Resp and ENT 2 Flashcards
List some causes of cough in infancy
Infections:
- URTI
- Bronchiolitis
- Pneumonia
Congenital malformations of the airway
GORD
CF
List some causes of cough in preschool children
Infections:
- URTI
- Croup
- Acute bronchitis
- Pneumonia
Foreign body
Asthma
CF
Passive smoking
List some causes of cough in school-age to adolescence
Asthma Infections - URTI Smoking Postnasal drip Psychogenic CF
List some red flags of a serious lower respiratory infection in children
Productive cough which improves with abx but quickly recurs
Restriction of activity
Failure to grow or gain weight
Clubbing
Persistent tachypnoea
Ddx of a loose, productive cough (3)
1) Bronchitis
2) CF
3) Bronchiectasis
Ddx of a wheezy cough (2)
1) Asthma
2) Bronchitis
What does a barking cough suggest?
Croup
What is paroxysmal cough?
Frequent and violent coughing that can make it hard for a person to breathe
Ddx of cough with vigorous exercise (3)
1) Exercise-induced asthma
2) CF
3) Bronchiectasis
What should be included on examination of a child presenting with a cough?
1) Growth
2) Signs of respiratory distress
- In an infant, tachypnoea or expiratory grunting may be only signs
3) Chest examination
4) Other signs - eg clubbing, signs of atopy eg eczema
What investigations can be done for a child presenting with a cough and what may they show?
FBC
- Raised WCC in infection
- Possible eosinophilia in asthma
Blood culture - LRTI
Pernasal swab - Pertussis
CXR - LRTI
CXR + barium swallow - Congenital anomalies of airway / GORD
Sweat test - CF
Videofluoroscopy and bronchcoscopy - Inhaled foreign body
Trial of bronchodilators and peak flow measurements - Asthma
Which children are most at risk of inhaling a foreign body?
Toddlers - their behaviour of putting things in their mouths
How may an inhaled foreign body present?
Depends on location, ranges from no symptoms to complete obstruction
Larynx:
- Croupy cough and stridor
- Hoarseness
- Dyspnoea
Bronchus:
- Chest pain or no symptoms for a few days until development of pneumonia infection, collapse, or obstructive emphysema
Oesophagus:
- Drooling
- Dysphagia
NB ask about foreign body inhalation when persistent cough or chest infection not resolving
What is the most common location for an inhaled foreign body?
Right main bronchus
What may be seen on examination of a child with an inhaled foreign body?
Monophonic wheeze or absent breath sounds on affected side
Unilateral chest expansion
What investigations may be done for an inhaled foreign body?
CXR and neck radiographs with lateral views
- Inspiratory and expiratory films
Bronchoscopy
ABG if in severe distress
What is the management of an inhaled foreign body?
ABCDE
Effective cough:
- Encourage cough and continue to check for deterioration to ineffective cough or until obstruction relieved
Ineffective cough, conscious:
- 5 back blows
- 5 thrusts
(Chest for infant, abdo for child <1yr)
Ineffective cough, unconscious:
- Open airway
- 5 breaths
- Start CPR (15:2)
What is otitis media? Give 5 subtypes
OM = umbrella term of acute inflammation of the middle ear
1) Acute otitis media
2) Otitis media with effusion (glue ear)
3) Chronic suppurative otitis media
4) Mastoiditis
5) Cholesteatoma
What is the pathophysiology of AOM? Why are children more prone to it?
Infecting organisms reach the middle ear from the nasopharynx to the ear
As children grow bigger, the angle between the Eustachian tube and the wall of the pharynx becomes more acute so that coughing or sneezing tends to push it shut
In small children, the less acute angle facilitates infected material being transmitted through the tube to the middle ear
What is the most common cause of AOM?
Bacterial:
- Haemophilus influenze
- Strep pneuomniae
- Moraxella catarrhalis
- Strep pyogenes
Viral:
- RSV
- Rhinovirus
List some RF for AOM (5)
1) Young
2) Male
3) Smoking in household
4) Formula feeding - breast milk protective
5) Craniofacial abnormalities eg Down’s syndrome, cleft palata
What symptoms may AOM present with?
Pain (young children may pull at ear) Malaise Irritability / crying / poor feeding Fever Coryza Vomiting
What signs may be noted on examination of a child with AOM?
1) High temp - febrile convulsions my be associated with temperature rise in AOM
2) Red, yellow or cloudy tympanic membrane
3) Bulging tympanic membrane
4) An air-fluid level behind the tympanic membrane
5) Discharge in auditory canal secondary to perforation of tympanic membrane (may obscure view completely)
+/- red pinna
A distressed child with AOM suddenly settles quickly, what do you suspect has happened? What may you see?
Perforation of the eardrum relieves pain
The ear may then start to discharge green pus
What is otitis media with effusion (OME)?
= glue ear
Collection of fluid in the middle-ear cleft. Chronic inflammatory condition without acute inflammation, often following AOM
What is the treatment of AOM?
Usually no treatment required - paracetamol and ibuprofen
Abx if <4 days no improvement / systemically unwell . perforation and/or discharge in ear canal:
- 5 day course of amoxicillin
- If penicillin allergy = erythromycin / clarithromycin
Warm compress over ear can help to reduce pain
How does OME present?
Hearing loss (most common cause of hearing loss in childhood)
Ear pain with fullness / popping
+/- hx or recurrent ear infection or URTI
On examination:
No signs of inflammation or discharge
Loss of light reflex
Presence of bubbles or fluid level
Can progress to a red, bulging TM which can perforate and discharge
What is the prognosis of OME?
Self-limiting illness and 90% have complete resolution within one year but recurrence is common
Surgery recommended for those with persistent bilateral OME lasting 3/more months, hearing loss or those with LD
What is the surgical management of OME?
1st line = insertion of grommets (ventilation tubes)
- Remain in place for 6-12 months after which they fall out naturally
Adenoidectomy only if recurrent URTI is a feature
In broad terms, list 3 causes of SOB
1) Airway obstruction
2) Abnormal lung mechanics
3) Hypoxia
List some causes of abnormal lung mechanics leading to SOB
Restrictive lung disease:
- Chest wall deformity
Parenchymal lung disease:
- Pneumonia
- Pulmonary HTN
Muscle weakness:
- Duchenne muscular dystrophy
- Diaphragmatic paralysis
List some causes of hypoxia leading to SOB
Ventilation perfusion mistmatch:
- Lung disease
- Pneumonia
- Pneumothorax
- PE
Heart disease:
- Cyanotic CHD
- Pericarditis
- Myocarditis
List some causes of stridor (5)
Acute:
1) Croup
2) Acute epiglottitis
3) Foreign body
Chronic:
4) Laryngomalacia
5) Subglottic stenosis
What is important to ask when taking a history of a child with stridor?
Coryza and fever?
Nature of stridor
- Degree of stridor depends on respiratory effort of inspiratory breath (louder when crying, quieter when sleeping)
Aspiration?
Features of onset
- Laryngomalacia (floppy larynx) is a congenital condition that improves with age
- Subglottic stenosis can develop after a previous intubation
What does a hx of coryza and fever in a child presenting with stridor suggest?
Croup
= acute laryngotracheobronchitis
What is the main ddx of croup?
Acute epiglottitis = life-threatening illness
Rare following HiB vaccination
What should be included on examination of a child with stridor?
Chest signs
- Crepitations and wheeze suggest croup (rare with acute epiglottitis or foreign body obstruction)
Do not examine throat of a child with severe stridor
- Acute airway obstruction may occur
- Signs of increasing airway obstruction = cyanosis, confusion, reduction in stridor with exhaustion, drooling with increasing dysphagia
What parts of the body can TB affect? (4)
Lungs
Meninges
Bones
Joints
What are the symptoms of TB? (6)
1) Cough
2) Tiredness
3) Weight loss
4) Night sweats
5) Haemoptysis
6) Lymphadenopathy
What is the most serious complication of TB in childhood?
Miliary TB = primary infection is not adequately contained and invades the bloodstream, resulting in severe disease
What is found in on examination of a child with TB?
Depends on focus of infection
Primary in lung:
- Bronchial obstruction, pleural effusion etc
Primary in tonsils:
- Cervical adenitis
Primary in small bowel:
- Malabsorption, peritonitis
Miliary TB:
- Mengitis, chest signs, hepatosplenomegaly
What investigations are done for TB?
Confirmatory tuberculin sensitivity by Heaf or Mantoux testing
CXR for pulmonary TB
Culture of gastric washings
What is the management of TB?
Even in asymptomatic, tuberculin positive require treatment
Pulmonary:
- 2 months of isoniazid, rifampicin and pyrazinamide
- Then 4 months of isoniazid and rifampicin
Miliary spread:
- 3 months of isoniazid, rifampicin, ethambutol and pyrazinamide
- Then 12-28 months of isoniazid and rifampicin
Notifiable disease
What is the are some complications of TB?
Postprimary TB may present as local or disseminated (miliary) disease, affecting:
- Bones
- Joints = arthritis
- Kidneys = haematuria, renal failure
- Pericarium = constrictive pericarditis
- CNS = mental retardation, hydrocephalus morbidity and mortality is significant if TB detected late
How is TB prevented?
Bacile Calmette-Guérin (BCG) = live attenuated virus given intradermally at birth to high risk families
What causes whooping cough?
Bordetella pertussis
How is whooping cough prevented?
Immunisation with killed organism given at 2, 3 and 4 months and at school entry
How does whooping cough present?
3 stages:
1) Catarrhal = 1-2 weeks
- Mild cough, fever and coryza
2) Paroxsymal = 2-6 weeks
- Severe paroxsymal cough, followed by inspiratory whoop +/- vomiting +/- seizures +/- fever
- Coughing usually worse at night
- Babies usually don’t whoop, apnoea may be found in place of whoop
- Conjunctival haemorrhage (capillary rupture) due to cough
3) Convalescent - 2-4 weeks
- Lessening symptoms which may take month to reover
What is found on examination of whooping cough?
Very distressed at end of paroxysm Infant very unwell Dyspnoea Nasal discharge Apathetic Weight loss
How is whooping cough confirmed?
Diagnosis is clinical
Confirmed by pernasal swab culture in early disease
What is the management of whooping cough?
14 day course of erythromycin given early shortens illness, but is ineffective later
Avoid school or nursery for 48hrs if taking abx, 3 weeks if no treatment
Notifiable disease
Prophylactic erythromycin to close contacts
