Paeds Resp

Question 1

What is the difference between wheeze and stridor?

Answer 1

Wheeze is an obstruction of the lower respiratory tract and stridor is obstruction outside of the chest. Wheeze is heard as a continuous whistling noise heard more on expiration. Stridor is a high-pitched sound heard more in inspiration.

Question 2

What are the three main causes of a wheeze?

Answer 2

Viral induced wheeze
Asthma
Persistent infantile wheeze - happy wheezers

Question 3

What are the differentials for an acute wheeze?

Answer 3

Foreign body: Sudden onset wheezing, choking, stridor

Pneumonia: Auscultatory crackles, Fever

Bronchiolitis: Seasonal pattern, Nasal flaring & Intercostal recessions

Question 4

What are the differentials for a chronic wheeze?

Answer 4

Asthma: Episodic pattern, Cough &Response of bronchodilators

CF

Vascular ring: Exacerbated by neck flexion & Relieved by neck hyperextension

Question 5

What are the three main differentials for stridor?

Answer 5

Croup

Epiglottitis

Bacterial tracheitis

Question 6

What suggests croup in a child presenting with stridor?

Answer 6

Seasonal pattern
Barking cough
Temp <38.5
Harsh rasping stridor

Question 7

What suggests Epiglottitis in a child presenting with stridor?

Answer 7

Stridor
Drooling - due to inability to swallow
Sudden onset over hours

Question 8

What suggests Bacterial tracheitis in a child presenting with stridor?

Answer 8

High fever
Appears very ill
Rapidly progressive airway obstruction + thick secretions
Caused by staph aureus
IV Abx and intubation/ventilation if required

Question 9

When is the peak incidence of croup?

Answer 9

6 months to 3 years

Question 10

What are the RFs for croup?

Answer 10

Young

Male

Question 11

What is the aetiology of croup?

Answer 11

Parainfluenza virus types 1 or 3
RSV
Influenza A and B
Adenovirus

Question 12

What is the clinical presentation of croup?

Answer 12

Barking cough
Stridor
Hoarse voice
Respiratory distress (Tracheal tug, Chest recessions, Tachypnea)
Lethargy 
Symptoms worse at night 
Agitation

Question 13

What investigations would you do in suspected croup?

Answer 13

CRP
FBC
U+Es

Question 14

How do you manage croup?

Answer 14

Single dose of oral dexamethasone 0.15mg/kg
Nebulised adrenaline 
Temporary relief of symptoms
Supportive 
Kept calm 
O2 therapy if required 
Call ENT/Anaesthetist = airway support

Question 15

What is epiglottitis?

Answer 15

Intense swelling of the epiglottis causing upper airway obstruction
Caused by h. Influenzae - which is now vaccincated against
Very acute onset

Question 16

What is the presentation of epiglottitis?

Answer 16

Sore throat in a septic looking child
Child unable to speak or swallow (drooling)
Sitting upright, immobile with open mouth to optimise airway
Soft inspiratory stridor, increases resp distress, little or no cough

Question 17

How do you manage epiglottitis?

Answer 17

Do not examine throat is suspected
Call anaesthetics and ENT surgeon
IV cefotaxime

Question 18

What is whooping cough?

Answer 18

Pertussis (also known as whooping cough) is an upper respiratory tract infection (URTI) characterised by a severe cough. Bordetella pertussis is the typical aetiological agent.

Question 19

What is the presentation of pertussis?

Answer 19

Catarrhal stage (Coryza for 7 days)
Inspiratory whoop (forced inhalation against a closed glottis)
Spasms of cough – worse at night, cause vomiting, cyanosis, epistaxis and subconjunctival haemorrhages.
Paroxysmal phase 3-6 weeks but can persist for months (100 day cough)

Question 20

What investigation do you undertake in pertussis?

Answer 20

Nasal swab

Question 21

How do you manage pertussis?

Answer 21

< 1 month old Azithromycin 5 days
>1 month old Azithromycin/ Erythromycin 7 days or Trimethoprim for 7 days if abx resistance
School exclusion

Question 22

What is bronchiolitis?

Answer 22

Most common LRTI in children
Increases incidence in winter
90% 1-9 months
7 day

Question 23

What is the aetiology of bronchiolitis?

Answer 23

Respiratory syncytial virus (RSV) accounts for the majority of cases, although rhinovirus, human metapneumovirus, influenza, parainfluenza, and adenovirus can all cause bronchiolitis as well.

Question 24

What are the RFs for bronchiolitis?

Answer 24

Breast fed for less than 2 months
Smoke exposure
Having siblings at school/ nursery
Chronic lung disease due to prematurity

Question 25

What is the pathophysiology of bronchiolitis?

Answer 25

Proliferation of goblet cells causing excess mucus production
IgE mediated type 1 allergic reaction causing inflammation
Bronchiolar constriction
Infiltration of lymphocytes causing submucosal oedema
Infiltration of cytokines and chemokines

Question 26

What is the presentation of bronchiolitis?

Answer 26

History: 
Low grade fever 
Nasal congestion 
Rhinorrhoea 
Cough 
Feeding difficulty 

Examination: 
Tachypnoea 
Grunting 
Nasal flaring 
Intercostal, subcostal or supraclavicular recessions 
Inspiratory crackles 
Expiratory wheeze 
Hyperinflated chest 
Cyanosis or pallor

Question 27

What are the differentials for bronchiolitis?

Answer 27

Pneumonia 
Croup 
CF 
Bronchitis 
HF - hard to diagnose.

Question 28

What are the investigations for bronchiolitis?

Answer 28

Pulse oximetry
Enzyme-linked immunosorbent assay (ELISA) rapid antigen detection or reverse transcriptase polymerase chain reaction (RT-PCR) of nasal swab (RT-PCR more sensitive but not available everywhere yet)
Chest X-ray (not necessary for diagnosis)

Question 29

What is the management of bronchiolitis?

Answer 29

Supportive:

Humidified O2
NG feeds
Fluids

Question 30

What is the prophylaxis treatment for bronchiolitis?

Answer 30

Palivizumab.

Palivizumab is a humanised monoclonal antibody that binds to the F protein of respiratory syncytial virus (RSV) and inhibits viral infection and replication.In the first year of life, the AAP recommends prophylaxis for infants born before 29 weeks, or preterm infants with chronic lung disease of prematurity; or infants with haemodynamically significant congenital heart disease; or infants with pulmonary abnormalities or neuromuscular disease that impairs the ability to clear secretions from the upper airways.

Question 31

What is the pathophysiology of asthma?

Answer 31

Chronic inflammatory disorder of lower airways secondary to hypersensitivity
Reversible airway obstruction
Atopy, genetic predisposition and environmental factors all effect bronchial inflammation.

Pathophysiology:
Bronchial inflammation 
  a) Oedema 
  b) Excessive mucus production → mucous plug 
  c) Infiltration with cells 

Bronchial hyperresponsiveness
a)Exaggerated twitchiness to inhaled stimuli

Airway narrowing
a) Reversible airflow obstruction (peak flow variability )

Symptoms

a) Wheeze
b) Cough
c) Breathlessness
d) Chest tightness

Question 32

What are the clinical features of asthma?

Answer 32

Intermittent dyspnea 
Sputum production 
Disturbed sleep (quantify by nights/ weeks)
Wheeze
Nocturnal Cough 
Diurnal variation 
Decreased exercise tolerance

Question 33

What are the investigations for asthma?

Answer 33

Clinical symptoms
Spirometry: FEV1:FVC < 70%
Bronchodilator reversibility – FEV1 improvement by 12% or more
FeNO >= 35ppb
CXR: May show hyperinflation. Helps distinguish from other cardiac and pulmonary diseases such as cardiac failure, bronchiectasis, or situs inversus.

Question 34

What suggests a severe asthma attack?

Answer 34

In < 5’s
Sats <92%, unable to talk, HR >140, RR >40 use of accessory neck muscles

In > 5’s
Sats <92%, PEF <50%, unable to complete sentences, HR >125, RR >30 use of accessory neck muscles

Question 35

What suggests a life-threatening asthma attack?

Answer 35

In < 5’s
Sats <92%, silent chest, bradycardic, poor resp effort, altered consciousness, cyanosed

In > 5’s
Sats <92%, PEF <33% silent chest, bradycardic, poor resp effort, altered consciousness, cyanosed

Question 36

What is the acute management of asthma?

Answer 36

ABCDE
High flow O2
Salbutamol nebs 
Back to back if severe (in HCU environment) 
SE Hypokalemia (drives K+ out of cells) 
IV hydrocortisone 
Or oral if tolerated 
Ipratropium Bromide Nebs 
Magnesium Sulphate IV 
Call ICU 
Salbutamol IV 
Arrhythmias 
ECG monitoring

Question 37

What is the chronic management of asthma?

Answer 37

AVOID TRIGGERS & EDUCATION

Step 1: short acting beta agonist (Salbutamol)
If this is needed more than once a day or three times a week then move to…

Step 2 : Inhaled corticosteroid (beclometasone dipropionate (BDP), budesonide, and fluticasone propionate)

Step 3: increase corticosteroid and add LABA ( Salmeterol or formoterol)

Step 4: Add ons (montelukast, theophylline and omalizumab)

Question 38

What causes CF?

Answer 38

Mutation in the gene of the long arm of chromosome 7 in the region 7q31.2
Most common inherited disease in white populations
Much less common in afro-caribbean and Asian people
Prevalence is 1 in 2500 new-born
9000 people currently with CF in UK

Question 39

What is the pathophysiology of CF?

Answer 39

Mutations in chromosome 7 which codes for CF transmembraneous conductance regulator protein, a chloride channel and regulatory protein found in epithelial cell membranes in lungs, pancreas, GI and reproductive tract.
Decreased transport of chloride and/or CFTR affected ions, such as sodium and bicarbonate, leads to an alteration in viscosity and tenacity of mucus produced at the epithelial surfaces and to increased salt concentration in sweat gland secretions.

Question 40

How does CF affect each system?

Answer 40

Respiratory Tract:
Chloride ion movement and sodium reabsorption is affected in the defective cells.
This rescues the amount of water in secretions which results in reduced airways surface liquid (ASL)
ASL = impt component of mucociliary escalator → impedes mucous clearance
Provides a niche for bacterial growth (bacterial are protected against host immune system and antibiotics)

Pancreas
Pancreatic insufficiency → CF related DM

GI Tract
Small intestine secretes viscous mucous which can cause bowel obstruction in utero
In utero CF causes cholestasis - leading to neonatal jaundice
This can cause intestinal obstruction syndrome and CF related liver disease in later life

Reproductive tract
98% of men are infertile
Congenital absence of the vas deferens

Question 41

What are the clinical features of CF in neonates?

Answer 41

Meconium Ileus
Screening identifies the majority of cases (Guthrie test)
Failure to Thrive
Prolonged neonatal jaundice

Question 42

What are the clinical features of CF in infancy?

Answer 42

Failure to thrive
Recurrent chest infections
Pancreatic insufficiency - steatorrhoea

Question 43

What are the clinical features of CF in childhood?

Answer 43

Rectal prolapse
Nasal polyps (high indication it is CF)
Sinusitis

Question 44

What are the clinical features of CF in adolescence?

Answer 44

Pancreatic insufficiency - DM
Chronic lung disease
DIOS, gallstones, liver cirrhosis.

Question 45

What is seen on examination in CF?

Answer 45

Hands: finger clubbing
Face: nasal polyps
Chest: hyperinflated, crepitations, portacath (indwelling vascular access device)
Abdomen: fecal mass (if constipated/DIOS) may have a scar from ileostomy (meconium ileus)

Question 46

What investigations would you do for CF?

Answer 46

Clinical history and FH of disease are key diagnostic features.
Sweat sodium measurement > 60mmol/L
Blood DNA analysis of gene defect
Radiology showing features of CF
Absent vas deferens and epididymis
Blood immunoreactivity tyrosine levels.
Genetic screening for the carrier state together with counselling should be offered to those with a family history of CF.

Question 47

What is the management of CF?

Answer 47

Should be managed by MDT, parents should be involved as part of the team as well.
No cure for CF: the aims of treatment are to minimize progression of the disease (early identification of infection) and maintain adequate nutrition and development.

Nutrition – strong link between good nutrition and good development/ prognosis for CF

Education to improve QoL, good nutrition and prompt treatment of exacerbations

Clearly explaining diagnosis and providing written information and support information
Lifelong and life limiting condition

General care
Stopping smoking, vaccinations

Oxygen therapy if necessary

Antibiotic treatment:
70% of adults with CF have Pseudomonas infection in sputum
Nebulised antipseudomonal antibiotic therapy helps improve lung function and decreases risk of relevant exacerbations

Drug therapy:
B2 agonists
Inhaled corticosteroids
Purely symptomatic relief

Airway clearance:
Twice daily physiotherapy is needed 
Inhalation of recombinant DNAse (Reduces viscosity of mucous)
Hypertonic saline by inhalation
Amiloride - inhibits sodium transport
Acetylcysteine

Non-invasive ventilation
Improves symptoms in chronic respiratory failure

Treat pancreatic insufficiency

Question 48

What is the aetiology of paediatric pneumonia?

Answer 48

Bacterial:
Strep Pneumonia 
H influenzae (vaccinated against)
Staph aureus / klebsiella
TB
Mycoplasma  

Viral:
 RSV 
Influenza A and B 
Parainfluenza 
HIV (Bacterial infection remains major cause of fitness)

Question 49

What are the clinical features of pneumonia?

Answer 49

Fever 
Cough 
Rapid breathing 
Lethargy 
Poor feeding 
‘Unwell child’ 

Resp distress:
Use of accessory muscles (Sternocleidomastoid, trapezius, abdominal)
Head bob
Recessions (Tracheal tug, Subcostal, Intercostal, Sternal)
Nasal flaring
Audible sounds (Stridor, wheeze)
Tachypneic, Tachycardic

Older children:
Pleural pain 
Crackles 
Bronchial breathing 
Expiration and inspiration sound the same

Question 50

What investigations do you do for pneumonia?

Answer 50

Sputum sample:
MC+S

CXR:
Consolidation

Question 51

What is the management of pneumonia?

Answer 51

1st line:
Oral amoxicillin
Target bacteria cell wall

2nd line:
Clarithromycin

Atypical - Macrolide:
Inhibits protein synthesis of bacteria.

Question 52

What is bacterial bronchitis?

Answer 52

Persistent inflammation of the lower airways driven by chronic infection
Chronic wet cough in children

Caused by:
Haemophilus influenzae
Moraxella catarrhalis

Tx:
High dose antibiotics - co=amoxiclav (4+ weeks)
Physiotherapy
Thought to be a precursor to bronchiectasis (permanent dilatation of the bronchi)