Lower resp Flashcards
what are common lower resp conditions in children?
asthma bronchitis bronchiolitis bronchiectasis cystic fibrosis
what are common upper resp conditions in children?
croup
whooping cough
epiglottitis
what cells mediate allergic asthma?
Th2 T cells
what cells do activate Th2 T cells when allergens bind to them?
dendritic cells
what cytokine is involved in the inflammatory process of asthma?
leukotriene C4
what environmental factors are involved with asthma?
low birth weight prematurity parental smoking atopy cold air and exercise atmospheric pollution NSAIDs B blockers
what viruses most commonly cause viral chest infections in children?
rhinovirus
respiratory syncytial virus
state two clinical patterns of wheeze?
episodic viral wheeze
multiple trigger wheeze
what resp conditions could finger clubbing suggest?
CF and bronchiectasis
what signs on examination may be present for asthma?
wheeze
use of accessory muscles
what investigations can be done for asthma?
spirometry (FEV1:FVC <70% if poor control)
peak expiratory flow rate bronchial provocation tests exercise testing skin prick testing exhaled nitric oxide (NO production in bronchial epithelial cells is increased with Th2 driven eosinophilic inflammation
what investigation can be done to diagnosis CF?
chloride sweat test
what investigation can be done to rule out GORD?
oesophageal pH testing
what investigation can be done to exclude bronchiectasis ?
high resolution CT
what gene is associated with asthma?
ADAM33
what are the aims of good control of asthma?
full school attendance no sleep disturbance <2/week daytime symptoms no limitations of daily living no exacerbations using salbutamol <2/week
if asthma is suspected what treatment should be started?
inhaled corticosteroid
what are the 5 step wise management of asthma ?
as required SABA (short acting b-2 agonist - salbutamol)
regular inhaled corticosteroid
add on therapy
- LABA (salmeterol/formeterol)
- increase ICS dose
- stop LABA and start leukotriene receptor antagonist
increase ICS dose
regular oral steroids and refer to paediatrician
state the name of a leukotriene receptor antagonist
montelukast
if no treatment works for asthma was specialist medication can be used?
Omalizumab
what is the action of Omalizumab for asthma?
reduces free IgE in the blood. This reduces IgE mediated inflammatory response
what should LABA be prescribed with?
ICS
what ICS is used in children?
beclometasone
what should all children diagnosed with asthma have?
written asthma management plan
what are the signs of life threatening asthma exacerbation ?
O2 sats <92% PEFR <33% predicted silent chest altered GCS confusion exhaustion cyanosis
what is the immediate management of asthma exacerbation ?
oxygen
bronchodilators (inhaled SABA - if severe nebulised)
ipatropium bromide (anti-muscuranic)
corticosteroids (prednisolone)
what is the second line treatment for asthma exacerbation?
IV salbutamol
magnesium sulphate
what condition is exhaled nitric oxide raised in?
hay fever
what is bronchiolitis commonly caused by?
respiratory syncytial virus
what pathophysiology occurs during bronchiolitis
proliferation of goblet cells causing excess mucus
IgE mediated type 1 allergic reaction causing inflammation
bronchiolar constriction
infiltration of lymphocytes causing submucosal oedema
infiltration of cytokines and chemokines
what would be seen on examination of bronchiolitis ?
tachypnoea grunting intercostal, subcostal recessions inspiratory crackles expiratory wheeze hyper inflated chest cyanosis
what are DD for bronchiolitis ?
pneumonia croup CF heart failure bronchitis
what should the management of bronchiolitis be in hospital ?
oxygen if sats <92%
give fluids via NG tube
consider CPAP if resp failure
perform upper airway suctioning
should antibiotics be used for bronchiolitis ?
no
- caused by parainfluenza virus
what are some complications of bronchiolitis ?
hypoxia dehydration fatigue persistent cough/wheeze bronchiolitis obliterans
how long does bronchiolitis usually last?
7-10days
what LRTI organisms can lead to bronchial damage and bronchiectasis ?
strep pneumonia staph aureus adenovirus measles influenza Bordetella pertussis Mycobacterium tuberculosis
what is the hereditary of primary ciliary dyskinesia ?
autosomal recessive
what is young syndrome ?
A rare condition associated with bronchiectasis, reduced fertility and rhinosinusitis.
what is yellow nail syndrome ?
rare syndrome associated with pleural effusions, lymphoedema and dystrophic nails. Bronchiectasis occurs in around 40% of patients.
what condition is suggested by Bilateral upper lobe bronchiectasis?
CF
what condition is suggested by unilateral upper lobe bronchiectasis?
post TB infection
what condition is suggested by Focal bronchiectasis (lower lobe) ?
foreign body inhalation
what are some complications of bronchiectasis?
Recurrent infection Life-threatening haemoptysis Lung abscess Pneumothorax Poor growth and development
what is the key symptom of bronchiolitis ?
chronic productive cough
what will a CXR of bronchiectasis
bronchial wall thickening and airway dilation
which spirometry pattern does severe bronchiectasis have?
mixed obstructive/restrictive
what gene is associated with CF?
CF transmembrane conductance regulator gene
what GI complications does CF have?
bowel obstruction in utero can cause meconium ileus
CF related liver disease
- causes cholestasis and can result in neonatal jaundice
distal intestinal obstruction syndrome
what reproductive complication does CF have?
98% of males are infertile due to the absence of vas deferens
what are signs of CF in children?
failure to thrive recurrent chest infections Rectal prolapse Nasal polyps (N.B. strongly suspect CF in children presenting with nasal polyps) Sinusitis
what specific mutation is the most common for CF in the UK?
ΔF508
what changes does CF cause to the pancreas?
the pancreatic duct is usually occluded in utero causing permanent damage to the exocrine pancreas
what are signs of CF in infants?
meconium ileus
failure to thrive
prolonged neonatal jaundice
how is CF screened in neonates?
part of the Guthrie test
what are the two key aims of CF management?
early treatment of infection
optimisation of nutrition
on examination what may be seen on the hands, face, chest and abdo?
Hands: finger clubbing
Face: nasal polyps
Chest: hyperinflated, crepitiations, portacath (indwelling vascular access device)
Abdomen: faecal mass (if constipated/DIOS), may have a scar from ileostomy (meconium ileus)
what two things are required for a diagnosis of CF?
fitting clinical history
positive chloride sweat test
what investigations can be done for CF?
CXR (hyperinflation, bronchial thickening)
Chloride sweat test
sputum sample
annually- glucose tolerance test liver function and coagulation bone profile lung function testing
faecal elastase (pancreatic function) Chest CT (for bronchiectasis) genetic analysis
how is a sweat sample collected for chloride testing?
pilocarpine iontophoresis
what are signs of CF in a young adult?
Pancreatic insufficiency: diabetes mellitus
Chronic lung disease
DIOS, gallstones, liver cirrhosis
is a single sweat test sufficient to diagnosis CF?
no
- require a second test or genetic testing
what level of chloride is required for a sweat test?
> 60mmol/L
40-60 is borderline and should be repeated
what MDT would be involved in the treatment of CF?
patient’s GP, a respiratory paediatrician, a specialist CF nurse, a dietician, physiotherapist, psychologist and social worker.
state what the management of CF would be ?
patient and family education
twice daily physiotherapy
mucolytics and DNase (reduces viscosity)
hypertonic saline
pancreatic enzyme supplements
fat soluble vitamins (ADEK)
ensure for weight gain
prophylactic antibiotics
infections should be treated for 2 weeks
Regular azithromycin has been shown to reduce exacerbations and improve lung function even in those not chronically infected with Pseudomonas aeruginosa.
annual follow up
what complications can occur in the resp tract for CF patients?
allergic bronchopulmonary aspergillosis (ABPA) bronchiectasis pulmonary HTN pneumothorax nasal polyps
what complications can occur in the GI tract for CF patients?
rectal prolapse (Tx = laxatives) distal intestinal obstruction syndrome (DIOS)
do CF patients have early or delayed puberty ?
delayed puberty
- delay of 2 years
What bacteria’s chronic infection is associated with worsening lung function and must be treated aggressively in CF patients?
pseudomonas aeruginosa
The CTFR gene encodes the CFTR protein, what channel ion does this form?
chloride channel
