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Year 4 Paeds > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Define Apnoea

A

Cessation of respiratory airflow

Note: short breathing pauses of 5-10 seconds are normal and common in preterms

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2
Q

Define Apnoea of Prematurity

A

Cessation of breathing for >20 seconds, or <20 seconds with a drop in SpO2 and bradycardia

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3
Q

Give 3 causes of Apnoea of Prematurity

A

Immaturity of breathing responses to changes in O2 and CO2

Collapse of airways due to poor tone

Nasal Obstruction (neonates are obligate nasal breathers)

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4
Q

Define OSA and give some causes

A

Snoring associated with periods of ineffective breathing

Adenotonsillar Hypertrophy, Obesity, Macroglossia, Micrognathia

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5
Q

How might OSA present in a child?

A

Snoring and sleep disturbance

Daytime sleepiness

Enuresis

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6
Q

How would you investigate and manage OSA?

A

Ix - Sleep Study, CXR, EEG

Mx - CPAP, ?Weight Loss, ?Adenotonsillectomy

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7
Q

What is Expiratory Apnoea Syncope? (AKA Blue Breath Holding Spells)

A

Precipitated by anger/crying

Cannot catch breath (stuck in expiration)

Goes blue, stiff then limp with rapid recovery

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8
Q

Name three investigations for Apnoea

A

Lumbar Puncture
CXR
Bloods (U&Es, Glucose, Culture)

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9
Q

Define Wheeze

A

High pitched musical respiratory sound usually heard on expiration. Associated with airway narrowing and limitations.

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10
Q

Give 5 causes of acute wheeze

A 
Viral Episodic Wheeze
Bronchiolitis/Bronchitis
Bacterial tracheitis
Foreign Body Aspiration
Anaphylaxis
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11
Q

Give two structural and two functional causes of chronic wheeze

A

Structural - Tracheobronchomalacia, Tracheal Web

Functional - Asthma, CF

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12
Q

How is a Wheeze managed?

A

Treat underlying cause

Beta Agonists and Steroids

Oxygen

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13
Q

Define Stridor

A

Harsh respiratory sound produced by turbulent flow in narrow upper airways, affected by severity of narrowing

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14
Q

What three associated symptoms with Stridor or should you ask about as a priority?

A

Fever

Drooling (Secure Airway, ENT referral)

Barking Cough (Dexamethasone, Intubate and Admit)

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15
Q

Give 5 causes of Acute Stridor

A 
Croup (Laryngotracheobronchitis)
Epiglottitis
Bacterial Tracheitis 
Peritonsillar Abscess
Anaphylaxis
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16
Q

Give two congenital causes and two acquired causes of Chronic Stridor

A

Congenital - Laryngomalacia, Subglottic Stenosis

Acquired - Vocal cord paralysis, Tumours

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17
Q

In an Acute Stridor or you should avoid looking at the throat until resus equipment is at hand. How else could you assess severity?

A 
Only on crying?
At rest?
Chest Retraction?
Cyanosis?
Tachypnoea/Tachycardia?
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18
Q

Define Cyanosis

A

Bluish/Purplish discolouration of tissues due to increased concentration of deoxygenated haemoglobin in capillary beds

Mostly appreciated in lips/nail beds/mucous membranes

Can be central or peripheral

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19
Q

Give three AIRWAY causes of Cyanosis

A

Choanal Atresia
Laryngomalacia
Pierre Robin Syndrome

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20
Q

Give three BREATHING causes of Cyanosis

A

Hypoventilation/Apnoea

Pneumonia

Congenital Diaphragmatic Hernia

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21
Q

Give three CIRCULATION causes of Cyanosis

A

Anaemia
Methaemaglobinaemia
Cyanotic CHD

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22
Q

State five categories of a cough history

A 
Onset (Any preceding symptoms)
Duration
Nature (Dry or Wet)
Triggers
Associated Sx
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23
Q

Give 3 viral causes of Acute Cough

A

URTI (Cold)
Laryngotracheobronchitis
Bronchiolitis

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24
Q

Give 2 bacterial causes of Acute Cough

A

Epiglottitis

Bacterial Pneumonia

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25
Q

How would an inhaled foreign body appear on a CXR?

A

The object may be visible on the CXR

Hyperinflation on affected side due to air trapping

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26
Q

Give three Pulmonary causes of a chronic cough

A

Asthma
Post Infectious
CF

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27
Q

Give three Extra - Pulmonary causes of a chronic cough

A

Post Nasal Drip
Cardiac
GORD

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28
Q

Define Protracted Bacterial Bronchitis

A

Chronic Wet Cough as a diagnosis of exclusion

Resolves with 2-6 weeks of treatment

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29
Q

State the boundaries for Tachypnoea in Neonates/Infants/Children/Adolescents

A

Neonates - >60
Infants - >50
Child - >40
Adolescent - >30

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30
Q

State 5 red flags of a Cough

A 
Sudden Onset (choking)
Weight Loss
Night Sweats
Cyanosis
Clubbing
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31
Q

Define Breathlessness

A

Laboured or increased work of breathing from increased airway resistance, characterised by nasal flaring, grunting, and usage of accessory muscles

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32
Q

Give four differentials for breathlessness in a child

A

Airway obstruction
DKA
Pneumonia
CHD

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33
Q

What would point to a Cardiac cause of breathlessness in a child?

A

Squatting when fatigued
Poor weight gain
Hepatomegaly
Oedema

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34
Q

Asthma is the most common chronic condition in children. State the definition

A

Reversible and paroxysmal constriction of the airways

Early features include inflammatory exudate, and late features include airway remodelling

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35
Q

Asthma is a multifactorial disease in which susceptible individuals have an exaggerated response to various stimuli. Describe the classical pathophysiology.

A

Driven by TH2 cells which release cytokines resulting in activation of humoral system

Humoral system causes increased proliferation of mast cells/eosinophils/dendritic cells

Leukotrienes cause cytotoxicity and histamine causes exudate production

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36
Q

Give four risk factors for Asthma

A

Genetic (trend of atopy)
Prematurity
Parental Smoking
Early Viral Bronchiolitis

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37
Q

There are various triggers that affect Asthma, what effects do NSAIDs have?

A

Shunts the arachadonic pathway towards leukotriene production which is cytotoxic

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38
Q

How could you describe the pattern of wheezing in asthmatic individuals?

A

Infrequent - discrete episodes lasting a few days with no interval sx

Frequent - occurring 2 to 6 times weekly

Persistent - occurring most days and may occur at night

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39
Q

What is Pre- School Wheeze?

A

50% have at least one significant wheeze by their 5th Birthday

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40
Q

Asthma is normally a clinical diagnosis, what are the two main investigations that could be carried out?

A

Spirometry - if child is over 6, should be normal in between exacerbations if well controlled

PEFR - if over 5y/o

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41
Q

What are Bronchial Provocation Tests?

A

A test used in uncertain cases to assess airway hyper responsiveness to histamine or metacholine

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42
Q

How is the Exhaled Nitric Oxide investigation used?

A

Produced in bronchial epithelial cells, and it’s production is increased with TH2 driven inflammation

Positive result is >35ppb

Note: Also raised in hay fever

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43
Q

What investigations could be done to rule out differentials of Asthma?

A 
Oesophageal pH
Bronchoscopy
Chlorine Sweat Test
Nasal Brush Biopsy (exclude PCD)
HRCT
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44
Q

How would you manage Asthma in children under 5 on a day to day basis?

A

Treat without investigation

Inhalers via Metered Dose Inhaler with spacer

1) SABA as reliever therapy
2) + 8 week trial of ICS
3) + Leukotriene Antagonist (eg Montelukast - beware of behavioural issues)

45
Q

How would you manage Asthma in children 5-16 on a day to day basis?

A

1) SABA reliever
2) add low dose ICS
3) SABA + ICS + Leukotriene antagonist
4) Stop Leukotriene, start ICS and LABA and SABA
5) MART regimen (Maintenance and Reliever therapy)
6) Higher steroid dose MART regime
7) Increase ICS/Add Theophylline/Oral Steroids/Biologics

46
Q

What are the contents of a Fostair combined inhaler?

A

Beclametasone

Formeterol

47
Q

What are the contents of a Seretide combined inhaler?

A

Fluticasone and Salmeterol

48
Q

What are the contents of a Symbicort combined inhaler?

A

Budesonide

Formeterol

49
Q

Describe the features of Mild/Mod Asthma Exacerbation

A 
SpO2>92%
Resp Rate under 30(>5) or (<5)
Minimal accessory muscle use
Full Sentences
Wheeze
50
Q

Describe the features of Mod/severe Asthma Exacerbation

A 
SpO2<92%
PEFR 33-50% predicted
Resp Rate over 30(>5) or 40 (<5)
Incomplete Sentences
Tachycardia
Accessory Muscles and Wheeze
51
Q

Describe the features of Life Threatening Asthma Exacerbation

A 
SpO2<92%
PEFR <33% predicted
Silent Chest and Poor Resp Effort
Altered consciousness
Cyanosis
52
Q

How is an Asthma Exacerbation managed?

A

1) If O2<94% give O2
2) Nebulised Salbutamol
3) 3d Oral Prednisolone
4) +/- Ipratropium Bromide

Consider IV Salbutamol or MgSO4 if severe

53
Q

What is involved in an Asthma discharge bundle?

A 
SpO2>94% on air
Assessed inhaler technique
Four hourly bronchodilators 
Written asthma management plan
GP follow up 2d
54
Q

Define Bronchiectasis

A

Abnormal dilation of airways associated with destruction of bronchial tissue. Secondary to an inflammatory response to infection causing structural damage and dilation

55
Q

What are the 5 broad causes of Bronchiectasis?

A 
Post Infectious
Immunodeficiency 
Primary Ciliary Dyskinesia
Post Obstructive
Congenital
56
Q

Give four immunodeficiencies that could result in Bronchiectasis

A

Hypogammaglobulinaemia
CVID
IgA/IgG specific
Ataxia Telangiectasia

57
Q

Give three of the most common genetic causes of Bronchiectasis

A

Kartageners (Sinusitis, Bronchiectasis, Situs Inversus)
Young’s (Sinusitis, Bronchiectasis, Infertility)
Yellow Nail Syndrome (Pleural Effusions, Lymphoedema, Dystrophic Nails)

58
Q

Describe the possible CXR findings of Bronchiectasis

A

Bronchial Wall Thickening
Airway Dilation

Or normal

59
Q

Describe the HRCT findings of Bronchiectasis

A

Bronchial Wall Thickening
Visible Peripheral Bronchi
Signet Sign

CF - bilateral upper lobe
Post TB - Unilateral upper lobe

60
Q

What tests could you do to determine the underlying cause of Bronchiectasis?

A

Chloride Sweat Test
Immunoglobulin panel
Ciliary Brush Biopsy
WCC differential

61
Q

How is Bronchiectasis managed?

A 
Chest Physio
Exacerbations managed 
Vaccinations
Bronchodilators
Regular Follow Ups
62
Q

Define Bronchiolitis

A

Viral infection of the Bronchioles usually caused by RSV

AKA Viral LRTI

63
Q

Describe the pathophysiology of Bronchiolitis

A 
Excess Mucous (Goblet Cell Proliferation)
Inflammation (IgE type 1 allergic response)
Bronchiolar Constriction

Ball Valve effect resulting in hyperinflation, airway resistance, atelectasis and VQ mismatch

64
Q

Give three risk factors and one protective factor

A

Smoke Exposure, Siblings Nursery Attendance, Prematurity

Breast Feeding

65
Q

How does a baby with Bronchiolitis present?

A

Coryzal symptoms for 2-5 days
Poor feeding

OE - Tachypnoea, Grunting, Recessions, Wheeze, Crackles

66
Q

Give three differentials for Bronchiolitis

A

Pneumonia
Croup
Heart Failure

67
Q

How would you investigate suspected Bronchiolitis

A

Lab - Nasopharyngeal Aspirate, if pyrexia then blood and urine culture
Imaging - CXR (if diagnostic uncertainty or atypical course)

68
Q

Describe some red flags of Bronchiolitis

A

RR>60 or Apnoea
Dehydration
Central Cyanosis
O2 Sats <92%

69
Q

The majority of Brinchiolitis cases are managed supportively at home (resolving in 7-10 days), how are they managed as an inpatient?

A

Oxygen therapy
Fluids (if required)
?CPAP
Secretions - suction

No role for steroids/dilators/antimicrobial

70
Q

Define Croup (AKA Laryngotracheobronchitis) and give two risk factors

A

Viral Upper Respiratory Tract (commonly parainfluenza) with a peak incidence at 2 years characterised by Stridor, Hoarse Voice and Barking Cough

Male, Autumn/Spring

71
Q

Describe the typical history of a patient with Croup

A

1-4 day non specific coryza

Progressing to Barking Cough and Hoarseness

Worse at night and associated with fever

72
Q

Describe the typical examination of a patient with Croup

A

Stridor?

Respiratory Distress?

73
Q

What is the severity scoring system for Croup and what are the parameters?

A

Westly Scoring System

Consciousness, Cyanosis, Stridor, Air Entry, Retractions

Mild - <4
Mod - >4
Severe - >6

74
Q

How do you differentiate between Croup and Epiglottitis?

A

Epiglottitis:

Soft Stridor
More Acute
Drooling
Not necessarily preceded by coryza

75
Q

When would you consider admission for croup?

A

Previous history of severe airway obstruction
<6 months old
Immunocompromised
Uncertain Diagnosis

76
Q

What advice would you give parents concerning Croup?

A

Usually resolves within 48 hours but can last up to a week
Antibiotics not appropriate
Paracetamol/Ibuprofen for pain/fever
Safety net

Can give a single dose of Oral Dexamethasone if Mild

77
Q

If inpatient, how is Croup treated?

A

Steroids
Nebulised Adrenaline
O2 therapy as required

78
Q

How does Cystic Fibrosis affect the lungs?

A

Reduces airway surface liquid which normally encourages mucous clearance and serves an immunological function

79
Q

How does a Cystic Fibrosis affect the Pancreas?

A

Normally occluded in pancreas which causes permanent damage to exocrine pancreas rendering pancreatic insufficiency

Overtime Endocrine pancreas becomes affected (CF related Diabetes)

80
Q

How does CF affect GI Tract?

A

Bowel Obstruction - Meconium Ileus
Cholestasis - Neonatal Jaundice
Dismal Intestinal Obstruction Syndrome

81
Q

How does CF affect Reproductive Tract?

A

98% of Men are infertile due to congenital absence of Vas Deferens

Pregnancy associated with deterioration in lung health

82
Q

How does CF present in Neonates?

A 
Meconium Ileus (distension, bilious vomit)
Failure to Thrive
Prolonged Jaundice
83
Q

How does CF present in Infants?

A

Failure to thrive
Recurrent Chest Infections
Steatorrhoea (Pancreatic Insufficiency)

84
Q

How does CF present in Childhood and Adolescence?

A

Nasal Polyps, Sinusitis, Pancreatic Insufficiency, Chronic Lung Disease, Gall Stones

85
Q

What might be seen OE of a child with Cystic Fibrosis?

A

Clubbing
Nasal Polyps
Chest (Hyperinflated, Crepitations, Portocath)
Abdomen (Faecal Mass, Ileostomy scar)

86
Q

How is CF diagnosed?

A

Fitting Clinical History and Positive Chloride Sweat Test

Chloride Sweat Test - collected by Pilocarpine Iontophoresis, >60mmol/l is suggestive

87
Q

What should be monitored annually in CF patients?

A

OGTT
LFTs/Coag/Bone Profile
Faecal Elastase

88
Q

How should Airway Clearance in CF be managed?

A

Twice daily physiotherapy

Mucolytics (DNAse - decreases viscosity by digesting DNA, Hypertonic Saline)

89
Q

How should Nourishment and Exercise in CF be managed?

A

Exercise should be encouraged
Creon taken before or with meals containing fats
Fat soluble vitamin supplements
Monitor growth and weight (may require build up milkshakes)

90
Q

How should Infection prevention and management in CF be managed?

A

Prophylactic Abx until age of 3
Infections treated with 14d Abx (even if asymptomatic)
Clinics are split to avoid patient cross contamination

91
Q

How does CF affect non pancreatic endocrine function?

A

Delays puberty by around 2 years

Reduces bone mineral density

92
Q

Whooping Cough is a highly infectious notifiable disease caused by Bordetella Pertussis. What is the vaccine schedule against it?

A

Given at 2,3, and 4 months

Booster at 3 y 4 m

Immunity wanes after 5-10 years

93
Q

Describe the clinical features of Whooping Cough (the three phases)

A

Catarrhal Phase (Generalised URTI)

Paroxysmal Phase (2-8 weeks of Paroxysms followed by gasp/apnoea)

Convalescent Phase (may last up to three months, gradually decreasing cough)

94
Q

How is Whooping Cough Investigated?

A

<2 weeks - Nasopharyngeal Aspirate/Swab

> 2 weeks - Anti Pertussis IgG Serology

Lymphocytes is

95
Q

How is Whooping Cough managed?

A

Antibiotics don’t alter clinical course but do alter infectivity so only give in first three weeks (Azithromycin or Clarithromycin first line)

Paracetamol/Ibuprofen/Fluids

Avoid school for three weeks (or 5 days with Abx)

96
Q

When COVID - 19 occurs severely in a child, what is thought to be the cause?

A

Cytokine Storm Syndrome

97
Q

Describe the features of Paediatric Inflammatory Multisystem Syndrome

A

Toxic Shock
Atypical Kawasaki
?Covid

98
Q

Give two Bacterial/Viral/Atypical causes of LRTI (encompasses Bronchitis, Bronchiolitis, Pneumonia)

A

Bacterial - Strep Pneumoniae, H Influenza
Viral - Influenza A, RSV
Atypical - Mycoplasma, Legionella

99
Q

LRTIs present quite typically with grunting and tachypnoea. What are the parameters for Tachypnoea in Children?

A

0-5 months >60/min

6-12 months >50/min

> 12 months >40/min

100
Q

How should Community Acquired LRTIs be managed in Children?

A

Mild/Mod - Amoxicillin (+/- PO Erythromycin)

Severe - IV Co- Amoxiclav (may add PO Erythromycin for atypical cover)

101
Q

How should Hospital Acquired LRTIs be managed in Children?

A

Mild/Mod - Co Amoxiclav

Severe - Piperacillin and Tazobactam

102
Q

Obstructive Sleep Apnoea is a spectrum from snoring - upper airway resistance to apnoea. Give three different aetiologies

A

Adenotonsillar Hypertrophy
Obesity
Neuromuscular Disease

103
Q

How does OSA present?

A

Snoring

Mouth Breathing

Witnessed Apnoeic Episodes (strangles/quiet breathing followed by gasp)

Poor concentration at school (day time sleepiness less common)

104
Q

How is OSA investigates?

A

Overnight Polysomnography
Airway Assessment
CT/MRI (structural causes?)

105
Q

Describe the management options for OSA

A

Medical - CPAP, Weight Loss

Surgical - Adenotonsillectomy, Tracheostomy

Orthodontic - Mandibular advancement

May just outgrow

106
Q

Apart from the normal presentation and Ix of Pneumothorax, what can be done in a child?

A

Trans illumination of Chest Wall

107
Q

Name a cause of a long standing brassy cough

A

Airway Malacia

108
Q

Name a cause of an acute brassy cough

A

Tracheitis

Year 4 Paeds (15 decks)

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