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Year 4 - Child health > Respiratory > Flashcards

Respiratory Flashcards

1
Q

What is bronchiolitis?

A

Inflammation and infection of the bronchioles, typically in a <1year old

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2
Q

What is the most common cause of bronchiolitis?

A

RSV (Respiratory syncytial virus)

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3
Q

What is the epidemiology of bronchiolitis?

A

Generally only occurs in under 1 year olds, very common in winter. Can rarely occur in up to 2 year olds if they are ex-premature or have chronic lung disease

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4
Q

Why does this condition only affect very young children?

A

In more mature airways, the swelling and mucus is proportionally too little to have any impact on breathing.

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5
Q

What is the presentation of bronchiolotis?

A

Coryzal symptoms
Signs of respiratory distress
Dyspnoea
Tachypnoea
Apnoeic episodes
Mild fever (<39)
Poor feeding
Wheeze and crackles on auscultation

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6
Q

What are the signs of respiratory distress?

A

Tachypnoea
Subcostal recessions
Intercostal recessions
Accessory muscles
Head bobbing
Tracheal tugging
Nasal flaring
Cyanosis
Abnormal airway sounds

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7
Q

What is the typical course of RSV infection (bronchiolitis)?

A

Day 0 URTI
Day 1-2 Chest symptoms
Day 3-4 Worst symptoms
Day 7-10 Length of symptoms
Week 2-3 Full recovery

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8
Q

RSV can be managed at home, what are the reasons for admission?

A

Age <3 months
Prematurity, Downs, CF
<75% milk intake
Dehydration
Resp rate >70
Sats <92%
Moderate to severe respiratory distress
Apnoeic episodes
Parents not comfortable at home

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9
Q

Management of bronchiolitis?

A

Largely supportive
~Adequate intake - Oral, NG, IV. Avoid overfeeding
~Saline nasal drops and nasal suctioning to clear nasal secretions
~ Supplementary oxygen - sats <92%
~Ventilatory support if needed

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10
Q

Types of ventilatory support?

A

3 types which can be stepped up as the child fatigues and is less able to self ventilate
1. High-flow humidified oxygen - via tight nasal cannula, delivers air and oxygen continuously with some pressure, adds PEEP to maintain airway at end expiration
2. CPAP - sealed nasal cannula, higher and more controlled pressures
3. Intubation and ventilation - insert ET tube to fully control ventilation

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11
Q

What are the signs of poor ventilation?

A

Rising pCO2 - airway collapse and cant clear CO2
Falling pH, sign of increased CO2 and respiratory acidosis

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12
Q

What monoclonal antibody targets RSV?

A

Palivizumab

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13
Q

When is palivizumab given?

A

Monthly injections to high risk babies to protect against RSV infection and bronchiolitis

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14
Q

What conditions are considered high risk and receive palivizumab

A

Ex-premature
Congenital heart disease

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15
Q

What is a viral induced wheeze?

A

An acute wheezy illness caused by viral infection in infants

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16
Q

Pathophysiology of viral induced wheeze?

A

Infection causes a small amount of inflammation which triggers smooth muscle constriction and subsequent bronchospasm leads to symptoms

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17
Q

What is Poiseuille’s law?

A

Flow rate is proportional to radius of a tube to the power of 4

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18
Q

Risk factors for viral induced wheeze?

A

Prematurity
Hx of bronchiolitis
Exposure to cigarette smoke

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19
Q

What are features of viral induced wheeze as opposed to asthma?

A

Presents before 3yrs
No atopic history
Only occurs during viral infections

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20
Q

Presentation of viral induced wheeze?

A

Viral illness for 1-2 days preceding
SOB
Respiratory distress
Expiratory wheeze throughout the chest

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21
Q

Management of viral induced wheeze?

A

Same as acute asthma in children

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22
Q

Difference in pathophysiology of bronchiolitis and viral induced wheeze?

A

Bronchiolitis - wet lungs (inflammation and mucus production)
Viral induced wheeze - bronchospasm (caused by inflammation)

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23
Q

Presentation of acute asthma

A

Worsening SOB
Respiratory distress
Tachypnoea
Expiratory wheeze throughout the chest
Reduced air entry

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24
Q

What is a silent chest?

A

Absence of wheeze in acute asthma. Airways are so tight that not enough air can pass to create a wheeze. Life threatening.

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25
Q

What are signs of moderate asthma?

A

Peak flow >50% predicted
Normal speech

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26
Q

What are signs of severe asthma?

A

Peak flow <50% predicted
Sats <92%
Unable to complete sentences in one breath
Resp distress
RR > 40 (1-5yrs) or >30 (>5yrs)
HR >140(1-5yrs) or >125 (>5yrs)

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27
Q

What are signs of life-threatening asthma?

A

Peak flow <33% predicted
Sats <92%
Exhaustion and poor resp effort
Hypotension
Silent chest
Cyanosis
Confusion

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28
Q

What are the principles of management of viral induced wheeze and asthma?

A

Supplementary O2
-if less than 94% or working hard
Bronchodilators
-salbutamol, ipratropium and mag sulphate
Steroids
-prednisolone (oral) or hydrocortisone (IV)
Abx
-only if bacterial cause identified

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29
Q

What is the order in which bronchodilators are ‘stepped up’

A

Inhaled or nebulised salbutamol
Inhaled or nebulised ipratropium bromide
IV mag sulphate
IV aminophylline

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30
Q

What do you do at the end of the bronchodilator ladder if control is not established?

A

Very serious situation
Call anaesthetist and ICU
May need intubation and ventilation

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31
Q

What should be monitored when using high doses of salbutamol?

A

Serum potassium, salbutamol can cause potassium to be absorbed from blood into cells. Also may cause tremor and tachycardia

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32
Q

When to discharge an acute asthma patient?

A

Well on 6 puffs 4 hourly of salbutamol.

Finish steroid course (3 days)
Provide safety netting
Individual asthma plan

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33
Q

Presentation suggestive of chronic asthma?

A

Episodic
Diurnal
Dry cough with wheeze and SOB
Has typical triggers (cold, dust, emotion, exercise, smoke)
Atopy (FHx of atopy)
Bilateral widespread polyphonic wheeze
Symptoms improve with bronchodilators

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34
Q

Investigations to aid in diagnosing asthma

A

Spirometry with reversibility testing
Direct bronchial challenge with histamine or methacholine
FeNO
Peak flow variability

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35
Q

Elements of complete asthma control?

A

No daytime symptoms
No nocturnal symptoms
No need for rescue medication
No asthma exacerbations
No limitations on activity
Normal lung function
Minimal side effects from medication

36
Q

What is pneumonia?

A

Infection of the lung tissue. Causes inflammation and sputum fills the airways and alveoli

37
Q

Presentation of pneumonia?

A

Productive cough
High fever (>38.5)
Tachypnoea
Tachycardia
Dyspnoea
Lethargy
Delirium

38
Q

Signs of pneumonia

A

Derangement in obs
Tachypnoea
Tachycardia
Hypoxia
Hypotension
Fever
Confusion

39
Q

What are the characteristic chest signs of pneumonia?

A

Bronchial breath sounds
~equally loud on inspiration and expiration
Focal coarse crackles
Dullness to percussion

40
Q

Causes of pneumonia?

A

Bacterial
~Strep. pneumoniae
~Group A Strep
~Group B Strep
~Staph. aureus
~Haem. influenzae (pre-vax/unvax)
~Mycoplasma

Viral
~RSV
~Parainfluenza virus
~influenza virus

41
Q

Investigations for pneumonia

A

CXR
Sputum cultures and throat swabs
Blood cultures for septic patients
Capillary blood gas to monitor acidosis and blood lactate

42
Q

Management of pneumonia

A

Abx according to local guidelines
Often Amoxicillin, adding a macrolide
O2 given when sats <92%

43
Q

What are some further investigations for recurrent LRTI?

A

FBC
CXR
Serum immunoglobulins
IgG to previous vaccines
Sweat test for CF
HIV test

44
Q

What is croup?

A

Acute URTI causing oedema in the larynx of young children

45
Q

What are the causes of croup?

A

Parainfluenza
Influenza
Adenovirus
RSV
used to be caused by diphtheria which can lead to epiglottitis

46
Q

Presentation of croup

A

Increased work of breathing
Barking cough - clusters of coughing episodes
Hoarse voice
Stridor
Low grade fever

47
Q

Management of croup

A

Mostly at home with rest and fluids
Oral dexamethasone is very effective (150 mcg/kg single dose)
Prednisolone where dexamethasone is not available

Stepwise:
~oral dexamethasone
~oxygen
~neb budesonide
~neb adrenalin
~intubation and ventilation

48
Q

What is epiglottitis?

A

Inflammation of epiglottis by infection, typically with haem. influenza type B. Can swell to completely obscure airway within hours of symptoms so is a life-threatening emergency

49
Q

Illness script for epiglottitis

A

Rapid onset symptoms of fever, sore throat, difficulty swallowing in an unvaccinated child who is sitting forward and drooling

50
Q

Presentation of epiglottitis

A

Sore throat and stridor
Drooling
Tripod position
High fever
Difficulty or pain swallowing
Muffled voice
Scared and quiet child
Septic and unwell appearance

51
Q

Investigations for epiglottitis

A

Do not perform investigations as they may agitate the child and prompt airway closure

If a lateral neck x-ray is performed then ‘thumbprint sign’ may be observed

52
Q

Management of epiglottitis

A

Do not distress the patient
Alert most senior paediatrician and anaesthesiologist available
Ensure secure airway
IV abx
Steroids

53
Q

What is laryngomalacia?

A

Supraglottic larynx is structured in a way that allows partial airway obstruction when the larynx flops across the airway

54
Q

What structural changes are present in laryngomalacia?

A

Aryepiglottic folds are shortened , pulling the epiglottis into the classic omega shape

55
Q

Presentation of laryngomalacia?

A

Occurs in infants, peaking at 6 months
Inspiratory stridor
Worse when feeding, upset, lying on their back

56
Q

Disease course of laryngomalacia

A

Resolves itself as the larynx matures and grows

57
Q

What causes whooping cough?

A

Bordetella pertussis

58
Q

Why is it called whooping cough?

A

Coughing fits are so severe that an inspiratory whoop may be heard after fits as they can’t take in air during fits

59
Q

Presentation of whooping cough

A

Starts with:
Mild coryzal symptoms
Low grade fever
Mild dry cough

Week 1+:
Sudden and recurring coughing attacks with cough free periods between
Patients may vomit or faint from coughing intensity

60
Q

Diagnosis of pertussis

A

Swab with PCR testing and culture can confirm diagnosis within 2-3 weeks

When cough >2 weeks can test for anti-pertussis toxin immunoglobulin G

61
Q

Management of pertussis

A

Notifiable disease
Prevent spread
Macrolides can be beneficial in the first 21 days
Close contacts are given prophylactic abx if they are vulnerable
Admit if acutely unwell

62
Q

Prognosis of pertussis

A

Typically resolved in 8 weeks however may last several months

63
Q

What is CLDP?

A

Chronic lung disease of prematurity occurs in premature babies causing damage to alveoli

64
Q

Features of CLDP

A

Low O2 sats
Increased work of breathing
Poor feeding and weight gain
Crackles and wheezes on chest auscultation
Increased susceptibility to infection

65
Q

Prevention of CLDP

A

Giving corticosteroids to mothers at risk of premature delivery

Use CPAP rather than intubation and ventilation when possible
Using caffeine to stimulate the respiratory effort
Not over-oxygenating

66
Q

Management of CLDP

A

Sleep study to assess oxygen saturations
May be discharged with low dose oxygen at home
Monthly injections of palivizumab

67
Q

What is primary ciliary dyskinesia?

A

Kartagener’s syndrome is an autosomal recessive condition affecting the cilia in various cells in the body

68
Q

What are the risk factors for PCD?

A

Consanguinity in parents
Family history

69
Q

Features of PCD

A

Dysfunction of motile cilia in body leads to mucus buildup in the lungs, providing great site for infection. Leads to similar presentation to CF

Also causes subfertility by affecting cilia in fallopian tubes and flagella of sperm

70
Q

What is Kartagener’s triad?

A

Three key features of PCD:
Paranasal sinusitis
Bronchiectasis
Situs inversus

71
Q

Diagnosis of PCD

A

Careful history for consanguinity
Sample of ciliated epithelium of upper airway through nasal brushing or bronchoscopy

72
Q

Management of PCD

A

Similar to CF and bronchiectasis:
Daily physiotherapy
High calorie diet
Abx

73
Q

What is CF?

A

Autosomal recessive genetic condition affecting mucus glands

74
Q

What genetic mutation causes CF?

A

Mutation of the cystic fibrosis transmembrane regulatory gene on chromosome 7 - most common of which is delta-F508

75
Q

What electrolyte channel is mutated in CF?

A

Chloride

76
Q

Key consequences of CF mutation?

A

Thick pancreatic and biliary enzymes
~block ducts resulting in lack of lipase
Low volume thick airway secretions
~recurrent infections and colonisation
Congenital bilateral absence of vas deferens

77
Q

First sign of CF (pathognomonic)

A

Meconium ileus (no meconium in 24hrs)

78
Q

Symptoms of CF

A

Chronic cough
Thick sputum
Recurrent RTI
Steatorrhoea
Abdo pain and bloating
Salty child
Failure to thrive

79
Q

Signs of CF

A

Low weight and height on charts
Nasal polyps
Finger clubbing
Crackles and wheeze on auscultation
Abdo distention

80
Q

Causes of clubbing in children

A

Hereditary clubbing
Cyanotic heart disease
Infective endocarditis
Cystic fibrosis
Tuberculosis
IBD
Liver cirrhosis

81
Q

3 methods of diagnosing CF

A

Newborn blood spot
Sweat test (gold standard)
Genetic testing for CFTR

82
Q

How is a sweat test done for CF?

A

~Pilocarpine is attached to the skin on a patch
~Electrodes on either side and small current passed between, prompting sweat
~Sweat absorbed and tested for chloride concentration
~Diagnostic criteria is >60mmol/L

83
Q

Common microbial colonisers in CF

A

~Staphylococcus aureus
~Haemophilus influenza
~Klebsiella pneumoniae
~Escherichia coli
~Burkholdheria cepacia
~Pseudomonas aeruginosa

84
Q

Treatment for pseudomonas aeruginosa

A

Nebulised tobramycin
Oral ciprofloxacin

85
Q

Management of CF

A

Specialist MDT
~Chest physio
~Exercise
~High calorie diet
~CREON tablets
~Prophylactic flucloxacillin
~Bronchodilators such as salbutamol
~Nebulised DNase
~Nebulised hypertonic saline
~Up-to-date vaccinations

86
Q

CF monitoring

A

6 monthly clinic visits and regular monitoring for sputum colonisation
Monitoring for diabetes, osteoporosis, vitamin D deficiency and liver failure

87
Q

Prognosis of CF

A

Life expectancy is improving and is currently 47 years
~90% develop pancreatic insufficiency
~50% develop diabetes and need insulin
~30% develop liver disease

Year 4 - Child health (2 decks)

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