Corrections - Respiratory Flashcards
When should you admit children with croup to hospital?
1) moderate or severe croup
2) <3 months of age
3) known upper airway abnormalities (e.g. Laryngomalacia, Down’s syndrome)
Easily audible stridor at rest is a clinical sign of what severity of croup?
Moderate severity -> admit to hospital
Is the characteristic ‘whoop’ always present in pertussis?
No - can be absent
What class of medication is etanercept?
TNF-inhibitor
What is a key side effect of TNF-inhibitors?
Reactivation of TB
For the following conditions, what is the pathogen?
1) Bronchiolitis
2) Croup
3) Common cold
4) Flu
5) The most common cause of CAP
6) Most common cause of bronchiectasis exacerbations
7) Acute epiglottitis
8) Pneumonia following influenza
1) RSV
2) Parainfluenza virus
3) Rhinovirus
4) Influenza
5) Strep. pneumoniae
6) H. influenzae
7) H. influenzae
8) Staph. aureus
What is the most appropriate way to confirm a diagnosis of pertussis?
Per nasal swab (involves taking a sample from the back of the nose and throat through the nose).
1st line for whooping cough if the onset of cough is within the previous 21 days?
Oral macrolide
What is the treatment for LATENT TB?
3 months of isoniazid (with pyridoxine) + rifampicin
OR
6 months of isoniazid (with pyridoxine)
What is the most common cause of cardiac arrest in children?
Respiratory causes that lead to hypoxia
What is an aspergilloma?
A fungal mass that is found in pre-formed body cavities.
What is an aspergilloma usually 2ary to?
TB
What is a characteristic CXR finding in aspergilloma?
The air crescent sign (where a crescent of air that surrounds a radiopaque mass present in a lung cavity is visible).
What is pyoderma grangrenosum?
A rare, non-infectious, inflammatory disorder.
Causes very painful skin ulceration (lower legs are most commonly affected).
Causes of pyoderma gangrenosum?
1) idiopathic (50%)
2) IBD
3) RA
4) primary biliary cirrhosis
What are the 4 commonest causes of an anterior mediastinal mass?
(4 T’s)
T - teratoma
T - terrible lymphadenopathy
T - thymic mass
T - thyroid mass
What antibodies are found in myasthenia gravis?
Anti-acetylcholine receptor antibodies
What is the commonest cause of stridor in neonates?
laryngomalacia (a congenital abnormality of the larynx)
What is the most common causative organism of discitis?
Staph. aureus
Following a splenectomy, what 4 infections are patients particularly at risk from?
1) Pneumococcus
2) Haemophilus
3) Meningococcus
4) Capnocytophaga canimorsus (usually from dog bites)
What vaccinations are offered after a splenectomy?
1) annual influenza
2) pneumococcal every 5 years
3) Hib, meningitis A & C
What is the prophylactic Abx of choice following a splenectomy?
Penicillin V
Which infection does prophylactic Pencillin V NOT protect the patient from following a splenectomy?
Haemophilus influenzae (due to the production of beta-lactamases by the organism).
But it DOES protect against Strep. pneumoniae.
What is the gold standard investigation for assessing drug sensitivities in TB?
Sputum culture
What are the 3 most common organisms causing post-splenectomy sepsis?
1) Strep. pneumoniae
2) H. influenzae
3) Meningococci
What type of organisms carry the greatest pathogenic risk following splenectomy?
Encapsulated organisms
What is toxoplasmosis?
An opportunistic infection caused by the parasite Toxoplasma gondii, which is found in the faeces of infected cats, and in infected meat.
Where is Toxoplasma gondii found?
In the faeces of infected cats, and in infected meat.
What inefction accounts for around 50% of cerebral lesions in patients with HIV?
Toxoplasmosis
In bronchiolitis, what management step does the presence of grunting indicate?
Immediate referral to hospital -> indicates severe respiratory distress.
Which type of pneumonia can cause deranted LFTs?
Legionella
In which 2 respiratory conditions should you AVOID examining the throat due to the risk of precipitating airway obstruction?
1) Croup
2) Epiglottitis
Is a throat exam contraindicated in whooping cough?
No
What can acute toxoplasmosis in the immunocompetent patient mimic?
EBV infection: low grade fever, generalised lymphadenopathy with prominent cervical lymph nodes and malaise.
What investigation is paramount in females with toxoplasmosis?
Pregnancy test & counselling (due to the risk of congenital toxoplasmosis).
What is kyphoscoliosis?
What condition can it be seen in?
A deviation of the normal curvature of the spine.
Can be seen in ankylosing spondylitis.
How can kyphoscoliosis affect the lungs?
Can cause a restrictive lung deficit
What is the most common cause of Addison’s disease in industrialised nations?
Autoimmune disease (i.e. autoimmune adrenalitis)
WHat is the most common cause of Addison’s disease worldwide?
TB
Is coal worker’s pneumoconiosis associated with upper or lower zone lung fibrosis?
Upper
Is silicosis associated with upper or lower zone lung fibrosis?
Upper
What is the most common neurological infection seen in HIV?
Cerebral toxoplasmosis
What does a CT scan show in cerebral toxoplasmosis?
multiple brain lesions with ring enhancement
What is the recommended treatment for mild-moderate croup?
A single stat dose of oral dexamethasone (0.15mg/kg)
What is allergic bronchopulmonary aspergillosis (ABPA)?
A condition characterised by a hypersensitivity response to the fungus aspergillus.
Patients may live in damp buildings where fungal spores may grow and be inhaled. They can also be found in soil, compost, plants, and air conditioning systems.
Who is ABPA most common in?
People with asthma or COPD
Describe the drug regime for active TB
Rifampicin, isoniazid, pyrazinamide and ethambutol for 2 months.
Followed by a continuation phase with rifampicin and isoniazid for an additional 4 months.
Which TB drug can cause acute interstitial nephritis?
Rifampicin
Role of macrolides in the management of pertussis?
Have not been shown to alter the course of the illness, but can reduce the risk of spread.
Which type of test is non-specific for mycobacterium (i.e. detecting all species)?
Acid-Fast bacilli (AFB) smear
Which organism causing meningitis does the India ink stain on CSF analysis point towards?
Cryptococcus neoformans
Infection with which 2 bacteria is associated with increased morbidity and mortality in CF?
1) Pseudomonas
2) Bulkholderia species
What is an important CF-specific contraindication to lung transplantation?
Chronic infection with Burkholderia cepacia
Child aged < 5 years with asthma not controlled by a SABA + paediatric low-dose ICS, what is next step?
Add LTRA
If there is normal spirometry or obstructive spirometry with a negative bronchodilator reversibility (BDR) test in suspected asthma, what is the next step? (note - in children aged 5-16 y/o)
FeNO test
How can Mycoplasma pneumoniae affect Hb?
Can cause haemolytic anaemia
What is surfactant deficient lung disease (AKA respiratory distress syndrome)?
Condition caused by insufficient surfactant production and structural immaturity of the lungs.
Seen in premature infants.
Risk factors for surfactant deficient lung disease?
1) Prematurity
2) Male sex
3) Diabetic mothers
4) C-section
Clinical features of surfactant deficient lung disease ?
- tachypnoea
- intercostal recession
- expiratory grunting
- cyanosis
What does a CXR typically show in surfactant deficient lung disease?
‘Ground-glass’ appearance with an indistinct heart border.
Management of surfactant deficient lung disease?
1) prevention during pregnancy: maternal corticosteroids to induce fetal lung maturation
2) oxygen
3) assisted ventilation
4) exogenous surfactant given via endotracheal tube
What type of picture on lung function tests does neuromuscular disorder cause?
Restrictive
What type of picture on lung function tests does bronchiectasis cause?
Obstructive
What CD4 count does PCP occur at?
<200
What post bronchodilator FEV1 indicates in COPD:
a) stage 1 COPD
b) Stage 2 COPD (moderate)
c) Stage 3 COPD (severe)
d) Stage 4 COPD (very severe)
a) >80%
b) 50-79%
c) 30-49%
d) <30%
What are 2 options for low dose ICS in asthma?
Beclometasone
Budesonide
In what condition should you be cautious prescribing EllaOne (ulipristal acetate) as emergency contraception?
In severe asthma i.e. controlled with oral steroids.
Due to the anti-glucocorticoid effect of ulipristal acetate.
Management of child aged 5-16 years with asthma not controlled by a SABA + paediatric low-dose ICS + LRTA?
Stop LRTA and add LABA e.g. salmeterol
Management of warm autoimmune haemolytic anaemia?
Steroids +/- rituximab
What is the Abx of choice for GBS prophylaxis during birth?
Intrapartum IV benzypenicillin
Is cyanosis in the neonatal period normal?
Peripheral cyanosis (e.g. hands and feet) is very common in the first 24 hours of life.
May occur when the child is crying or unwell from any cause.
What test may be used to differentiate cardiac from non-cardiac causes of cyanosis in the neonatal period?
Nitrogen washout test (AKA the hyperoxia test).
What does the nitrogen washout test involve?
The infant is given 100% oxygen for ten minutes after which arterial blood gases are taken.
A pO2 of less than 15 kPa indicates cyanotic congenital heart disease.
What pO2 level indicates cyanotic CHD in the nitrogen washout test?
<15 kPa
Give 3 causes of cyanotic congenital heart disease
1) ToF
2) TGA
3) Tricuspid atresia
Initial management of suspected cyanotic congenital heart disease?
1) Supportive care
2) Prostaglandin E1 e.g. alprostadil (to maintain patent ductus arteriosus)
What is alprostadil?
Prostaglandin E1
Is maternal lamotrigine use safe in pregnancy?
Yes - not been associated with any adverse outcomes for mother or infant.
What is epiglottitis most commonly caused by?
HiB
When are children routinely vaccinated against HiB?
8, 12 and 16 weeks
What is bronchiolitis most commonly caused by?
RSV
1st line management of acute otitis media?
Adequate analgesia with appropriate safety netting.
What are Abx only indicated in otitis media?
1) Ear drum is perforated
2) <2 years old and bilateral infection
3) Present for ≥4 days
4) <3 months old
What is the dose of adrenaline for anaphylaxis in paediatrics:
1) age <6 months
2) age 6 months to 6 years
3) 6-12 years
4) >12 years
1) 100-150 micrograms (0.1 - 0.15 ml 1 in 1,000)
2) 150 micrograms (0.15 ml 1 in 1,000)
3) 300 micrograms (0.3ml 1 in 1,000)
4) 500 micrograms (0.5ml 1 in 1,000)
What can be given for prophylaxis of RSV (causing bronchiolitis)?
Palivizumab
It is given subcutaneously once a month during bronchiolitis season (winter).
Which medication is most likely to reduce the period of infectivity in whooping cough (pertussis)?
Macrolides (if the onset is <21 days).
What is the most appropriate way to confirm a diagnosis of pertussis?
Per nasal swab
Is audible stridor at rest an indication for admission in croup?
Yes
Stepwise management of asthma in children <5?
1) SABA as required
2) + ICS (8 week trial)
- if symptoms resolve and then recur <4 weeks –> start paediatric low dose ICS
- if symptoms resolve and then recur >4 weeks –> repeat 8 week ICS trial
3) SABA + ICS + LTTA
4) Stop LTRA and refer to specialist
What is Poiseuille’s law?
The flow rate is proportional to the radius of the tube to the power of 4.
Therefore, halving the diameter of the tube decreases flow rate by 16 fold.
Safe discharge criteria following an asthma attack in a child?
1) Bronchodilators are taken as inhaler device with spacer every 4 hours or more (e.g. 6 puffs every 4 hours)
2) SpO2 >94%
3) Inhaler technique assessed/taught
4) Written asthma management plan given and explained to parents
5) GP should review the child 2 days after discharge
Management of viral induced wheeze?
1st line –> SABA or anticholinergic via spacer
2nd line –> intermittent LTRA or ICS or both
Is there a role for oral pred in viral induced wheeze?
No
Management of multiple trigger wheeze?
Trial of ICS or LTRA for 4-8 weeks
What does the CFTR gene encode?
CFTR protein (chloride channel) –> pumps Cl- into secretions –> draws water in –> thins secretions.
How can CF present in neonates?
(3)
1) meconium ileus
2) failure to thrive
3) prolonged neonatal jaundice
What causes pancreatic enzyme insufficiency in CF?
Thick pancreatic & biliary secretions cause blockage of the ducts, resulting in a lack of digestive enzymes such as pancreatic lipase in the digestive tract.
Where is the CFTR gene found?
Chromosome 7
What is the most common variant of the CFTR mutation in CF?
delta-F508
When are the majority of cases of CF picked up?
Heelprick test at birth
What is the diagnostic chloride concentration for cystic fibrosis?
> 60 mmol/l
Most common cause of bronchiectasis in children?
CF
Describe stools in CF
Steatorrhoea (due to lack of lipase enzymes)
What can pseudomonas colonisation be treated with in CF?
Long term nebulised Abx e.g. tobramycin
What vitamin supplements are required in CF?
A, D and E supplements (as these fat soluble vitamins are poorly absorbed in pancreatic insufficiency).
Pancreatic enzyme replacement is not enough hence children with pancreatic insufficiency will also need to take vitamin A, D and E supplements.
what are the fat soluble vitamins?
A, D, E, K
What can aid airway clearance in CF?
Hypertonic saline
How long should all courses of Abx in CF last?
2 weeks
What does Kartagener’s syndrome have a strong association with?
Consanguinity
What is involved in the management of respiratory manifestations in CF?
1) Twice daily chest physiotherapy
2) Prophylactic antibiotics and antibiotics for acute exacerbations
3) Inhaled bronchodilators
4) Mucolytics (oral or inhaled): hypertonic saline or dornase alfa
What is the role of chest physiotherapy in CF?
To increase airway secretion clearance and reduce airway obstruction –> minimise risk of infection.
What is allergic bronchopulmonary aspergillosis (ABPA)?
An allergic reaction to the presence of aspergillus.
What can ABPA initially be treated with?
Oral prednisolone
What is the role of DNase (dornase alpha) in CF?
Inhaled mucolytic –> reduces volume & viscosity
What is the key investigation for establishing the diagnosis of PCD?
Take a sample of the ciliated epithelium and examine the action of the cilia.
Sample can be taken via:
1) nasal brushing
2) bronchoscopy
What are 2 methods of obtaining a sample of ciliated epithelium?
1) bronchoscopy
2) nasal brushing
What prophylactic Abx do patients with CF take long term to prevent staph. aureus infections?
Flucloxacillin
What is important to cover in Kartagener’s syndrome history?
Careful FH –> consanguinity?
What are some risk factors for bronchiectasis in young people? (3)
1) CF
2) Prematurity
3) Recurrent LRTIs
Define acute chest syndrome (in sickle cell)
New pulmonary infiltrates on CXR + dyspnoea, chest pain, cough or hypoxia.
This is caused by vaso-occlusion within the pulmonary microvasculature → infarction in the lung parenchyma.
What is pneumoconiosis?
A restrictive lung condition. Typically seen in coal-miners.
Breathing problems with clear chest, what condition?
PE
Chronic infection with which 2 bacteria are associated with increased morbidity and mortality?
1) Pseudomonas
2) Bulkholderia
How often should chest physiotherapy and postural drainage be performed in the management of chronic CF?
Twice daily
What is postural drainage?
A technique that involves laying/ sitting in certain positions to drain secretions from your airways using gravity.
Mx of a patient who is >= 40 years old presenting with unexplained haemoptysis?
2 ww referral
What is typically the presenting feature of MEN II?
Medullary carcinoma of the thyroid
