Paeds - Resp Flashcards
A 3year old boy presents to you with a barking cough, hoarse voice and stridor - where is his infection if it is caused by an infection?
Barking cough, hoarse voice and stridor are due to laryngeal/tracheal infections.
A 2 year old boy presents to you with a barking cough, hoarse voice and stridor.
What are your differentials for an infective cause? And give the other symptoms he would be experiencing with each of them
1) Croup - preceded by low-grade fever and coryza, worse at night and when crying
2) Bacterial tracheitis - very high fever, toxic looking child, worsening obstruction, copious thick secretions
3) Acute epiglottitis - High fever, ill, painful to swallow
A 2 year old girl presents with a barking cough, she has a hoarse voice, stridor that are all worse at night. She has been unwell for the past few days with cold like symptoms.
What could be the pathogens responsible?
Sounds like viral croup
Parainfluenza
Human metaneumovirus
Respiratory syncytial virus
A 2 year old girl presents with a barking cough, she has a hoarse voice, stridor that are all worse at night. She has been unwell for the past few days with cold like symptoms.
How do you asses the severity of her illness/airways obstruction?
RR, HR, WOB - tracheal tugs and chest wall retractions, degree of stridor, altered mental state (confused/agitated)
A 2 year old girl presents with a barking cough, she has a hoarse voice, stridor that are all worse at night. She has been unwell for the past few days with cold like symptoms.
How do you treat?
You suspect mild/mod viral croup
Oral prednisolone
Viral - x abx
cause is inflammatory - reduce that with steroids
A 2 year old girl presents with a barking cough, she has a hoarse voice, stridor that are all worse at night. She has been unwell for the past few days with cold like symptoms. O/E she has increased WOB, with tracheal tug and a high pitched stridor, the child is very unwell with raised RR.
How would you treat?
You suspect severe viral croup
Nebulised adrenaline
Oral prednisolone
A 4 year old girl has a high fever, is toxic looking and getting worse - she has a barking cough, hoarse voice and stridor with thick secretions.
What is the cause and how would you treat?
A 4 year old girl has a high fever, is toxic looking and getting worse - she has a barking cough, hoarse voice and stridor with thick secretions.
Bacterial tracheitis
Staph Aureus
Penicillin
Describe the presentation for a child with acute epiglottis
High fever, toxic/very ill, acute onset - hours, stridor, hoarse voice,
sitting up with mouth open, not drinking - painful throat
Life threatening
A 5 year old boy has acute epiglottitis - how do you treat?
Intubate
IV cefuroxime - against H. influenza B
Prophylaxis - rifampicin to house hold contacts
What is coryza?
Coryza
= the common cold
Irritation and swelling of the mucous membranes in the nose
Commonly caused by rhinovirus, coronavirus or RSV
A 8 year old boy complains of a sore throat - O/E he has enlarged lymph nodes.
What advise would you give?
Sore throat - pharyngitis
Usually viral cause - adenovirus, enterovirus and rhinovirus - abx not of use
Will ease in the next few days - reassurance
What are the causes of tonsillitis?
Intense inflammation of the tonsils with purulent exudate
Group A haemolytic strep
Epstein-bar virus
A 6 year old girl complains of a sore throat, headache, feeling tired with a bit of tummy ache. O/E you see surface exudates on inflamed tonsils and cervical lymphadenopathy
What do you think is the cause and how would you treat her?
Suspect bacterial cause of tonsillitis.
Group A strep
- give penicillin
A 10 month old presents very upset and with a fever.
O/E she has no respiratory signs and had bright red tympanic membranes that are red and bulging with no light reflection.
What do you think is the diagnosis and what is the cause?
Acute otitis media = acute infection of the middle ear.
Usually viral - Respiratory syncytial virus, rhinovirus
Or if bacterial - pneumococcus or H.influenzae
A 10 month old presents very upset and with a fever.
O/E she has no respiratory signs and had bright red tympanic membranes that are red and bulging with no light reflection.
What do you think is the diagnosis and how would you treat?
Acute otitis media = acute infection of the middle ear.
Advise regular pain relief with paracetamol/ibuprofen (may be needed for up to a week)
May give prescription for amoxicillin if no improvement for 3 days
How do you confirm otitis media with effusion ?
<4 - flat trace on tympanometry with evidence of conductive loss on pure tone audiometry
or reduced hearing on a distraction hearing test if older
What is the most common cause for conductive hearing loss in children?
Otitis media with effusion
How can otitis media with effusion be treated?
Abx - only reduce duration of pain, not hearing loss
Grommets - ventilation tubes
What is whooping cough?
It is a highly contagious bacterial respiratory infection caused by Bordetella Pertussis
Explain the course of disease for whooping cough
Intubation period - Up to 3 weeks intubation period before onset of any symptoms
Catarrhal stage - coryzal like symptoms, nasal congestion - 2 weeks
Paroxysmal stage - 1-10 weeks, paroxysmal coughing out bursts, followed by quick inspiration (whoop) lots of snot, may vomit, worse at night
Convalescent stage - up to 2 months - chronic cough, becoming less violent
A 3 year old presents at 10pm due to having a very bad and loud cough for the past couple of days, it comes in busts and is a spasmodic cough followed by a funny noise. He vomited at home just after he coughed. He has been unwell for over a week with runny nose, and sneezing.
What investigations do you request and what is your working diagnosis?
ABC - okay
Nasal and throat swab
FBC - lymphocytosis
Working diagnosis = Bordetella Pertussis/whooping cough
A 3 year old presents at 10pm due to having a very bad and loud cough for the past couple of days, it comes in busts and is a spasmodic cough followed by a funny noise. He vomited at home just after he coughed. He has been unwell for over a week with runny nose, and sneezing.
What treatment do you give?
Suggests he is in the paroxysmal phase - less effect of abx
Give erythromycin - reduces contagiousness and severity of symptoms slightly
Macrolide abx for the GNB bordetella pertussis
A 4 year old girl presents with a paroxysmal cough followed by inspiratory wheeze, its worse at night and she has vomited because of it. She has also had a week of cold like symptoms.
You suspect that she has whooping cough caused by bordetella pertussis
She has a 3 month old sister - what are your concerns here?
Vaccinations complete at 4 months old
in the 6 in 1 vaccine given at 2,3 & 4 months
sister has reduced immunity so may have more severe reaction, sister is an infant so more likely to get apnoea instead of paroxysm cough which is more dangerous
Close contacts get prophylactic erythromycin
Whooping cough/bordetella pertussis is included in the 6 in 1 (previously 5 in 1) vaccine schedule given at 2, 3 and 4 months.
What other diseases are included in the vaccine?
Diptheria Tetanus Polio Hib Hep B
Explain the pathology of bronchiolitis and how it leeds to the symptoms
Viral infection causing inflammation in the wall of the bronchioles. Reduced air flow due to this inflammation and increased mucosal secretions and SM tightening around bronchioles. Causes air to be trapped in alveolar leading to hyperinflation.
Dry cough - irritation in airways
Wheeze - due to air way obstruction
SOB - due to reduced airflow and over inflation
Explain the signs you would see in an infant with bronchiolitis
Hyperinflation - prominent sternum, downwardly displaced liver
Sub costal and intercostal recessions
Fine end inspiratory crackles and wheeze
Is there a vaccine available for bronchiolitis?
There is a vaccine available for premature high risk babies - monoclonal abs palivizumab for RSV. It has to be given monthly as its only passive immunity
What can cause bronchiolitis?
Respiratory syncytial virus RSV Human metapnuemovirus Parainfluenzae influenzae adenovirus
A 5 month old present with increased WOB and a dry cough
O/E you see sub and intercostal recessions, and a tracheal tug. He has a prominent sternum, fine end inspiratory crackles and wheeze.
What do you suspect is the diagnosis and how would you treat?
Bronchiolitis
Treat with humidified O2 via a nasal cannula
What is the difference between stridor and wheeze?
Stridor is a high-pitched noise from turbulent air from the upper air ways - usually inspiratory.
Wheeze is expiratory coarse whistling sounds - usually lower airways
What are the pathogens that cause pneumonia in children?
New borns - Group B strep
Younger - Viral > Bacterial = RSV + strep pneumoniae
Older - Bacterial > Viral = Strep pneumonia, chlamydia pneumonia + mycoplasma pneumoniae
What are the principles of treatment for CAP in paeds?
Are they hypoxic? O2 therapy if <92%
<2 exectant + supportive as more likely viral cause
>2 amoxicillin
Severe/suspected mycoplasma or chlamydia pneumoniae the cause add a macrolide - erythromycin
A 6 year old presents with a cough, and difficulty breathing and being generally unwell. She has a fever.
You suspect that she has CAP
What examinations would you find to confirm this diagnosis?
Raised temperature Increased respiratory rate >40 Nasal flaring Bronchial breathing Chest recessions End inspiratory coarse crackles may be heard over the infected area
A 3 year old presents with difficulty breathing, she has a wheeze is showing signs of increased work of breathing.
What are your treatment options?
> 5 wheeze
1st line = montelukast - leukotrine receptor antagonist
2nd line = salbutamol - SABA
3rd line = ipotropium bromide - anticholinergic
A 2 year old presents to hospital with a wheeze and shortness of breath - he has been admitted twice in the past with similar symptoms. You suspect that it is a viral induced wheeze but what are in your differentials?
Tracheobronchomalacia/laryngo malacia
CF
Ciliary dyskinesia
Give 2 examples of reliever inhalers that can be used for asthma
Relievers:
SA beta agonists = salbutamol
Anticholinergic = ipotropium bromide
Give examples of preventers that can be used to treat asthma
ICS = beclomethasone, budesomide LABA = salmeterol, formoterol Leukotrine inhibitors = montelukast Methylxanthines = Theophylline Oral steroids = prednisolone
A 8 year old present to you in A&E in a drowsy state. His mum tells you he has had problems breathing and has asthma. He is showing a poor respiratory effort and has02 sats of 90%.
He is having a life threatening asthma attack.
How would you treat?
O SHITME
O2 Salbutamol Nebs Ipratropium bromide IV hydrocortisone Theophylline
Explain the pathophysiology that causes asthma
Genetics + atopy + trigger
Cause bronchial inflammation - oedema, increased mucus secretion and infiltration of cells - and bronchial hyper responsiveness
Lead to airways narrowing (reversible)
Causing symptoms: wheeze, cough, SOB, tight chest
What are the side effects of steroids?
Adrenal suppression - less adrenal stimulation due to less ACTH –> fatigue, wt loss and appetite, N/V/D, depression
Stunted growth - only in the short term - no affect on adult height
A 2 year old boy presents with a cough. From the history you elicit that he has suffered from many chest infections and has had a ‘wet’ cough for a few months now.
You suspect that he has had a chronic lung infection. What could be the cause?
Causes of chronic lung infection: CF Ciliary dyskinesia Immune deficiency Chronic aspiration
Explain the pathology behind CF especially in the lungs
Autosomal recessive disease due to faulty CFTR gene on chromosome 7.
Faulty CFTR proton pump on cell membranes leading to problems with Cl- ion transport. Problems in Lungs, sweat glands, pancreas, liver, bowel, and reproductive organs.
In the lungs: Cl- not transported out of cells into the airways - greater negative charge inside of cells - sodium and water drawn into cells - increased viscosity of mucus in airways - decreased mucociliary transport - accumulation of mucus - increased bacterial infections - inflammation - damage to lungs.
Explain the problem that CF causes in the pancreas
Less Cl in the pancreatic juices - increased viscosity - remains in pancreas - activation of pancreatic proteolytic enzymes causes damage to pancreas Exocrine enzymes (proteases, lipases & amylase) fail to reach bowl for digestion - steatorrea and malabsorption Endocrine enzymes - insulin - DM
How is CF diagnosed?
Sweat test
