Paediatric Respiratory

Question 1

Give three ways in which childhood asthma differs from adult asthma

Answer 1

Gender - boys > girls in childhood, women > men in adulthood
Severe asthma
Occupational asthma is uncommon

Question 2

Describe the clinical presentation of asthma

Answer 2

Wheeze
SOB at rest
 - "sooking in" of ribs
Dry cough
 - nocturnal, exertional
Usually at least one trigger
Parental asthma/atopy
Responds to treatment

Question 3

What breath sounds are often mistaken for wheeze by parents?

Answer 3

Rattle
Stertor (“snoring”)
Stridor

Question 4

What is the most likely cause of respiratory illness in children under 18 months old?

Answer 4

Infection

Question 5

In what age group is asthma most likely to present?

Answer 5

Children 5 years and over

Question 6

What is the differential diagnosis for an isolated cough?

Answer 6

NOT asthma! (No wheeze)
Bronchitis
Pertussis
Habitual cough
Tracheomalacia (lifelong loud cough)

Question 7

What are the goals of asthma treatment?

Answer 7

• “minimal” symptoms during day and night
• minimal need for reliever medication
• no attacks (exacerbations)
• no limitation of physical activity

( normal lung function (in practical terms FEV1 and/or PEF >80% predicted or best) - this is not what the patient is worried about)

Question 8

How can control of asthma be measured?

Answer 8

SANE:
SABA use per week (>2 = poor control)
Absence of school/nursery
Nocturnal symptoms per week (>1 = poor control)
Exertional symptoms per week

Question 9

What is the first treatment that should be tried in the management of asthma?

Answer 9

Low dose inhaled corticosteroids (regular preventer)

Also, don’t forget non-medicinial interventions e.g. stop smoking, remove environmental triggers etc

Question 10

What is the main treatment for acute asthma in children?

Answer 10

Oral steroids (not nebuliser)

Question 11

How long do symptoms of rhinitis usually last?

Answer 11

1 - 2 weeks

Question 12

How long do the symptoms of otitis media (esp earache) usually last?

Answer 12

2 - 6 days

Question 13

What pathogens most commonly cause otitis media?

Answer 13

Primary infection is usually viral
- rhinovirus

May develop secondary bacterial infection:

• pneumococcus
• H influenzae

Question 14

How should otitis media be treated?

Answer 14

Analgesia

Does NOT require antibiotics (lots of side effects for minimal benefit)

Question 15

What pathogens most commonly cause croup, epiglottitis and tracheitis?

Answer 15

Croup: para flu 1
Epiglottitis: H. influenzae B
Tracheitis: staph or strep

Question 16

Which types of respiratory tract infection typically present with a “barking cough”?

Answer 16

Croup

Tracheitis

Question 17

What is the treatment for croup?

Answer 17

Oral dexamthasone

Question 18

How long does croup usually last? If it persists beyond this, what is a more likely diagnosis?

Answer 18

1 - 3 days

Croup which does not resolve is more likely to be tracheitis

Question 19

How does croup differ from epiglottitis?

Answer 19

Child with epiglottitis is systemically unwell (low bp, febrile, lethargic) and will require intubation and antibiotics asap (epiglottitis is a medical and surgical emergency)

Question 20

How much does the epiglottis have to swell to obstruct the airway?

Answer 20

The epiglottis obstructs the airway when it becomes three times the size

Question 21

How can you differentiate viral tonsillitis from bacterial tonsillitis?

Answer 21

Throat swab - cannot tell just by looking

Question 22

Which antibiotic is contraindicated in tonsillitis/pharyngitis? Why?

Answer 22

Amoxicillin should not be given in case the infection is caused by EBV (glandular fever)

Question 23

How long do the symptoms of pharyngitis/tonsillitis (sore throat) usually last?

Answer 23

1 - 5 days

Question 24

What are the management options for pharyngitis / tonsillitis?

Answer 24

Analgesia

If antibiotics are to be given, give 10 days penicillin (but not amoxicillin)

Question 25

What pathogens most commonly cause lower respiratory tract infections?

Answer 25

* Viruses in <35% (higher in younger) * Bacteria: Pneumococcus, Mycoplasma, Chlamydia * Mixed infection in <40%

Question 26

Describe the main clinical features of tracheitis

Answer 26

Croup which doesn't get better (barking cough) Child becomes systemically unwell - fever Biphasic stridor

Question 27

What pathogens most commonly cause bronchiolitis?

Answer 27

RSV Paraflu III HMPV

Question 28

What age group are affected by bronchiolitis?

Answer 28

infants (under 1 year)

Question 29

What are the symptoms of bronchiolitis?

Answer 29

* Nasal stuffiness * Tachypnoea * Poor feeding (due to nasal stuffiness) * Crackles with or without wheeze

Question 30

Describe the management of bronchiolitis

Answer 30

Maximum observation, minimal intervention | - no routine need for CXR, bloods or bacterial cultures; usually monitor O2 sats

Question 31

Describe the natural history of bronchiolitis

Answer 31

Well for the first 2 days after cough develops deteriorates between 2 - 5 days after cough develops Stabilises 5 - 7 days after cough develops Starts to recover 7 days after cough develops (can take up to 14 days for child to fully recover)

Question 32

What are the main clinical features of bronchitis?

Answer 32

Child is systemically well Loose rattly (wet) cough with URTI No wheeze/creps in chest

Question 33

Which pathogens most commonly cause bronchitis?

Answer 33

Pneumococcus | Haemophilus

Question 34

Describe the pathopysiology of bronchitis

Answer 34

Disturbed mucociliary clearance due to interference by the infection o Minor airway malacia (floppiness) can exacerbate it o Cough simply replaces mucociliary escalator o The problem is not infection; endogenous bacteria proliferate due to loss of the mucociliary escalator (therefore antibiotics will not help)

Question 35

Describe the natural history of bronchitis

Answer 35

``` Following URTI Lasts 4 weeks 60-80% respond First winter bad Second winter better Third winter fine Pneumococcus/H flu ```

Question 36

When should we worry about respiratory infection in a child? (What are the red flags?)

Answer 36

* Age <6 mo, >4yr * Static weight * Disrupts child’s life * Associated SOB (when not coughing) * Acute admission * Other co-morbidities (neuro/gastro)

Question 37

Which type of respiratory infection causes conjunctival haematoma in children?

Answer 37

Whooping cough (pertussis)

Question 38

When can a LRTI be called a pneumonia?

Answer 38

Focal signs Creps High fever (generally avoid using the word "pneumonia" due to associated anxiety)

Question 39

Describe the management options for pneumonia/LRTI

Answer 39

Nothing if symptoms are mild - address hydration, nutrition and oxygenation (always offer to review if things get worse!) Give antibiotics if 2 days fever, cough and focal signs - Oral Amoxycillin first line - Oral Macrolide second choice (if allergic or atypical pathogen) Oral: only IV if vomiting

Question 40

For which respiratory infections should antibiotics be given?

Answer 40

Tracheitis - augmentin LRTI/pneumonia (usually) - oral amoxycillin Empyema - IV antibiotics NOT bronchitis/bronchiolitis/croup