Paeds respiratory

Question 1

Differential for the common cold

a) nasal itching, sneezing, watery rhinorrhoea, and nasal obstruction. It is also often accompanied by itchy, watery eyes.
b) Sore throat, caused by a variety of organisms, including the adenoviruses and Streptococcus pyogenes.
c) initially presents with systemic symptoms, including fever, rigors, headaches, myalgia, malaise and anorexia.
d) presents with persistent severe sore throat, fever, cervical lymphadenopathy and malaise; it is particularly common in teenagers and young adults.
e) the cough may develop later but is characteristic and is much more severe than that associated with the common cold, distress and post-tussive vomiting
f) The nasal discharge is unilateral, purulent, foul-smelling and blood-stained.
g) In infants, consider the possibility of a more serious condition (3 examples)

Answer 1

a) Allergic rhinitis
b) Pharyngitis
c) Influenza
d) Infectious mononucleosis (glandular fever)
e) Whooping cough
f) Inhaled foreign object
g) Meningitis, pneumonia, sepsis

Question 2

Main pathogen causing:

a) Croup
b) Bronchiolitis. Tested for how?
c) Common cold
d) Pharyngitis - most common? 2nd most common?
d) Pneumonia/bronchitis - give 3

Answer 2

a) Parainfluenza
b) RSV; throat swabs for rapid RSV antigen testing
c) Rhinovirus, coronavirus
d) Viral, GABS (20-40% children, 10% adults)
e) Strep pneumoniae, haemophilus influenzae,

Question 3

Management of common cold/viral URTI:

a) General advice/education
b) Self-care measures
c) Who should not have honey?

Answer 3

a) ABx will not affect duration or symptoms
- Likely self-limiting
- Safety-netting - red flags, when to seek help
- No need to take time off work or school
- Adequate hand-washing/ hygiene measures

b) - Regular fluids
- OTC lozenges, honey-based warm drinks
- Adequate rest
- Analgesia/antipyretics for fever or headache
- Vapour rubs applied to the back or chest. Gargling with salt water

c) Infants - risk of botulism

Question 4

Complications of a common cold

a) Secondary ______ infection
b) Sites that may be infected through viral spread

Answer 4

a) Bacterial

b) Otitis media, sinusitis, pneumonia (rare)

Question 5

Immunodeficiency.

a) Who to investigate for immunodeficiency?
b) What investigations to do?
c) Types of infections common in those with ID. Other red flags
d) Types of: primary ID, secondary ID
e) Management - 3 options

Answer 5

a) Frequent or unusually severe infections
Infection with unusual organism
Family history

b) FBC : low total WBC, neutrophil or lymphocytes
Total IgG, IgA, IgM +/-E
Responses to routine immunisations
Lymphocyte subsets: numbers of T and B cells
Lymphocyte function

c) In one year: 2 pneumonias, 4 OMEs, 2 sinusitis, recurrent skin/organ abscesses, 2 sepsis, 2 thrush; failure of ABx effect, FTT, FHx
d) hypogamma (?X-linked), SCID, ; malignancy, chemotherapy, HIV, steroids, malnutrition, chronic disease, splenectomy
e) Antibiotic / antiviral prophylaxis, Prompt treatment of infections, Replacement IGs, Bone marrow transplant

Question 6

Acute asthma management

a) OH SHIT ME
b) Also, before leaving hospital make sure to…?

Answer 6

Oxygen
Salbutamol
Hydrocortisone/prednisolone
Ipratropium
Theophylline
MgSO4
Escalate

b) - Check inhaler technique and compliance
- Arrange review
- Asthma action plan

Question 7

Bronchiolitis.

a) Cause and risk factors
b) Clinical features (4 Cs)
c) vs. viral wheeze (main differential) or pneumonia
d) Diagnosis
e) Management
f) Vaccine - who is eligible? (3)

Answer 7

a) - RSV, other viruses
- Children < 2 (usually <1 year); RFs - prem, LBW, passive smoke, chronic lung disease (or history of ventilation), congenital heart disease, immunocompromised

b) - Coryzal history (1 - 3 days), followed by:
- Cough, AND
- Chest recession / tachypnoea, AND
- Crackles / wheeze on auscultation (usually widespread)
- Other features: fever, poor feeding, lethargy

c) - Viral wheeze: history/FHx of atopy, no crackles, episodic symptoms, responsive to bronchodilators
- Pneumonia: fever > 39C, focal crackles

d) NPA sample- RSV rapid antigen testing

e) - Mainstay: reassure that usually self-limiting, mostly managed at home, fluids and good nutrition, temperature control (antipyretics only if pyrexial)
- If admitting to hospital - give oxygen to maintain SpO2 above 92%
- Hospital care: oxygen, NG feeding if necessary, for those with respiratory failure - high-flow oxygen or CPAP

f) Pavalizumab:
- Chronic lung disease (BPD)
- Congenital heart disease
- Severe combined immunodeficiency (SCID)

Question 8

Bronchiolitis: indications for referral to secondary care

Answer 8

• Apnoea (observed or reported).
• Marked chest recession or grunting.
• Respiratory rate >70 breaths/minute.
• Central cyanosis.
• Oxygen saturation of less than 92%.
• The child looks seriously unwell to a healthcare professional

Question 9

Croup.

a) Cause and risk factors
b) Clinical fx
c) Diagnosis
d) Management

Answer 9

a) - Parainfluenza, other viruses (e.g. RSV)
- Demographics: 6 months - 3 years; autumn and spring

b) Prodrome: coryzal, URTI
- Characteristic barking cough and hoarse cry (worse at night) and inspiratory stridor
- Severe: drowsiness, cyanosis, recessions

c) Clinical - do not agitate the child or examine the throat

d) - Mild-severe: Oral dexamethasone (+ 2nd dose if needed after 12 hours)
- Mod-severe: nebulised adrenaline
- General: fluids, temperature control, adequate nutrition, oxygen if required, keep child calm, don’t examine throat

Question 10

Croup: assessment of severity (Westley score)

- Mnemonic - CRABS

Answer 10

o	Consciousness (Reduced = 5)
o	Recessions (0 - 3: none, mild, moderate, severe)
o	Air entry reduced (0 - 2: normal, mild and marked reduction)
o	Blue (cyanosis = 5)
o	Stridor (0 - 2: none, on exertion, at rest)

Mild croup: 0 - 3 (manage at home)
Moderate: 4 - 6 (hospital)
Severe: 7+ (hospital)

Question 11

Whooping cough.

a) Clinical features
b) Investigations
c) Management

Answer 11

a) Paroxysmal cough, post-tussive vomiting

b) NPA aspirate/swab culture
- for bordetella pertussis

c) - Macrolide antibiotic (eg. clarithro)
- Notify PHE
- Admit if unwell infant