Resp Flashcards

Question

How does epiglottis present on a CXR?

Answer 1

‘thumb sign’ (swelling of epiglottis)

Answer 2

**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

Answer 3

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

Answer 4

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

Answer 5

- FHx of asthma / atopy - Passive / active smoking - URTIs - Cold weather - Inhalant allergies - Food allergens

Answer 6

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)

Answer 7

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)

Answer 8

- 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

Answer 9

*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) 4. It not resolved = IV bolus magnesium sulphate 5. If not resolved = IV infusion salbutamol 6. If not resolved = IV infusion aminophylline 7. 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

Answer 10

(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

Answer 11

- 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*

Answer 12

**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**

Answer 13

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

Answer 14

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

Answer 15

Clear/mucopurulent discharge Nasal block

Answer 16

**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

Answer 17

Otitis media Acute sinusitis

Answer 18

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

Answer 19

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

Answer 20

Strep pneumoniae Haemophilus influenzae Rhinoviruses

Answer 21

Nasal obstruction e.g. septal deviation or nasal polyps Recent local infection e.g. rhinitis or dental extraction Swimming/diving Smoking

Answer 22

Facial pain / swelling / tenderness > typically frontal pressure which is worse on bending forward Nasal discharge > usually thick and purulent Nasal obstruction Influenza-like illness

Answer 23

*If signs of:* - Severe systemic infection - Intraorbital or periorbital problems (e.g. periorbital cellulitis, displaced eyeball, double vision) - ICP complications

Answer 24

**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

Answer 25

Middle ear infection Extremely common in children (most 6-12m)

Answer 26

Typically preceded by URTIs (most infections secondary to bacteria) e.g. S. pneumoniae, H. Influenzae, Moraxella catarrhalis

Answer 27

FHx, male, cleft palate, Down’s Syndrome

Answer 28

- 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

Answer 29

**Clinical diagnosis (with otoscopy)** - Tympanic membrane bright red and bulging with loss of normal light reflex - May see pus in middle ear

Answer 30

Severe systemic infection Complications e.g. meningitis, mastoiditis, facial nerve palsy Children <3m with temp >38

Answer 31

**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

Answer 32

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

Answer 33

Middle ear canal fills with fluid

Answer 34

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

Answer 35

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

Answer 36

- Cleft palate - Down’s Syndrome - Hearing loss - Structurally abnormal tympanic membrane - Cholesteatoma discharge

Answer 37

**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

Answer 38

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

Answer 39

Bacterial infection common - Moderate temperature - Lymphadenopathy - Diffuse swelling - Variable pain - Puritus - Moving ear/jaw is painful - Impaired hearing

Answer 40

- Fungal - Associated with underlying skin conditions, diabetes, immunosuppression - Discharge and itch are common

Answer 41

**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

Answer 42

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

Answer 43

Discharge first Then Ear pain, itch O/E red, swollen, or eczematous canal

Answer 44

Swabs and culture

Answer 45

**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

Answer 46

Refer to ENT specialist - Avoids the risk of delays that could impact on their overall development e.g. speech development

Answer 47

- Adenovirus - Enterovirus - Rhinovirus - GAS in older children

Answer 48

EBV (mono) GAS

Answer 49

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

Answer 50

**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

Answer 51

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

Answer 52

**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

Answer 53

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

Answer 54

GAS infection can progress to Scarlet Fever

Answer 55

**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

Answer 56

**Clinical diagnosis** Also - FBC, ELISA, rapid antigen etc

Answer 57

**1. Phenoxymethylpenicillin** (2nd line = azithromycin) **2. Advice** = should resolve in 1w, exclude for 24hrs from nursery after starting abx **3. Notify PHE**

Answer 58

**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)

Answer 59

**Neonatal:** - Meconium ileus, sometimes prolonged jaundice **Infancy:** - Recurrent chest infections, malabsorption (steatorrhoea, FTT) **Older children:** - Asthma, ABPA, recurrent chest infections

Answer 60

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

Answer 61

* Decreased muscle mass * Protuberant abdomen * Hyperinflation * Coarse crepitations * Expiratory wheeze * Wet cough * Clubbing * Bilateral absence of the vas deferens

Answer 62

**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)

Answer 63

*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

Answer 64

Chronic infection with Pseudomonas and Bulkholderia

Answer 65

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

Answer 66

* 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

Answer 67

**Flexible laryngoscopy** (performed in all pts to assess laryngeal anatomy and related comorbidity) O2 monitor

Answer 68

**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

Answer 69

Respiratory distress Failure to thrive Cyanosis

Answer 70

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

Answer 71

**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

Answer 72

**Clinical diagnosis** EEG > only if dx unclear ECG > rule out arrythmia

Answer 73

*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

Answer 74

Infection of the lung parenchyma

Answer 75

**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

Answer 76

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

Answer 77

**Signs of consolidation** - Decreased breath sounds - Bronchial breathing - Coarse crepitations - Stony dullness to percussion - Increased tactile/vocal fremitus

Answer 78

**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)

Answer 79

**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

Answer 80

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

Answer 81

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

Answer 82

**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

Answer 83

- Nasal swabs (culture and PCR = Bordetella pertussis) - FBC - Notify HPU

Answer 84

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

Answer 85

**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)

Answer 86

Significant morbidity and mortality in infants <6m >> Apnoea associated with paroxysms can cause sudden death

Answer 87

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

Answer 88

Underlying CHD

Answer 89

Rifampicin

Answer 90

- NSAIDs - Beta blockers - ACE inhibitors - Adenosine

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Resp Flashcards

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