Resp R-W

Question 1

What is Respiratory distress syndrome?

Answer 1

Respiratory compromise in neonate due to surfactant deficiency

Question 2

What is the background of Respiratory distress syndrome?

Answer 2

50% of infants born 28-32 weeks. Most common <28weeks.

Surfactant deficiency -> high alveolar surface tension -> alveolar collapse -> right to left intraplaural shunting. Deficiency may be:

· Primary: immaturity, hypoxia intrapartum, acidosis, hypothetmia, hypotension

· Secondary: MAS, intrapartum asphyxia, CpulmonaryLD, infections

Respiratory compromise made worse in immature infants due to soft thoracic cage -> ribs and sternum cave in when trying to generate high ithroacic pressure -> seesaw breathing.

Pathology:

· Macroscopic: lung is airless and ruddy – liver looking

· Microscopic: diffuse alectasis of distal air pacesw tih distension of airways and perilymphatic areas.

Question 3

What is the history and exam findings of Respiratory distress syndrome?

Answer 3

Respiratory distress signs: tachypnea, tachycardia, recession, grunting, nasal flaring, seesay breathing, cyanosis, there may be aopnea and hypothermia.

Question 4

What are the investigations for Respiratory distress syndrome?

Answer 4

ABG: respiratory acidosis (alectasis) metabolic acidosis (lactate generation fue to hypoxia) and low O2 (R -> L shunting)

CXR: bilateral diffuse ground glass appearance

Echo: ?PDA

Question 5

What is the management of Respiratory distress syndrome?

Answer 5

Prevention: identify at risk infants, ACT to estimate fetal lung maturity (leptin:sphigomyelin ratio, phosphatydilglycerol presence), prophylactic antenatal steroids in at risk infants to increase surfactant production.

Treatment: Surfactant administration via ETT to be given prophylactically at delivery, correction of hypoglycaemia, hypothermia and electrolyte issues. Prophylactic antibiotics.

Ventilation: CPAP via nasal cannula or conventional. HFOV may have to be used.

Question 6

What are the complications and prognosis of Respiratory distress syndrome?

Answer 6

Acute: PTX, ICH, periventricular leucomalacia, PDA, pulmonary haemorrage, NEC or FG perforation

Chronic: CLD, ROP, neurological impairment

Improving with prenatal steroids and surfactant therapy. Used to be poor (60%M)

Question 7

What is Transient Tachypnoea of the newborn?

Answer 7

Acute, self limiting tachypnea in the absence of another cause (ie. met acidosis, RDS or infection)

Question 8

What is the background of Transient Tachypnoea of the newborn?

Answer 8

Most common cause of respiratory distress in infants. <1% of neonates have this. Occurs in term neonates.

Secondary to impairment in resorption of lung fluid, leading to low pulmonary compliance and decreased tidal volume with increased dead space.

Associated with elective C section, precipitate deliveries, and maternal asthma.

Pathophysiology: In uter lung epithelium secretes CL- and fluid, does not reabsorb Na. Post delivery switch to Na reabsorption due to NA/A production/ Changes in O2 tension. With short delivery or lack of stages (C section) Na+ resorption does not occur -> fluid remains.

Question 9

What is the history and exam findings of Transient Tachypnoea of the newborn?

Answer 9

Occurs within first 1-3h following normal delivery. Most resolve in 72h.

Early onset tachypnea in neonate, may have signs of respiratory distress

Question 10

What are the investigations for Transient Tachypnoea of the newborn?

Answer 10

CXR: Perihilar streaking (distended veins and lymph) patchy infiltrates and fluid, flat diaphragm.

ABG: low pO2

Blod culture: exclude infections or pneumonia

Question 11

What is the management of Transient Tachypnoea of the newborn?

Answer 11

Exclude other causes (RDS, infection by GBS, MAS, pulmonary haemorrage, cerebral yperventilation.

Ventrilatory support may be required, CPAP

IV fluids, NBM until RR <60, to decrease aspiration. Prophylactic antibiotic unless infection excluded.

Diuretics do not improve outome.

Question 12

What are the complications and prognosis of Transient Tachypnoea of the newborn?

Answer 12

None with good tx.

Excellent, self limiting, ?wheezing in childhood. .

Question 13

What is URT infection?

Answer 13

A number of different conditions affecting the upper respiratory tract (coryza, otitis, pharyingitis, tonsillitis)

Question 14

What is the background of URT infection?

Answer 14

Very common with two peaks – starting nursery (2-3) and school (4-5)

· Viruses cause >90% URTI

· Coryza: rhinovirus, coronavirus, RSV

· Pharyngitis: adeno, entero, rhino, GAS

· Tonsillitis: EBV, GAS

· Otitis: flu, paraflu, entero, adeno, Strep pneu, HI, Moraxella

· Non immunized: diphtheria,

Asociated with immunodeficiency if recurrent

Pathology: inflammation of URT with agent leading to production of serous discharge and swelling of mucosal lining.

Question 15

What is the history and exam findings of URT infection?

Answer 15

General: ethargy, poor feeding

Coryza: sneezing, sore throat, fever

Pharyngitis/tonsillitis: cough, pain swallowing, fever, sore abdomen (mesenteric adenitis_

Mono: Prolonged lethargy, malaise, sore throat

Otitis: ear pain, conductive hearing loss.

General: pyrexia, tachycardia, lymphadenopathy (cervical)

Coryza: nasal dischars

Pharyngitis: pharynx, tonsillar fauces and soft palate inflamed.

Tonsillitis: red, swollen tonsils with or without white exudates. Follicular with white exudates EBV, GAS,

Otitis media: red tympanic membrane and conductive hearing loss.

Question 16

What are the investigations for URT infection?

Answer 16

Throat swab: for culture and PCR, GAS. Test diphtheria in non immunized.

Blood: ASOT, monospot.

Question 17

What is the management of URT infection?

Answer 17

Symptomatic pyrexia: Control fever and prevent dehydration. Do no use aspiring (Reye syndrome). Reducing fever does not prevent febrile seizures.

Active treatment: oral antibiotics (penicillin, erythromycin) if GAS found, to prevent rheumatic fever.

Surgical: tonsillectomy if recurrent tonsillitis.

Question 18

What are the complications and prognosis of URT infection?

Answer 18

Recurrent tonsillitis, peritonsillar abscess (quinsy), post streptococcal immunological response (PSGN, rhF)

Excellent – usually lasts at most 2 weeks.

Question 19

What is Whooping cough (pertussis)?

Answer 19

RT infection characterized by cough followed by whoop due to sudden massive inspiratory effort.

Question 20

What is the background of Whooping cough (pertussis)?

Answer 20

Boracella pertussis bacterium, incubation of 7-10d and contagious three weeks from cough onset. Preterm infants or those with systemic abnormalities are at higher risk of complications.

594/y in England and wales. Peak age 3, very dangerous if child <6m.

Question 21

What is the history and exam findings of Whooping cough (pertussis)?

Answer 21

Three stages:

1. Catharral stage: 1-2weeks, indistinguishable from common URTI with nasal congestion, cough, sneeze etc.
2. Paroxysmal stage: 1-6 weeks, consisting of paroxysms coughing with whoop, with vomiting, dyspnea, seizures. <6m no whoop but aopnea instead.
3. Convalescent stage: weks to months, chronic cough.

Older children: no specific stages.Symptoms in these patients feature continouous coughing, suffocation and strangulation feelings.

Question 22

What are the investigations for Whooping cough (pertussis)?

Answer 22

High WCC, lymphocytosis, CRP/ESR.

Immunohistochemistriy DIF testing of nasal swabs.

Question 23

What is the management of Whooping cough (pertussis)?

Answer 23

Immunisation is key

Prophylaxis: avoid contact, erythromycin to siblings of affected.

Respiratory isolation of affected for 5d after stargint Abx, or until 3wk post coughing onset.

Admit if M6m, vomiting with dehydration, respiratory distress, aopnea associated with peroxysms.

NOtifiable disease CDCC

Question 24

What are the complications and prognosis of Whooping cough (pertussis)?

Answer 24

Peroxysmal cough – may cause petechiae and conjunctival haemorrages. Dehydration and weight loss.

3% seizures. If encephalopathy occurs, 1/3 die, 1/3 remain impaired, 1/3 recover.

Secondary infections: otitis media, bronchiectasis, pneumonia

6-8wk, prolonged illness may occur (100 day cough). Significant mortality in <6m.

Question 25

What is viral induced wheeze?

Answer 25

• An acute viral infection of the lower respiratory tract

* The most common serious respiratory infection of infancy

Question 26

What are the clinical features of viral induced wheeze?

Answer 26

Intermittent episodes

• Very common, especially in < 5 years

Question 27

What investigations do you use for viral induced wheeze?

Answer 27

clinical diagnosis in < 5 years

Question 28

What is the management of viral induced wheeze?

Answer 28

o Salbutamol trial → continue if effective
▪ If child has cough and becoming wheezy and short of breath, can give
4-6 puffs of inhaler with spacer (maximum of 4 hourly)
▪ If symptoms worsening, give 6-10 puffs every 4 hours and arrange to
see GP
▪ If symptoms of respiratory distress, call 999 and give 10 more puffs whilst awaiting ambulance

o Monitoring

Question 29

What is sinusitis?

Answer 29

• Symptomatic inflammation of the mucosal lining of the nasal cavity and paranasal
sinuses
• Infection of the paranasal sinuses may occur with viral URTIs
• Occasionally you might get a secondary bacterial infection
• The frontal sinuses are rarely affected because they do not develop until late
childhood

Question 30

When do you refer to hospital with sinusitis?

Answer 30

• Refer to hospital if there are symptoms and signs of:
o Severe systemic infection
o Intraorbital or periorbital problems (e.g. periorbital cellulitis, displaced
eyeball, double vision)
o Intracranial complications (e.g. features of meningitis)

Question 31

How do you manage sinusitis if there are symptoms under 10 days?

Answer 31

o Do NOT offer an antibiotic
o ADVISE
▪ Acute sinusitis is usually caused by a virus and takes 2-3 weeks to
resolve
• It can be complicated by bacterial infection (2% risk)
▪ Symptoms, such as fever, can be managed using paracetamol or
ibuprofen
▪ Some people may find some relief using nasal saline or nasal
decongestants
▪ Medical advise should be sought if symptoms worsen rapidly, if
they do not improve in 3 weeks or become systemically unwell

Question 32

How do you manage sinusitis if there are symptoms over 10 days?

Answer 32

o Consider high-dose nasal corticosteroid for 14 days for adults and children > 12 years old (e.g. mometasone)
▪ May improve symptoms but unlikely to affect duration of illness
▪ Could cause systemic side-effects

o Consider NO antibiotic prescription or back-up prescription
▪ Antibiotics are unlikely to change the course of the illness
▪ The back-up prescription should be used if symptoms get
considerably worse of it is still has not improved by 7 days
▪ 1st line: phenoxymethylpenicillin
• NOTE: clarithromycin if penicillin allergy
▪ 2nd line: co-amoxiclav

o Advise patients to seek medical advice if they develop complications or
their symptoms don’t improve/worsen
▪ Consider alternative diagnoses such as dental infection

o ADVICE: NHS Choices information on Sinusitis