Paeds - Respiratory

Question 1

Most common cause of Croup vs Bronchiolitis

Answer 1

Croup - Tolders with barking cough and stridor- usually caused by parainfluenza virus

Bronchiolitis - infants with SOB and wheeze- most commonlly caused by respiratory syncytial virus

mnemotic - croup ends in p - for parainfluenza

bronchiolitis ends in an S for syncytial

Question 2

What age children get bronchiolitis?

why is this?

Answer 2

Infants

Bronchiolitis is very common in winter. Bronchiolitis is generally considered to occur in children under 1 year. It is most common in children under 6 months. It can rarely be diagnosed in children up to 2 years of age, particularly in ex-premature babies with chronic lung disease.

When a virus affects the airways of adults, the swelling and mucus are proportionally so small that it has little noticeable effect on breathing. The airways of infants are very small to begin with, and when there is even the smallest amount of inflammation and mucus in the airway it has a significant effect on the infants ability to circulate air to the alveoli and back out. This causes the harsh breath sounds, wheeze and crackles heard on auscultation when listening to a bronchiolitic baby’s chest.

Question 3

An infant presents with:
- coryzal symptoms
- signs of respiratory distress
- dyspnoea
- poor feeding
- mild fever (under 39)
- apnoeas
- wheeze and crackles on auscultation

Diagnosis

Answer 3

Bronchiolitis

Bronchiolitis usually starts as an upper respiratory tract infection (URTI) with coryzal symptoms. From this point around half get better spontaneously. The other half develop chest symptoms over the first 1-2 days following the onset of coryzal symptoms. Symptoms are generally at their worst on day 3 or 4. Symptoms usually last 7 to 10 days total and most patients fully recover within 2 – 3 weeks. Children who have had bronchiolitis as infants are more likely to have viral induced wheeze during childhood.

Question 4

One of the foundations of paediatrics is being able to spot the signs of respiratory distress

Answer 4

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

Question 5

Wheeze vs grunt vs stridor

Answer 5

Wheezing is a whistling sound caused by narrowed airways, typically heard during expiration

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

Stridor (gasp noise) is a high pitched inspiratory noise caused by obstruction of the upper airway, for example in croup

Note from lecture - Wheeze is poltphonic because multiple calibres of lower airways invovled and also expiratory because during expiration the intrathroacic pressure increases and it causes the walls of the smaller airways (already narrowed by inflamation) to collapse.

In contrast stridor is inspiratory because the negative intrathoracic pressure is greatest causes the upper airways to vibrate.

Question 6

Reasons for admission of infants with bronchilitis - approx 7

Answer 6

Aged under 3 months or any pre-existing condition such as prematurity, Downs syndrome or cystic fibrosis
50 – 75% or less of their normal intake of milk
Clinical dehydration
Respiratory rate above 70
Oxygen saturations below 92%
Moderate to severe respiratory distress, such as deep recessions or head bobbing
Apnoeas
Parents not confident in their ability to manage at home or difficulty accessing medical help from home

Question 7

Management of bronchiolitis

Answer 7

Patients typically only require supportive management:

Ensuring adequate intake. This could be orally, via NG tube or IV fluids depending on the severity. It is important to avoid overfeeding as a full stomach will restrict breathing. Remeber that when feeding, harder to ventilate so poor feeding is sign of a respiratory/cardiovascular issue in infants (think about going blue in CHD)

Saline nasal drops and nasal suctioning can help clear nasal secretions, particularly prior to feeding
Supplementary oxygen if the oxygen saturations remain below 92%
Ventilatory support if required
There is little evidence for treatments such as nebulised saline, bronchodilators, steroids and antibiotics.

Question 8

Types of ventilatory support in children - Low yield

Answer 8

As breathing gets harder, the child gets more tired and less able to adequately ventilate themselves. They may require ventilatory support to maintain their breathing. This is stepped up until they are adequately ventilated:

High-flow humidified oxygen via tight nasal cannula (i.e. “Airvo” or “Optiflow”). This delivers air and oxygen continuously with some added pressure, helping to oxygenate the lungs and prevent the airways from collapsing. It adds “positive end-expiratory pressure” (PEEP) to maintain the airway at the end of expiration.
Continuous positive airway pressure (CPAP). This involves using a sealed nasal cannula that performs in a similar way to Airvo or Optiflow, but can deliver much higher and more controlled pressures.
Intubation and ventilation. This involves inserting an endotracheal tube into the trachea to fully control ventilation.

Capillary blood gases are useful in severe respiratory distress and in monitoring children who are having ventilatory support. Ovs dont forget that sats are the main thing used, this is just extra info for you aaron x

The most helpful signs of poor ventilation are:

Rising pCO2, showing that the airways have collapsed and can’t clear waste carbon dioxide.
Falling pH, showing that CO2 is building up and they are not able to buffer the acidosis this creates. This is a respiratory acidosis. If they are also hypoxic, this is classed as type 2 respiratory failure.

Question 9

KEY
Prophalaxis of bronchiolitis in premature babies and babies with congenital heart defects

Answer 9

Palivizumab is a monoclonal antibody that targets the respiratory syncytial virus. A monthly injection is given as prevention against bronchiolitis caused by RSV. It is given to high risk babies, such as ex-premature and those with congenital heart disease.

It is not a true vaccine as it does not stimulate the infant’s immune system. It provides passive protection by circulating the body until the virus is encountered, as which point it works as an antibody against the virus, activating the immune system to fight the virus. The levels of circulating antibodies decrease over time, which is why a monthly injection is required.

Question 10

What is croup?
Who does it affect and how does it present?
Cause?
Rx?

Answer 10

Croup is an acute infective respiratory disease affecting young children. It typically affects children aged 6 months to 2 years, however they can be older. It typically presents with increased work of breathing, low grade feverl barking cough/horse voice and inspiratory stridor.

It is an upper respiratory tract infection causing oedema in the larynx, NOT THE EPIGLOTIS!

The classic cause of croup that you need to spot in your exams, is parainfluenza virus. Other causes are adenovirus, influenza and RSV (RSV causes bronchiolitis)

Most cases can be managed at home with simple supportive treatment (fluids and rest). It usually improves in less than 48 hours and responds well to treatment with a single sode of dexamethasone (can be repeated after 12 hours).

Stepwise options in severe croup to get control of symptoms:

Oral dexamethasone
Oxygen
Nebulised budesonide (steroid)
Nebulised adrenalin
Intubation and ventilation

Important not to examine the throat - can cause them to get aggitated and desaturate.

Question 11

A popular exam question is: both parents are healthy, one sibling has cystic fibrosis and a second child does not have the disease, what is the likelihood of the second child being a carrier?

Answer 11

Remember that cystic fibrosis is autosomal recessive.
We know the child doesn’t have the condition, so the answer is two in three.

XX/XX = XX, Xx, Xx, xx . Since doesnt have it they can’t be xx, so they have a 2/3 chance of being Xx (a carrier)

Question 12

What chromosome is the cystic fibrosis transmembrane conductance regulatory gene found on and what is the inheritence pattern.

Answer 12

Autosomal recessive - Chromosome 7
The most common mutation is the delta-F508 mutation
This gene codes for cellular channels, particularly a type of chloride channel.

Question 13

What are the consequences of the cystic fibrosis mutation? 3 key things

Symptoms?

Answer 13

The muation affects mucus flands and leads to:

Thick pancreatic and biliary secretions that cause blockage of the ducts, resulting in a lack of digestive enzymes such as pancreatic lipase in the digestive tract

Low volume thick airway secretions that reduce airway clearance, resulting in bacterial colonisation and susceptibility to airway infections

Congenital bilateral absence of the vas deferens in males. Patients generally have healthy sperm, but the sperm have no way of getting from the testes to the ejaculate, resulting in male infertility

Presenation:
Poor weight and height gain (failure to thrive)
Finger clubbing
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
Parents may report the child tastes particularly salty when they kiss them, due to the concentrated salt in the sweat

Question 14

A newborn presents as not passing meconium within 24 hours, abdominal distention and vomiting, what is the most likely diagnosis?

Answer 14

cystic fibrosis

Meconium ileus is often the first sign of cystic fibrosis. The first stool that a baby passes is called meconium. This is usually black and should be passed within 24 hours of birth. In about 20% of babies with CF, the meconium is thick and sticky, causing it to get stuck and obstruct the bowel. This is called meconium ileus, and is practically pathognomonic for cystic fibrosis

///

EXAM QUESTION: A CONTRAST ENEMA SHOWS:
- Microcolon: A narrow, underdeveloped colon due to lack of fetal bowel content passing through.
- Impacted meconium pellets, visible in the distal ileum.

Key Differentiating Point:
- In Hirschsprung’s disease, the colon is primarily affected, and meconium backs up in the colon.
- In cystic fibrosis, the problem is in the distal ileum, causing obstruction there, with a microcolon downstream.

///

Cystic fibrosis is screened for at birth with the newborn bloodspot test.

If cystic fibrosis is not diagnosed shortly after birth it can present later in childhood with typical signs and symptoms, recurrent lower respiratory tract infections, failure to thrive or pancreatitis.

Meconium ileus is also associated with hirshprungs disease but i think that is far less common? be vigilant in exams me - In fairness this is similar to hirsprungs asscoiated enterocolitis but that is a few weeks not 24 hours in.

Question 15

Causes of Clubbing in Children -6

Answer 15

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

Question 16

Cystic fibrosis - There are three key methods for establishing a diagnosis that you should remember for your exams?

Interpretation of the gold standard?

Answer 16

Newborn blood spot testing is performed on all children shortly after birth and picks up most cases

The sweat test is the gold standard for diagnosis

Genetic testing for CFTR gene can be performed during pregnancy by amniocentesis or chorionic villous sampling, or as a blood test after birth

The sweat test is the key investigation to remember for cystic fibrosis. It is the gold standard for confirming the diagnosis. A patch of skin is chosen for the test, typically on the arm or leg. Pilocarpine is applied to the skin on this patch. Electrodes are placed either side of the patch and a small current is passed between the electrodes. This causes the skin to sweat. The sweat is absorbed with lab issued gauze or filter paper and sent to the lab for testing for the chloride concentration. The diagnostic chloride concentration for cystic fibrosis is more than 60mmol/l.

Question 17

Patients with cystic fibrosis struggle to clear the secretions in their airways. This creates a perfect environment with plenty of moisture and oxygen for colonies of bacteria to live and replicate. What are some examples of common colonisers? - name the 2 key ones and hwo they are treated?

Answer 17

Staphylococcus aureus
Pseudomonas aeruginosa
Others:
Haemophilus influenza
Klebsiella pneumoniae
Escherichia coli
Burkhodheria cepacia

TOM TIP: The key colonisers to remember for your exams are staph aureus and pseudomonas. Patients with cystic fibrosis take long term prophylactic flucloxacillin to prevent staph aureus infection. Pseudomonas should be remembered as a particularly troublesome coloniser that is hard to treat and worsens the prognosis of patients with cystic fibrosis.

Once patients become colonised with pseudomonas, it can be very difficult to get rid of. Often, these bacteria can become resistant to multiple antibiotics. Colonisation with pseudomonas leads to a significant increase in morbidity and mortality in patients with CF. In the past there were gatherings and social events organised for children with cystic fibrosis to meet up and share their experiences, however this was stopped due to the risk of spreading pseudomonas. The general advice is now to avoid contact with other children with cystic fibrosis. Cystic fibrosis clinics have separate clinic rooms for children with pseudomonas to minimise the risk of transmission.

Pseudomonas colonisation can be treated with long term nebulised antibiotics such as tobramycin. Oral ciprofloxacin is also used.

Question 18

Management of Cystic fibrosis? 6

Answer 18

Chest physiotherapy several times a day is essential to clear mucus and reduce the risk of infection and colonisation
Exercise improves respiratory function and reserve, and helps clear sputum
High calorie diet is required for malabsorption, increased respiratory effort, coughing, infections and physiotherapy
CREON tablets to digest fats in patients with pancreatic insufficiency (these replace the missing lipase enzymes)
Prophylactic flucloxacillin tablets to reduce the risk of bacterial infections (particularly staph aureus)
Treat chest infections when they occur
Bronchodilators such as salbutamol inhalers can help treat bronchoconstriction
Nebulised DNase (dornase alfa) is an enzyme that can break down DNA material in respiratory secretions, making secretions less viscous and easier to clear
Nebulised hypertonic saline
Vaccinations including pneumococcal, influenza and varicella

Other Treatment Options

Lung transplantation is an option in end stage respiratory failure
Liver transplant in liver failure
Fertility treatment involving testicular sperm extraction for infertile males
Genetic counselling

Question 19

Monitoring and prognosis of cystic fibrosis

Answer 19

Monitoring for:
- pseudomonas colonisation
- diabetes
- osteoporosis
- Vitamin D deficiency
- liver failure

Prognosis depends on multiple factors, including severity of symptoms, type of genetic mutation, adherence to treatment, frequency of infection and lifestyle. Life expectancy is improving and currently the cystic fibrosis trust gives a median life expectancy of 47 years.

90% of patients with CF develop pancreatic insufficiency
50% of adults with CF develop cystic fibrosis-related diabetes and require treatment with insulin
30% of adults with CF develop liver disease
Most males are infertile due to absent vas deferens

Question 20

What typically causes epiglottitis?

Presentation?

Investigation?

Answer 20

Epiglottitis is inflammation and swelling of the epiglottis caused by infection, typically with haemophilus influenza type B. The epiglottis can swell to the point of completely obscuring the airway within hours of symptoms developing. Therefore, epiglottitis is a life threatening emergency.

Epiglottitis is now rare due to the routine vaccination program, which vaccinates all children against haemophilus. You need to be extra cautious and have high suspicion in children that have not had vaccines. It can present in a similar way to croup, but with a more rapid onset.

THIS CAME UP - In you exams keep a lookout for an unvaccinated child presenting with a fever, sore throat, stridor, difficulty swallowing that is sitting forward (tripod position) and drooling and suspect epiglottitis.

If the patient is acutely unwell and epiglottitis is suspected then investigations should not be performed. Performing a lateral xray of the neck shows a characteristic “thumb sign” or “thumbprint sign”. This is a soft tissue shadow that looks like a thumb pressed into the trachea. This is caused by the oedematous and swollen epiglottis. Neck xrays are also useful for excluding a foreign body.

Question 21

Management of epiglottitis

Answer 21

Epiglottitis is an emergency and there is an immediate risk of the airway closing. A key point that is often talked about with epiglottitis is the importance of not distressing the patient, as this could prompt closure of the airway. Don’t examine them and don’t make them upset.

Management of epiglottis centres around ensuring the airway is secure. Most patients do not require intubation, however there is an ongoing risk of sudden upper airway closure, so preparations need to be made to perform intubation/tracheostomy at any time.

Additional treatment once the airway is secure:

IV antibiotics (e.g. ceftriaxone)
Steroids (i.e. dexamethasone)

Most children recover without requiring intubation. A common complication to be aware of is the development of an epiglottic abscess, which is a collection of pus around the epiglottis. This also threatens the airway, making it a life threatening emergency. Treatment is similar to epiglottitis.

Question 22

Pathophysiology of a viral-induced wheeze?

Answer 22

When these small airways encounter a virus (commonly RSV or rhinovirus) they develop a small amount of inflammation and oedema, swelling the walls of the airways and restricting the space for air to flow. This inflammation also triggers the smooth muscles of the airways to constrict, further narrowing the space in the airway.

This swelling and constriction of the airway caused by a virus has little noticeable effect on the larger airways of an older child or adult, however due to the small diameter of a child’s airway, the slight narrowing leads to a proportionally larger restriction in airflow. This is described by Poiseuille’s law, which states that flow rate is proportional to the radius of the tube to the power of four. Therefore, halving the diameter of the tube decreases flow rate by 16 fold.

Air flowing through these narrow airways causes a wheeze, and the restricted ventilation leads to respiratory distress. For some reason, certain children are much more prone to this airway swelling than others. There seems to be a hereditary element, so when assessing a wheezy child ask about a family history of viral-induced wheeze. These children are at higher risk of developing asthma in later life.

This is really similar to the pathophysiology of bronchiolitis

Question 23

A 3 year old presents with SOB, signs of respiratory distress, and an expiratory wheeze throughout the chest two days after having a fever and cough.

Diagnosis?

Management?

Answer 23

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
TOM TIP: Neither viral-induced wheeze or asthma cause a focal wheeze. If you hear a focal wheeze be very cautious and investigate further for a focal airway obstruction such as an inhaled foreign body or tumour. These patients will require an urgent senior review.

The distinction between a viral-induced wheeze and asthma is not definitive. Generally, typical features of viral-induced wheeze (as opposed to asthma) are:

Presenting before 3 years of age
No atopic history
Only occurs during viral infections

Asthma can also be triggered by viral or bacterial infections, however it also has other triggers, such as exercise, cold weather, dust and strong emotions. Asthma is historically a clinical diagnosis, and the diagnosis is based on the presence of typical signs and symptoms along with variable and reversible airflow obstruction.

Management of viral-induced wheeze is the same as acute asthma in children - oxygen, salbutamol, steroids.

Question 24

What is Pneumonia? KEY

Causes of pneuomonia in children?

Answer 24

Pneumonia is simply an infection of the alveoli. It causes inflammation of the lung tissue and sputum filling the airways and alveoli. Pneumonia can be seen as consolidation on a chest xray. It can be caused by a bacteria, virus or atypical bacteria such as mycoplasma.

Bacterial

Streptococcus pneumonia is most common
Group A strep (e.g. Streptococcus pyogenes)
Group B strep occurs in pre-vaccinated infants, often contracted during birth as it often colonises the vagina.
Staphylococcus aureus. This causes typical chest xray findings of pneumatocoeles (round air filled cavities) and consolidations in multiple lobes.
Haemophilus influenza particularly affects pre-vaccinated or unvaccinated children.
Mycoplasma pneumonia, an atypical bacteria with extra-pulmonary manifestations (e.g. erythema multiforme).

Viral

Respiratory syncytial virus (RSV) is the most common viral cause
Parainfluenza virus
Influenza virus

Question 25

Presentation of a pneumonia - 2 key ones?

Characteristic chest signs of pneumonia?

Answer 25

Cough (typically wet and productive)
High fever (> 38.5ºC)

Tachypnoea
Tachycardia
Increased work of breathing
Lethargy
Delirium (acute confusion associated with infection)

There are characteristic chest signs of pneumonia:

Bronchial breath sounds. These are harsh breath sounds that are equally loud on inspiration and expiration. These are caused by consolidation of the lung tissue around the airway.
Focal coarse crackles caused by air passing through sputum similar to using a straw to blow into a drink.
Dullness to percussion due to lung tissue collapse and/or consolidation.

ME- FOCAL INFECTION IS KEY WITH BACTERIAL PNEUMONIA, VIRAL INFECTION IS MORE WIDESPREAD

Question 26

Paediatric Pneumonia:
- Investigations?
- management?

Answer 26

Ix:
-CXR - useful if there is doubt but not required to confirm
- sputum cultures, throat swabs for bacterial culture and viral PCR can help establish the causitive organism
- capillary blood gas analysis for monitiring respiratory acidosis and blood lactate in unwell children

Rx:
- amoxicillin is first line
- adding a macrolide will cover an atypical pneumonia (mycoplasma)
- IV antibiotics in sepsis
- Oxygen saturations should be maintained above 92%

Me just a note when reviewing - adults and children are targtted above 94% susually but in RDS and pneuomnia the minimum level is lower at 92%

Question 27

Investigations for children with recurrent LRTI requiring antibiotics 6

Answer 27

This is your card for immunocompromised basically.

When a child is having recurrent admission requiring antibiotics for a lower respiratory tract infections it is worth considering further investigations for underlying lung or immune system pathology.

A thorough history (including family history) and examination is needed to assess for reflux, aspiration, neurological disease, heart disease, asthma, cystic fibrosis, primary ciliary dyskinesia and immune deficiency.

The following tests can be done:
- Full blood count to check levels of various white blood cells.
- Chest xray to screen for any structural abnormality in the chest or scarring from the infections.
- Serum immunoglobulins to test for low levels of certain antibody classes indicating selective antibody deficiency.
- Test immunoglobulin G to previous vaccines (i.e. pneumococcus and haemophilus). Some patients are unable to convert IgM to IgG, and therefore cannot form long term immunity to that bug. This is called an immunoglobulin class-switch recombination deficiency.
- Sweat test to check for cystic fibrosis.
- HIV test, especially if mum’s status is unknown or positive.

Question 28

What causes an acute exacerbation of asthma?

Presentation?

Answer 28

An acute exacerbation of asthma is characterised by a rapid deterioration in the symptoms of asthma. This could be triggered by any of the typical asthma triggers, such as infection, exercise or cold weather.

Presentation
Progressively worsening shortness of breath
Signs of respiratory distress
Fast respiratory rate (tachypnoea)
Expiratory wheeze on auscultation heard throughout the chest
The chest can sound “tight” on auscultation, with reduced air entry

A silent chest is an ominous sign. This is where the airways are so tight it is not possible for the child to move enough air through the airways to create a wheeze. This might be associated with reduce respiratory effort due to fatigue. A less experienced practitioner may think because there is no respiratory distress and no wheeze the child is not as unwell, however in reality this a silent chest is life threatening.

Question 29

Grading the severity of acute exacerbations of asthma

Answer 29

Moderate:
- peak flow >50% predicted
- normal speech
- no other features

Severe:
- Peak flow <50% predicted
- unable to complete sentence in one breath
- saturations below 92%
- High resp rate >30 above 5ys, and above 40 below 5ys

Life threatening:
- peak flow <33% predicted
- sats also below 92
- exhaustion and poor respiratory effort
- cyanosis
- silent chest
- hypotension
- altered conciousness

Question 30

Management of acute exacerbations of asthma:
- 4 staples of management
- management for mild cases
- managmeent for severe cases? - KEY THEY TESTED THIS

Answer 30

Staples of management in acute viral induced wheeze or asthma are:

• Supplementary oxygen if required (i.e. oxygen saturations less than 94% or working hard)
• Bronchodilators (e.g. salbutamol, ipratropium and magnesium sulphate)
• Steroids to reduce airway inflammation: prednisone (orally) or hydrocortisone (intravenous)
• Antibiotics only if a bacterial cause is suspected (e.g. amoxicillin or erythromycin)

Mild cases can be managed as an outpatient with regular salbutamol inhalers via a spacer (e.g. 4-6 puffs every 4 hours).

Moderate to severe cases require a stepwise (brinchodilator ladder) approach working upwards until control is achieved:
- Salbutamol inhalers via a spacer device: starting with 10 puffs every 2 hours
- Nebulisers with salbutamol / ipratropium bromide
- Oral prednisone (e.g. 1mg per kg of body weight once a day for 3 days)
- IV hydrocortisone
- IV magnesium sulphate
- IV salbutamol
- IV aminophylline

LAST RESORT- ANATHSTISIS They may need intubation and ventilation (Rapid sequence induction = intubation).

NOTE - If the CO2 and pH starts climbing (no longer acidotic) that is bad sign that they are tiring…

Consider monitoring the serum potassium when on high doses of salbutamol as it causes potassium to be absorbed from the blood into the cells.

It is also worth noting that salbutamol causes tachycardia and a tremor.

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

Question 31

Presentation suggesting asthma vs another diagnosis?

typical asthma triggers?

Answer 31

Presentation Suggesting a Diagnosis of Asthma

Episodic symptoms with intermittent exacerbations
Diurnal variability, typically worse at night and early morning
Dry cough with wheeze and shortness of breath
Typical triggers
A history of other atopic conditions such as eczema, hayfever and food allergies
Family history of asthma or atopy
Bilateral widespread “polyphonic” wheeze heard by a healthcare professional
Symptoms improve with bronchodilators

Presentation Indicating a Diagnosis Other Than Asthma

Wheeze only related to coughs and colds, more suggestive of viral induced wheeze
Isolated (no other sx) or productive cough
Normal investigations
No response to treatment
Unilateral wheeze suggesting a focal lesion, inhaled foreign body or infection

Typical Triggers
Dust (house dust mites)
Animals
Cold air
Exercise
Smoke
Food allergens (e.g. peanuts, shellfish or eggs)

Question 32

Ix for paediatric asthma

Answer 32

There is no gold standard test or diagnostic criteria for asthma. A diagnosis is made clinically based on a typical history and examination. Children are usually not diagnosed with asthma until they are at least 2 to 3 years old. When there is a low probability of asthma and the child is symptomatic, consider referral to a specialist for diagnosis.

When there is an intermediate or high probability of asthma, a trial of treatment can be implemented and if the treatment improves symptoms a diagnosis can be made.

There are investigations that can be used where there is an intermediate probability of asthma or diagnostic doubt:

Spirometry with reversibility testing (in children aged over 5 years)
Direct bronchial challenge test with histamine or methacholine
Fractional exhaled nitric oxide (FeNO)
Peak flow variability measured by keeping a diary of peak flow measurements several times a day for 2 to 4 weeks

Question 33

KEY Management of chronic asthma in children

Answer 33

Under 5:
- SABA - salbutamol prn
- Corticosteroid inhaler or montelukast
- add the other one from step 2

5-12:
1. SABA- salbutamol prn
2. regular corticosteroid inhaler
3. LABA - salmeterol
4. Increase corticosteroid to medium dose, add montelukast, oral theophyline
5. high dose corticosteroid

12+/ same as adults:
1. SABA
2. regular corticosteroid inhaler
3. LABA - salmeterol
4. Increase corticosteroid to medium dose, add montelukast, oral theophyline (saba) or LAMA (tiotropium)
5. high dose ICS, oral salbutamol

ME - Learn under fives (easy), Learn: salbutamol, ICS, LABA (salmeterol), ICS AGAIN, then… monteleukast, theophyline or adults tiotropium

Using an inhaler with a spacer
- spray the dose and take steady breaths in and out 5 times, or exhale and take one deap breath in and hold for 10 seconds

Question 34

Whooping cough:
- infectious organism
- U or LRTI?
- presentation?
- Ix?
- Rx?
complication?

Answer 34

Whooping cough is an upper respiratory tract infection caused by Bordetella pertussis (a gram negative bacteria).

Children and pregnant women are vaccinated against pertussis. The vaccine becomes less effective a few years after each dose.

Presentation
Pertussis typically starts with mild coryzal symptoms, a low grade fever and possibly a mild dry cough.

More severe coughing fits start after a week or more. These involve sudden and recurring attacks of coughing with cough free periods in between. This is described as a paroxysmal cough. Coughing fits are severe and keep building until the patient is completely out of breath. Patient typically produces a large, loud inspiratory whoop when the coughing ends. Patients can cough so hard they faint, vomit or even develop a pneumothorax. Bear in the mind that not all patients will “whoop” and infants with pertussis may present with apnoeas rather than a cough

Ix:
- Nasopharangeal swap with PCR testing and bacterial culture
- After 3 weeks - anti-pertussis toxin IgG oral fluid test

Management
- notifable disease
- supportive care- admission for apnoaes, cyanosis or severe coughing fits
-Macrolide antibiotics such as azithromycin, erythromycin and clarithromycin can be beneficial in the early stages (within the first 21 days) or vulnerable patients. Co-trimoxazole is an alternative to macrolides.
- Close contacts with an infected patient are given prophylactic antibiotics if they are in a vulnerable group, for example pregnant women, unvaccinated infants or healthcare workers that have contact with children or pregnant women.

The symptoms typically resolve within 8 weeks, however they can last several months. It is also known as the “100-day cough” due to the potential long duration of the cough. A key complication of whooping cough is bronchiectasis.

Question 35

What is Bronchopulmonary dysplasia?

Prevention? 4

Management? 2

Answer 35

Chronic lung disease of prematurity (CLDP) is also known as bronchopulmonary dysplasia. It occurs in premature babies, typically those born before 28 weeks gestation. These babies suffer with respiratory distress syndrome and require oxygen therapy or intubation and ventilation at birth. Diagnosis is made based on chest xray changes and when the infant requires oxygen therapy after they reach 36 weeks gestational age.

The lung damage comes from pressure and volume trauma of artificial ventilation, oxygen toxicity and infection with the CXR characteristically showing widespread areas of opacification and sometimes cystic changes, fibrosis and even lung collapse.

Features:
Low oxygen saturations
Increased work of breathing
Poor feeding and weight gain
Crackles and wheezes on chest auscultation
Increased susceptibility to infection

Prevention:
- Giving corticosteroids (e.g. betamethasone) to mothers that show signs of premature labour at less than 36 weeks gestation can help speed up the development of the fetal lungs before birth and reduce the risk of CLDP.
- Using CPAP rather than intubation and ventilation when possible
- Using caffeine to stimulate the respiratory effort
- Not over-oxygenating with supplementary oxygen

Management:
- Babies may be discharged with a low dose of oxygen to continue at home
- monthly palivizumab injections to prevent RSV infection

Question 36

KEY

Croup and Bronchiolitis - which virus causes each?

Answer 36

CrouP - P arainfluenza virus

BronchiolitiS - Syncytial virus

Question 37

GENERAL MEDICAL CARD

Pneumonia vs LRTI

Answer 37

LRTIs encompass a range of conditions, including:
Bronchitis: Infection of the bronchi, usually causing a productive cough.
Bronchiolitis: Inflammation of the smaller airways, typically seen in young children.
Pneumonia: Infection of the air sacs (alveoli) in the lungs.

Pneumonia:
Pneumonia is a specific type of LRTI that affects the alveoli (air sacs in the lungs), causing them to fill with fluid or pus, leading to difficulty breathing and other systemic symptoms like fever and cough.
It is typically more severe than other LRTIs and can be caused by bacteria, viruses, or fungi.

Both bronchitis and pneuomonia cause a cough but pneumonia is more severe usually also causes a high fever and more pronounced breathlessness (usuallly exertional). On auscultaiton only pneumonia will have crepitations (high pitched), bronchitis will have rhonchi (low pitched) and wheeze

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