Paeds - resp Flashcards

1
Q

what are the most common viral causes of respiratory infections?

A
respiratory syncytial virus (RSV) 
rhinoviruses 
parainfluenza 
influenza 
metapneumovirus 
adenovirus
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2
Q

what are the most common bacterial causes of respiratory infections?

A
streptococcus pneumoniae 
sterptococci 
haemophilus influenzae 
bordetella pertussis
mycoplasma pneumoniae
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3
Q

what increases the risk of respiratory infection?

A
parental smoking 
overcrowded housing, damp housing 
poor nutrition 
underlying lung disease 
male gender 
haemodynamically significant congenital heart disease 
immunodeficiency
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4
Q

whar are the classifications of respiratory infections?

A

upper respiratory tract infection (common cold, sore throat (pharyngitis including tonsilitis), acute otitis media, sinusitis)
Laryngeal tracheal infection (croup, bacterial tracheitis, acute epiglottitis)
bronchiolitis
pneumonia

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5
Q

what are the symptoms of a common cold?

A
acute onset 
rhinitis
sore throat 
sneezing 
post-nasal drainage/drip 
cough 
fever 
non-specfic red pharynx 
nasal mucosal oedema
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6
Q

what are the common causes of the common cold (coryza)?

A

rhinoviruses, coronaviruses, RSV

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7
Q

what is pharyngitis?

A

pharynx and soft-palate are inflamed and local lymph nodes are enlarged and tender

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8
Q

what are the different types of sore throat?

A

pharyngitis
tonsilitis
laryngitis

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9
Q

what is tonsilitis?

A

intense inflammation of the tonsils often with a purulent exudate

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10
Q

what are common causes of tonsilitis?

A

Usually viral - most commonly caused by rhinovirus, coronavirus and adenovirus
group A beta-haemolytic streptococci, and EBV

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11
Q

what are the symptoms and signs of tonsilitis?

A

pain on swallowing
fever >38
tonsillar exudate
cervical lymphadenopathy

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12
Q

how do you treat bacterial tonsilitis?

A

1st line - amoxicillin

2nd line - clarithromycin

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13
Q

what is the criteria used for antibiotic prescription in tonsilitis?

A

the centor criteria

  • presence of tonsilar exudate
  • tender anterior cervical lymphadenopathy or lymphadenitis
  • history of fever
  • absence of cough

3 must be present

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14
Q

what test can be used to detect group A streptococcus pharyngitis?

A

rapid antigen detection test s

should be used routinely in patients with sore throat to allow immediate point-of-care assessment

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15
Q

what is bronchiolitis?

A

it is a condition characterised by acute bronchiolar inflammation
usually caused by RSV virus - 75-80% of cases

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16
Q

what age group does bronchiolitis usually affect, when is the common time for it to occur?

A

it is almost exclusively an infantile disease - commonly affecting children under 2
most common cause of serious RTU in children under one
maternal IgG provides protection to neonates

higher incidence in winter months

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17
Q

what can cause bronchiloitis other than RSV?

A

rhinovirus
influenza virus
may be secondary to a bacterial infection

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18
Q

what are the symptoms of bronchiolitis?

A

coryzal symptoms, including virus precede:
dy cough
increasing breathlessness
wheezing, fine inspiratory crackles
feeding difficulties
tachypnoea
increased work of breathing may be present - retractions, grunting, nasal flaring

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19
Q

what are the features of bronchiolitis that NICE recommend immediate referral for?

A
apnoea 
child looks seriously unwell to health care professional 
severe resp distress
central cyanosis 
persistant oxygen sats less than 92%
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20
Q

what are the features of bronchiolitis that NICE recommend consider referral for?

A

a resp rate over 60BPM
difficulty breast feeding or inadequate oral fluid intake
clinical dehydration

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21
Q

how would you diagnose bronchiolitis?

A

largely clinical
nasopharyngeal aspirate or throat swab - RSV rapid testing and viral cultures
blood and urine cultures if child is pyrexic
FBC
ABG if severely unwell

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22
Q

what is the treatment for bronchiolitis?

A

supportive care, supplemental oxygen and mechanical ventiliation

prenisolone can be given

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23
Q

what is the prophylaxis for bronchiolitis and who is it given to?

A

monthly IM injetion of palivizumab

given to preterm babies born before 29 weeks, or babies born with chronic lung disease of prematurity before 32 weeks
also can be given to those who are severely immunocomomised

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24
Q

what is croup?

A

Viral URTI

croup is also known as laryngotracheobronchitis - common respiratory disease of childhood

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25
what are the causes of croup?
usually parainfluenza | other causes include RSV adenovirus, rhinovirus, enterovirus
26
what age group does croup commonly affect? | what time of year is it common?
commonly children who are between 6 months and 3 years | Autum
27
what are the features of croup?
stridor (high pitched, wheezing sound caused by disrupted airflow) barking seal like cough, which is typically worse at night fever coryzal symptoms if severe there may be signs of resp distress
28
what are the red flag signs of rep failure?
cyanosis lethargic/decreased level of consciousness labored breathing tachycardia
29
what are the differentials of croup?
``` epiglottitis inhaled foreign body acute anaphylaxis bacteria tracheitis diptheria ```
30
what is pseudomembranous croup?
aka bacterial tracheitis rare but very dangerous similar to viral croup but child has high fever, appears toxic and has rapidly progressive aiway obstruction with copious amounts of thick airway secretions it is caused by staphylococcus aureus treatment is with IV Abx, intubation and ventilation if needed
31
what is mild, moderate and severe croup defined as?
mild: 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 moderate: 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 severe: 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
32
when should you consider admission for croup?
moderate or severe croup < 6 months of age known upper airway abnormalities (e.g. Laryngomalacia, Down's syndrome) uncertainty about diagnosis (important differentials include acute epiglottitis, bacterial tracheitis, peritonsillar abscess and foreign body inhalation)
33
how should you diagnose and manage croup?
clinical diagnosis mild croup - single dose of oral dexamethasone moderate - single dose of oral dexamethasone plus nebulised adrenaline severe - single dose oral dexamethasone plus nebulized adrenaline plus oxygen
34
what are causes of stidor in children?
croup acute epiglotittis inhaled foreign body laryngomalacia
35
what is asthma?
a chronic respiratory condition characterised by reversible and paroxysmal constriction of the airways secondary to type 1 hypersensitivity
36
what are the risk factors for the development of asthma?
``` personal or family history of atopy antenatal factors: maternal smoking, viral infection during pregnancy low birth weight not being breastfed maternal smoking around the child exposure to high concentrations of allergens (e.g. house dust mite) air pollution premature birth ```
37
what other atopic conditions are associated with asthma?
IgE-mediated atopic conditions such as eczema alleric rhinitis (hay fever)
38
what are the precipitating factors for asthma?
cold air atmospheric pollution NSAIDs and beta-blockers exposure to allergens
39
what are the clinical features of asthma?
symptoms worse at night and early morning symptoms that have a non-viral trigger cough dyspnoea wheeze, chest tightness- episodic triggers increased work of breathing there may be expiratory wheeze on auscultation reduced peak expiratory flow rate
40
what investigations would you perform for asthma?
spirometry - FEV1 and FVC (FEV1 will be reduced, FVC normal ) peak expiratory flow response to bronchodilator on spirometry CXR ``` also consider skin prick testing fractional expired nitic oxide - elevated sputum culture exercise testing ```
41
what are the differentials for asthma?
``` bronchiolitis episodic viral wheeze inhaled foreign body recurrent aspiration cardiac failure CF primary ciliary dyskinesia ```
42
how is asthma managed in children?
SABA when required add a regular preventer - very low dose ICS or LTRA if less than 5. Initial add on therapy - very low dose ICS plus inhaled LABA or LTRA next consider increasing ICS dose or add LTRA or LABA if no response to LABA consider stopping
43
what are the two clinical patterns of preschool wheeze?
viral episodic wheeze - wheezing only in response to viral infection and no interval symptoms. Usually resolves by 5 years. Triggered by viruses that can cause the common cold. Multiple trigger wheeze - wheeze in response to viral infection but also to another trigger such as exposure to aeroallergens and exercise. A significant proportion go on to have asthma
44
what would finger clubbing suggest?
CF or bronchiectasis
45
how do you manage viral episodic wheeze?
treatment is symptomatic only first-line - SABA second line - LTRA - montelukast
46
how do you manage multiple trigger wheeze?
trial of either ICS or LTRA - typically for 4-8 weeks
47
when should you consider hospital admission for children with asthma?
if after a high dose of bronchodilator therapy they: - have not responded adequately clinically - if they are becoming exhausted - have decreased oxygen sats less than 92% - if CXR is indicated if there are unusual features or signs of severe infection
48
what are the classifications of a mild, moderate and severe acute asthma attack?
MILD: : SaO2 >92% in air, vocalizing without difficulty, mild chest wall recession and moderate tachypnoea MODERATE: SpO2 >92%, PEF>50% best or predicted, no clinical features of severe asthma SEVERE: SaO2 <92% PEFR 33-50%, cannot complete sentences in one breath or too breathless to feed or talk. Heart rate >125 (if over 5 years) or >140 (2-5 years) RR > 30 (over 5 years) or >40 (2-5 years) LIFE THREATENING: SaO2 <92% ,PEFR <33%, silent chest, poor resp effort, cyansis, hypotension, exhaustion, confusion
49
how do you manage a mild to moderate acute asthma attack?
- give beta-2 agonist via a spacer - one puff every 30-60 seconds up to a max of 10 puffs if symptoms not controlled repeat and refer to hospital
50
how should severe asthma attacks be managed?
if low oxygen sats give high flow oxygen SABA via nebuliser ipratropium bromide can be added if no response to SABA steroid therapy should be given for 3 days 2nd line IV salbutamol - essential to monitor for salbutamol toxicity magnesium sulphate can be considered
51
whar are the common causes of pneumonia in different age groups?
Newborn - organisms from the mother's genital tract particularly group B streptococcus, E.coli, klebsiella, staph aureus infants and young children - RSV most common, streptococcus pneumoniae, chlamydia trachomatis Children over 5 - mycoplasma pneumoniae, streptococcus pneumoniae and chlamydia pneumoniae ar the main causes at all ages mycobacterium tuberculosis should be considered
52
what are the clinical features of pneumonia in children? and what would examination show?
fever and difficulty breathing = the most common presenting symptoms usually preceded by an upper RTI cough lethary poor feeding unwell child localised chest, abdo or neck pain is a feature or pleural irritation and suggests bacterial infection examination will show signs of resp distress, desaturation and syanosis tachypnoea, nasal flaring and chest indrawing end inspiratory coarse crackles over the affected area classical signs of consolidation - dull percussion, decreased breath sounds and bronchial breathing oxygen sats may be decreased
53
what are the investigations you would perform for pneumonia?
CXR - may confirm diagnosis but cannot differentiate between viral and bacterial Nasopharageal aspirate - viral immunoflourenence identify viral causes blood tests - FBC and acute phase reactants blood cultures
54
how should you treat pneumonia in children?
first line treatment is amoxicillin for all children with pneumonia for children under 5 alternatives include co-amoxiclav for tyical pneumonia (steptococcus oneumoniae) or clarithromycin for atypial pneumonia (mycoplasma pneumoniae and chlamydia trachomatis) if over 5 years - consider macrolide (clarithromycin) if mycoplasma or chlamydia is suspected, if staoh aureus suspected the consider macrolide or flucloxacillin with amoxicillin severe pneumonia: co-amoxiclav , cefotaxime or cefuroxime IV
55
when would you consider admission for pneumonia?
most cases can be managed at home, admission is indicated if: - oxygen sats less than 92% - severe tachypnoea - difficulty breathing - grunting - apnoea - not feeding
56
what is cystic fibrosis?
an autosomal recesive disorder which leads to a defect in the CF transmembrane receptor protein which causes defective ion transport in exocrine glands. causes thickening of respiratory mucus - the lungs therfore prone to inadequate mucociliary clearance, chronic bacterial in
57
what is the screening for CF?
all newborn babies are screened for CF | blood spot analysis on the Gurthrie card
58
what are the presentations of CF at different age groups
infancy - meconium ileus, prolonged neonatal jaundice Childhood - recurrent lower respiratory chest infection, bronchiectasis, poor appetite, rectal prolapse, nasal polyps, sinusitis Adolescence: bronchiectasis, DM, cirrhosis and portal hypertension, distal intestinal obstruction, pneumothorax, haemoptyysis, male infetiltiy short stature delayed puberty female subfertility weight loss or poor weight gain 90% of children with CF have pancreatic eocrine insuficiency (lipase, amylase and proteases) resulting in maldigestion and malabsorption
59
how do you diagnose CF?
sweat test - abnormally high sweat chloride immunoreactive trypsinogen test (new born screening) CXR glucose tolerance test LFT faecal elastase to assess pacreatic function genetic anlysis
60
what could cause a false positive sweat test for CF ?
``` malnutrition adrenal insufficiency glycogen storage disease nephrogenic diabetes insupidus hypothyroidism G6PD ectodermal dysplasia ```
61
how do you manage CF?
MDT approach annual review in specialist center For ongoing respiratory disease: twice daily physiotherapy to clear airway secretions and postural drainage, inhaled bronchodilator (salbutamol), inhaled mucolytic (dornase alpha), if they have chronic pseudomonas infection give inhaled tobramycin GI disease: monitoring and optimising nutrion pacreatic insuficiency - pancreatic enzyme replacement (pancreatin), H2 antagonist or PPI (ranitidine or omeprazole), fat soluble vitamin supplementation (A, D, K and E) liver disease - ursodeoxycholic acid
62
what is epiglottitis?
it s cellulitis of the supraglottis it is a life threatening emergency due to high risk of repiratory obstruction caused by haemophilus influenzae tpe B (HiB) - Hib immunisation has led to a 99% reduction in the incidence most common in the age group 1-6 years but can affect all age groups **** important to distinguish between epiglottitis and croup
63
what are the symptoms of epiglottitis?
``` the onset is very acute/rapid high fever and generally unwell - toxic looking child stridor drooling of slaiva increasing resp difficulty over hours sore throat tripod position ```
64
what investigations would you perform for suspected epiglottitis?
larygoscopy lateral neck radiograph FBC blood cultures
65
how do you treat epiglottitis?
secure airway and supplemental O2 IV Abx (cefotaxime or ceftriaone or ampicillin or clindamycin) dexamethasone can be added to reduce inflammation inhaled adrenaline - of upper airways are compromised intubation once stable - oral Abx - amoxicillin or cefaclor
66
what are the differences in presentation between croup and epiglottitis?
Epiglottitis is rapid onset (hours), croups is days croups has coryza prior to onset croup has barking cough, epiglottitis usually has no cough corup they can drink/feed epiglottitis will have drooling saliva epiglottitis will have a high fever croup has rasping stridor epiglottitis is a soft stridor in epiglottitis their voice will be weak or silent
67
what can cause stridor in children?
Croup – harsh loud stridor (mostly viral, 6 months to 6 years of age, harsh loud stridor, coryza, mild fever and hoarse voice) Epiglottitis – (caused by H. influenzae type b, rare since Hub immunisation Bacterial tracheitis – harsh loud stridor, higher fever, toxic Inhaled foreign body – chocking on peanut, sudden onset of cough or respiratory distress Laryngomalacia – recurrent or continuous since birth.
68
what is surfactant deficient lung disease?
AKA respiratory distress sydrome caused by inadequate production of surfactant type 2 from the pneumocytes in the lungs low surfactant leads to alveoli collapsing on expiration and this increases the energy needed for breathing
69
what are the risk factors for surfactant deficient lung disease?
``` Premature maternal DM at term multiple pregnancy fam history of RDS csection hypothermia male>female ```
70
what are the causes of secondary surfactant deficiency?
* Intrapartum asphyxia * RTI: GB-BHS pneumonia * Meconium aspiration pneumonia * Pulmonary haemorrhage * Pulmonary hypoplasia * Congenital diaphragmatic hernia
71
what is the presentation of surfactant deficient lung disease?
``` Early signs • Tachypnoea >60 • laboured breathing • grunting • recession: subcostal and intercostal • Nasal flaring • Cyanosis • Diminished breathing sounds Late signs • Fatigue • Apnoea • Hypoxia ```
72
how do you manage surfactant deficient lung disease?
1. surfactant replacement therapy: endotracheal tube 2. antibiotics 3. O2 : SaO2 85-93% • Mild: via a hood • Moderate: CPAP • Severe : endotracheal tube 4. Nutrition • If the infant is stable: IV nutrition: amino acids and lipids • If resp status is stable: small volume of gastic feed via a tube
73
what causes whooping cough?
bordetella pertussis
74
what are the symptoms of whooping cough?
One week of coryza (Catarrhal phase), then the child develops a characteristic paroxysmal or spasmodic cough followed by a characteristic inspiratory whoop (paroxysmal phase). Often worse at night Often vomiting can occur In infants the whoop may be absent, but apnoea may occur at this age Epistaxis and subconjunctival haemorrhage may occur vigorous coughing Paroxysmal phase may last 3-6 weeks and symptoms gradually decrease but may persist for many months (convalescent phase)
75
how is whooping cough diagnosed?
nasal swab | PCR and serology
76
how is whooping cough managed?
under 6 month - admit - notifiable disease - oral macrolide - clarithromycin - houshold contacts - prophylais - school exclusion for 48 hours followin commencing antibiotics
77
what are the complications of whooping cough?
subconjunctival haemorrhage pneumonia bronchiectasis seizures
78
how should inhaled drugs be administered in children under 3?
face masks
79
what are the risks associated with long term use of inhaled steroids?
adrenal suppression growth supprsion osteoporosis high dose steroids may cause adrenal crisis
80
what are some upper RTI?
``` rhinitis otitis media pharyngitis tonsilitis larygitis ```
81
what are some lower RTI?
``` bronchitis croup epiglottitis tracheitis bronchiolitis pneumonia ```
82
what can pneumococcus cause/ what is it course of infection?
consolidation of the nasopharynx - -> upper airways mucosa infection - otitis media, sinusitis - ->lower airway mucosal infection - bacterial bronchitis, pneumonia - -> occult septicaemia, pneumonia with septicaemia, meningitis
83
what is pneumonia?
resp disease characterised byinflammation of the lung parenchyma (excluding the bronchi) with congestion caused by viruses, bacteria or irritants
84
what is the bronchiectasis vicious circle hypothesis?
infection --> inflammation --> impaired muco-ciliary clearance --> infection
85
who would be in the MDT team for CF?
``` paediatric pulmonologist physio dietician nurse liason primary care team teacher psychologist ```
86
what are some causes of wheeze in children?
pneumonia, pulmonary oedema, bronchogenic cyst enlarged left atrium compressing left mainstem bronchus chest deformity asthma brochiolitis bronchitis CF polyps airway obstruction - foreign body, mucus, pus, blood