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MSRA Content > Level 1 - Respiratory > Flashcards

Level 1 - Respiratory Flashcards

1
Q

What is asthma?

A
  • Chronic airway inflammation, bronchial hyper-reactivity and reversible airway obstruction
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2
Q

Pathology of asthma?

A
  • mix of genetic predisposition, atopy and environmental triggers that cause:
    o Bronchial inflammation
    o Infiltration of neutrophils, eosinophils, mast cells, lymphocytes
    o Bronchial hypersensitivity
    o Airway narrowing
    o Thicker, excessive mucous production
    o. Reversibility
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3
Q

Epidemiology of asthma?

A
  • Commonest childhood chronic illness
  • 15-20% of children
  • Males>females
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4
Q

Risk factors for asthma?

A
  • Atopy (40% have FHx)
  • Smoking
  • Low birth weight/Premature birth
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5
Q

Triggers for asthma exacerbation?

A
  • Allergens (house dust mite, pollen, pets, feathers, fur)
  • Exercise
  • Viruses
  • Cold
  • Smoke/Pollution
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6
Q

Symptoms of asthma?

A 
-	Cough
o	Recurrent, dry cough
o	Worse at night and with exercise (diurnal variation)
-	Wheeze
o	Expiratory noise due to airway narrowing
o	Prolonged expiration
o	Responds to bronchodilators
-	Shortness of breath
o	Limiting exercise, daily life
-	Stunted growth
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7
Q

Signs of asthma? When is it worse?

A

Signs (usually normal between exacerbations)

  • Barrel-shaped chest
  • Accessory muscle use
  • Hyperinflated chest
  • Harrisons sulcus
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8
Q

What symptoms are there in an acute asthma attack? How is it classified?

A
  • Acute SOB, cough, wheeze, work of breathing
  • Severity
    o Mild – breathlessness, PEFR >50% of expected
    o Severe – cannot complete sentances, RR >25, pulse >130bpm, PEFR <50% of expected
    o Life-Threatening – ACHEST3392
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9
Q

DDx of asthma?

A 
Bronchiolitis
Pneumonia/TB
Inhaled foreign body
Croup
Cystic Fibrosis
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10
Q

Investigations for children under 5?

A
  • Treat symptoms based on observation and clinical judgement
  • Review child regularly
  • If still have symptoms at 5 years, carry out objective testing
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11
Q

When to perform investigations for asthma in children 5-16 years?

A
  • Treat immediately if they are acutely unwell
  • Perform objective tests for asthma if the equipment is available and testing will not compromise treatment of the acute episode
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12
Q

Give the objective investigations in asthma? Give the positive result values?

A 
o	Spirometry
	FEV1/FVC<70% of predicted
o	BDR test
	FEV1 improvement of >12% if positive
	Diagnosed if both spirometry and BDR positive
o	FeNO test
	If uncertain and negative spirometry and BDR
	35ppb or more is positive test
	Refer if negative
o	PEFR variability 2-4 weeks
	If normal spirometry OR obstructive spirometry, negative BDR, positive FeNO
	>20% variability is positive
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13
Q

What happens if child unable to perform objective tests in asthma?

A
  • Treat based on observation and clinical judgement

- Try doing the tests again every 6 to 12 months

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14
Q

What other investigations may be needed to rule out other DDx in asthma?

A

Chest X-Ray – if exclusion of pneumothorax is needed
Allergy tests – skin prick test
Sputum culture

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15
Q

General measures in asthma management?

A

Reduce exposure to triggers
Monitor disease
- Symptom and PEFR diary
- After starting or adjusting medicines for asthma, review the response to treatment in 4 to 8 weeks
Educate the family about good inhaler technique

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16
Q

When will you move up asthma ladder in chronic treatment?

A

3x SABA per week, woken

3 month usually

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17
Q

Step 1 in asthma treatment in children all ages?

A
  • Inhaled short-acting B2 agonist (salbutamol, terbutaline, ipratropium bromide (infants/children))
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18
Q

Step 2 in asthma treatment in children under 5?

A

Add LTRA

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19
Q

Step 3 in asthma treatment in children under 5?

A

• Low dose ICS – 8-week trial

  • If symptoms resolved then reoccurred within 4 weeks of stopping ICS – restart on low-dose ICS
  • If symptoms resolved but reoccurred beyond 4 weeks of stopping ICS, repeat low-dose ICS
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20
Q

Step 4 in asthma treatment in children under 5?

A

•Refer to respiratory physician

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21
Q

Step 2 in asthma treatment in children aged 5-16?

A

• Add inhaled paediatric low dose ICS

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22
Q

Step 3 in asthma treatment in children aged 5-16?

A

• Add on LABA
 Review 4-8 weeks
 If no response, stop LABA and start LTRA

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23
Q

Step 4 in asthma treatment in children aged 5-16?

A

• Add LTRA

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24
Q

Step 5 in asthma treatment in children aged 5-16?

A

• Increase dose of ICS to paediatric moderate dose

Referral to paediatrician

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25
Q

Step 6 in asthma treatment in children aged 5-16?

A

Increase ICS dose to high dose
Trial of theophylline
Refer to paediatrician

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26
Q

What inhalers should be used in children and what else should be prescribed?

A
  • <5 years, use pMDI and spacer device
    • If not tolerated, DPI in 3-5 years or nebuliser
  • 5-16 years, pMDI and spacer device
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27
Q

Management of mild & severe acute exacerbation in asthma?

A

Mild - 10 puffs of SABA (given when no oxygen requirement), prednisolone 1-2mg/kg PO 3 days, give 10 puffs of inhalers when needed and space out

Severe
- 1. High flow Oxygen (100%, 15L)

    1. Salbutamol nebulised
      o 10 puffs of SABA if not life-threatening
      o 5mg O2-nebulised in 4mL saline (2.5mg if <5 years)
      o Continuously then every 30 mins and space out
    1. Hydrocortisone IV/Prednisolone oral
      o Hydrocortisone – 100mg IV
      o Prednisolone – 1-2mg/kg to max 40mg (50mg >12 years)
    1. Ipratropium bromide nebulised
      o Can do same time as salbutamol
      o 0.25mg in 4mL saline
      o Every 20-30 mins for 1st 2 hours then everyW 8 hours if needed
    1. Magnesium sulphate IV one-off dose
      o 40mg/kg over 20 mins (<2g)
    1. Theophylline (Aminophylline IV)
      o 5mg/kg over 20 mins
      o Give ondansetron as causes vomiting
  • Before discharge
    o Need PEFR >75%, good inhaler technique
    o Wheeze plan
    o Inhaled steroids and oral prednisolone (3 days)
    Follow-up GP in 1 week and clinic in 4 weeks
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28
Q

What complications dose excessive steroid usage cause children in asthma?

A

Excessive steroid use

- Impaired growth, adrenal suppression, oral candidiasis

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29
Q

Pathology of bronchiolitis?

A
  • RSV (respiratory syncytial virus) invades the nasopharyngeal epithelium and spreads to the lower airways
  • Increased mucus production, desquamation and then bronchial obstruction
  • Net effect = pulmonary hyperinflation and bronchiolar atelectasis (one or more areas of your lungs collapse or don’t inflate properly)
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30
Q

Typical time course of bronchiolitis?

A
  • Typically, a 9-day illness
    o 3 days prodrome- cold and harsh cough
    o 3 days fever + high pitched wheeze + breathless
    o 3 days: recovery
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31
Q

Epidemiology of bronchiolitis?

A
  • COMMONEST serious respiratory infection of infancy: 2-3% of all infants are admitted to hospital with the disease each year during winter.
  • Usually in infants <2 years old, affects everyone by the age of 2
  • 90% are aged 1-9months
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32
Q

Risk factors for bronchiolitis?

A 
o	CHD (congenital heart defect)
o	Chronic lung disease e.g. CF
o	Prematurity
o	Immunodeficiency
Passive smoking
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33
Q

Causative agents in bronchiolitis?

A
  • RSV (respiratory syncytial virus, single-stranded RNA) - 80%
  • Others include parainfluenza, influenza, adenovirus, rhinovirus, metapneumovirus and mycoplasma pneumonia
  • Dual infection with RSV + metapneumovirus severe bronchiolitis
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34
Q

Symptoms of bronchiolitis?

A
  • Preceded by coryzal symptoms
  • Dry cough respiratory distress (worsening SOB) + wheeze
  • Low Fever
  • Feeding difficulty
  • Episodes of apnoea
  • Rarely encephalopathy with seizures due to hyponatraemia
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35
Q

Signs of bronchiolitis?

A
  • Cyanosis or pallor
  • Sharp, Dry cough
  • Tachypnoea + tachycardia
  • Subcostal and intercostal recession
  • Chest hyperinflation prominent sternum + liver displaced downwards
  • Pauses in breathing or apnoea
  • On auscultation:
    o Wide spread wheeze
    o Prolonged expiration
    o Fine end-inspiratory crackles
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36
Q

Investigations in bronchiolitis?

A
  • Vital Signs to measure level of respiratory distress
  • Nasal/Throat Swabs
    Others:
  • Capillary blood gas only done in severe infections
    Throat swabs
  • CXR only needed in atypical cases to rule out pneumothorax/lobar collapse
    o Will show hyperinflation, widespread consolidation
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37
Q

Management of bronchiolitis?

A

Most infants treated at home

Hospital when:
- Feeding poorly, lethargy, sats <94%, tachypnoea

Hospital treatment:
- Humidified O2 via high flow nasal cannula
o SpO2 >92%
- If tachypnoea, minimise oral feed - use NGT feeds

  • Mechanical ventilation if severe
    o CPAP or via high flow nasal cannula
  • Not routinely given but nebulised salbutamol to ease wheeze
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38
Q

Prevention of bronchiolitis?

Mortality increase in which groups (given preventative measures)?

A
  • Palivizumab (monoclonal antibody to RSV) given monthly by IM injection for 6 months in high risk pre-term infants

Congenital heart, preterm infants, immunodeficiency

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39
Q

What does croup stand for?

A

Laryngotracheobronchitis

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40
Q

Name the 3 common conditions in tracheal inflammation?

A

Viral croup
Spasmodic croup
Acute epiglottitis

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41
Q

What is viral croup? Due to what?

A

URTI
 Mucosal inflammation affecting the nose to the LRT
 Due to parainfluenza, influenza and RSV in children aged 6 months – 6 years

42
Q

What is spasmodic/recurrent croup?

A

 Barking cough and hyperreactive upper airways

 No respiratory tract symptoms

43
Q

What is acute epiglottitis?

A

 Life-threatening swelling of the epiglottis and septicaemia due to H. Influenzae type B infection
 Now rare due to Hib immunization

44
Q

Epidemiology of laryngotracheal infections?

A
  • Viral croup= 95% of the laryngotracheal infections
  • Most common in autumn
  • Peak at 2yrs old, in children aged 6M-6yrs
45
Q

What is acute epiglottitis most common?

A
  • Acute epiglottitis: most commonly in ages 1 – 6 years, rare due to Hib immunisation
46
Q

Causative agents in viral croup?

A

o MOST COMMONLY due to parainfluenza

o Others include Influenza and RSV

47
Q

Causative agents in acute epiglottitis?

A

o H. Influenzae type B infection

48
Q

Symptoms of croup?

A 
Develops in days
-	Often worse at night
o	Barking cough
o	Harsh stridor
o	Hoarseness preceded by fever &amp; coryzal URTI
49
Q

Symptoms of acute epiglottitis?

A 
Develops in minutes to hours
-	Often worse at night
o	High fever, toxic-looking child
o	Intensely painful throat
	Stops swallowing or speaking
o	Saliva drooling
o	Respiratory difficulty
o	Child sitting immobile, upright, with open mouth
50
Q

Difference between croup and epiglottitis?

A

Croup
Days, preceding cough, severe, barking cough, can drink, closed mouth, not toxic, <38.5, harsh, rasping stridor
Hoarse, Stridor voice

Acute epiglottitis
Hours, no coryza, absent or slight cough, no feeding, drooling saliva, toxic, >38.5, soft, whispering stridor
Weak or silent voice (reluctant to speak)

51
Q

Examination in croup/epiglottitis?

A
  • Examination—DO NOT EXAMINE THE THROAT—assess severity:
    o Degree of stridor and subcostal recession
    o RR
    o HR
    o LOC (drowsy?), tired, exhausted
    o Pulse oximetry
52
Q

What else should be done in epiglottitis? and severe croup?

A
  • Anaesthetist makes diagnosis by laryngoscopy – cherry-red swollen epiglottis
  • Electively intubate before obstruction occurs
53
Q

Immediate management to croup/epiglottitis?

A
  • LEAVE CHILD ALONE - DO NOT DISTRESS (especially in epiglottitis)
    o Differentiate between croup and acute epiglottitis
    o Stabilise child, give oxygen and keep airway open
54
Q

Management of mild viral croup?

A

o Mild illness can be managed at home
 Usually resolves after 48hours
 Take paracetamol/ibuprofen PRN
o If there is recession and stridor at rest, then return to hospital

55
Q

Management of moderate/severe croup?

A 
o	Infants <1yr need closer attention
o	Tx include:
	Moist or humidified air
•	Ease breathing 
	Steroids
•	Oral dexamethasone (0.15mg/kg stat dose) or oral prednisolone (1-2mg/kg stat) or nebulised budesonide (2mg stat dose)
	Nebulised adrenaline (epinephrine)
•	Transient relief of Sx (airway obs)
	My need endotracheal intubation.
56
Q

Management of acute epiglottitis? Prevention of acute epiglottitis?

A

o Manage in ICU after endotracheal intubation
o Once procedure completed take blood cultures and start IV Abx
 Cefuroxime IV for 7-10 days
o Rifampicin prophylaxis to close contacts

57
Q

Definition of pneumonia?

A
  • Acute infection of lower respiratory lung parenchyma
58
Q

When does incidence of pneumonia peak?

A

during infancy

59
Q

When is no cause for pneumonia found?

A
  • 50% no cause found
60
Q

Causative organisms of pneumonia in neonates?

A

 Organisms of the genital tract
 Group B Streptococcus
 Gram negative enterococci

61
Q

Causative organisms of pneumonia in Infants&young kids?

A

 RSV most common
 Streptococcus pneumoniae, Haemophilus influenzae, Bordetella pertussis, Chlamydia trachomatis
 Rare but serious cause S.aureus
 Influenza, parainfluenza, adenovirus

62
Q

Causative organisms of pneumonia in children >5y?

A

 Streptococcus pneumoniae
 Mycoplasma pneumoniae (all ages)
 Chlamydia pneumoniae

63
Q

Causative organisms of pneumonia in all ages?

A

 Mycoplasma tuberculosis

64
Q

Risk factors for pneumonia?

A 
o	Congenital lung cyst
o	Chronic lung disease
o	Immunodeficiency
o	CF
o	Sickle cell disease
o	Tracheostomy
65
Q

Symptoms of pneumonia?

A 
o	Fever
o	Shortness of breath
o	Usually preceded by URTI
o	Cough
o	Malaise
o	Poor feeding
66
Q

Signs of pneumonia?

A

o Grunting
o Recessions
o Use of accessory muscles
o Pleural pain
o End-inspiratory course crackles and bronchial breathing
o Dullness on percussion
o Decreased breath sounds and oxygen saturations low

67
Q

Investigations in pneumonia?

A
  • Chest X-ray
    o Consolidation usually lobar – classical Streptococcus pneumoniae in right upper lobe
    o Pleural effusion shows blunting of costophrenic angles
  • Nasopharyngeal aspirate
    o To identify viral causes
  • Bloods
    o FBC (increased WCC, neutrophils usually in bacteria), CRP, ESR
    o Cultures
68
Q

Prevention of pneumonia in children:?

A

o Vaccination against Streptococcal pneumoniae (Pneumococcal) and Hib have decreased incidence

69
Q

Acute management in primary care for pneumonia?

A 
	Analgesia and paracetamol for fever
	Encourage fluid intake
	Do not smoke in house
	Antibiotics
•	Amoxicillin
•	Alternatives: Co-amoxiclav, erythromycin, azithromycin, clarithromycin
•	For 7-14 days
70
Q

Secondary care of pneumonia?

A 
	Admit if O2 sats <92% and signs of respiratory distress
	Oxygen, analgesia
	IV fluids
	IV co-amoxiclav 7-14 days
Alt: Clarithromycin
71
Q

What antibiotics to give in CAP pneumonia in secondary care - neonates?

A

Neonates - IV benzylpenicillin + gentamicin

72
Q

What antibiotics to give in CAP pneumonia in secondary care - children?

A

o Oral Amoxicillin

o Alternatives: clarithromycin (if pen allergic)

73
Q

What antibiotics to give in CAP pneumonia in secondary care - children severe?

A

<3 months - IV ceftriaxone, cefotaxime

3 months to 18 years - IV co-amoxiclav/amoxicillin

74
Q

What antibiotics to give in HAP pneumonia in secondary care - severe?

A

 IV Amoxicillin/Co-amoxiclav

 Tazocin (if >5 days in hospital)

75
Q

Complications of pneumonia?

A
  • Pleural Effusions
  • Empyema or lung abscess
  • Sepsis
  • Bronchiectasis
76
Q

Definition of pharyngitis?

A

local imflammation of oropharynx with enlarged and tender lymph nodes

77
Q

Definition of tonsilitis?

A

form of pharyngitis where there is intense inflammation of the tonsils, often with purulent exudate

78
Q

Epidemiology of URTI?

A
  • Highest incidence in children and young adults
  • More common in winter
  • URTI are 80% of respiratory infections
79
Q

Causative agents of common cold?

A

 Rhinovirus, coronaviruses and RSV (however RSV usually causes acute bronchiolitis)

80
Q

Causative agents of pharyngitis?

A

 Adenoviruses, enteroviruses, rhinoviruses, influenza types A and B
 In older children, group A B-haemolytic streptococcus

81
Q

Causative agents of tonsillitis?

A

 Group A B-haemolytic streptococcus

 EBV

82
Q

Causative agents of epiglottitis?

A

Hib

83
Q

Symptoms and signs of URTI?

A
  • Fever (+/- febrile convulsions)
  • Painful throat
  • Exudate present in bacterial tonsillitis
  • Earache and nasal discharge
  • Difficulty feeding and drinking
84
Q

Examinations in URTI?

A
  • Clinical examination – pus on tonsils indicates bacterial infection
  • Neck – think bacterial infection if tender lymphadenopathy
85
Q

What is the Centor criteria?

A 
Tonsillar exudate
Tender anterior cervical lymphadenopathy or lymphadenitis
History of fever (over 38°C)
Absence of cough
IF 3 OR 4, CONSIDER ANTIBIOTICS
86
Q

General management of URTI?

A
  • Majority caused by viral infections
  • 40% of symptoms resolve within 3 day and 85% within 1 week
  • Symptomatic relief
    o Paracetamol and ibuprofen
87
Q

When to give antibiotics and what in URTI? What to avoid in all cases?

A

o If positive culture or Centor criteria 3 or 4:
 Tonsilllar exudate
 Tender anterior cervical lymphadenopathy
 Fever
 Absence of cough
o Prescribe penicillin V (phenoxymethylpenicillin) for 10 days
o Alternatives: erythromycin or clarithromycin for 5 days
AVOID AMOXICILLIN AS CAUSES RASH IN EBV

88
Q

Complications of URTI?

A
  • Otitis Media
  • Sinusitis
  • Peritonsillar abscess (quinsy)
  • Para-pharyngeal abscess
89
Q

Definition of cystic fibrosis? (CF)

A
  • Autosomal recessive condition causing a defective CFTR protein on chromosome 7
90
Q

What is CFTR?

A
  • CFTR is a cAMP dependent chloride channel found in membrane of cells
91
Q

What pathology does CF lead to?

A
  • Leads to excessively thick mucus in many body systems
    o Reduction in airway surface liquid layer and impaired ciliary function
    o Chronic endobronchial infection ensues
    o Thick meconium is produced
    o Pancreatic ducts also become blocked by thick secretions
    o Abnormal sweat glands
92
Q

Epidemiology of CF?

A
  • Incidence of 1 in 2500 live births with a carrier rate of 1 in 25
  • Average life expectancy is mid-30s
93
Q

Symptoms and Signs in CF in infancy?

A
  • Meconium ileus (1 in 10)
  • Prolonged neonatal jaundice
  • Failure to thrive
  • Recurrent chest infections
    o Cough, purulent sputum, chest deformity
    o Initially S.aureus, H.inflenziae
    o Pseudomonas aeruginosa, burkholderia cepacia colonisations
  • Malabsorption (vit ADEK), steatorrhoea – failure to thrive
94
Q

Symptoms and Signs in CF in young child?

A
  • Nasal Polyp
  • Sinusitis
  • Recurrent LRTI
  • Bronchiectasis
  • Diarrhoea
  • Rectal Prolapse
  • FTT
95
Q

Symptoms and Signs in CF in older child?

A
  • Allergic bronchopulmonary aspergillosis
    Recurrent LRTI
  • Diabetes Mellitus
  • Cirrhosis/Portal Hypertension
  • Intestinal Obstruction
  • Pneumothorax
  • Sterility in males – congenital absence of vas deferens
96
Q

Signs of CF?

A
  • Evidence of malnutrition, poor weight gain
  • Hyperinflation of the chest
  • cough (purulent sputum)
  • Coarse inspiratory crackles
  • Expiratory wheeze
  • Finger clubbing
97
Q

What testing is available to diagnoses CF?

A
  • Screened for in Guthrie test
  • Sweat Test >60mmol/l
    o Measuring sodium and chloride concentrations in sweat
  • Gene Testing
    CT head and thorax
98
Q

General management of CF?

A
  • Requires the MDT approach and reviewed anuallly - tertiary centre
99
Q

Respiratory management of CF?

A
  • Physiotherapy twice a day to remove secretions
    o Parents taught airway clearance at home using percussion and postural drainage
    o Older children taught forced expiration technique
  • Physical exercise beneficial
  • Oral flucloxacillin prophylaxis needed
  • Nebulised DNAse decreases sputum viscosity
  • If pseudomonas infection:
    o May need oral/IV broad-spectrum Abx
  • If respiratory function decreases, offer azithromycin
  • regular sputum samples
100
Q

Other management of CF?

A
  • Increase calorie intake by increasing portion size/high calorie foods (150% of normal)
  • Offer oral pancreatic enzyme replacement therapy (Creon)
  • Omeprazole helps absorption
  • Fat-soluble vitamins (ADEK)

MSRA Content (87 decks)

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