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Resp Flashcards

1
Q

What is Bronchiolitis?

A

Viral infection characterised by acute bronchiolar inflammation

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2
Q

What is the cause of bronchiolitis?

A

Respiratory syncytial virus

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3
Q

What are the RFs for bronchiolitis?

A

Prematurity
Chronic lung disease
Congenital / acquired lung disease
CHD
Immunodeficiency
FHx of atopy
Winter

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4
Q

What are protective factors for bronchiolitis?

A

Breastfeeding and parental avoidance of smoking

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5
Q

What are the symptoms of bronchiolitis?

A

Illness tends to peak at day 5
Dry cough, SOB, wheeze, fever, poor feeding

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6
Q

What are the signs O/E of bronchiolitis?

A

General = pyrexia, tachycardia, irritability, lethargy

Resp = tachypnoea, subcostal/intercostal recessions, nasal flaring, grunting, high-pitched expiratory wheeze, fine bi-basal end expiratory crackles, cyanosis if severe

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7
Q

What is the admission criteria for bronchiolitis?

A
  • Inadequate feeding
  • Resp distress / central cyanosis / hypoxia
  • Child looks unwell
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8
Q

What are the investigations for bronchiolitis?

A

Clinical diagnosis with SpO2

Bloods (increased WCC, hyponatraemia)

CBG (consider with worsening resp distress)

CXR (if suspicion of pneumonia)

Serology (RSV with nasopharyngeal aspirate)

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9
Q

What is the management of bronchiolitis?

A

Parental advice + safety netting:

  • Bring child back if worsening resp distress, worsening feeding, fever, or generally worried

Supportive if severe:

  • Oxygen via nasal cannula or mask (SpO2<92)
  • Fluids by NGT (cannot take enough orally)
  • CPAP (if impending resp failure)
  • Nebulised saline
  • Consider PT in children with relevant co-morbidities

> Most recover in 2 weeks

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10
Q

What is used to prevent bronchiolitis?

A

Palivizumab

For high-risk preterm infants (congenital or acquired lung disease, CHD, immunodeficiency)

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11
Q

What is croup?

A

Viral infection of the airway characterised by progressive spread of inflammation down the respiratory tract, starting at the larynx then trachea and bronchi

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12
Q

What age does croup present?

A

Common between 6m-6y (peak 2yrs)

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13
Q

What is the cause of croup?

A

Most common = Parainfluenza

Other = RSV, influenza, rhinoviruses

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14
Q

What are the RFs for croup?

A

More in autumn months
LBW
Prematurity

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15
Q

What are the symptoms of croup?

A

Coryza
Barking / croupy cough
Hoarse voice
Stridor 1-2d after cough
Increased respiratory effort
Sx often worse at night

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16
Q

What are the signs O/E of croup?

A

Mild = barking cough, alert + well perfused

Moderate = barking cough, alert + well perfused, inspiratory stridor, chest retractions

Severe = barking cough (may be quiet), stridor (may be biphasic), agitated or lethargic, +/- cyanosis

Impending resp failure = barking cough (may be quiet/absent), stridor (may be soft), chest retractions (may be reduced), lethargic, fatigued, reduced LOC, cyanosis

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17
Q

What are the investigations for croup?

A

Clinical dx

  • Do NOT examine throat (could worsen breathing difficulties)

Westley Croup Severity Score

  • Mild = 0-2
  • Moderate = 3-7
  • Severe = 8-11
  • Impending resp failure = 12-17
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18
Q

What are the signs of croup on a CXR?

A

steeple sign

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19
Q

What is the management for croup?

A

Single dose oral dexamethasone 0.15mg/kg
(all children regardless of severity)

+Admit if moderate/severe
+Add nebulized adrenaline in moderate
+Add oxygen in severe
+Consider intubation in impending resp failure
+Paracetamol or ibuprofen (if destressed)
+Can repeat dex if symptoms persist

> > > Sx tend to resolve in 3-5d

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20
Q

What are the complications of croup?

A

Upper airway obstruction is the major complication

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21
Q

What is epiglottitis?

A

Rare but serious infection characterised by intense swelling of the epiglottis and associated with sepsis

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22
Q

What causes epiglottitis?

A

Haemophilus influenza type B

  • Quite uncommon now due to vaccination
  • Most common in UK is GAS
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23
Q

What are the S/S of epiglottitis?

A

Rapid onset

  • High fever (‘toxic-looking’)
  • Stridor (soft inspiratory)
  • Drooling (child cannot swallow)
  • Tripod sign/position (immobile, upright and open mouth)
  • High RR
  • (NO cough)
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24
Q

What are the investigations for epiglottitis?

A

Do NOT lie child down, do NOT examine child’s throat

Clinical diagnosis and immediate anaesthetic opinion (made by direct visualisation by senior/airway trained staff)

Also:

  • CXR (if concern of foreign body)
  • Blood cultures
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25
Q

How does epiglottis present on a CXR?

A

‘thumb sign’ (swelling of epiglottis)

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26
Q

What is the management of epiglottitis?

A

MEDICAL EMERGENCY, ABCDE approach

  1. Urgent admission and transferal to ITU
  2. Secure airway (endotracheal intubation may be necessary)
  3. Supplemental oxygen
  4. IV antibiotics = cefuroxime / ceftriaxone
  5. +/- dexamethasone / adrenaline

> > > Most children recover in 2/3d

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27
Q

What is VEW?

A

Inflammatory airway disease caused by viral infection and considered to be a precursor to asthma (‘pre-school asthma’)

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28
Q

What is asthma?

A

Chronic inflammatory airway disease characterised by variable reversible airway obstruction, airway hyperresponsiveness and bronchial inflammation (wheezing isn’t transient and persists past pre-school)

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29
Q

What are the RFs for VEW/asthma?

A
  • FHx of asthma / atopy
  • Passive / active smoking
  • URTIs
  • Cold weather
  • Inhalant allergies
  • Food allergens
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30
Q

What are the symptoms of VEW/asthma?

A

Wheeze
Breathlessness
Non-productive cough (productive if superimposed infection)
Chest pain / tightness
Trouble sleeping > sx worse at night/morning (lower cortisol levels at night mean it’s anti-inflammatory effect is reduced)

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31
Q

What are the signs of VEW/asthma?

A

End-expiratory polyphonic wheeze
Hyperinflated chest
Use of accessory muscles
Tachypnoea
Hyperresonant percussion
Harrison’s Sulcus > indentation on chest roughly along the sixth rib (usually bilateral)

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32
Q

What are the investigations for VEW/asthma?

A
  • Examination
  • Obs
  • PEFR

Diagnosis:

  • Spirometry - FEV1/FVC <70% and FEV1 <80% predicted
  • Bronchodilator reversibility test - 12% pre-/post-difference

Consider:

  • PEFR variability
  • FeNO testing
  • Bloods, sputum culture, CXR
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33
Q

What is the management of an acute asthma attack?

A

Admit those with severe or life-threatening classification

1. High flow oxygen (if hypoxia, achieve normal sats 94-98%, face mask, Venturi mask or nasal cannula)

2. Burst therapy – 3x salbutamol nebs, 2x ipratropium bromide nebs

3. Corticosteroids (stat dex, or 3d PO prednisolone, or IV hydrocortisone if not tolerated)

  1. It not resolved = IV bolus magnesium sulphate
  2. If not resolved = IV infusion salbutamol
  3. If not resolved = IV infusion aminophylline
  4. Intubate and ventilate if classified as life-threatening > transfer to ICU

After pt stabilised

  1. Wean salbutamol (1-hourly > 2-hourly > 3-hourly > 4-hourly)
  2. Home = stable on 4-hourly tx, PEF at 75% of best/predicted, SpO2 > 94%
  3. 3-5d course of PO prednisolone
  4. Pt education
    - When drugs should be used (regularly or PRN)
    - How to use the drug (inhaler technique)
    - What each drug does (relief vs prevention)
    - How often and how much can be used (frequency and dosage)
    - What to do if asthma worsens (a written personalised asthma management action plan should be compiled)
  5. Follow-up = within 2d of discharge
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34
Q

What is the management of chronic asthma?

A

(1) SABA prn (salbutamol)

(2) SABA + low-dose ICS (becotide / Beclomethasone)

(3) SABA + ICS + LTRA (montelukast)

(4) 5-15yrs = switch LTRA to LABA (salmeterol)
<5yrs = stop LTRA and refer to specialist

(5) Change ICS+LABA maintenance therapy to MART regimen with paediatric low-dose ICS
SABA + MART (formoterol) + low-dose ICS

(6) Increase ICS dose / consider changing back to fixed-dose of a moderate-dose ICS + separate LABA
SABA + MART + paediatric moderate-dose ICS / moderate-dose ICS + LABA

(7) SABA + one of:
- Paediatric high-dose ICS (part of fixed-dose regimen)
- Theophylline (trial additional drug)
- Specialist advice

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35
Q

What is the acute management of VEW?

A
  • 1st line = SABA (e.g. salbutamol) via a spacer
  • Consider anticholinergic
  • Consider oxygen
  • Consider ipratropium bromide

There is now thought to be little role for oral prednisolone in children who do not require hospital treatment

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36
Q

What is the chronic management of VEW?

A

1. SABA via a spacer

  • When child wheezy/breathless > up to 10 puffs every 4hrs
  • If they do not respond / need it again > seek help

Rarely

2. Intermittent LRTA, lose-dose ICS, or both

3. Increase to moderate-dose ICS

3. If still uncontrolled, refer to specialist

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37
Q

What is rhinitis?

A

Acute and self-limiting inflammation of URT mucosa, involving nose, throat, sinuses or larynx (common cold)

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38
Q

What are the causes of rhinitis?

A

Rhinovirus (50%)
Coronavirus (10%)
Influenza (5%)
Parainfluenza (5%)
RSV (5%)

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39
Q

What are the S/S of rhinitis?

A

Clear/mucopurulent discharge
Nasal block

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40
Q

What is the management of rhinitis?

A

Health education

  • Self-limiting (virus, no abx)
  • Cough may persist for 4w after cold
  • Generally, recovery in 2w

Supportive management

  • Paracetamol / Ibuprofen
  • Adequate fluid intake
  • Consider decongestants or antihistamines
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41
Q

What are the complications of rhinitis?

A

Otitis media
Acute sinusitis

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42
Q

What is sinusitis?

A

Infection of the mucus membranes of the paranasal/maxillary sinuses from viral URTIs. Can get a secondary bacterial infection

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43
Q

When does sinusitis present?

A

Uncommon until after 10yrs (frontal sinuses don’t develop until late childhood)

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44
Q

What are the causes of sinusitis?

A

Strep pneumoniae
Haemophilus influenzae
Rhinoviruses

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45
Q

What are the RFs for sinusitis?

A

Nasal obstruction e.g. septal deviation or nasal polyps

Recent local infection e.g. rhinitis or dental extraction

Swimming/diving

Smoking

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46
Q

What are the symptoms of sinusitis?

A

Facial pain / swelling / tenderness > typically frontal pressure which is worse on bending forward

Nasal discharge > usually thick and purulent

Nasal obstruction

Influenza-like illness

47
Q

When do you refer sinusitis to hospital?

A

If signs of:

  • Severe systemic infection
  • Intraorbital or periorbital problems (e.g. periorbital cellulitis, displaced eyeball, double vision)
  • ICP complications
48
Q

What is the management of sinusitis?

A

Sx <10d:
Advice

  • Virus, 2-3w to resolve
  • Simple analgesia
  • Consider nasal saline or nasal decongestants

Safety net

  • If sx worsen rapidly / do not improve in 3w / systemically unwell, then seek medical attention

Sx >10d:
High-dose nasal corticosteroid 14d (if >12, e.g. mometasone)

  • May improve sx but unlikely to affect duration of illness
  • Could cause systemic side effects

Abx not indicated but can give delayed abx

  • 1st line = phenoxymethylpenicillin (clarithromycin if allergic)
  • 2nd line = co-amoxiclav
  • Only use if sx rapidly worsen / don’t improve in 7d
49
Q

What is acute otitis media?

A

Middle ear infection

Extremely common in children (most 6-12m)

50
Q

What are the causes of acute otitis media?

A

Typically preceded by URTIs (most infections secondary to bacteria)

e.g. S. pneumoniae, H. Influenzae, Moraxella catarrhalis

51
Q

What are the RFs of acute otitis media?

A

FHx, male, cleft palate, Down’s Syndrome

52
Q

What are the S/S of acute otitis media?

A
  • Ear pain > infant may scream and pull at the ear
  • Fever
  • Hearing loss
  • Recent viral URTI sx
  • Ear discharge > may occur if tympanic membrane perforates
53
Q

What are the investigations for acute otitis media?

A

Clinical diagnosis (with otoscopy)

  • Tympanic membrane bright red and bulging with loss of normal light reflex
  • May see pus in middle ear
54
Q

When do you admit a patient with acute otitis media?

A

Severe systemic infection

Complications e.g. meningitis, mastoiditis, facial nerve palsy

Children <3m with temp >38

55
Q

What is the management of acute otitis media?

A

Advice

  • Lasts about 3d (up to 1w)
  • Most recover without abx (can give delayed abx)
  • Regular ibuprofen / paracetamol
  • Safety net > seek help if sx not improved after 3d / worsen greatly

Abx if:

  • Sx last more than 4d / not improving
  • Systemically unwell but not requiring admission
  • Age <2yrs
  • Perforation and/or discharge in the canal

Abx of choice

  • 1st line = amoxicillin, 5d
  • Penicillin allergy = clarithromycin, erythromycin
56
Q

What are the complications of acute otitis media?

A
  • Unresolved AOM with perforation may develop into chronic suppurative otitis media (CSOM) (>6w)
  • Hearing loss
  • Labyrinthitis
  • Mastoiditis
  • Meningitis
  • Brain abscess
  • Facial nerve paralysis
57
Q

What is Otitis Media with Effusion (OME) / Glue Ear ?

A

Middle ear canal fills with fluid

58
Q

What are the symptoms of OME / Glue Ear?

A

Typically causes conductive hearing loss in one or both ears, which can impact on speech and language development > learning difficulties

59
Q

What are the signs of OME / Glue Ear?

A

O/E eardrum is dull and retracted, often with a fluid level visible

60
Q

When does a patient with OME / Glue Ear need an immediate ENT referral?

A
  • Cleft palate
  • Down’s Syndrome
  • Hearing loss
  • Structurally abnormal tympanic membrane
  • Cholesteatoma discharge
61
Q

What is the management of OME / Glue Ear?

A

Active observation 6-12w

  • Two hearing tests (pure tone audiometry), 3m apart
  • If persist past 6-12w, refer to ENT

ENT management

  • Non-surgical = temporary hearing aids, auto-inflation with a balloon
  • Surgical = grommets (with myringotomy)
    *Benefits don’t last longer than 12m
62
Q

What is Otitis Externa?

A

Inflammation of the outer ear > auricle, external auditory canal and out surface of eardrum

63
Q

What are the S/S of acute diffuse otitis externa (Swimmer’s Ear)?

A

Bacterial infection common

  • Moderate temperature
  • Lymphadenopathy
  • Diffuse swelling
  • Variable pain
  • Puritus
  • Moving ear/jaw is painful
  • Impaired hearing
64
Q

Describe chronic otitis externa

A
  • Fungal
  • Associated with underlying skin conditions, diabetes, immunosuppression
  • Discharge and itch are common
65
Q

Describe necrotising otitis externa

A

Life-threatening extension into mastoid and temporal bones

  • Mainly in elderly
  • Mainly due to P. aeruginosa or S. aureus
  • Criteria: pain, oedema, exudate, micro abscess, granulation tissue, pseudomonas culture

> Urgent ENT referral

66
Q

What are the RFs of otitis externa?

A
  • Hot / humid climates
  • Immunocompromised
  • Narrow external ear canal
  • Swimming
  • Diabetes
  • Obstruction of canal
  • Older age
  • Wax build-up
  • Insufficient wax (predispose infection)
67
Q

What are the S/S of otitis externa?

A

Discharge first

Then Ear pain, itch

O/E red, swollen, or eczematous canal

68
Q

What are the investigations for otitis externa?

A

Swabs and culture

69
Q

What is the management for otitis externa?

A

In otherwise healthy people:

  • Topical antibacterial ear drops e.g. ciprofloxacin / dexamethasone / acetic acid / neomycin
    Prior to the use of topical ear drops, the ear canal needs to be cleaned of any debris or wax
  • Plus analgesia

Refractory to tx, diabetic, immunocompromised:

  • Add oral abx (ciprofloxacin/amoxicillin)

Advice:

  • Keep ear clean and dry
  • No swimming/water sports for 10-7d
  • Avoid damage to the ear (don’t let shampoo etc get in it)

Necrotising:

  • Topical and systemic antibacterial therapy plus debridement
70
Q

What is the management for otitis media with effusion in a patient with Down syndrome or cleft lip/palate?

A

Refer to ENT specialist

  • Avoids the risk of delays that could impact on their overall development e.g. speech development
71
Q

What are the causes of pharyngitis?

A
  • Adenovirus
  • Enterovirus
  • Rhinovirus
  • GAS in older children
72
Q

What are the causes of tonsillitis?

A

EBV (mono)
GAS

73
Q

What are the S/S of an URTI?

A
  • Sore throat
  • Fever
  • Dysphagia / odynophagia
  • Hoarseness
  • GORD
  • Rhinitis
  • Lethargy / fatigue
  • Post-nasal drip
  • Laryngitis = dysphonia / aphonia
74
Q

What is the Centor Score?

A

Determines the likelihood of bacterial over viral

1 point for:

  • Tonsillar exudate
  • Tender / swollen anterior cervical lymph nodes
  • Temperature >38
  • Absence of cough
  • Age 3-14yrs

Likelihood of GAS:

  • 1 = (5-10%) > no abx
  • 2 = (11-17%) > rapid strep test
  • 3 = (28-35%) > rapid strep test
  • 4 = (51-53%) > abx + rapid strep test
  • 5 = (51-53%) > abx + rapid strep test
75
Q

What are the investigations for an URTI?

A
  • Temp
  • ENT exam > inflammation of tonsils with purulent exudate
  • Consider swabs
  • Rapid strep test (2-5 Centor Score)
76
Q

What is the management of tonsillitis?

A

Confirmed bacterial tonsilitis = ABX

  • Phenoxymethylpenicillin, 10d (clarithromycin if pen-allergic)
  • Prevent sequalae e.g. rheumatic fever
  • AVOID amoxicillin as can cause widespread maculopapular rash if mono

+Advice

  • Simple analgesia
  • Adequate fluid intake
  • Saltwater gargling
  • Lozenges or anaesthetic sprays (difflam)
  • Avoid school until 24hrs after starting abx and the child is feeling well
77
Q

When do you admit a patient with an URTI?

A
  • Difficulty breathing
  • Peri-tonsillar abscesses (quinsy)
  • Cellulitis
  • Suspected rare cause e.g. Kawasaki disease, diphtheria
78
Q

What are the complications of an URTI?

A

GAS infection can progress to Scarlet Fever

79
Q

What are the S/S of Scarlet Fever?

A

Rash +/- erythroderma

  • 12-48hrs later
  • Neck and chest, then spread to trunk and legs
  • Characteristic sandpaper texture
  • ‘Pastia’s lines’ (rash prominent in skin creases)

Strawberry tongue

  • <2d = white tongue
  • > 2d = desquamated strawberry tongue

Also:

  • Fever, coryza

> May progress to rheumatic fever with a week latency period

80
Q

What are the investigations for Scarlet Fever?

A

Clinical diagnosis

Also - FBC, ELISA, rapid antigen etc

81
Q

What is the management of Scarlet Fever?

A

1. Phenoxymethylpenicillin (2nd line = azithromycin)

2. Advice = should resolve in 1w, exclude for 24hrs from nursery after starting abx

3. Notify PHE

82
Q

What is Cystic Fibrosis?

A

Autosomal recessive disorder causing increased viscosity of secretions (e.g. lungs and pancreas)

Due to defect in CFTR gene, which encodes a cAMP-regulated chloride channel (Chr7)

(Lifelong condition characterised by thick secretions)

83
Q

What are the presenting features of CF?

A

Neonatal:

  • Meconium ileus, sometimes prolonged jaundice

Infancy:

  • Recurrent chest infections, malabsorption (steatorrhoea, FTT)

Older children:

  • Asthma, ABPA, recurrent chest infections
84
Q

What are the later features of CF?

A
  • Short stature
  • Difficulty putting on weight
  • DM
  • Delayed puberty
  • Rectal prolapse (due to bulky stools)
  • Nasal polyps, sinusitis
  • Male infertility, female subfertility
85
Q

What are the signs of CF?

A
  • Decreased muscle mass
  • Protuberant abdomen
  • Hyperinflation
  • Coarse crepitations
  • Expiratory wheeze
  • Wet cough
  • Clubbing
  • Bilateral absence of the vas deferens
86
Q

What are the investigations for CF?

A

Antenatal tests:

  • First trimester = Chorionic villus sampling (CVS)
  • Second trimester = Decrease intestinal ALP in amniotic fluid

Screening at birth:

  • Guthrie’s Test: Samples tested for serum immunoreactive trypsin (IRT) - will be raised in CF
  • If +ve: Samples screened for common CF gene mutations
  • If 2 mutations: Infant will have sweat chloride test - abnormally high sweat chloride >60 in CF

Also:

  • Genetic tests (including the family) - DNA mutation detection

CXR:

  • Hyperinflation
  • Peri-bronchial shadowing
  • Bronchial wall thickening
  • Ring shadows

Lung function tests:

  • Obstructive picture with air trapping and hyperinflation (decreased FEV1, increased TLC)
87
Q

What is the management of CF?

A

MDT approach > refer to specialised CF centre

Infection management > PROPHYLACTIC ABX + MONITORING

  • Common infections = S. aureus, H. influenzae, P. aeruginosa, Burkholderia cepacia complex
  • Prophylaxis oral fluclox and azithromycin (reduce exacerbation chance)
  • Rescue packs = prompt IV abx (any S/S of infection)
  • Minimise contact with other CF patients
  • If end stage CF disease, lung transplantation only option

Resp management > PHYSIO + MUCOLYTICS

  • Increased monitoring with spirometry and sx watches
  • PT twice a day (airway clearance manoeuvres and devices + encourage physical activity)
  • Mucolytic therapy - rhDNase, hypertonic saline

Nutritional management > ENZYME TABLETS + HIGH CALORIE DIET

  • Specialist dietician
  • High calorie and high fat diet
  • Fat soluble vitamin supplements
  • Pancreatic enzyme replacement with every meal > CREON

Psychological management > SUPPORT

  • Counselling for carer and patient
88
Q

What increases morbidity / mortality in CF?

A

Chronic infection with Pseudomonas and Bulkholderia

89
Q

What is laryngomalacia?

A

Congenital abnormality of the larynx cartilage that predisposes to supraglottic collapse during inspiration, resulting in intermittent upper airway obstruction and stridor

90
Q

What are the S/S of laryngomalacia?

A
  • No sx at birth, presents 2-6w old
  • Noisy respiration and inspiratory stridor
  • Worse supine, when feeding, or if agitated
  • GORD +/- feeding difficulties, increased cough/choking
  • Normal cry (no abnormality with vocal cords)
  • Baby otherwise comfortable
91
Q

What are the investigations for laryngomalacia?

A

Flexible laryngoscopy (performed in all pts to assess laryngeal anatomy and related comorbidity)

O2 monitor

92
Q

What is the management of laryngomalacia?

A

Conservative:

  • Close observation and monitoring of weight
  • Resolve by 18-24m (70% by 1y)
  • May initially worsen with age, max at 6-8m

Endoscopic supraglottoplasty:

  • If airway compromise or feeding disrupted sufficiently to prevent normal growth
93
Q

What are the complications of laryngomalacia?

A

Respiratory distress
Failure to thrive
Cyanosis

94
Q

What are Breath Holding Attacks?

A

A developmental condition in which the child experiences a brief episode of apnoea

95
Q

What are the types of breath holding attacks?

A

Pallid (white) BHA:

  • Painful stimulus (knock to head or falling)
  • Child stops breathing and loses consciousness
  • Child becomes pale and hypotonic
  • Reflex anoxic seizure

Cyanotic (blue) BHA:

  • Anger/frustration/vigorous crying/fear
  • Child cries and holds breath in expiration
  • Rapid onset of cyanosis
  • Brief tonic-clonic jerks, opisthotonos, bradycardia
96
Q

What are the investigations for breath holding attacks?

A

Clinical diagnosis

EEG > only if dx unclear
ECG > rule out arrythmia

97
Q

What is the management for breath holding attacks?

A

Acute attacks resolve spontaneously

Parental education / reassurance:

  • Behaviour modification with distraction
  • Stay calm during attack – it should pass in less than 1 minute.
  • Lie the child on their side – do not pick them up.
  • Stay with them until the episode ends.
  • Make sure they cannot hit their head, arms or legs on anything

Medical:

  • Atropine sulphate may be considered in refractory/severe pallid attacks associated with seizures
98
Q

What is Pneumonia?

A

Infection of the lung parenchyma

99
Q

What are the causes of pneumonia?

A

Young children = VIRUS

  • Neonates = mothers genital tract commensals (GBS, E. coli, gram -ve enterococci, chlamydia trachomatis)
  • Infants/young children = RSV, parainfluenza, influenza

Older children = BACTERIA

  • S. pneumoniae most common
  • M. pneumoniae, chlamydia pneumoniae, mycoplasma pneumonia, mycobacterium TB

Aspiration pneumonia = enteric gram -ve bacteria

Non-immunised = Haemophilus influenza, Bordetella pertussis, measles

100
Q

What are the symptoms of pneumonia?

A
  • Cough + sputum (yellow/green, rusty in strep pneumoniae)
  • Fever, SOB
  • Diarrhoea
  • Vomiting (particularly post-coughing)
  • Poor feeding
  • Preceding UTI
101
Q

What are the signs O/E of pneumonia?

A

Signs of consolidation

  • Decreased breath sounds
  • Bronchial breathing
  • Coarse crepitations
  • Stony dullness to percussion
  • Increased tactile/vocal fremitus
102
Q

What are the investigations for pneumonia?

A

Basic: Obs, cyanosis/hydration status
Bloods: FBC, U&Es, VBG
CXR: Focal consolidation = bacterial, diffuse consolidation = viral

If TB exposure:

  • Ix: manteaux test
  • Mx: RIPE, or prophylaxis (isoniazid)
103
Q

What is the management for pneumonia?

A

Consider admission if:

  • Dehydration, decreased activity, respiratory distress, predisposing diseases (e.g. chronic lung disease)

Supportive:

  • Maintain O2 sats >92
  • IV resus in dehydration / shock

Abx:

  • 1st line = amoxicillin (clarithromycin if allergic)
  • 2nd line = co-amoxiclav + (if atypical pathogen suspected) clarithromycin (erythromycin in pregnancy)

Pneumonia associated with influenzae = co-amoxiclav

Aspiration pneumonia = metronidazole

104
Q

What is Whooping Cough?

A

An infectious disease caused by the gram -ve bacterium Bordetella pertussis

105
Q

What are the RFs for Whooping Cough?

A
  • Unvaccinated (infants routinely vaccinated at 2m, 3m, 4m and 3-5y)
  • Peak age is 3yrs
  • Higher mortality in infants
106
Q

What are the stages of whooping cough?

A

Catarrhal phase:

  • 1-2w coryzal sx (indistinguishable from common URTIs)
  • Most infectious at this stage

Paroxysmal stage:

  • 1-6w continuous bouts of coughing followed by inspiratory whoop
  • +/- vomiting
  • +/- epistaxis
  • +/- conjunctival haemorrhages
  • Fine in between coughing fits
  • Children: worse at night/when feeding, may go blue/red
  • Infants: apnoea rather than whoop

Convalescent stage:

  • Up to 3m of chronic cough that becomes less paroxysmal
  • Cough improves over this time
107
Q

What are the investigations for whooping cough?

A
  • Nasal swabs (culture and PCR = Bordetella pertussis)
  • FBC
  • Notify HPU
108
Q

When do you admit a patient with whooping cough?

A

<6m and acutely unwell (significant breathing difficulty, significant complications e.g. seizures, pneumonia)

109
Q

What is the management of whooping cough?

A

Abx if onset of cough <21d:

  • <1m = clarithromycin
  • > 1m = azithromycin
  • Pregnant = erythromycin
  • Macrolide contraindicated/not tolerated = co-trimoxazole
  • Household contacts offered prophylactic abx

Advice:

  • Rest + fluids + simple analgesia
  • Educate parents (may take weeks to fully resolve, immunisations, prophylaxis, safety net)
  • Avoid nursery until 24hrs of abx or 21d after onset of cough

> Usually lasts 6-8w but prolonged illness can occur (100-day cough)

110
Q

What is the prognosis for whooping cough?

A

Significant morbidity and mortality in infants <6m

> > Apnoea associated with paroxysms can cause sudden death

111
Q

When do you offer a tonsillectomy ?

A

7 episodes within 1 year
5 episodes per year for 2 years
3 episodes per year for 3 years

112
Q

What can cause a bronch infection to be more severe?

A

Underlying CHD

113
Q

What household prophylaxis is given for epiglottitis ?

A

Rifampicin

114
Q

What drugs are contraindicated in asthmatics?

A
  • NSAIDs
  • Beta blockers
  • ACE inhibitors
  • Adenosine

Paeds (18 decks)

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