Respiratory Flashcards
What bacteria will cause pneumonia?
Streptococcus pneumonia
Group A/B strep ( B colonizing the vagina so think in infants)
Staphylococcus aureus
Hib (pre-vaccinated/unvaccinated)
Mycoplasma pneumonia
What is a viral cause of childhood pneumonia?
RSV (respiratory syncytial virus)
(Parainfluenza, influenza)
What is childhood pneumonia?
Inflammation of lung tissue and sputum fill airways and alveoli
(visible as consolidation on CXR)
What are the x3 key clinical signs pneumonia?
- Bronchial breath sounds
- Focal course crackles
- Dullness to percussion
A 13 year old presents with a high-grade fever and wet, productive cough. They describe feeling like their heart is racing and they appear to be struggling to breath. What is the most likely diagnosis?
Pneumonia
Also consider hypoxia, hypotension, lethargy and delirium (in extreme cases) as other symptoms.
If sepsis suspected what criteria should be implemented?
BUFALO
Bloods, urine output, fluids, antibiotics, lactate, oxygen.
What should be done to diagnose pneumonia?
Chest X-Ray
Sputum sample, throat swabs
What are the x3 key clinical signs of pneumonia?
- Bronchial breath sounds
- Focal course crackles
- Dullness to percussion
What is the 1st line of management for pneumonia (+ what to cover what?)
Amoxicillin (+macrolide to cover atypical pneumonia e.g. erythromycin, clarithromycin, azithromycin)
If patient is suffering recurrent URTI then what should be considered (i.e. what test is carried out and what for)?
FBC - WBC
CXR - structural abnormalities
Serum immunoglobulins - selective antibody deficiency
IgG - unable to convert IgM to IgG (due to a immunoglobulin class-switch deficiency)
Swab - cystic fibrosis
HIV - mum unknown status (/+ve)
What is croup and what age of children does it target?
Acute URTI causing oedema in the larynx affecting 6 months to 2 year old children
What are the causes of croup?
Parainfluenza
Influenza
Adenovirus
RSV
If a patient has been diagnosed as having croup caused by parainfluenza what is the expected disease course and what should they be treated with?
Generally improves within 48 hours
Good response to dexamethasone
What is the clinical presentation of a patient with croup?
‘Barking cough, increased work of breathing, low-grade fever.’
Hoarse voice, stridor.
What is a treatment for croup?
PO dexamethasone
Oxygen
Nebulized budesonide, adrenaline
What is the clinical presentation of a patient with croup?
‘Barking cough, increased work of breathing, low-grade fever.’
Hoarse voice, stridor.
What is epiglottis?
Infection causing swelling and inflammation of the epiglottis (potentially significantly so that it obscures the airway)
What is the clinical presentation of a patient with croup?
‘Barking cough, increased work of breathing, low-grade fever.’
Hoarse voice, stridor.
What is the clinical presentation of a patient with epiglottitis (x3 key)?
Sore throat and stridor, high fever with drooling,
What is the clinical presentation of a patient with epiglottitis (x3 key)?
- Sore throat (struggling to swallow) and stridor
- Drooling
- Tripod position (sat forward hand on each knee)
Quite + unwell child, muffled voice
What is present on lateral X-Ray of the neck in a child with epiglottitis?
Thumb sign or thumbprint sing (need to exclude foreign body)
What is the clinical presentation of a patient with croup?
‘Barking cough, increased work of breathing, low-grade fever.’
Hoarse voice, stridor.
What is the treatment for epiglotittis?
- Keep the patient calm (don’t want to further close the airway)
- Tracheostomy may be required (speak to senior anesthetist)
- IV antibiotics (e.g. ceftriaxone), steroids (dexamethasone) may be required
What are the complications of epiglotittis?
Abscess, death if not treated correctly
What is the clinical presentation of a patient with croup?
‘Barking cough, increased work of breathing, low-grade fever.’
Hoarse voice, stridor.
What causes bronchiolitis in 80% of the cases?
RSV
Briefly describe the epidemiology of bronchiolitis (think risk group and when) (2 marks)
<1 year old (peak 3-6 months)
Can be children up to 2 years old with chronic lung disease
October to March peak incidence
Why is a baby at higher risk of bronchiolitis than an adult?
Babies have very small airways therefore much less inflammation and mucus is required to create a blockage (also fewer alveoli)
Clinical presentation of a child with bronchiolitis?
Coryzal Sx
Persistent cough
AND Tachypnoea and/or chest (subcostal/substernal/intercostal) recession
AND wheeze and/or crackles on chest auscultation
Poor feed, mild fever, dyspnoea, signs of respiratory distress
What is the disease progression of bronchiolitis in an infant?
Starts as URTI w/ coryzal symptoms (50% spont. resolve)
Then chest Sx over following 24-48 hours lasting 7-10 days and resolving by 2-3 weeks.
How might a child display respiratory distress? (8 things to consider)
- Raised respiratory rate
- Use of accessory muscles (sternocleidomastoid, abdominal, intercostal muscles)
- Intercostal, subcostal recession
- Nasal flaring
- Head bobbing
- Tracheal tugging
- Cyanosis
- Abnormal airway noises
Why does a child wheeze when they have bronchiolitis?
Whistling sound caused by narrowed airways during expiration
Why does a child grunt when they have bronchiolitis?
When they exhale with the glottis partially closed it will increase the positive end-expiratory pressure
What is the clinical presentation of a patient with croup?
‘Barking cough, increased work of breathing, low-grade fever.’
Hoarse voice, stridor.
What are x2 signs of poor ventilation (in the context of bronchiolitis)?
- Rising pCO2 - airways collapsed and can’t clear waste CO2
- Falling pH - respiratory acidosis due to CO2 build-up (T2RF)
What is an example of a monoclonal antibody given to high-risk babies (especially those born premature or with CHD) as prophylaxis against bronchiolitis?
Palivizumab (monthly)
What ventilatory support should be provided to an infant with bronchiolitis?
High-flow Oxygen via a tight nasal cannula
CPAP
Intubate and ventilate
What is the typical management for bronchiolitis?
Hospital admission if signs of respiratory distress
What is the genetic pattern of cystic fibrosis (CF)?
Autosomal recessive (1 in 25 carrier)
What is the pathophysiology of cystic fibrosis?
Cr7 mutation of the CFTR transmembrane protein.
-> Abnormal ion transport across the epithelial cell leading to reduction in the airway surface liquid layer
What is impaired and what is retained in cystic fibrosis?
Impaired ciliary function and retention of mucopurulent secretions
What cause the characteristic chronic infections of cystic fibrosis (bacterium names)?
S. aureus, haemophilius influenzae, pseudomonas aeruginosa, bukholderia species.
What will a bacterial respiratory infection result in patients with cystic fibrosis being admitted with?
Damage to bronchial walls, bronchiectasis, abscess formation
What is the clinical presentation of a patient with croup?
‘Barking cough, increased work of breathing, low-grade fever.’
Hoarse voice, stridor.
Clinical features of a patient with cystic fibrosis?
- Poor growth
- Recurrent chest infections
- Malabsorption (potential PEG tube)
- Failure to thrive
What affects 10-20% of infants with cystic fibrosis (GI)?
Meconium ileus - intestinal obstruction with vomiting, abdominal distension and failure to pass meconium
What endocrine issue can affect CF patients?
Pancreatic exocrine insufficiency (lipase, amylase, protease)
What can be observed on examination of a child with CF? (hyper or hypo-inflation?)
- Chest hyperinflation
- Purulent sputum
- Cough
- Coarse inspiratory crepitations
- Expiratory wheeze
- Finger clubbing (established disease)
What is the test carried out to determine CF diagnosis?
Sweat test - chloride in the sweat will be markedly elevated
(also genetic testing for the CFTR protein)
Which bacterial infection is associated with more rapid lung function decline?
Pseudomonas infection - give daily nebulized antipseudomonal antibiotics
How to treat pancreatic insufficiency?
PO enteric-coated pancreatic replacement therapy
What antibiotic is given as a continuous prophylactic PO antibiotic for CF (not for pseudomonas specifically)?
Flucloxacillin PO
Why are men virtually always infertile if they have CF (women are they too?)?
No vas deferens.
Female normal fertility
What screening test is performed for CF?
Immunoreactive trypsinogen (IRT) - raised in CF
Routine heel-prick blood in Guthrie test
What is given for distal intestinal obstruction syndrome in adults and teenagers with CF?
PO Gastrografin
What is the clinical presentation of a patient with croup?
‘Barking cough, increased work of breathing, low-grade fever.’
Hoarse voice, stridor.
What should be given due to the risk of liver disease in teenagers and adults with CF?
Regular ursodexoycholic acid to improve bile flow
What clinical features are described by CF patients during infancy?
- Meconium ileus in the newborn period
- Prolonged neonatal jaundice
- Failure to thrive
- Recurrent chest infections
- Malabsorption, steatorrhea
What is the clinical presentation of a patient with croup?
‘Barking cough, increased work of breathing, low-grade fever.’
Hoarse voice, stridor.
What clinical features are described by CF patients when they are a young child?
What clinical features are described by CF patients when they are a young child?
- Bronchiectasis
- Rectal prolapse
- Nasal polyp
- Sinusitis
What is the clinical presentation of a patient with croup?
‘Barking cough, increased work of breathing, low-grade fever.’
Hoarse voice, stridor.
What clinical features are described by CF patients when they are an older child and adolescent?
- Allergic bronchopulmonary aspergillosis (ABPA)
- DM
- Cirrhosis and portal hypertension
- Distal intestinal obstruction (DIOS)
- Pneumothorax or recurrent hemoptysis
- Sterility in males
