Pulmonology Flashcards
Define paediatric asthma
Recurrent (3 or more episodes) wheezing and or dyspnoea that respondS to bronchodilator has asthma until proven otherwise
Can only be diagnosed from age 3
Name clinical features asthma (5)
• Expiratory wheeze
• dry cough
• dyspnoea
• allergic facies: Dennie Morgan lines /folds in atopic dermatitis, allergic shiners (infraorbital edema and darkening), allergic nasal crease/salute
• long face syndrome: open mouth, flat and long midface, retract upper lip, narrowing of hard palate causing crowding of maxillary teeth
Diagnosis asthma? (5)
Children under 5
• recurrent wheeze /bronchiolitis > 3 episodes
• positive bronchodilator response
• family and personal history atopy
Children over 5
• same history
• lung function tests: peak flow meter or spirometry
Treatment acute asthma attack? (2)
Emergency!
• beta 2 agonist eg albuterol 2-10 puffs via spacer,/nebulisation, increase by 2 puffs every 2 minutes up to 10 puffs
• oral prednisone 2mg/kg po
Treatment chronic asthma? (5)
Goal = free from symptoms and unrestricted lifestyle, can attend school and participate in sports.
Follow GINA guidelines: (children 6-11)
• step 1 intermittent asthma: No controller, saba eg albuterol as needed (alternative: low dose inhaled corticosteroids taken with saba or daily low dose inhaled corticosteroids)
• step 2: daily low dose ICS (controller) eg beclate and saba (reliever) as needed (alternative controller: daily leukotriene receptor antagonist, or low dose iCs taken when saba is taken)
• step 3: low dose ics-laba or medium dose ics, and saba as needed (alt: low dose ics and ltra)
• step 4: medium dose ics-laba, refer for expert advice, saba reliever (alt: high dose ics-laba,or add on tiotropium, or add on lrta)
• step 5: refer for phenotypic assessment and add on therapy eg anti-ige (alt: add il-5, or add low dose ocs)
Name red flag symptoms for chronic lung disease (6)
• Chronic cough > 3 weeks
• copious mucous secretion (productive cough)
• cough on feed / history choking
• recurrent or persistent noisy breathing (snoring, stridor, wheeze)
• dyspnoea, exercise intolerance
• recurrent and non-resolving lower respiratory tract infections (pneumonia, bronchiolitis)
Name red flag signs for chronic lung disease (6)
• Stunted (typical) or wasted growth
. Hypoxia chronic
• clubbing
• allergic face
• chest wall deformity
• persistent abnormalities on auscultation
How tell if clubbing? (2)
Loss of shamroth window when put fingers together
And Lovibond’s angle (clubbing > 180)
Also: Curth’s angle (distal phalangeal joint); Goyal and Griffith’s index of nail curvature
Define bronchiectasis
Impaired clearing of secretions from affected parts of lung resulting in repeated lower respiratory tract infections, due to permanent destruction of bronchial walls and lung tissue from chronic infection
→ irreversible airway dilatation and distortion
“Vicious cycle” of infection, inflammation, airway damage
How classify bronchiectasis? Name 8 causes.
• Cystic fibrosis related
• non cystic fibrosis related
-focal (do bronchoscopy)
→ foreign body (most common)
→ endobronchial masses and tumours
-generalised diffuse
→ HIV
→ Tb
→ primary ciliary dyskinesia
→ primary immunodeficiency states
→ aspiration (neuromuscular disease, cleft lip and palate, trachea oesophageal fistula, GERD, )
→ mediastinal masses eg lymphoma
Name 3 symptoms bronchiectasis
• Chronic productive cough
• halitosis
• haemoptysis
Name 8 signs bronchiectasis
• Clubbing
• chest deformities
• signs of air trapping: barrel chest, displaced liver, decreased cardiac dullness
• failure to thrive
• widespread coarse crackles
• stunting (higher metabolic demand)
• pulmonary hypertension
• cor pulmonale
If bronchiectasis due to local disease: trachea displaced to side of pathology and bronchial breathing and crackles
Treat bronchiectasis? (7)
• treat underlying cause
• “keep lungs clean”:
• treat acute exacerb with antibiotics (co-amoxiclaV: 2 weeks best)
• daily physio
• immunisations
•Immuno-modulation of air way inflammation with azithromycin in selected patients
• lobectomy of localised bronchiectasis, especially if no response to medical therapy
Aetiology cystic fibrosis?
Autosomal recessive, cftr gene on chromosome 7 which causes defective chloride ion pump found in lungs, intestines, pancreatic ducts, biliary tree, sweat glands, reproductive organs → mucous plugging and recurrent infections, exocrine pancreatic insufficiency
Presentation cystic fibrosis? (6)
• intestines: neonates: meconium ileum or plaque (suspect in any neonate with intestinal obstruction)
• biliary system: cholestatic jaundice - obstructed by thick viscous bile → chronic liver disease
• pancreas: obstruction → impaired excretion pancreatic enzymes → exocrine insufficiency
-steatorrhoea
-vitamin Kade deficiency → peripheral edema
• lungs: mucous plugging and recurrent infections, prolonged and recurrent wheezing, failure to thrive (week 1 ) → bronchiectasis
• reproductive: infertility
• Ent: sinus obstruction, chronic rhinosinusitis, polyposis
Diagnosis cystic fibrosis (3)
• two positive Sweat chloride test > 60 mmol/ L
• genetic test
Also: stool chemotrypsin and stool faecal elastase for git involvement
Treatment cystic fibrosis? (3)
• Lung: nebulisations to liquefy secretions, intensive physio, aggressive treatment of acute infections with antibiotics (pseudomonas aeruginosa prevent and eradicate: most rapidly lose lung function) , lung transplant if available
• pancreatic enzyme replacement: Creon
• multidisciplinary
Define chronic cough
> 21 days
Name 9 common acute causes of upper airway obstruction
Infectious
• laryngo - tracheo- bronchitis
• epiglottitis
• bacterial tracheitis
• retropharyngeal abscess
• paratracheal gland enlargement
Mechanical.
• foreign body
Allergic
• AngiOneurotic oedema
Trauma,,
• intubation injury
• thermal injury
Name 5 common chronic causes of upper airway obstruction
Congenital
• laryngomalacia
• laryngeal cysts
Infections
• laryngeal papillomatosis
• hypertrophy of tonsils and adenoids
Trauma
• subglottic stenosis
Name 6 causes of intrathoracic large airway obstruction
• Foreign body inhalation
• Tb gland obstruction
• congenital abnormalities
• anomalous artery
• bronchogenic cyst
• tracheomalacia
Name 7 causes of intrathoracic small airway obstruction
• Acute viral bronchiolitis
• asthma
• pneumonia with eosinophilia
• aspiration pneumonia
• cardiac failure
• cystic fibrosis
• bronchiectasis
Define and describe presentation lymphocytic interstitial pneumonitis (5)
• Chronic lymphocytic infiltrative disease from dysregulated immune response with hiv!/ebv interaction. Most common cause pulmonary disease in HIV infected children after PJP.
• common age 1-5!
• chronic cough, sob, recurrent pneumonia, FTT, clubbing!, generalised lymphadenopathy, parotid enlargement!, hepatosplenomegaly, barrel chest with diffuse crackles.
• CXR,: diffuse interstitial infiltrates with coarse nodular appearance (often confused with military tb)
• clinical diagnosis
• complications = bronchiectasis → corpulmonale
Treatment lymphocytic interstitial pneumonitis? (2)
• Arvs
• prednisone 2mg/kg for 30 days if very symptomatic.
Usually good outcome.
First line treatment Tb paeds for <8 years complicated and > 8 years?
RIPES
• rifampicin
• isoniazid (with pyridoxine)
• pyrazinamide
• ethambutol
• streptomycin
Name 5 constitutional symptoms Tb
• Chronic cough
• weight loss
• poor appetite
• haemoptysis
• night sweats
Define, describe symptoms and treatment bronchiolitis obliterans (4)
• HIV positive adolescents: obliterative bronchiolitis with extension of granulation tissue into alveoli, due to repeated viral infections/hiv itself (immune response)
• hyperinflation, expiratory weeze, diffuse crackles
• lung functions show obstructive picture
• treatment ARV, not great prognosis
Define, describe clinical presentation, diagnosis and treatment primary ciliary dyskinesia (4)
• Autosomal recessive, ultrastructural defects of cilia, impaired mucous clearance from lungs, paranasal sinuses and middle ears.
• blocked nose from birth, otitis media, situs inversus (kartagener syndrome), sinusitis, chronic lung disease with progression to bronchiectasis in second decade life,
• diagnose with radio isotope clearance test or measure absence nitric oxide in exhaled air and confirmed by determine electron microscopic appearance of cilia
• treatment similar to non-cf bronchiectasis
Describe respiratory system examination (13)
• Wash hands, Introduction and orientation, Consent , position and expose patient, ensure patient comfort
• General exam: acute/chronic, anxiety/ /restlessness, drooling, equipment, jaccold
• vitals: pulse rate and rhythm, temperature, bp, sats
• interpret anthropometry
• sign respiratory distress and severity: rr, breathing pattern, flaring, recession. Presence and character cough, wheeze, stridor, stertor, voice
• features allergic facies (long face, open mouth, shiners, Dennie Morgan lines, salute,nasal crease and discharge
• inspect chest: shape (bulging, barrel, Harrison sulCus, kyphosis, scoliosis) , movement (symmetrical, Hoover sign, paradoxes)
• palpate: tracheal deviation, cardiac apex, vocal fremitus
• percussion
• auscultate each lobe
• ent exam
• summary: anatomical section affected, pathology, cause of disease, degree of function compromised, complications
• differential diagnosis, most likely diagnosis, management
Name 2 causes cough with wheeze
• Asthma
• viral
Name causes productive cough
Lower respiratory tract infection
Name causes barking cough
• croup (usually viral, parainfluenza)
• laryngomalacia
Name 2 causes dry cough
• Allergies
• Tb
Name causes hoarse voice
Laryngitis
Name causes hot potato voice
Peritonsillar abscess
Thick, muffled voice
Name 5 causes acute stridor
• Croup
• foreign body
• bacterial tracheitis
• epiglottitis
- laryngitis
- VC dysfunction / spasm
Name 2 causes chronic stridor
• Laryngomalacia
• subglottic stenosis
Name 3 respiratory causes central cyanosis
•Persistent pulmonary ht
• bronchospasm
• lower respiratory tract infection
How does respiratory examination differentiate between upper and lower respiratory infections
Respiratory rate!
Only LRTI will have high rr as tidal volume is lowered by the LRTI (mv =tv x rate)
Cause hyper resonant percussion chest?
Decrease tissue density: pneumothorax
Cause dull percussion chest? (3)
Increased tissue density
• consolidation
• fluid
• tumour
• collapse
Cause stony dull percussion chest?
Pleural effusion
Cause bronchial breath sounds? How sound?
Consolidation, esp lobar pneumonia
Higher pitched harsh breath sounds (normal to be heard over trachea)
Length of inspiration and expiration equal
What is abdominal breathing?
Normal finding - abdomen and chest move in same direction. Out on inspiration, in on expiration.
Only pathological if move in opposite directions - paradoxical breathing (chest is abnormal not abdomen - chest move in on inspiration, out on expiration)
= severe resp distress. More commonly seen with upper obstructions
Causes course crackles (2)
• Consolidation
• pulmonary edema, (associated with left ventricular failure)
Causes fine crackles
Pulmonary fibrosis
Causes wheeze? How sound? (5)
• Polyphonic: asthma
• monophonic: foreign body
- inflammatory obstruction: bronchiolitis
- extraluminal compression: lymph nodes, vascular rings
- exaggerated physiological narrowing: bronchomalacia
High pitched expiratory sound due to distal small intrathoracic airway narrowing
Name the order of chest wall retractions as respiratory distress worsens (5)
• With worsening distress more negative pressure is created, causing first weaker then later stronger structures to move.
1. Subcostal in drawing
2. Tracheal tug
3. Supraclavicular
4. Intercostal
5. Sternal indrawing = paradoxical breathing (very severe resp distress)
Name 6 signs respiratory distress
• Tachypnoea ( to try maintain mv )
•Indrawings (increase pressure gradient to inhale more volume and increase tv )
• use accessory muscles (increase thoracic volume)
• opisthotonus position (extreme use accessory muscles, rare)
•Nasal flaring (cause higher flow and shorter inspiratory time, stabilises upper airway against larger negative pressure)
• auscultation: grunting
Causes increased vocal fremitus?
Consolidation
Hoover sign vs subcostal indrawing? (3)
• Acute Sign hyperinflation vs respiratory distress
. Diaphragm pulling in vs negative pressure “sucking in” weaker structures
• line of insertion of diaphragm fairly horizontal and felt over ribs vs fallows chest wall downwards from Xyphoid, felt immediately under ribs
Flattened diaphragm due to hyperinflation
Causes reduced vocal fremitus?
Effusion
Causes stridor? How sound?
Harsh, low pitched inspiratory noise
Upper airway obstruction
Identify pathology picture 1
Harrison’s sulcus: persistent furrow/concavity over same area of insertion of diaphragm on lower ribs. Prolonged abnormal pulling of diaphragm on ribs cause this, weeks to months of chronic lung problems.
Eg poorly controlled asthma
CHRONIC type of hoover sign
Identify pathology picture 2
Harrison’s sulcus
(Can feel better than see)
Name 2 causes pleural rub
Inflamed pleura secondary to
• pneumonia
• pulmonary embolism
Name 4 causes reduced air entry
• Pneumothorax
• consolidation
• severe asthma
• pleural effusion
Name 2 signs pulmonary hypertension on palpation
• Parasternal (and epigastric) heave due to right heart enlargement
• Palpable p2
• displaced apex beat
Treatment pneumonia in immune compromised children? (3)
Ampicillin, co-trimoxazole and aminoglycoside
Treatment pneumonia in children less than 3 months? (2)
Ampicillin and aminoglycoside
Treatment hospital acquired pneumonia in children? (3)
Aminoglycoside, piperacillin tazobactam, and vancomycin if suspected staph
Classify lung auscultation (8)
Musical sounds = turbulance (due to change in diameter, narrowing, )
Small airway = high pitch, large = low pitch
- wheeze (high pitch thus small airways, expiratory thus intrathoracic airways) (can be rarely combine insp and exp wheeze in severe obstruction bc insp widening of intrathroacic airway insufficient to prevent turbulence)
- stridor (low pitch thus large airways, inspiratory thus extrathoracic airways, can be combined inspiratory and expiratory with more severe obstruction bc exp widening of extrathoracic airway insufficient to prevent turbulence)
- stertor (snoring) (rough sound thus in less rigid walls, INSPIRATORY thus extrathoracic)
- musical/squeaky rhonchi (voluminous mucous cause narrowing, thus turbulence. Mucus is MOBILE, so moves or disappear cough, reposition, over time. Sound like wheeze except MOBILE)
Crackly sounds = fluid movement
- coarse crackles (rhonchi, rales) (large airways, mucus prod due to any reaction to infection/irritation/inflammation from anywhere in respiratory tract, usually diffuse)
- fine crackles (crepitations old terms) (small alveoli due to snapping open alveoli during inspiration from collapsed fluid filled alveoli due to infection or transudate eg oedema or blood, soft Velcro, usually localised NOT diffuse
Other
- bronchial breath sounds (air still moving through bronchi but alveoli not filling with air)
- grunting (increased intraluminal pressure to try avoid collapse fluid filled alveoli at expiration by closing vocal cords. Will ALSO have indrawings due to increased negative intrathoracic pressure!)
Which airways make noise on auscultation during inspiration and why?
Extrathoracic
Because physiologically narrower during inspiration
Which airways make noise on auscultation during expiration and why?
Intrathoracic airways
Because physiologically narrower during expiration
Name 5 signs hyperinflation lungs (air trapped at expiration)
Inspection
- Hoover sign
- increase AP diameter
Percussion
- decrease cardiac dullness
- liver dull below 6th ICS
Auscultation
- wheeze (intrathoracic small airways narrowing)
Name 3 causes stertor
- tonsil/ adenoid hypertrophy
- foreign body
- pharyngeal hypotonia
(Snoring, extrathoracic airway inspiratory narrowing)
Treatment primary pulmonary hypertension? (3)
- Iv prostanoids eg epoprostenol
- endothelin receptor antagonists eg macitentan
- phosphodiesterase 5 inhibitors eg sildenafil (selective pulmonary artery vasodilator)
Name 5 causes pulmonary hypertension
- Primary pulmonary ht or connective tissue disease eg SLE
- left heart failure (usually due to mi or systemic ht)
- chronic lung disease eg interstitial lung diseases
- pulmonary vascular disease eg pulmonary embolism
_Miscellaneous eg sarcoidosis, glycogen storage disease, haematological disorders
Name 2 symptoms and 4 signs pulmonary hypertension
• Sob = main symptom
• syncope
• tachycardia
• raised JvP
• hepatomegaly
• peripheral oedema
• sign increased PBF: cardiomegaly, cardiac failure, chest deformity (Harrison sulci, barrel chest )
- rv enlargement → epigastric, parasternal heave
- loud s2, palpable p2
Name 4 investigations that can be done and findings for pulmonary ht
- ECG changes caused by right sided heart strain:
→ right ventricular hypertrophy: larger r waves on right sided chest leads v1-v3 and S waves on left sided chest leads V4 -V6
→ right axis deviation
→ right BBB - CXR: dilated pulmonary arteries, r ventricular hypentrophy
-Raised nt - pro BNP = r ventricular failure
- echo to estimate pulmonary artery pressure
Name 3 most common causes of the common cold
- Mostly rhinovirus
- influenza virus
- coronaviruses
Name 6 supportive interventions for the common cold
- maintain adequate, warm liquid fluid intake
- infants: suction nose and upright positioning
- older children: saline nasal irrigation or sprays
- paracetamol for fever
- decongestants only >12 years
- cough: honey 7,5 - 10 ml before sleep! (Only > 1 year), cough lozenges or hard candy > 6 years
Identify picture 4 and what it indicates
Dennie Morgan lines: allergic facies
Identify picture 5
Allergic shiners and Dennie Morgan lines: allergy
Identify picture 6 and what it indicates
Allergic shiners, Dennie Morgan lines, allergic salute on nose
Identify picture 7 and what it indicates
Long face syndrome: flat nasal bridge, long mid face, protruding teeth, prognathism, droopy lower lip and hypotonic upper lip, sleep apnoea and fatigue
Indicate mouth breathing
Identify picture 8
Pectus carinatum
When does thymus disappear
2-8 years
Identify picture 18. What does it indicate?
Hoover sign
Sign hyperinflation.
At expiration, air trapped lungs don’t allow diaphragm to come Up in dome shape. Inspiration, diaphragm’s muscle contraction can only shorten inwards not downwards.
Felt over ribs.
Harrison sulcus vs Hoover sign (3)
- chronic vs acute
- sign of abnormally weak bones (eg rickets) or chronic respiratory disease (eg chronic severe asthma) vs sign of hyperinflation
- in drawing of ribs by diaphragm at lower end of rib cage at 6th rib during inspiration and expiration vs flat diaphragm causing pulling in of inferior ribs on inspiration bc diaphragm contract inward instead of downward
Name 3 clinical signs laryngotracheobronchitis.
- barking cough
- hoarseness
- Acute stridOr (most common cause) (oedema → airway obstruction
- preceded by URTI
Most common cause laryngotracheo bronchitis?
Almost always viral (parainfluenza) (sometimes HSV, measles, candidiasis in HIV )
Classification and treatment laryngotracheo bronchitis? (4)
Grade 1: inspiratory stridor (observe)
2: + expiratory (adrenaline nebs)
3: + pulsus paradoxus (intubate, steroids )
4: impending apnoea (intubate, steroids )
Differential acute stridor without prodrome? (2)
- Foreign body
- Angioneurotic oedema
Differential stridor with incomplete immunisation and membrane in upper airway?
Diphtheria
Differential stridor with high fever, dysphagia, drooling or sitting position? (3)
- Epiglottitis
- retropharyngeal abscess
- bacterial tracheitis
Differential stridor with recurrent upper airway obstruction?
Laryngeal papilloma
Criteria diagnosis anaphylaxis? (3)
Any :
- sudden onset illness (minutes to hours) with involvement skin, mucosa or both ( eg generalised hives, itching / flushing, swollen lips - tongue - uvula) and sudden resp symptoms signs / sudden reduced bp or symptoms end organ dysfunction
- 2 or more after exposure to likely antigen/trigger: sudden skin/ mucosal symptoms and signs, respiratory, reduced bp or end organ dysfunction, git
- reduced bp after exposure to known allergen
Name 6 indications epipen
- Previous severe anaphylaxis to food, latex, aero allergens
- coexistent unstable / moderate to severe asthma withgood allergy
- exercise induced anaphylaxis
- idiopathic anaphylaxis
- untreated venom allergy with systemic reactions
- underlying mast cell disorder with previous systemic reactions
