virus
Rhinovirus
Adenovirus
Influenza virus
Mycoplasma pneumoniae

Question 24

What is seen on a CXR in bronchiolitis?

Answer 24

Non specific and patchy infiltrates
Focal atelectasis
Air trapping 
Flattened diaphragm 
Increased anteroposterior diameter
Peribronchial cuffing

Question 25

How is assisted ventilation given in bronchiolitis?

Answer 25

Via nasal or facemask CPAP for full ventilation

Question 26

What suggests a bacterial infection in pneumonia?

Answer 26

Localised chest pain, abdominal or neck pain are a feature of pleuritic irritation

Question 27

What are second line treatments for pneumonia?

Answer 27

<5: Co-amoxiclav or cefaclor for typical cases
Erythromycin, clarithromycin or azithromycin for atypical cases
>5: if Staph. Aureus is suspected consider using macrolide or combination of Flucloxacillin with Amoxicillin
Severe- Co-amoxiclav, Cefotaxime or Cefuroxime IV

Question 28

What are the complications of whooping cough?

Answer 28

Pneumonia
Convulsions
Bronchiectasis
Leucocytosis and lymphocytosis on blood coutn