Respiratory Flashcards
1
Q
Bronchiolitis:
- Definition
- Causes
- Pathophysiology
- Risk factors (4)
- Symptoms (5)
- Signs (8)
- DD (4)
- Investigations (4)
- Management
- Complications (6)
A
Bronchiolitis:
- Definition: viral infection of the bronchioles (doesn’t contain cartilage) affecting children 3-6 months (mums igG protects newborns) mostly in winter/spring. Lasts 7-10 days but cough up to 6 weeks
- Causes: resp synctial virus, mycoplasma, adenovirus
- Pathophysiology: 1. Proliferation of goblet cells = excess mucus. 2. IgE mediated reaction = inflammation. 3. infiltration lymphocytes = submucosal oedema. 4 = infiltration cytokines + chemokines. These all cause inflammation hence increased airway resistance so atelectasis, ventil perfusion mismatch and hyperinflation
- Risk factors: breast fed for <2 months, smoke exposure, siblings in nursery/school, chronic lung disease due to prematurity
- Symptoms: fever, nasal congestion, rhinorrhea, cough, feeding difficulty
- Signs: tachypnoea, grunting, nasal flaring, intercostal recessions, inspiratory crackles, expiratory wheeze, hyperinflated chest, cyanosis/pallor
- DD: pneumonia, croup, HF, bronchitis
- Investigations: throat swab or nasopharyngeal aspirate, blood/urine culture, bloods (fbc, abg if unwell), cxr (hyperinflation, focal atelectasis, air trapping, flattened diaphragm, peribronchial cuffing)
- Management: admit if comorbid, apnoea, resp distress (grunting, rr>70), central cyanosis, oxy humidified if sats <92%, dehyd, Give oxy if <92, CPAP if resp failure, fluids, suctioning. Discharge if >92 for 4 hours, adequate intake, stable. Usually lasts 7-10 days and cough up to 6 weeks
- Complications: hypoxia, dehyd, fatigue, resp fail, cough/wheeze persistent, bronchiolitis obliterans
2
Q
Asthma:
- Definition
- Pathophysiology
- Risk factors
- Triggers (10)
- Symptoms (4)
- What to ask in history
- Investigations
- Management
- Criteria for mod, severe, life threatening attack for 2-5, and >5 years
- Management for exacerbation
A
Asthma:
- Definition: chronic inflammatory lung disease where episodic reversible bronchoconstriction due to a type 1 hypersensitivity reaction. 1/11 children affected
- Pathophysiology: an inflammatory reaction due to a TH2 response which causes proliferation eosinophils, dendritic, and mast cells which release inflammatory mediators such as histamine, leukotrienes and prostaglandins which amplify an inflammatory response + cause bronchoconstriction. There is also an increased number of goblets cells and sm hyperplasia which can cause mucus plugging. Overtime there is airway epithelial damage causing shedding and basement membrane thickening decreasing lumen diameter.
- Risk factors: Fam history of atopy, viral bronchiolitis in early life, environmental (low birth weight, preterm, parent smoking)
- Triggers: cold, dust, animal dander, smoking, exercise, URTI, pollution, stress, nsaids/aspirin (inc production leukotrienes), beta blockers (prevent bronchodilation)
- Symptoms: episodic symptoms of: dry cough, worse at night (inc psns), wheeze, sob
- What to ask in history: age onset, freq, severity (school? pe? sleep? play?), previous treatments tried, any hospital attendances, food allergies, triggers, disease history (atopy, viral infections), fam hist atopy
-
Investigations: clinical diagnosis before age of 5, if over 5 then can be clinical diagnosis but measure lung baseline: PEFR, spirometry with bronchodilator reversibility (obstructive FEV1/FVC <70%, FEV1 improves >12%), if spirometry normal then FENO (>35ppb) (NO made by bronchial epithelial cells and inc production in those with TH2 drive eosinophilic inflammation), dinural peak flow variation for 2-4 weeks if diagnositic uncertainity.
To rule out other things: cxr, cl- sweat test, oesophageal ph study, HRCT, sputum culture -
Management:
Aims: full school attendance, no sleep disturbance, <2/week symptoms/salbut <2, no limitations on activity, no exacerbations
Inhalers with spacer + technique + asthma management plan. For 5-12 years:
1. SABA + ICS as needed
3. ICS + LTRA + SABA 8-12 weeks
4. ICS + LABA + SABA
Or if SABA + ICS doesnt work straight onto MART regimen low dose + SABA
If under 5, 8 week ICS + SABA. If reoccurs then restart. If still not controlled ICS + LTRA
If regular oral steroids then refer to resp paed. Can trial monoclonal ab for IgE
3
Q
Cystic fibrosis:
- Definition
- What 3 systems does it affect
- Presentations (4)
- Symptoms (8)
- Signs (4)
- Investigations
- Lifestyle advice (9)
- Management - general, professionals, infection
- Complications (7)
A
Cystic fibrosis:
- Definition: autosom recessive disease where mut in CFTR chloride channel in epithelial tissues which drives cl against conc grad which affects enac hence na reabsorption reducing water secretions and airway surface liquid needed for mucus clearance + ideal conditions for bacteria to grow
- What 3 systems does it affect: respiratory, GI (pancreas (pancreatic duct occluded in utero causing permanent damage), biliary cirrhosis), vas deferens (infert)
-
Presentations
1. meconium ileus (+ vomiting, abdo distension, delay in passing due to sticky secretions)
2. intestinal malabsorption/ failure to thrive/steatorrhea (pancreatic insuff)
3. recurrent chest infections (chronic cough/sputum)
4. newborn screening pos
5. Neonatal jaundice - Symptoms: presentations above in neonates/infancy. As childhood progresses these also: nasal polyps, chronic sinusitis, repeated LRTI, steatorrhea, liver disease/gallstones, male infertility (absence vas deferens), DIOS (distal ileum/proximal colon thick palp RIF faecal mass, diabetes (fibrosed pancreas)
- Signs: finger clubbing, hyperinflated chest/crepitations, faecal mass palp in RIF, polps nasal
-
Investigations: sputum samples, chloride sweat test >60mmol/l (defective channel means cl not reabsorbed into sweat duct cells), glucose tolerance tests, bloods (lfts, coag, bone profile, lfts), cxr, hrct, genetic analysis via amniocentesis
Criteria diagnosis: sibling positive/newborn screening positive + pos sweat test/ genetic mutations analysis - Lifestyle advice: no smoking, avoid other CF patients (pseudomonas trapped in mucus and burkholderia cepacia (contraind to lung transplant)), avoid ill, avoid jacuzzis, clean nebulisers, avoid rotting soil (aspergillus fumigatus), annual influ jab, na tablets in hot weather/exercise, exercise to inc resp function, monitor growth, high calorie diet
-
Management: physio for exercise clearance x2 day, neb dnase mucolytics to break down secretions, creon, vitadek, prophylactic abx amoxicillin, insulin therapy, kaftrio cftr modulators if homozy for delta f508 mut (lumacaftor/ivacaftor) improve fev1/infections/qol, ng/peg/calorie supplements, gastrografin for DIOS (draws water into bowel by osmosis)
Resp, dietician, physio, cf, nurse specialist
Airway infection: (staph aures, h influ, pseudo) then sputum cultures, 2 wks high dose abx. Chronic pseudom bad as forms biofilms/resistance so long term azithromycin and treat with neb abx/oral ciprofloxacin - Complications: resp infections, low body weight, DIOS, diabetes, bronchiectasis, allergic bronchopul aspergillosis, rectal prolapse
4
Q
Bronchiectasis:
- Definition
- Pathophysiology
- Causes (7)
- Causative organisms (4)
- Symptoms (7)
- Signs (3)
- Investigations
- Management
- Bronchiectasis infective exacerbation guidelines
- Complications (5)
A
Bronchiectasis:
- Definition: chronic dilatation of 1 or more bronchi which exhibit poor mucus clearance causing predisposition to recurrent bacterial infection. Potentially reversible in children
- Pathophysiology: in non CF causes inflammatory response leads to structural damage within bronchial walls = dilatation. Scarring reduces number of cilia predisposing to further infections
- Causes: post infectious (whooping cough, tb, strep pneum, staph aures), immune deficiency (hypogammaglobulinaemia, HIV), primary ciliary dyskinesia (auto recessive reduced efficacy), post obstructive (foreign body), congenital syndromes (yellow nail), allergic bronchopul aspergillosis, CF
- Causative organisms of exacerbation: haem influ, pseudom aerug, moraxella catar, fungi aspergillosis, non tuberculosis mycobacterium
- Symptoms: LOTS sputum + cough, chest pain, sob exertion, haemoptysis, recurrent lrti, fatigue, not thriving
- Signs: finger clubbing, inspiratory crackles, wheeze
- Investigations: HRCT gold standard diagnostic (bronchial wall thickening, diameter bronchus larger than artery = signet ring), cxr (bronchial wall thickening/dilatation), bronchoscopy (if focal), spirometry (obstructive and then mixed when scarring occurs), CF sweat test, bloods (fbc ig levels, hiv), auto ab RF, microbiological assessment
- Management: chest physio for mucus clearance, abx 10-14 days if acute exacerbation (amoxicillin if haem influ, if pseudo then ciprofloxacin but remember achilles tendonitis), bronchodilators if wheeze, pulmon rehab if MRC dyspnoea > or equal 3, flu vaccines, long term abx if recurrent exacerbations
- Bronchiectasis infective exacerbation guidelines: deterioration in 3 or more symptoms in 48 hours: cough, sputum vol/consistency, purulence, fatigue, haemoptysis
- Complications: recurrent infections, haemoptysis, lung abscess, pneumothorax, poor growth
5
Q
Obstructive sleep apnoea:
- Definition
- Risk factors (3)
- Pathophysiology
- Causes (4)
- Symptoms (4)
- Signs (3)
- Complications (3)
- Investigations
- Management
- Extra facts - epworth sleepiness scale
A
Obstructive sleep apnoea:
- Definition: obstruction of upper airway during sleep of which arousal is required to activate pharyngeal dilators so sleep disruption
- Risk factors: male, obese, downs, sickle cell
- Pathophysiology: all muscles relax when we sleep, so some narrowing of upper airway is normal but here there is excessive relaxation or small pharyngeal size with normal relaxation
- Causes: macroglossia, large adenoids/tonsils, craniofacial abnormalities, obesity
- Symptoms: snoring, excessive sleepiness, rise in bp with each arousal, nocturia, behavioural problems due to lack of sleep
- Signs: snoring, pauses in breathing, mouth breathing
- Complications: failure to grow, high cholesterol, htn
- Investigations: overnight oximetry (sats decrease), limited sleep study (oximetry, body movement, HR), full polysomnography (limited sleep study + EEG)
- Management: based on symptoms not severity, sleep slightly elevated, weight loss, surgery for tonsils, mandibular devices, if severe nasal CPAP (contin pos airway pressure applies pressure to maintain patency also used in pul oedema + CHF)
-
Extra facts: epworth sleepiness scale - >9
Watching tv, sitting, passenger in car, lying down to rest, sitting + talking - look online
6
Q
LRTI: Pneumonia:
- Definition
- Causes
- Symptoms (6)
- Signs (6)
- Investigations
- Management
- Tests for recurrent LRTI
A
LRTI: Pneumonia:
- Definition: infection of lung parenchyma causing sputum which fills airways
-
Causes:
Viral: resp syncytial, parainflu, influenza
CAP: strep pneum, haem influ (esp if unvaccinated), group b strep (pre-vaccinated)
Atypical: chlamydia pneum, leigonella pneumophilia, mycoplasma pneum
HAP: mrsa, ecoli, pseudomonas - Symptoms: cough + sputum, high fever >38.5, sob, chest pain, lethargic, delirium
- Signs: tachypnoea >60/cardia, hypoxia (decreased oxy sats), hypotension, dull percussion due to consolidation, focal coarse crackles as air passes through sputum, bronchial breath sounds on inspir/expir caused by consolidation
- Investigations: sputum cultures + viral pcr, bloods (crp, fbc, u+es), CBG (to monitor lactate/metab state), cxr gold standard
- Management: oxygen if <92, 5 days amoxicillin, add erythromycin for atypical. Clarithromycin if penicillin allergy
- Tests for recurrent LRTI: bloods (fbc, serum ig esp igG (some patients can’t turn igm into igg hence get long term immunity - ig class switch recombination def), sweat test, hiv test, cxr (structural abnormalities)
7
Q
URTI: Whooping cough:
- Definition
- Causes
- Pathophysiology
- Risk factors (2)
- Symptoms - 3 phases
- Investigations
- Diagnostic criteria
- Management
- Complications (5)
- DD (4)
A
Whooping cough:
- Definition: URTI, notifiable disease!!
- Causes: bordetella pertussis. Vaccine at 2, 3, 4 months age and booster at 3 yrs 4 months, also vaccine if pregnant
- Pathophysiology: gram - bacillus spreads through aerosolised droplets produced by the cough of an infected individual. Bacteria attach to resp epithelium and produce toxins which paralyse cilia and promote inflamm impairing resp secretions
- Risk factors: non vaccination, exposure to infected
-
Symptoms:
Stage 1 catarrhal phase 1-2 weeks: rhinitis, conjunctivitis, irritable, sore throat, low grade fever, dry cough
Paraoxysmal phase 2-8 weeks: severe paroxysms of coughing followed by inspiratory gasp (whoop sound) more common at night (apnoea if <3 months) and followed by vomiting
Convalescent phase up to 3 months: freq/severity cough gradually decreases - Investigations: bloods (fbc - lymphocytosis), if cough <2 weeks culture of nasopharyngeal aspirate or swab. + pcr testing. If >2 then anti pertussis toxin IgG serology if <5 years old, if >5 yrs then anti p toxin detection in oral fluid (however false pos if had vaccine within the year)
-
Management: if cough <21 days clarithromycin. If not tolerate co-trimoxazole. Reduces infectivity. Paracet/ibu, fluids. Admit if <6 months + v unwell, if breathing difficulties, feeding issues, complications
Avoid school until cough over 21 days or had abx for 5 days. Close contacts if vulnerable prophylactic abx - Complications: pneumonia, seizures, otitis media, bronchiectasis, pneumothorax from whoop
- DD: bronchiolitis (<1, acute, wheeze or crackles but no signs in whooping), pneumonia (high temp, focal crackles), asthma (recurrent episode, exercise or night induced), tb (growth failure, weight loss, country/contact)
8
Q
Home ventilation
- Types
- Conditions its used in
A
9
Q
Primary ciliary dyskinesia
- Definition
- Triad
- Investigations
- Management
A
10
Q
Viral wheeze
- Definition
- Risk factors
- Investigations
- Management
A
11
Q
URTI: Croup:
- Definition
- Pathophysiology
- Causes (6)
- Risk factors (3)
- Symptoms (2)
- Signs (4)
- Red flags for respiratory failure (4)
- DD (4)
- Investigations (4)
- Management
- Complications (4)
- Extra facts - Westley croup score
A
Croup:
- Definition: acute laryngotracheitis/laryngotracheobronchitis is URTI viral infection in 6 months to 3 years
- Pathophysiology: inflammation in supraglottic, glottic, subglottic and tracheal level causes airway narrowing causing turbulent flow causing stridor noise and barking cough due to impaired movement through vocal cords
- Causes: parainfluenza virus, resp syncytial virus, adenovirus, rhinovirus, enterovirus, measles
- Risk factors: male, autumn/spring, genetics
- Symptoms: 1-4 days cough/rhinorrhoea/fever which progresses into barking cough + hoarseness, worse at night
- Signs: stridor, decreased air sounds, tachypnoea, intercostal recession
- Red flags for resp failure: cyanosis, lethargic, laboured breathing, tachycardia
- DD: epiglottitis (differences in word document), inhaled foreign body, anaphylaxis, bacterial tracheitis
- Investigations: clinical diagnosis, bloods (fbc, crp, u+es), cxr to see if foreign body, laryngoscopy
-
Management:
Advise parents, improves in 48 hours, paracet/ibu, fluids. Seek urgent advice if stridor/high fever/HR/resp failure
Admit if previous airway obstruction , <6 months, immunocompromised, poor response to treatment)
Single dose oral dexamethasone (0.15mg/kg) or oral pred (1-21mg/kg), neb adren, oxygen, keep them calm - Complications: lymphadenitis, otitis media, dehydration, pneumothorax
-Extra facts: Westley croup score
Mild: no stridor at rest, happy with barking cough, no/mild intercostal recession
Moderate: easy audible stridor at rest, some agitation, recession at rest
Severe: distress, recession, stridor
