Resp

Question 1

Wheeze V Stridor

Answer 1

Wheeze = polyphonic, expiratory noise, mainly from lower airway.
Stridor = Inspiratory, harsh noise, from larger upper airways.

Question 2

Signs of acute upper airway obstruction

Answer 2

Stridor
Hoarseness
Barking cough
Variable dyspnoea

Question 3

Differential diagnosis for a child with STRIDOR 🤷‍♀️🤷‍♀️🤷‍♀️

Answer 3

Croup/laryngotracheobronchitis
Pseudomembranous croup/Bacterial tracheitis
Rhinitis
Epiglottitis
Anaphylactic reaction
Inhaled foreign body
Whooping cough/Pertussis
Retropharyngeal abscess

Question 4

Croup epidemiology and pathogenesis

Answer 4

Upper airway obstruction and inflammation
Mostly due to viral infection
Commonly 6months-6years
Mostly due to parainfluenza virus

Question 5

Classic symptoms of croup

Answer 5

Coryzal of several days
Barking cough, strider hoarse voice, respiratory distress.
Low grade fever
Can have respiratory distress with signs such as intercostal and sternal indrawing/recessions.
Symptoms worse at night and on agitation.

Question 6

Management of croup

Answer 6

Most mild cases can be managed at home with appropriate safety-net advise and basic analgesia.
Oral dexamethasone (0.15mg/kg), oral prednisolone or nebulised steroids can be prescribed to reduce severity and duration.
If severe = nebulised adrenaline with oxygen facemask. but beware of rebound effect.

Question 7

Pseudomembranous croup

Answer 7

Bacterial tracheitis
More acute onset
Bacterial cause (croup mostly viral) S.aureus.
VERY HIGH FEVER, airway obstruction, increased secretions creating mucopurulent exudate.
Loud harsh stridor.
Treat with IV flucloxacillin.

Question 8

Epiglottitis causative organism

Answer 8

H.influenza type B

Question 9

Clinical features of epiglottis

Answer 9

ACUTE ONSET - EMERGENCY!
Drooling saliva
Very ill child/toxic
Very high temp over 38.5
Soft stridor
Very sore throat preventing child from speech and swallowing.
Difficulty in breathing/resp distress
No cough
No coryza prodrome

Question 10

Management of epiglottitis

Answer 10

DO NOT EXAMINE THROAT!
SECURE AIRWAY!
IV access
Cefuroxime
Rifampicin for close contact prophylaxis.

Question 11

Bronchiolitis main causative organism and peak age of onset

Answer 11

Respiratory syncytial virus

Affects children less than 12months old.

Question 12

Clinical features of bronchiolitis

Answer 12

Apnoea in under 4months
Coryza prodrome
Sharp dry cough
Tachypnoea
Low grade temp
Hyperinflation
Pallor and cyanosis
Sub and inter-coastal recessions

Question 13

Differentials for bronchiolitis

Answer 13

Pneumonia
Infective exacerbation of asthma
Viral induced wheeze
Whooping cough
GORD
Cystic fibrosis

Question 14

Risk factors for developing bronchiolitis

Answer 14

Preterm (<32weeks)
Cystic fibrosis
Congenital heats defect babies
Very young babies
Neuromuscular disorder babies

Question 15

Diagnosing bronchiolitis

Answer 15

CLINICAL DIAGNOSIS

PCR of nasopharyngeal secretions for causative organisms (msc)

Question 16

Treating bronchiolitis

Answer 16

No cure, supportive care.
High flow O2/CPAP
Isolation treatment/barrier nursing.
Good feeding and fluid intake.

Question 17

Prophylaxis of bronchiolitis

Answer 17

Monoclonal antibody for RSV. Given to high risk babies (e.g.premature) via IM injection in winter months. expensive so limited use!

Question 18

Types of respiratory infections in children

Answer 18

Upper airway = coryza, otitis media, pharyngitis, tonsillitis.
Laryngeal/tracheal = croup, epiglottitis, bacterial tracheitis.
Bronchitis
Bronchiolitis = RSV
Pneumonia

Question 19

Aetiology of community acquired pneumonia in children

Answer 19

Most are viral - respiratory syncytial virus.
Neonate bacterial = group B strep (from mother’s tract), E.coli.
Infant bacteria = Strep pneuoniae, H.influenza, S.aureus.
Children over 5 bacteria = Mycoplasma pneumoniae, S.pneumoniae, Chlamydia pneumoniae.
Always consider mycoplasma tuberculosis.

Question 20

Clinical features of pneumonia

Answer 20

High fever
Cyanosis
Tachypnoea
Cough
Lethargy
Increased work of breathing = chest in-drawing, nasal flaring, grunting.
Poor feeding.
End expiratory coarse, focal crackles in auscultation.
Low Oxygen sats
(No hyperinflation)

Question 21

Symptoms and signs suggestive of a bacterial pneumonia

Answer 21

Localised chest, abdo or neck pain = pleural irritation.
Pleural effusion (absent breathes sounds, dull percussion)
Lobar consolidation
Leukocytosis.

Question 22

Investigations for pneumonia

Answer 22

SpO2
CXR - localised consolidation
FBC
Sputum and blood cultures
Do not require investigations if child is being treat with CAP at home (safety-net)

Question 23

Treatment of pneumonia

Answer 23

As viral and bacteria can not be easily differentiated, always give ABx -amoxicillin.

Question 24

Signs of a child with pneumonia needing hospital admittance

Answer 24

SpO2 less than 92%
Grunting, recessions, resp rate over 60breaths/min
Cyanosis
Signs of pneumonia complicated by effusion.
Unrousable and unresponsive to cues.
Temp over 38 if 3months or less

Question 25

Differentials for wheeze/cough/pneumonia

Answer 25

Viral induced wheeze. Acute exacerbation of asthma - Hx of asthma or atopy, worsened by asthma triggers. Bronchiolitis - sharp dry cough, prodrome. CAP - acute, localised consolidation. Bronchiectasis - copiious sptum, frequent RTI. CF - productive cough, GI symptoms, failure to thrive, chronic symptoms from birth. Pertussis - paroxysms coughing followed by inspiratory whoop.

Question 26

Asthma pathophys

Answer 26

Triggers e.g. pollen, dust mites cause IgE production via Th2 cells. Airway oedema, excess mucus production and plugging, white cell infiltration into epithelium. Bronchial hyper-responsiveness. Bronchoconstriction. Airway narrowing and obstruction. Reversible changes. INFLAMMATION + AIRWAY HYPERSENSITIVITY

Question 27

Risk factors for asthma

Answer 27

Low birth weight FHx/genetic atopy Pollution and exposure to tobacco smoke Hx of lung disease

Question 28

Clinical features of asthma

Answer 28

COUGH, WHEEZE, SOB. Recurrent, episodic polyphonic wheeze - worse at night and in early morning (diurnal variation). Wheeze is triggered by exercise, mites, emotions, laughter, dust etc Chest tightness, breathlessness, cough Symptoms worsened on infection (exacerbation)

Question 29

Details of the wheeze in asthma

Answer 29

Polyphonic Episodic Triggered by laughter, emotions, dust, pets, cold, allergens. Worse in early morning and night.

Question 30

Investigations for asthma

Answer 30

Fractional exhaled nitric oxide test = +ve if result over 40ppb Spirometry = FEV1/FVC < 70% Bronchodilator reversibility = bronchodilator will improve FEV1/FVC by 12% Variable peak expiratory flow = more than 20% variability in twice daily testing for 2-4weeks.

Question 31

Chronic asthma drug treatment

Answer 31

1) Short acting beta-2-agonist as reliever e.g. PRN salbutamol 2) Add inhaled corticosteroid as preventer e.g. OD beclometasone. 3) Add leukotriene receptor antagonist e.g. pd Montelukast. 4) Stop LRTA and add long-acting beta-2-agonist .e.g salmeterol. 5) MART regime = maintenance and deliver therapy e.g. ICS and LABA in 1 inhaler. 6) Increase ICS dose 7) Specialist assessment.

Question 32

How does treatment of asthma change if child under 5

Answer 32

If asthma not controlled on ICS and LRRA for to specialist

Question 33

General advise and education for asthma and review topics

Answer 33

``` Self-management education. Up to date on routine vaccines. Advise on avoiding triggers. Explain how to use inhalers. In review - ask about days off school, oral steroid use, inhaler technique and adherence. ```

Question 34

Signs in a moderately severe asthma exacerbation

Answer 34

peak expiratory flow rate is between 50-75%. Normal speech. No features of acute or life-threatening asthma

Question 35

Signs in an acute severe asthma exacerbation

Answer 35

``` PEFR between 33-50% tachypnoea tachycardia inability to complete sentences in a single breath use of accessory muscles inability to feed SpO2 less than 92% ```

Question 36

Signs of a life-threatening asthma exacerbation

Answer 36

``` PEFR less than 33% SpO2 less than 92% Altered consciousness exhaustion or arrhythmia hypotensive cyanosis silent chest confused. Poor resp effort ```

Question 37

Management of acute asthma exacerbation

Answer 37

1) High flow 100% oxygen 2) SABA + ipratropium bromide nebulised 3) Prednisolone or hydrocortisone 4) Consider Magnesium Sulphate 5) Aminophylline 6) Consider CPAP get some more help!

Question 38

Genetics of cystic fibrosis

Answer 38

Autosomal recessive. Chromosome 7 mutation at cystic fibrosis transmembrane conductance regulator gene (CFTR), dysfunctional cyclic AMP-regulated sodium/chloride channel.

Question 39

Diagnosis of cystic fibrosis

Answer 39

Guthrie test in postnatal period = raised immunoreactive trypsinogen. Sweat test = greater than 60mmol/L of chloride. Genetic counselling.

Question 40

Infancy clinical features of cystic fibrosis

Answer 40

Meconium ileus Prolonged neonatal jaundice Failure to thrive Recurrent chest infections with atypical organisms Steatorrheoa and malabsorption due to pancreatic insufficiency,

Question 41

Clinical features of a child with cystic fibrosis

Answer 41

``` Recurrent chest infections with atypical organisms (Bronchiectasis) Rectal prolapse Nasal polyp Sinusitis Distal intestinal obstruction syndrome ```

Question 42

Clinical features in an adolescent with cystic fibrosis

Answer 42

``` Diabets mellitus Cirrhosis and portal HTN Pneumothorax Allergic bronchopulomary aspergillosis Sterility/infertility ```

Question 43

Atypical organisms seen in cystic fibrosis RTI

Answer 43

S.aureus H.influenza P.aeruginosa

Question 44

Resp clinical features of cystic fibrosis

Answer 44

``` Persistent cough which produces purulent sputum. Hyperinflation of chest. Expiratory wheeze Coarse inspiratory creptations. Clubbing Haemoptysis Neutrophilic airway inflammation. ```

Question 45

Meconium ileus

Answer 45

Presents in first days of life. | Thick meconium causes bowel obstruction = vomiting, abdo distension and poor defection.

Question 46

Steatorrhoea

Answer 46

Oily, loose, pale fatty stools

Question 47

Pathophys of cystic fibrosis

Answer 47

``` Low chloride secretion High sodium reabsorption More viscous mucus Worse muco-cilary clearance. Increased bile concentration. Stagnation of pancreatic enzymes (DM) ```

Question 48

MDT for cystic fibrosis

Answer 48

``` Paediatrician Nures Physio Dietician Pharmacist Psychologist Social worker ```

Question 49

Annual review of cystic fibrosis

Answer 49

``` Pulmonary assessment. Nutrition assessment. DM testing Psych review exercise programme. ```

Question 50

Treatment for pulmonary symptoms of cystic fibrosis

Answer 50

Airway clearance techniques and exercises. Teach percussion and postural drainage. 2-3/day Immunomodulatory agent e.g. azithromycin or corticosteroid. Mucoactive agent e.g. rhDNase, hypertonic saline or mannitol dry powder.

Question 51

Treatment for GI symptoms of cystic fibrosis

Answer 51

Replace pancreatic enzymes e.g. Pancrex V High calorie diet Fat soluble vitamin supplements.

Question 52

Complications of cystic fibrosis

Answer 52

``` Diabetes mellitus Cirrhosis Distal intestinal obstruction syndrome Low bone density Pancreatic insufficiency. ```

Question 53

Type of immune response seen in asthma

Answer 53

Hypersensitivity type 1

Question 54

Contents of sputum from asthma

Answer 54

Curschmann's spirals | Charcot-Leyden crystals

Question 55

4 signs on auscultation of pneumonia

Answer 55

Crackles Pleural rub Increase vocal resonance Bronchial breathing