Paediatric RESP Flashcards
1
Q
What is the proper medical name for croup?
A
Viral laryngotracheobronchitis
2
Q
At what point of the year is croup most common?
A
Autumn
3
Q
What age group is affected by croup?
A
6m to 6y, peak 2y
4
Q
What is the main cause of croup?
A
Parainfluenza
5
Q
Recall 3 differentials for croup
A
Laryngomalacia
Acute epiglottitis
Inhaled foreign body
6
Q
Recall the signs and symptoms of croup
A
1st = coryzal Sx
2nd = barking cough (from vocal cord impairment) + stridor
7
Q
What investigations should be done for croup?
A
Clinical diagnosis
DO NOT EXAMINE THROAT
8
Q
How should croup be managed?
A
Westley score determines admission
Admit if RR>60, or complications
DEXAMETHOSONE TO ALL
For mild: discharge
For moderate: admit
For severe: admit and add nebulised adrenaline to dex
For impending respiratory failure: same as severe
9
Q
What is the most likely complication of croup?
A
Secondary bacterial superinfection
10
Q
What is the most common cause of acute epiglottitis?
A
Haemophilus influenza B (bacteria!!!!) hence is quite uncommon as vaccinated against
11
Q
What are the signs and symptoms of acute epiglottitis?
A
Medical emergency
No cough as in croup
High-fever (‘toxic-looking’)
Stridor is soft inspiratory with high RR
“Hot potato” speech
Drooling as child cannot swallow
Immobile, upright + open mouth: ‘tripod sign’
12
Q
How should acute epiglottitis be investigated and managed?
A
Do not lie child down or examine their throat (may precipitate a total obstruction)
- Immediately refer to ENT, paeds + anaesthetics –> transfer + secure airway
- Once airway is secured, blood culture, empirical Abx (cefuroxime) + dexamethosone
13
Q
In what age range is bronchiolitis seen?
A
1-9 months
3-6 month peak
14
Q
What is the most common cause of bronchiolitis?
A
RSV in 80%
15
Q
What are the signs and symptoms of bronchiolitis?
A
1st = coryzal Sx which progress to
2nd = dry, wheezy cough, SOB, grunting
16
Q
What are the examianation findings in bronchiolitis?
A
To distinguish from croup/ other ‘itis’
Auscultate: fine, bi-basal, end-inspiratory crackles
17
Q
What investigations should be done in bronchiolitis?
A
Cinical dx but can do an NPA (nasopharyngeal aspirate) to confirm
If there is significant respiratory distress + fever, do a CXR to rule out pneumonia
18
Q
What are the criteria for hospital admission in bronchiolitis?
A
Hospital admission:
If <2 months, lower threshold as they deteriorate quickly- apnoea/ cyanosis/ grunting
- Poor oral fluid intake
- SpO2 < 92% on normal room air
Supportive care: nasal O2, NG fluids/ feeds, CPAP if respiratory failure
19
Q
Over how long is bronchiolitis self-limiting?
A
2 weeks
20
Q
Describe the ‘spectrum’ of infant asthma
A
Bronchiolitis if <1y
Viral-induced wheeze (1-5y)
Asthma (>5)
21
Q
Describe the wheeze in asthma
A
End-expiratory polyphonic
22
Q
When are asthma symptoms worst?
A
Night/ early morning
23
Q
What will be seen OE in childhood asthma?
A
Hyperinflated chest + accessory muscle use
Harrisson’s sulci - depressions at base of thorax where diaphragm has grown in muscular size
24
Q
How should childhood asthma be diagnosed?
A
<5 years old = clinical dx
>5 years old = spirometry, bronchodilator, PEFR variability
25
Recall the PEFR range of moderate, severe, and life-threatening asthma
Moderate: 50-75%
Severe: 33-50%
Life-threatening: <33%
26
When should you admit a child with asthma?
When they are classified as severe or life-threatening?
27
How should paediatric asthma be managed in a hospital setting?
1. Burst step
- 3 x salbutamol nebs, or up to 10 inhales on a pump
- 2 x ipratropium bromide nebs (SE of too much = shivering, vomiting)
- Involve seniors if burst therapy has failed to work
2. IV Bolus step = give one of the following: MgSO4, salbutamol, aminophylline
3. Infusion step
- IV salbutamol/ aminophylline
4. Panic step
- Intubate + ventillate
28
Recall 4 contraindications of beta-agonists/ salbutamol
Beta-blockers
NSAIDs
Adenosine
ACE inhibitors
29
Recall outpatient management of asthma in children over 5
1. SABA
2. SABA + ICS
3. SABA + ICS + LTRA
4. SABA + ICS + LABA
5. SABA + low dose ICS MART
6. SABA + mod dose ICS MART / mod ICS + LABA
5. + increase ICS to paediatric high dose / Theophylline
30
What is the most common cause of rhinitis?
Rhinovirus
31
What is rhinitis more commonly known as?
Common cold
32
What is the general recovery time for rhinitis?
2 weeks
33
What are the possible complications of rhinitis?
Otitis media
Acute sinusitis
34
What is sinusitis?
Infection of the maxillary sinuses from viral URTIs
May lead to a secondary bacterial infection
35
How should sinusitis be managed?
If Sx last <10 days
- no Abx, advise them that virus will take 2-3w to resolve, simple analgesia
If Sx last >10 days, high dose nasal CS for 14 days
- this may improve Sx but is unlikely to reduce duration of illness
- Give back up prescription of Abx
36
When should a pt be admitted to hospital for sinusitis?
Severe systemic infection
Intraorbital/ periorbital problems (eg periorbital cellulitis, diplopia)
37
Why are children particularly vulnerable to otitis media?
Eustacian tubes are short, horizontal + function poorly
38
What are the 3 most common causative organisms in otitis media?
H influenza
S. pneumoniae
RSV
39
What investigations should be done in otitis media?
Temperature
Otoscopy
40
What would be seen on otoscopy in otitis media?
Bright red bulging tympanic membranes
Loss of normal light reaction
Perforation
Pus
41
Recall 3 indications for admission in acute otitis media
Severe systemic infection
Complications (eg meningitis, mastoiditis, facial nerve palsy)
Children <3 months with a temperature >38
42
When should abx be given in otitis media?
Delayed prescription if not better after 3 days or if it gets suddenly worse
Immediate Abx prescription if systemically unwell, age <2 yo
If there is a perforation: oral amoxicillin + review in 6w to ensure healing
43
What is another name for otitis media with effusion?
Glue ear
44
What are the signs and symptoms of otitis media?
Asymptomatic apartfrom possible reduced hearing
Can interfere with normal speech development
45
What does otoscopy show in otitis media with effusion?
Eardrum is dull + retracted, often with a fluid level visible
46
How should otitis media with effusion be investigated?
Tympanometry
Audiometry
47
When should a referral be made to ENT in otitis media with effusion?
If persistent past 6-12 weeks
48
What is the most common complication of chronic otitis media?
Mastoiditis (chronic OM --? Honeycomb structure behind ear inflamed --> discharge + swelling behind ear)
49
What is another name for acute diffuse otitis externa?
Swimmer's ear
50
What is the cause of chronic otitis externa?
Fungal cause
51
What is necrotising otitis externa?
Life-threatening extension into mastoid + temporal bones
52
What demographic of folks are most likely to get necrotising otitis externa?
The elderly
53
How should otitis externa be investigated?
If indicated: swabs + culture
54
How should otitis externa be managed?
Topical acetic acid (only effective for 1 week)
If indicated: topical Abx (neomycin/ clioquinol)
Wicking + removal of debris
55
Recall 2 indications for abx use in otitis externa?
Cellulitis
Cervical lymphadenopathy
56
What is tonsilitis?
Form of pharyngitis with inflammation of the tonsils + purulent exudate
57
What is the most common cause of bacterial tonsilitis?
Group A beta-haemolytic streptococcus
58
What score determines likelihood of bacterial over viral aetiology of tonsilitis? Recall it as well as the consequences of each score
Centor score:
+1: exudate
+1: tender anterior cervical LNs
+1: Temp >38
+1: Cough absent
+1: age 3-14
"CETTA"
1 = no abx
2/3 = rapid strep test
4/5 = rapid strep test + Abx
59
When should a referral for laryngoscopy be made in tonsilitis?
If persistent (>3w) and change in voice
60
When should you admit for tonsilitis/ pharyngitis/ laryngitis?
Difficulty breathing
Peri-tonsillar abscess (quinsy) or cellulitis
Suspected rare cause (eg kawasaki/ diptheria)
61
How would diptheria appear OE of the throat?
'web'/ pseudomembrane at back of throat
62
If bacterial tonsilitis is confirmed using rapid strep test, how should it be treated?
Phenoxymethylpenicillin 10 days QDS
63
What tx should be avoided in tonsilitis?
Amoxicillin in case it's EBV because then you would get a maculpapular rash
64
For how long should school be avoided in tonsilitis?
Unti 24 hours after abx have been started (in case of scarlet fever)
65
What should you advise for self-tx for tonsilitis if no abx indicated?
Paracetamol
Lozenges
Saltwater
Difflam (anaesthetic spray)
66
What is the connection between tonsilitis and scarlet fever?
GAS (s pyogenes) infection can progress from tonsilitis to scarlet fever
67
What are the signs and symptoms of scarlet fever?
Rash and erythroderma
Neck + chest --> trunk + legs
Characteristic sandpaper texture
Pastia's lines (rash prominent in skin creases)
Strawberry tongue (starts as white, then desquamates)
May progress to rheumatic fever with a week's latency
68
How should scarlet fever be managed?
Phenoxymethylpenicillin 10 days QDS
69
Upon which chromosome is the cAMP-dependent Cl channel defect in cystic fibrosis?
Chromosome 7
70
What is the incidence of cystic fibrosis in terms of number of live births?
1 in 25, 000
71
Recall some of the most important signs and symptoms of cystic fibrosis in children?
Meconium ileus
Recurring chest infections
Clubbing of fingers
72
When is cystic fibrosis screened for in children?
At birth: heel prick test
73
If cystic fibrosis screening is positive, what further tests can be done?
Immunoreactive trypsinogen
Sweat test (abnormally high NaCl)
Genetic tests
74
Recall the timeline of routine reviews in cystic fibrosis?
Weekly in 1st month
Every 4w in 1st year
Every 6-8w when 1-5y
Every 2-3m when 5-12yo
Then every 3-6m
75
What is the main method of monitoring for cystic fibrosis?
Spirometry
76
How frequent should physiotherapy be done for respiratory symptoms in CF?
twice a day
77
Recall the protocol for mucolytic therapy in cystic fibrosis
1st line = rhDNase
2nd line = rhDNase + hypertonic saline
Orkambi (lumcaftor + ivacaftor) may be effective in treating CF caused by the FGO8 mutation
78
How should recurrent infection be managed in cystic fibrosis?
Prophylactic abx: usually flucloxacillin + azithromycin
Rescue packs given for prompt IV Abx
79
How should cystic fibrosis patients be nutritionally managed?
High calorie + high fat diet (150% of normal) + fat-soluble vitamins
Pancreatic enzyme replacemet with every meal --> CREON
80
How can liver problems in cystic fibrosis be managed?
Ursodeoxycholic acid to help bile flow
81
What is laryngomalacia?
Congenital abnormality of larynx predisposing to supraglottic collapse during inspiration
82
What are the signs and symptoms of laryngomalacia?
At 2-6w they go all noisy with their breathing (nb: not present at birth:
GORD +/- feeding difficulties, cough + choking
Normal cry
83
How should laryngomalacia be managed?
Self-resolves within 18-24m so conservatively manage
If airway compromise/ feeding disrupted sufficiently to prevent normal growth --> endoscopic supraglottoplasty
84
What is a breath holding attack?
When child cries vigorously for <15s + then becomes silent
85
How should breath holding attack be managed?
Resolve spontaneously
86
What will be heard on auscultation in pneumonia?
Consolidation + coarse crackles
87
How should TB be investigated if there is exposure?
Manteaux test: if -ve excludes TB
If +ve --> IGRA test
If -ve --> prophylaxis (isoniazid)
If +ve --> tx
88
Recall the treatment of TB pneumonia
RIPE;
Rifampicin 6m
Isoniazid 6m
Pyrazinamide 2m
Ethanbutol 2m
89
How can pneumonia and bronchiolitis be differentiated clinically?
Bronchiolitis = fine crackles on auscultation,
Pneumonia = coarse crackles
90
How should pneumonia be managed?
1. Note severity using obs + examination
2. Decide on whether they need admitting or not
3. Abx (can't distinguish viral + bacterial so just do it) - mild CAP = amoxicillin, 2nd line (severe CAP) = co-amoxiclav + macrolides
91
How should you decide whether a child with pneumonia needs to be admitted?
SpO2 < 92% on air
RR>60
Child <3m
OE: grunting, cyanosis, chest recession marked
Low consciousness
T>38
92
What is the gram status of pertussis?
-ve
93
What are the signs and symptoms of pertussis?
1w coryzal Sx followed by continuous coughing followed by inspiratory whoop + vomiting
In infants it is apnoea rather than a whoop
94
What investigations should be done in pertussis?
Culture + PCR per nasal swab
95
How should pertussis be managed?
Notify HPU
Decide whether to admit
<1m: clarithromycin
1+months: azithromycin
96
How do you decide whether to admit in whooping cough?
If <6m or acutely unwell
97
What is the other name for paediatric chronic lung disease?
Bronchopulmonary dysplasia
98
What would the CXR show in chronic lung disease?
Widespread opacification
99
How should chronic lung disease be managed?
If severe: artificial ventilation/CPAP/ low-flow nasal cannula
Short course low-dose CS
100
What is the pathophysiology of bronchiolitis?
Causes both upper and lower airway disease due to inflammation of bronchioles, causing the wheeze and crackles also seen
101
What reasons related to bronchiolitis may cause a child to need admission?
Bronchiolitis causing difficulty breathing (especially in younger children who do not use nose to breathe yet)
Difficulty feeding
- Hydration status should be assessed
- Are they taking less than 50% of their feeds?
Apnoeas - may require respiratory support or HDU/ICU care
102
What are some risk factors for severe bronchiolitis?
Chronic lung disease
Congenital heart disease
Less than 3 months old
Premature (especially before 28w)
Neuromuscular disorder
Immunodeficiency
103
What would the in-hospital management of bronchiolitis involve?
Respiratory support if sats < 90%
NG tube with oral feeds, IV only if not tolerating
104
Why is a CXR advised against in suspected bronchiolitis?
The x-ray changes with bronchiolitis are similar to bacterial pneumonia so should not be used to differentiate or whether to give antibiotics
