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Child Health > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Asthma attack history

A 
Acuity of onset
Potential trigger
Regular medication
Frequency of preventer use and attacks
Frequency of oral steroid use
Previous ED/GP attendances
Social impact
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2
Q

Pathophysiology of asthma

A

Dendritic cells present allergens to Th2 type T-cells
Humoral immune system activated
Mast cells, eosinophils, dendritic cells proliferation
Inflammatory process, bronchoconstriction

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3
Q

Role of leukotriene C4 and histamine in asthma attack

A

Histamine increases production of an exudate

Leukotriene C4 is directly toxic to epithelial cells

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4
Q

Risk factors for asthma

A

Genetic: asthma/atopy in parents or siblings
Environmental factors: low birth weight, prematurity, parental smoking
Viral bronchiolitis in early life
Atopic dermatitis

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5
Q

Precipitating factors for asthma

A 
Cold air and exercise
Atmospheric pollution
NSAIDs increase leukotriene production
BB: prevent bronchodilation through catecholamines 
Exposure to allergens
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6
Q

Pattern of wheeze in asthma

A

Infrequent episodic wheezing lasting a few days, no symptoms at night
Frequent episodic wheezing (2-6weekly)
Persistent wheezing: wheeze and cough most days and disturbed nights

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7
Q

Preschool wheeze clinical patterns

A

RSV
Episodic viral wheeze
Multiple trigger wheeze
Wheezing episode preceded by coryzal symptoms

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8
Q

Asthma diagnosis history

A 
Age at onset of symptoms
Frequency of symptoms
Severity of symptoms: at night, effect on life 
Previous treatments tried
Any hospital attendances 
Presence of food allergies
Triggers 
Disease history 
FH of atopy
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9
Q

Examination of a child with asthma

A

Finger clubbing: CF, bronchiectasis
Chest shape: hyperinflated chest indicates poor asthma control
Chest symmetry
Breath sounds
Presence of crepitations: not suggestive of asthma
Presence of wheeze
Examination of throat to check for tonsillar enlargement

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10
Q

Asthma investigations

A 
Spirometry: FEV1:FVC<0.7 
PEFR
Bronchial provocation tests: histamine or metacholine
Exercise testing
Skin prick testing 
Exhaled nitric oxide 
CXR
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11
Q

What other investigations should be performed if there is doubt of a diagnosis of asthma?

A

Oesophageal pH to assess for GORD
Bronchoscopy to exclude structural abnormality
Chloride sweat test to exclude CF
Nasal brush biopsy to exclude primary ciliary dyskinesia
Serum IgG, IgA and IgM and response to vaccinations
HRCT to exclude bronchiectasis
Sputum culture

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12
Q

Signs of good asthma symptoms control

A 
Full school attendance
No sleep disturbance 
<2/week daytime symptoms
No limitations of daily activities 
No exacerbations 
Using salbutamol <2/week
Maintaining normal lung function
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13
Q

Omalizumab in asthma

A

Monoclonal antibody for IgE
Reduces free IgE in the blood
Given to children with persistent poor control
If evidence of allergic sensitisation to a perineal aeroallergen and a raised serum total IgE

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14
Q

Causes of wheeze in children

A

Respiratory infections: bronchiolitis, bronchiolitis obliterans
Airway abnormalities: bronchomalacia, chronic lung disease of prematurity
Foreign body inhalation

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15
Q

Mild/moderate asthma attack

A 
SpO2 >92%
RR >30 (>5), >40 (<5)
No or minimal accessory muscle use
Feeding well or talking in full sentences
Wheeze
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16
Q

Severe asthma attack

A 
SpO2<92%
PEFR 33-50% predicted 
RR >30 (over 5), >40 (<5)
Too breathless to feed or talk 
HR >125 (>5), >140 (<5)
Use of accessory muscles
Audible wheeze
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17
Q

Life-threatening asthma

A 
SpO2<92%
PEFR <33% predicted
Silent chest
Poor respiratory effort
Altered consciousness
Agitation/ confusion 
Exhaustion
Cyanosis
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18
Q

Immediate management of asthma attack

A

Oxygen, 94-98 aim
Bronchodilators
Ipratropium bromide (anti-muscarinic) if no or poor response to inhaled SABA
Corticosteroids: short 3 day course or steroids should be commenced, oral prednisolone is first line. IV hydrocortisone if child is vomiting lots

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19
Q

Second-line management of asthma attack

A

IV salbutamol

Magnesium sulphate

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20
Q

Safe discharge criteria for asthma

A

Bronchodilators with spacer at intervals of 4-hourly or more
SaO2>94% air
Inhaler technique assessed/taught
Written asthma management plan given and explained to parents
GP should review child 2 days after discharge

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21
Q

Acute cough

A

<4 weeks
Viral, bacterial infection
Pertussis

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22
Q

Prolonged acute cough

A

4-8 weeks
Post-viral cough
Children recovering from complicated pneumonia

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23
Q

DD of chronic wet cough (>8weeks)

A 
Persistent bacterial bronchitis 
Rhinitis and post-nasal drip
GORD
Bronchiectasis (CF vs non-CF)
Primary ciliary dyskinesia (PCD)
Immune problems- recurrent/unusual infections
Recurrent aspiration
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24
Q

Approach to patient with chronic cough

A 
History of infection
Nasal symptoms
Failure to thrive
Wheeze
Response to previous symptoms
Atopy 
CXR
Bloods- immune screen, allergy markers 
SALT
Lung function test
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25
Q

What is involved in an immune screen?

A

T-cell sub sets
Antibody response
Ig

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26
Q

What are the allergy markers?

A

Eosinophils
IgE
SIgE

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27
Q

Features and treatment of rhinitis with post-nasal drip?

A 
Throat clearing
Snoring
Blocked nose
Bad breath
Worse in morning and clears through day

Steroid nasal spray
Antihistamine

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28
Q

GORD features and treatment

A

Younger child
Vomits
Better when upright

Trial of PPI

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29
Q

Protracted bacterial bronchitis

A

Persistent bacterial infecton in lower airway
Presence of wet cough (>4 weeks)
Absence of symptoms or signs (i.e. specific cough pointers) suggestive or other causes
Cough resolves following a 2-4week course of an appropriate oral antibiotic

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30
Q

Symptoms of protracted bacterial bronchitis

A

Chest pain
History suggestive of inhaled foreign body
Exertional dyspnoea
Failure to thrive
Feeding difficulties
Cardiac or neuro developmental abnormalities
Recurrent sinopulmonary infections
Immunodeficiency or epidemiological risk factors for exposure to TB

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31
Q

Signs of protracted bacterial bronchitis

A

Respiratory distress
Digital clubbing
Chest wall deformity
Auscultation crackles

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32
Q

Tracheobronchomalacia

A

Floppy airways: flaccidity of supporting cartilage
Congenital, extrinsic compression, acquired
Treatment: nothing, prophylactic antibiotics, CPAP, surgery
Prognosis very good

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33
Q

Causes of bronchiectasis

A 
CF
Post-infectious
Immunodeficiency 
Ciliary dyskinesia 
Aspiration
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34
Q

Diagnosis of bronchiectasis

A

HRCT

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35
Q

Treatment of bronchiectasis

A 
Prophylactic Ax
Physiotherapy 
Aggressive LRTI treatment 
Nutrition
Regular monitoring, including lung function
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36
Q

CF diagnosis

A

Screening
Sweat chloride
Genotyping

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37
Q

Pathophysiology of CF in lungs

A

Defective CFTR protein on airway epithelial cells and submucosal glands
Decreased secretion of chloride and increased reabsorption of sodium and water
Reduced amount of water in secretions
Reduced airway surface liquid: important for immunology and mucocilialry escalator
Decrease mucus clearance
Ideal for bacteria, inflammation

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38
Q

CF manifestations

A

Recurrent chest infections, chronic wet cough
Exocrine pancreatic insufficiency
Failure to thrive
Neonate- meconium ileus, protracted jaundice, electrolyte abnormality
Intestinal obstruction
Male infertility-blockage of vas

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39
Q

Pathophysiology of pancreatic insufficiency in CF

A

Duct occluded in-utero causing permanent damage to exocrine pancreas
CF-related DM

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40
Q

GI tract pathophysiology in CF

A

Small intestine secretes viscous mucus
Bowel obstruction in-utero
Meconium ileus

Cholestasis in biliary tree
Neonatal jaundice

Later in life:
Distal intestinal obstruction syndrome
CF-related liver disease

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41
Q

Reproductive tract pathophysiology in CF

A

Congenital abscence of vas deferens

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42
Q

Clinical presentation of CF in neonates

A

Meconium ileus- abdominal distension, delayed passage of meconium and bilious vomiting in first days of life
Failure to thrive
Prolonged neonatal jaundice

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43
Q

Clinical presence of CF in infancy

A

Failure to thrive
Recurrent chest infections
Pancreatic insufficiency; steatorrhea

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44
Q

Childhood presentation of CF

A

Rectal prolapse
Nasal polyps
Sinusitis

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45
Q

Adolescent presentation in CF

A

Pancreatic insufficiency; diabetes mellitus
Chronic lung disease
DIOS, gallstones, liver cirrhosis

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46
Q

History of a patient with CF

A

Early treatment of infection and optimisation of nutrition
Persistent/recurrent productive cough
Failure to thrive
Complaints of bowel symptoms: steatorrhoea, constipation
Rectal prolapse
Nasal polyps

47
Q

Examination of a patient with CF

A

Finger clubbing
Nasal polys
Hyperinflated chest, crepitations, portacath
Faecal mass in abdomen, ileostomy scar from meconium ileus

48
Q

Diagnosis of CF

A

Fitting clinical history

Positive chloride sweat test

49
Q

Investigations in CF

A

CXR for hyperinflation and bronchial thickening
Chloride sweat test
Microbiological assessment, e.g. cough swab/sputum
Glucose tolerance test
LFT and coagulation
Bone profile
LFT: spirometry and lung clearance index
Faecal elastase to assess pancreatic function
Chest CT for bronchiectasis
Genetic analysis

50
Q

The chloride sweat test

A

Measures electrolyte concentration in sweat, >60mmol/L
Pilocarpine iontophoresis
Need a second positive test or genetic mutation identification to diagnose

51
Q

CF airway clearance and chest symptoms management

A

Twice-daily physiotherapy
Increased airway secretion clearance, will reduce airway obstruction and minimise risk of infection
DNase: inhaled and reduces viscosity of mucus by digesting DNA which is abundant in the sputum of patients with CF
Hypertonic saline: can aid airway clearance

52
Q

Nourishment and exercise for CF Mx

A

Pancreatic enzyme supplementation (Creon) with fat meals
ADE vitamin supplements
Monitor growth
Build-up milkshakes
Enteral feeding via gastrostomy if needed

53
Q

Managing/ preventing airway infections in children with CF

A

Common causative organisms; staphylococcus aureus, Haemophilus influenzae, pseudomonas aeruginosa
Patients need continual microbiological assessment to identify organisms colonised
Sputum cultures
Treat infections with 2 weeks of ax
Give regular azithromycin
Prophylactic ax in <3years
Chronic pseudomonas treat with inhaled ax due to biofilms
Side room

54
Q

Annual CF review

A 
Respiratory paediatrician
Dietician 
Physiotherapist
CF specialist nurse
Review of clinical symptoms, ax, microbiology
Bloods: FBC, renal function, LFTs, vitamines A,D,E, clotting profile, HbA1c
LFTs
CXR is normally performed 
>12 oral glucose tolerance test
55
Q

Non-resp complications of CF

A 
Rectal prolapse
DIOS: distal ileal obstruction 
Cholestasis
Gallstones
Liver cirrhosis 
CF-related diabetes
Delayed puberty: reduced bone mineral density
Arthritis
Infertility
56
Q

Respiratory complications of CF

A 
Allergic bronchopulmonary aspergillosis
Bronchiectasis
Haemoptysis
Pulmonary hypertension and right heart strain 
Pneumothorax 
Respiratory failure
Nasal polys
57
Q

Paediatric long term ventilation

A

<17
Medically stable
Requires a mechanical aid for breathing with invasively by tracheostomy or by non-invasive ask interface for all or part of the 24h day
For longer than 3 months

58
Q

Causes of stridor in children

A

Croup
Acute epiglottitis
Inhaled foreign body
Laryngomalacia

59
Q

Causes of OSA in children

A

Enlarged tonsils and adenoids
Obesity and Down;s syndrome: makes airway more collapsible
Abnormal facial structure
Narrow, floppy, soft airways (laryngomalacia)
Muscular dystrophy or cerebral palsy

60
Q

OSA symptoms

A 
Snoring and pauses in breathing followed by gasps or snorts 
Daytime sleepiness
Difficulty putting on weight
Mouth breathing
Nasal speech 
Hyperactivity
Irritable
61
Q

OSA assessment

A 
Parental observation 
Oxygen saturations
CO2 levels
Breathing movements 
Heart rate and rhythm
Airflow
Video and sound recording
62
Q

OSA treatment

A

Adenotonsillectomy

Nasal inhaled corticosteroid sprays or drops

63
Q

What is croup?

A

Acute laryngotracheobronchitis
Common viral childhood illness
Harsh barking cough, stridor, hoarseness of voice, fever

64
Q

Epidemiology of croup

A

6months-3 years

Peak incidence at 2 years

65
Q

Pathophysiology of croup

A

Mucosal inflammation anywhere between nose and trachea
Parainfluenza virus is most common
Impaired movement of vocal cords creates characteristic barking cough

66
Q

Potential causative organisms for croup

A 
Parainfluenza virus 
Respiratory syncytial virus
Adenovirus 
Rhinovirus 
Enterovirus 
Measles
Meta pneumovirus 
Influenza A and B
Mycoplasma pneumoniae
67
Q

Risk factors for croup

A

Male gender
Autumn and spring season
C/C variant of the CD14 C-159T gene

68
Q

History of a child with croup

A

1-4 day history of non-productive cough, rhinorrhoea and fever
Progressing to a barking cough and hoarseness
Symptoms worst at night
Red flags for resp failure: drowsiness and lethargy

69
Q

Clinical features from examination of croup

A

Stridor
Decreased airflow
Resp distress: tachypnoea, intercostal recession
Red flag for respiratory failure: cyanosis, lethargic/decreased level of consciousness, laboured breathing, tachycardia

70
Q

Mild croup

A

Occasional barking cough
No audible stridor at rest
No suprasternal, or intercostal recession
Child is happy and will drink, eat and play

71
Q

Moderate croup

A

Frequent barking cough
Audible stridor at rest
Suprasternal and sternal wall retraction at rest
Child isn’t distressed or agitated and will still show interest in surroundings

72
Q

Severe croup

A 
Frequent barking cough 
Prominent inspiratory stridor at rest
Marked sternal wall retractions
Child will appear distressed/ agitated or lethargic or restless
Tachycardia, hypoxaemia
73
Q

Croup vs epiglottis

A 
Days vs hours
Coryza vs no prior features 
Barking cough vs slight/if any
Can drink vs no feeding
Mouth closed vs drooling saliva
Non toxic vs toxic
Fever <38.5 vs >38.5
Rasping stridor vs soft stridor
Hoarse voice vs weak or silent
74
Q

Investigations for croup

A

FBC, CRP, U&Es
CXR: rule out inhaled foreign body
Pulse oximetry

75
Q

When would you consider admission in a croup child?

A

<6 months
Previous history of severe airway obstruction
Immunocompromised
Have had inadequate fluid intake
Have had a poor response to initial treatment
The diagnosis is uncertain
Significant parental anxiety

76
Q

Advice to parents for home-managed croup:

A

Symptoms resolve within 48hours but can last to one week
Paracetamol or ibuprofen to control pain and fever
No Ax needed
Ensure that child has adequate fluid intake
Seek urgent medical advice if symptoms worsen: high fever, stridor, heart rate (bacterial tracheitis)
Call ambulance if signs of respiratory failure

77
Q

When should immediate hospital admission occur for croup?

A

If child has moderate/severe croup or impending respiratory failure
Suspect serious disorder caused by infection, e.g. peritonsillar abscess, laryngeal diphtheria, non-infectious cause (foreign body, angioneurotic oedema)

78
Q

Treatment for croup

A

Single dose of oral dexamethasone (0.15mg/kg) or oral prednisolone (1-2mg/kg body weight)
Nebulised adrenaline to provide temporary symptomatic relief
Ensure child is calm
Oxygen therapy as required
Contact ENT and an anaesthetist if there is need for airway support

79
Q

Complications of croup

A 
Lymphadenitis 
Otitis media
Dehydration
Bacterial superinfection resulting in pneumonia or bacterial tracheitis 
Pulmonary oedema
Pneumothorax
80
Q

When are pertussis vaccines given?

A

2, 3, and 4 months of age
Booster at 3 years and 4months
Pregnant women

81
Q

Pathophysiology of pertussis

A

Bordetella pertussis
Gram-negative bacillus
Aerosol spread, very contagious
Bacteria attach to respiratory epithelium
Bacteria produce toxins which paralyse cilia and promote inflammation
Impaired clearance of respiratory secretions
Cough

82
Q

Risk factors for pertussis

A

Non-vaccination

Exposure to infected individuals

83
Q

Phases of pertussis

A

Catarrhal (first) phase lasts 1-2weeks

Paroxysmal (second) phase lasts for 2-8weeks

84
Q

Catarrhal phase of pertussis

A 
Rhinitis
Conjunctivitis 
Irritability
Sore throat 
Low-grade fever
Dry cough
85
Q

Paroxysmal phase of pertussis

A

Severe paroxysms of coughing, more common at night
Then inspiratory gasp, producing the classic whoop sound

<3 months, apnoea, vomiting after coughing
Conjunctival haemorrhages and facial petechiae due to vigorous coughing

86
Q

Examination of pertussis

A

Low grade fever
Conjunctival haemorrhages and facial petechiae
Chest auscultation usually normal

87
Q

Differential diagnosis of paroxysmal cough

A 
Bronchiolitis/ viral respiratory infection 
Mycoplasma pneumonia 
Bacterial pneumonia
Asthma 
Tuberculosis
88
Q

Pertussis investigations

A

<2 weeks cough: nasopharyngeal aspirate culture or nasopharyngeal swab is recommended
>2 weeks and <5: anti-pertussis toxin IgG serology
>2 weeks and 5-17: anti-pertussis toxin detection in oral fluid
Pertussis vaccine within last year can produce a false positive
FBC: lymphocytosis (+/- elevated WCC)

89
Q

Management of pertussis

A

Macrolides ax when cough <21 days
<1 months: clarithromycin
>1 months: azithromycin or clarithromycin
2nd line: co-trimoxazole or macrolides inappropriate
Supportive management
Cough takes 3 months to self-resolve
Avoid school or nursery until 21days cough or 5days ax

90
Q

Hospital admission indicated in pertussis

A

<6months
Significant breathing difficulties, e.g. apnoeic episodes, cyanosis, respiratory distress, severe paroxysms of coughing
Feeding difficulties
Significant complications, e.g. pneumonia or seizures

91
Q

Complications of pertussis

A

Secondary bacterial pneumonia
Seizures
Encephalopathy
Otitis media

92
Q

Pathophysiology of bronchiolitis

A

Proliferation of goblet cells: excess mucus
IgE-mediated TY1 allergic reaction: inflammation
Bronchiolar constriction
Infiltration of lymphocytes: submucosal oedema
Infiltration of cytokines and chemokines
Hyperinflation, increased airway resistance, atelectasis, VQ mismatch

93
Q

Risk factors for bronchiolitis

A

Breast fed for less than 2 months
Smoke exposure
Having siblings who attend nursery or school
Chronic lung disease due to prematurity

94
Q

History of bronchiolitis

A 
Increasing symptoms over 2-5days
Low-grade fever
Nasal congestion
Rhinorrhoea
Cough
Feeding difficulty
95
Q

Examination findings in bronchiolitis

A 
Tachypnoea
Grunting
Nasal flaring
Intercostal, subcostal or Supraclavicular recessions 
Inspiratory crackles
Expiratory wheeze
Hyperinflated chest
Cyanosis or pallor
96
Q

Bronchiolitis lab tests

A

Nasopharyngeal aspirate or throat swab- RSV rapid testing and viral cultures
Blood and urine culture if child is pyrexic
FBC
Blood gas (ABG)- if severely unwell

97
Q

Bronchiolitis CXR features

A 
Hyperinflation
Focal atelectasis
Air trapping
Flattered diaphragm 
Peribronchial cuffing
98
Q

Features of bronchiolitis for urgent hospital referral

A 
Apnoea
Child looks seriously unwell
Severe respiratory distress, e.g. grunting, marked recessions, RR>70
Central cyanosis
Oxygen sats <92%
99
Q

Management steps for bronchiolitis in hospital

A

If <92% give oxygen
Give fluids NG/orogastric if inadequate oral intake
CPAP if resp failure
Upper airway suctioning if upper airway secretions or apnoea

100
Q

When can u discharge bronchiolitis

A

Clinically stable
Taking adequate oral fluids
Maintaining sats >92% for more than 4 hours

101
Q

Complications of bronchiolitis

A 
Hypoxia
Dehydration
Fatigue
Respiratory failure 
Persistent cough or wheeze 
Bronchiolitis obliterans- airways permanently damaged due to inflammation and fibrosis
102
Q

Prognosis of bronchiolitis

A

7-10days

Most children can cough for up to 6 weeks

103
Q

What is bronchiectasis?

A

Abnormal dilatation of airways with associated destruction of bronchial tissue
Commonly occurs as a result of CF

104
Q

Pathophysiology of bronchiectasis

A

Inflammatory response to a severe infection
Structural damage within bronchial walls, which causes dilatation
Scarring from immune response
Scarring reduces number of cilia within bronchi

105
Q

Causes of bronchiectasis

A 
Streptococcus pneumoniae
Staphylococcus aureus
Adenovirus
Measles 
Influenza virus
Bordetella pertussis
Mycobacterium tuberculosis 
Antibody defects
HIV infection
Ataxia telangiectasia 
Primary ciliary dyskinesia
Post-obstructive: foreign body
Youngs
Yellow-nail syndrome
106
Q

Primary ciliary dyskinesia

A

Autosomal recessive genetic defect
Reduced efficacy or complete inaction of bronchial cilia
Problems in mucociliary clearance
Increased susceptibility to low-grade infections and irritation from foreign particles

107
Q

Youngs syndrome

A

Bronchiectasis
Reduced fertility
Rhinosinusitis

108
Q

Yellow-nail syndrome

A

Pleural effusions
Lymphoedema
Dystrophic nails

109
Q

Bronchiectasis history

A 
Chronic, productive cough 
Purulent sputum expectoration
Chest pain
Wheeze
Breathlessness on exertion
Haemoptysis 
Recurrent or persistent infections of LRTI
110
Q

Bronchiectasis examination

A

Finger clubbing
Inspiratory crackles
Wheezing

111
Q

Bronchiectasis imaging

A

CXR: bronchial wall thickening or airway dilatation
High resolution CT: gold-standard, bronchial wall thickening, diameter of bronchus larger than that of accompanying bronchial artery (signet ring) and visible peripheral bronchi
CF: Bilateral upper lobe bronchiectasis
Post-TB: unilateral upper lobe bronchiectasis
Foreign body inhalation: focal lower lobe bronchiectasis

112
Q

Bronchiectasis investigations

A 
Chloride sweat test 
FBC with leukocyte differential 
Immunoglobulin panel 
Specific ab levels to vaccinations, e.g. pneumococcal or Hib
If bronchoscopy: ciliary brush biopsy
HIV test
Microbiology
Lung function: spirometry obstructive in severe
113
Q

Management of bronchiectasis

A

Chest physiotherapy
Ax
Bronchodilators if wheeze present
Follow-up

114
Q

Complications of bronchiectasis

A 
Recurrent infection
Life-threatening haemoptysis 
Lung abscess
Pneumothorax
Poor growth and development

Child Health (20 decks)

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