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Phase 3a Finals > Paediatric Respiratory > Flashcards

Paediatric Respiratory Flashcards

1
Q

What is pneumonia?

A

inflammatory condition affecting alveoli of the lungs

mc - secondary to bacterial infection

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2
Q

causes of pneumonia

A

bacterial - mc :
- streptococcus pneumoniae - 80%. high fever, rapid onset and herpes labialis. - vaccine available

  • haemophilus influenzae - common in copd pts
  • staph aureus - following influenza infection or pts with CF

mycoplasma pneumoniae - atypical pneumonia - dry cough and atypical chest signs/x ray finds. autoimmune haemolytic anaemia and erythema multiforme poss seen

legionella pneumophilia - atypica. hyponatremia and lymphopenia common. - secondary to infected air conditioning units.

klebsiella pneumoniae - alcoholics

pseudomonas aeruginosa - pt with CF or bronchiectasis

moraxella catarrhalis - in immunocompromised pts or those with chronic pulmonary disease

viral

fungal :
- pneumocystis jiroveci - seen in hiv pts. dry cough exercise induced desaturations and absence of chest signs

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3
Q

Characteristic Chest signs of pneumonia

A

bronchial breath sounds - harsh inspiratory and expiratory breath sounds) -

focal coarse crackles - caused by air passing through sputum in the airways

dullness to percussion - due to lung tissue filled with sputum or collapsed

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4
Q

What is idiopathic interstitial pneumonia?

A

non infective causes of pneumonia.

eg:
- cryptogenic organising pneumonia - form of bronchiolitis that might come as a comp of Rheumatoid arthritis or amiodarone therapy

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5
Q

CAP VS HAP

A

community : most pts.

if develop within 48 hrs or more of admission : hap

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6
Q

symptoms of pneumonia

A

cough

purulent sputum (rust coloured/blood stained)

dyspnoea

chest pain: poss pleuritic

fever
malaise
haemoptysis - cough up blood

delirium

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7
Q

signs of pneumonia

A

signs of systemic inflammatory response:
- fever
-tachycardia
- hypotension
-confusion

tachypnoea

reduced oxygen saturations (95% or below 88% in copd)

auscultation:
- reduced breath sounds
-bronchial breathing
-crepitations/crackles

dullness on percussion (fluid)

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8
Q

Investigations for pneumonia

A

chest x ray : consolidation - opacity on x ray film in area of infection
- poss effusion

bloods:
fbc - neutrophilia in bacterial infection (raised wbc)

urea and electrolytes:
- check for dehydration

crp: raised
blood culture
abg: if ox sats low or pt has pre-existing resp disease eg copd.

sputum sample: diagnose causative organism after culture.

legionella antibodies if intermediate-high risk pts.

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9
Q

Risk stratification for pneumonia

what to do based off what scores? in hospital

A

CURB-65

C - confusion - abbreviated mental test score 8 or less/10
U - urea over 7 mmol/l
R - resp rate 30 or more/min
B - bp stystolic 90 or less and diastolic 60 or less
65 - AGE 65 OR MORE

home based care: 0 or 1 - low risk - <3% mortality risk

hospital : 2 or more - intermediate risk - 3-15%

intensive care if 3 or more - high risk - 15% mortatility

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10
Q

With reference to crp, how do you assess whether to give abx to pneumonia pts or not?

A

crp under 20 - dont give abx

crp 20-100 - consider delayed abx prescription

crp over 100 mg/L - offer abx therapy

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11
Q

Risk factors of pneumonia

A

age under 5 or over 65
smoking
recent viral RTI
chronic resp diseases: cystic fibrosis and COPD
immunosuppression: cytotoxic drug therapy and HIV

ivdu
other non-resp co-morbidities: dm or cv

pt at risk of aspiration: those with neuro diseases such as Parkinson’s disease or those with oesophageal obstruction.

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12
Q

Pathophysiology of pneumonia

A

pathogen entered the lower respiratory tract, inflammatory cascade begins.

neutrophils migrate to infected alveoli.
release cytokines.
activate immune response and induce fever.

accumulation of fluid and pus within alveoli that impairs gas exchange,

leads to hypoxic state which is characteristic of pneumonia

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13
Q

pneumonia in children - mc cause

treatment in kids

A

s.pneumoniae - mc causative agent of bacterial pneumonia in kids

amox : 1st line
macrolides add if no response

macrolide: if mycoplasma or chlamydia suspected

in pneumonia with influenza: co-amoxiclav

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14
Q

characteristic features of pneumococcal pneumonia:

A

rapid onset
high fever
pleuritic chest pain
herpes labialis - cold sores

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15
Q

Mx of Pneumonia : CAP

A

low-severity CAP:
- amox - 1st line
- if penicillin allergic - macrolide or tetracycline
- 5 day course of abx.

Mx of moderate-high severity CAP:
- dual abx therapy with abx + macrolide
- 7-10 day course.
- beta-lactamase stable penicillin like co-amoxiclav, ceftriaxone or piperacillin with tazobactam and a macrolide in high severity.

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16
Q

Discharge Criteria for Pneumonia

A

if in the past 24 hrs they have had 2 or more of these cant discharge:

  • temp over 37.5
  • rr over 100 breathspm
  • hr over 100 bpm
  • systolic bp 90 or less
    -ox sats under 90% on room air
  • abnormal mental status
  • inability to eat without assistance.
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17
Q

how quick should symptoms resolve in pneumonia?

A

1 week - fever stop
4 week - chest pain and sputum reduced
6 week - cough and breathlessness reduced
3 months - most sx resolved poss still fatigue

6 months - normal

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18
Q

in pneumonia when should i repeat cxr after clinical resolution

A

6 weeks

ensure consolidation is resolved and no underlying secondary abnormalities eg lung tumour

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19
Q

What is mycoplasma pneumoniae?

A

atypical pneumonia - younger pts.

epidemic every 4 yrs approx.

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20
Q

why does atypical pneumonias not respond to penicillin’s or cephalosporins?

A

lack peptidoglycan cell wall

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21
Q

features of mycoplasma pneumonia

A

prolonged and gradual onset.

flu like sx classically precede a dry cough

bilateral consolidation: X-RAY

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22
Q

how would you investigate for a mycoplasma pneumoniae?

A

mycoplasma serology

positive cold agglutination test - peripheral blood smear may show rbc agglutination

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23
Q

management of mycoplasma pneumonia

A

doxycycline (tetracycline) or a macrolide - eg erythromycin/clarithromycin

or

fluoroquinolones - levofloxacin

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24
Q

Complications of mycoplasma pneumonia

A
  • cold agglutins (IgM): may cause haemolytic anaemia, thrombocytopenia
  • erythema multiforme, erythema nodosum
  • meningoencephalitis, Guillain-Barre syndrome and other immune-mediated neurological diseases
  • bullous myringitis: painful vesicles on the tympanic membrane
  • pericarditis/myocarditis

gi: hepatitis, pancreatitis

renal: acute glomerulonephritis

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25
Q

What is legionella and tell me common how you get it?

A

caused by the intracellular bacterium legionella pneumophilia.

colonizes water tanks and qu might hint at air-conditioning systems or foreign holidays.

can cause SIADH leading to hyponat

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26
Q

features of legionella

A

flu-like sx including fever (over 95% pts)

dry cough

relative bradycardia

confusion

lymphopaenia

hyponatraemia

deranged lft

pleural effusion: seen in 30% pts

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27
Q

investigations fo legionella

A

urinary antigen - diagnostic

cxr : non specific:
- mid to lower zone predominance of patchy consolidation
-pleural effusions in around 30%

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28
Q

how to tx legionella

A

tx with erythromycin/clarithromycin

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29
Q

What is aspiration pneumonia?

A

happens because of foreign materials gaining entry to bronchial tree:

usually oral/gastric contents like food and saliva.

depending on acidity of aspiration a chemical pneumonitis can develop and bacterial pathogens adding to the inflammation.

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30
Q

Causes of aspiration pneumonia

A

due to incompetent swallowing mechanism like in neuro disease or injury like stroke, ms and intoxication.

iatrogenic: intubation

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31
Q

risk factors of aspiration pneumonia

A

poor dental hygiene

swallowing difficulties

prolonged hospitalisation or surgical procedures

impaired consciousness

impaired mucociliary clearance

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32
Q

more common sites affected for aspiration pneumonia

and why?

A

right middle and lower lung lobes- mc sites affected

because of the larger calibre and more vertical orientation of the right main bronchus

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33
Q

bacteria implicated in aspiration pneumonia

A

can be aerobic or anaerobic

aerobic:
- strept pneumoniae
-staph aureus
- haemophilus influenzae
- pseduomonas aeruginosa
-klebsiella: seen in aspiration lobar pneumonia in alcoholics

anaerobic:
-bacteroids
-prevotella
-fusobacterium
-peptostreptococcus

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34
Q

Tell me about pneumocystic jiroveci pneumonia : HIV

A

unicellular eukaryote

classified as a fungus but some say its a protozoa

PCP: mc opportunistic infection in AIDS

if cd4 count under 200/mm^3 - give pcp prophylaxis

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35
Q

features of pneumocystis jiroveci pneumonia

A

dyspnoea
dry cough
fever
very few chest signs

extrapulmonary signs: rare:
- hepatosplenomegaly
lymphadenopathy
choroid lesions

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36
Q

complication of PCP

A

pneumothorax

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37
Q

investigations in pneumocystis jiroveci pneumonia

A

CXR - bilateral interstitial pulmonary infiltrates but can present with other x ray findings: lobar consolidation. could be normal

Exercise- induced desaturation

sputum - usually fails to show pcp, bronchoalveolar lavage (bal) often needed to demonstrate pcp - silver stain - shows characterists cysts

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38
Q

mx of pneumocystis jiroveci pneumonia

A

co-trimoxazole

iv pentamidine - severe cases

aerosolized pentamidine - alternative - less effective with a risk of pneumothorax.

steroids - if hypoxic - po2 under 9.2kpa - steroids will reduce the risk of Resp failure by 50% and death by a 1/3

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39
Q

what might indicate sepsis secondary to pneumonia?

A

tachypnoea - raised resp rate

tachycardia - raised hr

hypoxia - low ox

hypotension- shock
fever
confusion

40
Q

which cause for HAP?

A

methicillin-resistant staphyloccocus aureus - MRSA

41
Q

atypical pneumonia causes

A

legions - legionella pneumophila
psittaci - chalmydia psittaci - contact with infected birds. parrot owner

m - mycoplasma
c-chlamydophila pneumoniae - mild-moderate chronic pneumonia and wheeze in school kid.

qs - q fever - coxiella burnetti - exposure to bodily fluids of animals. farmer with flu.

42
Q

comps of pneumonia

A

sepsis
ards
pleural effusion
empyema
lung abscess
death

43
Q

What is croup?

A

URTI
infants and toddlers

stridor caused by laryngeal oedema and secretions.

parainfluenza viruses account for most cases

44
Q

epidemiology of croup

A

peak incidence: 6 months - 3yrs
mc : autumn

45
Q

features of croup

A

cough - barking,seal like. worse at night

stridor - dont examine throat due to risk of precipitating airway obstruction

fever - low grade
coryzal symptoms
increased work of breathing: retraction

hoarse voice

46
Q

mx of croup

A

single dose of oral dexamethasone - 0.15mg/kg - regardless of severity.
prednisolone alternative

emergency:
high flow ox
nebulised adrenaline/budesonide

47
Q

ix of croup

A

clinical

cxr:
- posterior anterior view show subglottic narrowing - steeple sign

48
Q

with suspected croup pt, who should you admit?

A

moderate or severe croup

under 3 months of age

known upper airway abnormalities eg - laryngomalacia, downs

uncertainty about diagnosis

49
Q

differentials of croup

A

acute epiglottitis
bacterial tracheitis
peritonsillar abscess
foreign body inhalation

50
Q

severity grading of croup

mild
moderate
severe

A

mild:
- occasional barking cough
- no audible stridor at rest
- no/mild suprasternal and/or intercostal recession
-child happy and prepared to eat, drink and play

moderate:
- frequent barking cough
- easily audible stridor at rest
- suprasternl and sternal wall retraction at rest
- no/little distress or agitation
- child can be placated and interested in its surroundings

severe:
- frequent barking cough
-prominent inspiratory (and occasionally expiratory) stridor at rest

  • marked sternal wall retractions
    -significant distress and agitation, or lethargy or restlessness(sign of hypoxemia)
    -tachycardia occurs with more severe obstructive symptoms and hypoxemia
51
Q

common causes of croup

A

parainfluenza
influenza
adenovirus
respiratory syncytial virus - RSV

croup used to be caused by diptheria but not anymore bc of vaccination. if it was it would lead to epiglottitis - high mortality

52
Q

What is acute epiglottitis?

A

inflammation and swelling of epiglottis caused by infection: haemophilus influenza type b.

can get to complete obstruction of airway so life threatening.

rare now because of routine vaccination.

53
Q

presentation of acute epiglottitis

A

rapid onset
high temp
stridor, sore throat
drooling of saliva
difficulty/pain swallowing
scared/quiet child
septic/unwell
muffled voice

tripod position -pt find easier to breathe if leaning forward and extend neck in seating position

54
Q

how to make diagnosis of acute epiglottitis

A

direct visualisation

xray : lateral view shows swelling of epiglottis - thumb sign

55
Q

how would you manage acute epiglottitis?

A

endotracheal intubation - protect airway

if suspect dont examine throat - risk of acute airway obstruction.

if airway closes - tracheostomy - intubate through the neck

oxygen
iv abx - eg ceftriaxone
steroids - dexamethasone

56
Q

common complication of acute epiglottitis?

A

epiglottic abscess -
collection of pus around epiglottis.

threatens airway - life threating

tx same as epiglottis

57
Q

what is bronchiolitis?

A

inflammation and infection of the bronchioles - the small airways of the lungs.

caused by respiratory syncytial virus - most common.
other cause: mycoplasma, adenovirus

very common in winter. poss secondary to bacterial infection.

under 1 yr.
mc under 6 months.
rarely in children upto 2 yrs old.

58
Q

pathophysiology of bronchiolitis

A

when a virus affects airways of adults the swelling and mucus are proportionally so small that it doesnt affect breathing.

airways of infants are very small to begin with, even smallest amount of inflammation and mucus in airway has significant effect on the infants ability to circulate air to alveoli and back out.

so you get harsh breath sounds, wheeze and crackles on ausc when listening.

59
Q

presentation of bronchiolitis

A

coryzal sx : running or snotty nose, sneezing , mucus in throat and watery eyes.

signs of resp distress

dyspnoea
tachypnoea

dry cough

poor feeding

mild fever - under 39

apnoeas - episodes where child stops breathing

wheeze and crackles on auscultation

feeding difficulties - associated with increasing dyspnoea often the reason for hospital admission

60
Q

signs of resp distress in bronchiolitic pt

A

raised resp rate

use of accessory muscles of breathing eg: sternocleidomastoid, abdominal and intercostal muscles

intercostal and subcostal recessions

nasal flaring
head bobbing
tracheal tugging

cyanosis - due to low ox sats

abnormal airway noises

61
Q

give me 3 abnormal airway noises

A

wheezing - whistling - caused by narrowed airways - typically heard during expiration

grunting - caused by exhaling with the glottis partially closed to increase positive end-expiratory pressure

stridor: high pitched inspiratory noise caused by obstruction of the upper airway eg croup

62
Q

typical course of rsv - bronchiolitis

A

starts as urti with coryza

half get better spontaneous

other half: chest sx over 1st 1-2 days following coryza.

worst on day 3/4

sx last 7-10 days.

recover within 2-3 weeks.

63
Q

why might you admit a bronchiolitis pt

A

under 3 months or an pre-existing condition like prematurity, downs or CF

50-75% less of their normal milk intake

clinical dehydration
rr over 70
ox sats under 92
moderate-severe resp distress, eg grunting, deep recessions or head bobbing
apnoeas
central cyanosis.

parent not confident in their ability to manage at home or difficulty accessing medical help from home

64
Q

how would you manage bronchiolitis?

A

supportive

ensure adequate intake - oral/ng/iv. - avoid overfeeding full stomach will restrict breathing.

saline nasal drops and nasal suctioning. - help clear nasal secretions, prior to feeding esp.

supplementary ox: if ox sats below 92 (humidified via head box)

ventilatory support

65
Q

ix for bronchiolitis

A

immunofluorescence of nasopharyngeal secretions may show rsv

66
Q

what provides protection to newborns against RSV?

A

maternal IgG

67
Q

What is palivizumab?

who to give to?

A

monoclonal antibody- targets respiratory syncytial virus.

monthly injection - prevention against bronchiolitis caused by rsv.

give to high risk babies - ex-premature and those with congenital heart disease.

not a true vaccine because it doesn’t stimulate the infants immune system.

provides passive protection by circulating the body until the virus is encountered, at which point it works as an antibody against the virus, activating the immune system to fight the virus.

levels of circulating antibodies decrease over time -thats why monthly injection is required.

68
Q

ventilatory support types

A

high flow humidified via tight nasal cannula - delivers air and oxygen continuously with some added pressure, helping to oxygenate lungs and prevent airways from collapsing. it adds positive end-expiratory pressure to maintain the airway at the end of expiration.

continuous positive airway pressure - cpap. - sealed nasal cannula - can deliver much higher and more controlled pressures.

intubation and ventilation: insert endotracheal tube into trachea to fully control ventilation.

69
Q

most helpful signs of poor ventilation

A

rising co2 - shows airways have collapsed and cant clear waste co2

falling PH - showing that co2 is building up - cant buffer the acidosis this creates. resp acidosis. if they are also hypoxic - type 2 respiratory fialure.

70
Q

what to do, how to check severe respiratory distress ?

A

capillary blood gases.

71
Q

What is cystic fibrosis?

A

A phenylalanine deletion on the CFTR (CF transmembrane conductance regulator) gene on chromosome 7, causing secretions to become much thicker. Mainly affects pancreas and lungs.

Autosomal recessive.

72
Q

How does CF affect the pancreas and the lungs

A

Pancreas - thick pancreatic and biliary secretions block ducts, causing pancreatitis (autodigestion), cholangitis and lack of digestive enzymes in GI tract.

Causes failure to thrive, steatorrhoea and endocrine dysfunction e.g. CF diabetes.

Lungs - Impaired mucociliary clearance. Causes an obstructive pattern and thick immobile secretions = repeat S aureus and P aeruginosa infections.

73
Q

Earliest presentation of CF in neonates?

A

Meconium ileus - Meconium isnt passed and instead causes a blockage in the intestine.

74
Q

Clinical features of CF

A

Meconium ileus
Chronic cough, wheeze and recurrent infections (S aureus, P aeruginosa and H influenza)
Nasal polyps and sinusitis
Pancreatic insufficiency (steatorrhoea, malabsorption)
GORD
Clubbing

75
Q

Investigations of CF

A

Newborn guthrie heel prick screening (Immunoreactive trypsinogen)
GOLD: Chlorine sweat test. Pilocarpine induces sweating. Sweat has more chlorine (>60mmol/L)
Faecal elastase (pancreatic insufficiency)

76
Q

CF lifestyle advice

A

High calorie, high fat diet
No smoking
Regular exercise and physio
Flu vaccines

77
Q

Respiratory management of CF

A

Chest physio and exercise
Bronchodilator (Salbutamol)
Mucolytic (Dornose Alfa)
Nebulised Tobramycin if pseudomonas
Prophylactic flucloxacillin for life

78
Q

Digestive management of CF and problems caused by it (5)

A

High calorie high fat diet
Fat soluble vitamins (ADEK)
Pancreatic enzyme replacement (Creon)
PPI - omeprazole
Ursodeoxycholic acid (make bile more soluble)

79
Q

Complications of CF + life expectancy

A

Life expectancy <40
CF related diabetes
Liver/biliary cirrhosis
Recurrent URTI
Malabsorption
- Delayed puberty
- Osteoporosis
- Infertility

80
Q

Define Asthma

A

Chronic cough, dyspnoea and wheeze, characterised by reversible airway obstruction, airway hypersensitivity and inflamed bronchioles

this can be allergic/IgE mediated, or non IgE mediated (exercise, cold air and stress)

81
Q

Pathophysiology of Asthma

A

Allergen picked up by dendritic cells and presented to Th2 cells, which respond by releasing cytokines, releasing IgE which bind to mast cells, causing mast cell degranulation. This releases histamine, leukotrienes, prostaglandin.

This causes chronic airway inflammation causing:
- Bronchoconstriction and smooth muscle spasm
- Mucus hypersecretion

82
Q

Common triggers of asthma

A

Pollen, dust mites, grass
Cold air
Exercise
Pets
Tobacco smoke
Occupational allergens (bakers, manufacturers, lab work, welding)
Household mould

83
Q

Signs/Symptoms of asthma

A

Episodic shortness of breath, usually after trigger exposure.
- Diurnal PEFR variation (worse at night/early morning)
- Usually dry cough
- Expiratory wheezing/dyspnoea
- Chest tightness

84
Q

Asthma patient mucus microscopy result

A

Will contain spiral mucus plugs - casts from small bronchioles

85
Q

Ix in Asthma

A

Spirometry:
-FEV1/FVC <80% (obstructive picture)
- Bronchdilator reversibility

FeNO (Fraction of exhaled Nitric Oxide) - 40ppb in adults, 35 in kids. (parts per billion)

GOLD: PEFR - measure multiple times a day for 2-4 weeks. >20% variability diagnostic

86
Q

Patient taking regular aspirin/NSAIDs comes in with asthma-esque symptoms. what is this suggestive of?

A

Samter’s Triad

87
Q

What is Samter’s triad?

A

Inflammation and swelling of the airways in response to aspirin or NSAIDs

Leads to:
- Chronic asthma-esque history
- Recurrent nasal polyps
- Aspirin intolerance

88
Q

Asthma Mx Algorithm

A

1) SABA (Salbutamol)
2) SABA + lowdose ICS (beclometasone)
3) SABA + lowdose ICS + LTRA (montelukast)
4) SABA + lowdose ICS + LABA (Salmeterol) + LTRA in adults, - LTRA in kids.

89
Q

What are the goals of stepwise mx in asthma

A

Aim to use the lowest effective doses possible, only stepping up if previous treatment ineffective
Step down treatment every 3 months and reasess
Annual asthma reviews for stable asthma

90
Q

Give the PEFR, speech, resp and cardio ranges of moderate, severe and life threatening asthma exacerbations

A

PEFR
- M - 50-75% of best/predicted
- S - 33-50%
- LT - <33%

Speech
- M - normal
- S - cant complete sentences
- LT - Silent, exhausted, confused, coma

Resp
- M - RR<25/min
- S - RR>25/min
- LT - O2 sats <92%, chest silent, reduced respiratory effort or cyanosis

Cardio
- M - Pulse <110
- S - Pulse >110
- LT - Bradycardia, dysrhythmia, hypotension

91
Q

Signs of acute asthma exacerbation

A

Progressively worsening dyspnoea
Accessory muscle usage
Tachypnoea
Cyanosis
Silent chest

92
Q

Define bronchodilator reversibility

A

> 12% increase in FEV1, and >200ml increase in FVC

93
Q

Management of acute asthma attack

A

Hospital if life threatening or near-fatal asthma attack (High pCO2/need for ventilation), or if bronchodilator irreversible.
- Salbutamol up to 10mg/hour (1 puff every 30-60 seconds up to 10 puffs)
- Ipratropium bromide (SAMA)
- 3-5 days oral prednisolone for ALL kids with exacerbation
- MgSO4 if PEFR <50% and no bronchodilator response

94
Q

Checks to do at annual asthma review

A

Inhaler technique
Symptom scoring
Check HPC
Review treatment
Check growth in children, and potentially do spirometry

95
Q
A

Phase 3a Finals (26 decks)

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