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Phase 3a > Paeds - resp > Flashcards

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
Q

what are the causes of croup?

A

usually parainfluenza

other causes include RSV adenovirus, rhinovirus, enterovirus

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26
Q

what age group does croup commonly affect?

what time of year is it common?

A

commonly children who are between 6 months and 3 years

Autum

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27
Q

what are the features of croup?

A

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

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28
Q

what are the red flag signs of rep failure?

A

cyanosis
lethargic/decreased level of consciousness
labored breathing
tachycardia

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29
Q

what are the differentials of croup?

A 
epiglottitis 
inhaled foreign body 
acute anaphylaxis 
bacteria tracheitis 
diptheria
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30
Q

what is pseudomembranous croup?

A

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

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31
Q

what is mild, moderate and severe croup defined as?

A

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

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32
Q

when should you consider admission for croup?

A

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)

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33
Q

how should you diagnose and manage croup?

A

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

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34
Q

what are causes of stidor in children?

A

croup
acute epiglotittis
inhaled foreign body
laryngomalacia

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35
Q

what is asthma?

A

a chronic respiratory condition characterised by reversible and paroxysmal constriction of the airways
secondary to type 1 hypersensitivity

36
Q

what are the risk factors for the development of asthma?

A 
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
Q

what other atopic conditions are associated with asthma?

A

IgE-mediated atopic conditions such as
eczema
alleric rhinitis (hay fever)

38
Q

what are the precipitating factors for asthma?

A

cold air
atmospheric pollution
NSAIDs and beta-blockers
exposure to allergens

39
Q

what are the clinical features of asthma?

A

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
Q

what investigations would you perform for asthma?

A

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
Q

what are the differentials for asthma?

A 
bronchiolitis 
episodic viral wheeze 
inhaled foreign body 
recurrent aspiration 
cardiac failure 
CF
primary ciliary dyskinesia
42
Q

how is asthma managed in children?

A

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
Q

what are the two clinical patterns of preschool wheeze?

A

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
Q

what would finger clubbing suggest?

A

CF or bronchiectasis

45
Q

how do you manage viral episodic wheeze?

A

treatment is symptomatic only
first-line - SABA
second line - LTRA - montelukast

46
Q

how do you manage multiple trigger wheeze?

A

trial of either ICS or LTRA - typically for 4-8 weeks

47
Q

when should you consider hospital admission for children with asthma?

A

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
Q

what are the classifications of a mild, moderate and severe acute asthma attack?

A

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
Q

how do you manage a mild to moderate acute asthma attack?

A
  • 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
Q

how should severe asthma attacks be managed?

A

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
Q

whar are the common causes of pneumonia in different age groups?

A

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
Q

what are the clinical features of pneumonia in children? and what would examination show?

A

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
Q

what are the investigations you would perform for pneumonia?

A

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
Q

how should you treat pneumonia in children?

A

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
Q

when would you consider admission for pneumonia?

A

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
Q

what is cystic fibrosis?

A

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
Q

what is the screening for CF?

A

all newborn babies are screened for CF

blood spot analysis on the Gurthrie card

58
Q

what are the presentations of CF at different age groups

A

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
Q

how do you diagnose CF?

A

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
Q

what could cause a false positive sweat test for CF ?

A 
malnutrition 
adrenal insufficiency 
glycogen storage disease 
nephrogenic diabetes insupidus 
hypothyroidism 
G6PD
ectodermal dysplasia
61
Q

how do you manage CF?

A

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
Q

what is epiglottitis?

A

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
Q

what are the symptoms of epiglottitis?

A 
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
Q

what investigations would you perform for suspected epiglottitis?

A

larygoscopy
lateral neck radiograph
FBC
blood cultures

65
Q

how do you treat epiglottitis?

A

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
Q

what are the differences in presentation between croup and epiglottitis?

A

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
Q

what can cause stridor in children?

A

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
Q

what is surfactant deficient lung disease?

A

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
Q

what are the risk factors for surfactant deficient lung disease?

A 
Premature
maternal DM at term
multiple pregnancy 
fam history of RDS
csection 
hypothermia 
male>female
70
Q

what are the causes of secondary surfactant deficiency?

A
  • Intrapartum asphyxia
  • RTI: GB-BHS pneumonia
  • Meconium aspiration pneumonia
  • Pulmonary haemorrhage
  • Pulmonary hypoplasia
  • Congenital diaphragmatic hernia
71
Q

what is the presentation of surfactant deficient lung disease?

A 
Early signs 
•	Tachypnoea >60
•	laboured breathing 
•	grunting 
•	recession: subcostal and intercostal 
•	Nasal flaring 
•	Cyanosis 
•	Diminished breathing sounds 
Late signs 
•	Fatigue 
•	Apnoea 
•	Hypoxia
72
Q

how do you manage surfactant deficient lung disease?

A
  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
Q

what causes whooping cough?

A

bordetella pertussis

74
Q

what are the symptoms of whooping cough?

A

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
Q

how is whooping cough diagnosed?

A

nasal swab

PCR and serology

76
Q

how is whooping cough managed?

A

under 6 month - admit

  • notifiable disease
  • oral macrolide - clarithromycin
  • houshold contacts - prophylais
  • school exclusion for 48 hours followin commencing antibiotics
77
Q

what are the complications of whooping cough?

A

subconjunctival haemorrhage
pneumonia
bronchiectasis
seizures

78
Q

how should inhaled drugs be administered in children under 3?

A

face masks

79
Q

what are the risks associated with long term use of inhaled steroids?

A

adrenal suppression
growth supprsion
osteoporosis
high dose steroids may cause adrenal crisis

80
Q

what are some upper RTI?

A 
rhinitis 
otitis media 
pharyngitis 
tonsilitis 
larygitis
81
Q

what are some lower RTI?

A 
bronchitis 
croup 
epiglottitis
tracheitis 
bronchiolitis
pneumonia
82
Q

what can pneumococcus cause/ what is it course of infection?

A

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
Q

what is pneumonia?

A

resp disease characterised byinflammation of the lung parenchyma (excluding the bronchi) with congestion caused by viruses, bacteria or irritants

84
Q

what is the bronchiectasis vicious circle hypothesis?

A

infection –> inflammation –> impaired muco-ciliary clearance –> infection

85
Q

who would be in the MDT team for CF?

A 
paediatric pulmonologist
physio
dietician 
nurse liason 
primary care team 
teacher 
psychologist
86
Q

what are some causes of wheeze in children?

A

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

Phase 3a (41 decks)

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