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3a paeds > Paeds Resp > Flashcards

Paeds Resp Flashcards

1
Q

What is pneumonia?

A

Infection of the lower respiratory tract and lung parenchyma causes inflammation of the lung tissue & sputum filling the airways and alveoli

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2
Q

What are resp distress symptoms

A

tracheal tug
intercostal + diaphragm recession
nasal flaring
RR>60
accessory muscle use
wheeze
stridor
cyanosis
head bobbing

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3
Q

What is wheeze

A

obstructed lower airway
Expiratory whistle

asthma
bronchiectasis
CF
bronchiolitis

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4
Q

what is stridor

A

obstructed upper airway
high pitched harsh inspiration

croup
epiglottitis
laryngomalacia
foreign body

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5
Q

What is order of choice of oxygen supplementation

A

high flow O2
CPAP
intubation

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6
Q

How does pneumonia present?

A
  • Usually precede an upper respiratory tract infection
  • Cough (typically wet and productive)
  • Fever
  • SOB
  • poor feed
  • Lethargy
  • Increased work of breathing
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7
Q

What are the characteristic auscultation chest signs of pneumonia?

A

Bronchial breathing
Focal coarse crackles
Dullness to percussion

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8
Q

Is bacterial or viral pneumonia more common in young infants

A

viral pneumonia is more common in young infants

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9
Q

What are the signs of pneumonia?

A

Tachypnoea (raised respiratory rate)
Tachycardia (raised heart rate)
Hypoxia (low oxygen)
Hypotension (shock)
Fever
Confusion

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10
Q

What is the most common cause of pneumonia in neonates

A

Group B Strep, E coli, Klebsiella, Staph Aureus

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11
Q

What is the most common bacterial cause of pneumonia in children?

A

Streptococcus pneumonia

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12
Q

What is the most common cause of pneumonia in infants?

A

Strep pneumoniae, HiB, Chlamydia

haemophilus influenzae type b

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13
Q

What is the most common cause of pneumonia in school age children?

A

Strep pneumoniae, Mycoplasma pneumoniae, Haemophilus influenza,

Staph Aureus, group A Step,

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14
Q

What are the typical XRay findings of pneumonia?

A

upper lobe consolidation

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15
Q

What are the viral causes of pneumonia?

A

Respiratory syncytial virus (RSV) (MC)
Parainfluenza virus
Influenza virus

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16
Q

What Xray findings would you see for Staphylococcus aureus pneumonia?

A

pneumatocoeles (round air filled cavities) and consolidations in multiple lobes.

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17
Q

What are the investigations of pneumonia?

A

Clinical
FBC + bloods
Sputum culture and Gram stain:
CXR - fluid in the lungs (associated with Staph)

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18
Q

What is 1st line antibiotic for pneumonia?

A

Amoxicillin

Neonates: Broad spec IV Abx
Infants: Amoxicillin/Co-Amoxiclav
Over 5s: Amoxicillin/Erythromycin

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19
Q

What antibiotic is added to cover atypical pneumonia or in case of patient with penicillin allergy?

A

macrolide - erythromycin, clarithromycin or azithromycin

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20
Q

Name complications of pneumonia

A

Respiratory failure
Sepsis
Pleural effusion (in 1/3 cases)
Empyema
Lung abscess

Risk of parapneumonic collapse and empyema if so follow up at 4-6 weeks with a fluid sample

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21
Q

When should child be admitted for pneumonia

A

<93% O2 stat

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22
Q

What is croup

A

Acute laryngotracheobronchitis due to parainfluenxa virus

upper respiratory tract infection causing inflammation in the larynx

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23
Q

What is the classic cause of croup

A

parainfluenza virus

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24
Q

What is the epidemiology of croup

A

Peak incidence 6 months to 3 years
MC in autumn and winter

more common in male, preterm, and those with underlying resp disease

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25
Q

Name 3 causes of croup

A

Parainfluenza - MC
Influenza
Adenovirus
Rhinovirus

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26
Q

What did croup used to be commonly caused by and what did it lead to?

A

Croup caused by diphtheria leads to epiglottitis

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27
Q

what is the pathophysiology of croup?

A

Viral infection –> inflammation of the upper airway with oedema formation and infiltration of inflammatory cells –> narrowing of subglottic airway (inspiratory stridor) and increased work of breathing

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28
Q

What is mild croup

A

Occasional barking cough
No audible stridor at rest
No or mild suprasternal and/or intercostal recession
The child is happy and is prepared to eat, drink, and play

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29
Q

what is moderate croup

A

Frequent barking cough
Easily audible stridor at rest
Suprasternal and sternal wall retraction at rest
No or little distress or agitation
The child can be placated and is interested in its surroundings

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30
Q

what is severe croup

A
  • Frequent barking cough
  • Prominent inspiratory (and occasionally, expiratory) stridor at rest
  • Marked sternal wall retractions
  • Significant distress and agitation, or lethargy or restlessness (a sign of hypoxaemia)
  • Tachycardia occurs with more severe obstructive symptoms and hypoxaemia
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31
Q

When do you admit a child with croup?

A

moderate or severe croup
< 3 months of age
stridor at rest
known upper airway abnormalities (e.g. Laryngomalacia, Down’s syndrome)

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32
Q

What are respiratory failure red flag signs?

A
  • Drowsiness
  • Lethargy
  • Cyanosis
  • Tachycardia
  • Laboured breathing
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33
Q

How does croup present on examination?

A
  • 1-4 days history of non-specific rhinorrhea (thin, nasal discharge), fever and barking
    cough
  • Worse at night
  • Stridor
  • Decreased bilateral air entry
  • Tachypnoea
  • Costal recession
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34
Q

How is croup diagnosed?

A
  • clinical dx
  • FBC, CRP U+E
  • CXR - posterior-anterior angle
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35
Q

What are the XRay signs of croup?

A

posterior-anterior

steeple sign = subglottic narrowing

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36
Q

How is croup managed?

A
  • Single dose oral dexamethasone 0.15mg/kg
  • Paracetamol/Ibuprofen for fever/sore throat
  • Admission if moderate/severe and consider if dehydrated
  • Nebulised adrenaline for relief of severe symptoms
  • Oxygen if required
  • Monitor for needed ENT intervention if suspected airway blockage
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37
Q

What are complications of croup?

A
  • Bacterial Superinfection: (S. Aureus, pseudomembranous croup, thick green secretions Tx IV fludox)
  • Otitis Media
  • Dehydration due to reduced fluid intake
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38
Q

What is asthma?

A

chronic reversible airway obstruction characterised by mucus hyper-secretions, airway hyper-responsiveness and inflammation

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39
Q

What are causes/RH of asthma?

A
  • FHx atopy
  • PHx atopy
  • Samter’s Triad
  • Hygiene hypothesis
  • Genetic
  • Prematurity
  • Low birth weight
  • Parental smoking
  • Viral bronchiolitis in early life
  • Cold air
  • allergen eg dust pollution
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40
Q

patients with asthma also suffer from other IgE-mediated atopic conditions such as

A

atopic dermatitis (eczema)
allergic rhinitis (hay fever)

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41
Q

How does asthma present clinically?

A

Persistent recurrent resp distress with wheeze, worse at night and in morning

  • Episodic symptoms with intermittent exacerbations
  • Dry cough often worse at night
  • SOB
  • Wheeze
  • Reduced peak flow
  • Expiratory wheeze on auscultation
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42
Q

What is harrisons sulci

A

muscles insertions at diaphragm visible

associated with chronic asthma

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43
Q

How is asthma investigated >5 y/o

A
  • PEF diary -> 20% variable in 2-4 week period
  • CXR (hyperinflation)
  • FEV1:FVC < 0.8
  • Bronchodialtor >12% reversibility
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44
Q

What would spirometry investigation for asthma show?

A
  • FEV1 significantly reduced
  • FVC normal
  • FEV1:FVC may be <70% if poorly controlled
  • Reversible spirometry is highly suggestive of asthma
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45
Q

How is asthma investigated <5 y/o

A

clinical
same as viral wheeze

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46
Q

What would Fractional exhaled nitric oxide (FeNO) show for asthma?

A

High FeNO levels indicate your airways are inflamed or irritated.

> 35ppb

47
Q

What is the management plan for asthma for children >5 (7 steps - same as adults)

A

1: SABA (Salbutamol)

2: SABA + paediatric low-dose inhaled corticosteroid (ICS)

3: SABA + ICS + LTRA (Montelukast)

4: SABA + ICS + LABA (Salmeterol)

5: SABA + maintenance and reliever therapy (MART) and low dose ICS

Step 6: SABA + MART paediatric moderate-dose ICS

Step 7: SABA + MART High dose ICS (>400mcg), referral specialist care

48
Q

How is life threatening asthma classified?

A

Sp02 <92&
PEFR <33%

silent chest
altered GCS
cyanosis
decreased effort to breathe
poor resp effort

49
Q

How is severe asthma classified?

A

Sp02 <92&
PEFR 33%-50%

RR>30 (under 5)
RR >40 (over 5)

too breathless to feed talk

HR >140 (under 5s)
HR >125 (over 5s)

use of accessory muscles
audible wheeze

50
Q

How is mild-moderate asthma classified?

A

Peak flow 50%-75%
Breathless
SpO2 >92%

feeding well
talking in sentences
wheeze

51
Q

what is the management for Moderate to severe cases of asthma

A
  1. Nebulisers Salbutamol 10 puffs + spacer + PO Pred
    +
  2. Nebulisers ipratropium bromide +/- MgSO4
    +
  3. IV aminophylline

+ O2 if SpO2 <94%

52
Q

When can a child be discharged after asthma admission

A
  • stable on their discharge medication (i.e. no nebulisers or oxygen) for 12-24 hours
  • inhaler technique checked and recorded
  • PEF >75% of best or predicted

discharge can be considered when the child well on 6 puffs 4 hourly of salbutamol.

53
Q

What is benefit of a spacer

A

increase bioavailable drug by keeping neb in vacuum for longer

prevents thrush
easier to administer
avoid breathing med too fast

54
Q

What is total control for asthma defined

A

no daytime Sx
no acute attacks
no exercise Sx
no night waking

can consider decrease Tx if with control >3 months

55
Q

What can contribute to poor control of asthma

A

adherence
bad disease
choice of drugs
environment

56
Q

What type of resp failure is asthma attack

A

Type 2
hypercapnic
high CO2

57
Q

What is viral-induced wheeze

A

recurrent viral induced wheeze <5 years old due to lung immaturity

self resolving by 5

Episodic Wheeze - a symptom of viral URTI and symptom free in between events

Multiple trigger Wheeze - URTI and other factors trigger wheeze

58
Q

What are 2 RF for viral-induced wheeze

A

maternal smoking
prematurity

59
Q

What is airway inflation worse in children than adults?

A

due to the small diameter of a child’s airway, the slight narrowing leads to a proportionally larger restriction in airflow

(Poiseuille’s law = halving the diameter of the tube decreases flow rate by 16 fold)

60
Q

How does viral-induced wheeze present

A

Evidence of a viral illness (fever, cough and coryzal symptoms) for 1-2 days preceding the onset of:
- Shortness of breath
- Signs of respiratory distress
- Expiratory wheeze throughout the chest

61
Q

What are the typical features of viral-induced wheeze as opposed to asthma

A

Presenting before 3 years of age
No atopic history
no diurnal variation
Triggered by viral infection otherwise systemically well

62
Q

How is viral-induced wheeze managed?

A

same as acute asthma

  1. SABA inhaler via spacer maximum of 4 hourly up to 10 puffs
  2. SABA and ICS trial for 8 weeks
  3. SABA + ICS + LTRA
  4. escalate
63
Q

What is Bronchiolitis

A

inflammation and infection in the bronchioles, the small airways of the lungs.

widespread wheeze

64
Q

What is the epidemiology of Bronchiolitis

A

under 1 year
MC in under 6 months
Most commonly caused by RSV (Respiratory Syncytial Virus)

65
Q

Risk factors for Bronchiolitis

A
  • CHD (congenital heart disease)
  • preterm
  • CF
  • winter
  • immunodeficiency
  • smoke exposure
66
Q

What is the course of Bronchiolitis?

A

Symptom onset in 2-5 days after URTI w coryzal symptoms

~ 9 days of Sx, day 5 is peak

half get better half get chest symptoms following the onset of coryzal symptoms

67
Q

What are signs of respiratory distress

A

Raised respiratory rate
Use of accessory muscles of breathing, such as the sternocleidomastoid, abdominal and intercostal muscles
Intercostal and subcostal recessions
Nasal flaring
Head bobbing
Tracheal tugging
Cyanosis (due to low oxygen saturation)
Abnormal airway noises

68
Q

What are the clinical features of Bronchiolitis?

A
  • Low grade fever
  • Rhinorrhea and nasal congestion
  • Cough
  • Reduced feeding
  • Respiratory distress
  • Inspiratory crackles
  • decrease wet nappies
69
Q

What are Coryzal symptoms

A

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

70
Q

What is wheezing

A

whistling sound caused by narrowed airways, typically heard during expiration

71
Q

What is grunting?

A

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

72
Q

What is stridor

A

high pitched inspiratory noise caused by obstruction of the upper airway, for example in croup

73
Q

How is Bronchiolitis investigated

A

Generally clinical - widespread wheeze

Nasopharyngeal aspirate for RSV culture

FBC, Urine, Blood gas if severely unwell
CXR - not used usually but shows hyperinflation, air trapping and flattened diaphragm

74
Q

How is Bronchiolitis managed?

A

Supportive management from home

75
Q

What indicates urgent hospital admission for Bronchiolitis

A
  • Apnoea
  • Resp Rate > 70
  • Central cyanosis
  • SpO2 < 90%
  • 50-75% fluid dehydration
76
Q

How is bronchiolitis prevented?

A

IM Palvizumab against bronchiolitis (monthly monoclonal IgG injection)

provides passive immunity

77
Q

Who Palvizumab given to

A

preterm
CHD
CF w/ lung defect
immunocompromised

78
Q

What indicates hospital admission for Bronchiolitis

A
  • Resp Rate > 60
  • 50-75% fluid intake
  • clinical dehydration
79
Q

What is the inpatient management for Bronchiolitis

A
  • Oxygen to bring SpO2 up
  • Fluids
  • CPAP if in respiratory failure
  • Suctioning of secretions
  • Ribavirin for severe cases
  • No evidence for bronchodilatory, antibiotics or steroids in bronchiolitis
80
Q

What is complication of Bronchiolitis

A

bronchiolitis obliterans

81
Q

What is bronchiolitis obliterans

A

post transplant or recurrent infection

severe scarring

“popcorn lung”

HRCT = mosaic pattern

FEV1 : FVC 16-20%

82
Q

What is cystic fibrosis?

A

auto rec ΔF508 on CFTR gene of C7

decrease CFTR expression = more Na and Cl retention affecting mucus glands

83
Q

What is the pathophysiology of cystic fibrosis

A

lungs = impaired mucociliary clearance
GIT = impaired absorption due to thicker secretions
pancreas = B islet damage + decrease enzyme secretion
liver = biliary stasis

84
Q

How is cystic fibrosis detected

A

screened for at birth with the Guthrie heel prick (newborn bloodspot tes).

85
Q

What is the Guthrie heel prick

A

serum immunoreactive trypsin

5-9 days of life

also sickle cell
congential hypothyroid

86
Q

What are symptoms of cystic fibrosis in neonate

A

failure to pass meconium <48hrs

87
Q

How is meconium ileus treated

A

Gastrografin

88
Q

What are symptoms of cystic fibrosis in infant

A

jaundice
failure to thrive
recurrent chest infections

89
Q

What is MC caustive organism of recurrent chest infections in cystic fibrosis

A

P. aeruginosa in adults
S. aureus in kids

90
Q

How is P. aeruginosa treated

A

ciprofloxacin

91
Q

What are symptoms of cystic fibrosis in child

A

bronchiectasis
nasal polyps
sinusitis

92
Q

What are symptoms of cystic fibrosis in older childer

A

Congenital bilateral absence of vas deferens (infertile) (98% of males)
bronchopulmonary aspergillosis

93
Q

What is meconium ileus

A

first stool (meconium) is thick and sticky and can cause bowel obstruction

presents as not passing meconium within 24 hours, abdominal distention and vomiting.

94
Q

If cystic fibrosis is not diagnosed at birth how does it usually present?

A

recurrent lower respiratory tract infections, failure to thrive or pancreatitis.

95
Q

What are the symptoms of cystic fibrosis?

A
  • Chronic cough
  • Thick sputum production
  • Recurrent respiratory tract infections
  • Loose, greasy stools (steatorrhoea) due to a lack of fat digesting lipase enzymes
  • Abdominal pain and bloating
  • salty secretions
  • failure to thrive
96
Q

What are the signs of cystic fibrosis?

A

Low weight or height on growth charts
Nasal polyps
Finger clubbing
Crackles and wheezes on auscultation
Abdominal distention

97
Q

What are DDx for finger clubbing

A

Hereditary clubbing
Cyanotic heart disease
Infective endocarditis
Cystic fibrosis
Tuberculosis
Inflammatory bowel disease
Liver cirrhosis

98
Q

What are the three methods of diagnosing cystic fibrosis?

A
  • Newborn blood spot testing (guthrie heel prick)
  • The sweat test - more than 60mmol/l Ch (GOLD STANDARD)
  • Genetic testing CFTR gene during pregnancy by amniocentesis or chorionic villous sampling, or as a blood test after birth
99
Q

What is the sweat test

A

Pilocarpine applied to skin
Electrodes are placed
sweat is absorbed on filter paper and tested for chloride concentration

more than 60mmol/l = CF

100
Q

Name two key microbial colonisers of cystic fibrosis?

A

Staphylococcus aureus and Pseudomonas aeruginosa

Burkhodheria cepacia

101
Q

What long term prophylactic antibiotics do people with csystic fibrosis take?

A

flucloxacillin

102
Q

how is cystic fibrosis managed?

A

lungs = chest physio 2x daily (clearence, breathing techniques, mucoactive agents = sinase + lumacaftor + hypertonic saline

panc = CREON + OGTT annually <10 y/o

GI = high cal high fat diet

liver = LFT annual screen

  • Bronchodilators inhalers
  • Nebulised DNase (dornase alfa) makes secretions less viscous
  • Vaccinations including pneumococcal, influenza and varicella
  • lung transplant - last line

Fertility treatment
Genetic counselling

103
Q

what are Cf patients monitored for

A

sputum for colonisation
diabetes
osteoporosis
vitamin D deficiency
liver failure

104
Q

how is pseudomonas managed in CF

A

long term nebulised antibiotics such as tobramycin. Oral ciprofloxacin is also used.

Cystic fibrosis clinics have separate clinic rooms for children with pseudomonas to minimise the risk of transmission

avoid contact with other children with cystic fibrosis

105
Q

When is lung transplant CI in cystic fibrosis

A

burkholderia infections

106
Q

What is laryngomalacia

A

congenital floppy larynx
self resolving
inc risk of GORD –> PPI

107
Q

what is kartagener

A

primary ciliary dyskinesias

triad of bronchiectasis, sinusitis, and situs inversus

108
Q

How is cystic fibrosis progression monitored

A

chrispin norman score

109
Q

What is Epiglottitis?

A

acutely inflamed epiglottis in 6-12y due to HiB

life threatening emergency

110
Q

How does Epiglottitis present?

A

dysphagia, drooling, and distress

dehydration
Tripod position, sat forward with a hand on each knee

111
Q

how is Epiglottitis diagnosed?

A
  • call ent + anaesthetists
  • DO NOT examine airway
  • CXR lateral view - Thumb sign –> epiglottis swelling
    FBC, laryngoscopy
112
Q

how is Epiglottitis managed?

A

secure the airway first
- intubation/O2
- Nebulised adrenaline
- IV Abx - Ceftriaxone

113
Q

what Abx is given to Epiglottitis close contacts

A

Rifampicin
HiB vac

114
Q

what typically causes Epiglottitis

A

Haemophilus influenzae type b

3a paeds (12 decks)

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