Respiratory Flashcards
What type of ventilation is:
good?
ok?
bad?
High flow 02
CPAP
Intubation
What are respiratory distress Sx?
-Tracheal tug
-intercostal + diaphragm recession
-Nasal flaring
-RR>60
-Accessory muscle use
-wheeze
-stridor
-cyanosis
-head bobbing
What is a wheeze?
Conditions that have a wheeze?
what is heard?
obstructed lower airway
Asthma, COPD, bronchiectasis, CF, bronchiolitis
Expiratory whistle
What is a stridor?
Conditions that have a stridor?
what is heard?
Obstructed upper airway
Croup, epiglottitis, Laryngomalacia, foreign body
High pitched harsh inspiration
In a stridor, what % of airway is blocked?
Inspiratory =
Biphasic =
Expiratory =
70+%
larynx
trachea + glottis
bronchi
What is coryza?
causes?
Tx?
common cold
Rhinovirus, adenovirus
Supportive
What is pneumonia?
Infection and inflammation of the lung parenchyma
what are the causes of pneumonia in the neonate?
GBS
Gram -ve rods
what are the causes of pneumonia in the infant?
S.pneumo
HiB (if not vaccinated)
Rare + serious = S.aureus
TB
what are the causes of pneumonia in the >5y?
Mycoplasma pneumoniae
S.pneumo
Sx of pneumonia?
Resp distress
Fever >38c (before URTI)
Poor feed
productive cough
End inspiratory coarse crackles
Dx of pneumonia?
what would be seen?
FBC + bloods
Low SP02
Sputum MC+S
GS = Chest xray - upper lobe consolidation
what would be seen on chest xray in an S.aureus caused pneumonia?
pneumatoceles + multi lobar
Tx of pneumonia?
<93% O2 = admit
Antibiotics :
Infant = Amoxicillin
Mycoplasma = macrolide eg. erythromycin
What is croup?
due to?
Incubation time?
URTI
Laryngotracheobronchitis due to parainfluenza virus
10 or less days
Croup
what age range is affected? what age affected most?
what time of year?
M or F?
Epidemiology?
Between 6 months - 3 year old
2 years old
In winter
M 4:1
Preterm/intubation Hx
Sx of croup?
Low grade fever
Coryza (start/worse at night)
Horseness, stridor
then seal like barking cough
Worse at night
Dx of croup?
what is seen on investigations?
Clinical
AP Xray = steeple sign (subglottic tracheal narrowing)
what is used to assess the severity of croup?
out of?
Westley croup score
/17
guides Tx
What must not be done in Dx and why?
do not examine airway
Could trigger a spasm (sudden narrowing) of the airway
Tx of croup?
last line?
Single dose 0.15mg/kg PO Dexamethasone (+/- repeat in 12hr)
(nebulised budesonide - if PO steroid not able to take)
-Nebulised adrenaline 0.5ml 1:1000 (for Sx relief)
LL = ITU Intubate
when do you admit a Px with croup?
When can the kid go back to school?
Mod/severe, <6 months, laryngomalacia
No school till fever gone
Complication of croup?
Cause?
Sx?
Tx?
Bacterial superinfection or obstruction
S.aureus pseudomembranous croup, thick green secretion
Tx = IV Flucloxicillin
Ddx of croup?
Sx of that?
Bacterial Tracheitis
Barking cough, stridor, No steroid response
What diseases are notifiable to Public Health England?
Whooping cough
Epiglottitis
What is whooping cough?
Caused by?
noise?
what is whooping cough also called?
Pertussis
severe URTI caused by bacterium gram -ve bordetella pertussis
Adheres to resp epithelium
Loud inspiratory whoop
100 day cough
Sx of whooping cough?
Incubation period 7 days
1. >2weeks Catarrh (phlegm in airways)
2. Paroxysmal episodic whooping cough spells with:
post tussive vomiting, apnoeic attacks (common in infants)
3. Convalescence (recovery)
Dx of whooping cough?
Nasopharyngeal swab - PCR or bacterial culture
Cough >2 weeks = anti pertussis toxin IgG
FBC = Leukocytosis with lymphocytosis
Tx of whooping cough?
<1y = clarythromycin
>1y = azithromycin
within 21 days of cough
How long does the child have to be off school in whooping cough?
at least 48hrs post Abx
what prophylaxis is given in whooping cough?
what is given to close contacts that have been exposed to whooping cough?
DTaP Vaccine
erythromycin
What is the MC LRTI in under 2 year olds?
Bronchiolitis
What is epiglottitis?
EMERGENCY
Infection causing acutely inflamed epiglottis which obstructs airway
what is epiglottitis due to?
found in which age?
In 6-12yr M due to HiB (+ S.pneumo and S.pyogenes)
Sx of epiglottitis?
Dysphagia (difficulty swallowing)
Dysphonia (abnormal voice)
Drooling
Dehydration
Resp Distress
Tripoding (lean forward to help breathe better)
Inspiratory stridor +/- minimal cough
(5Ds)
Dx of epigottitis?
Clinical
Call ENT + Anaesthetics
(DO NOT EXAMINE AIRWAY)
Later do FBC, Laryngoscopy
Lateral neck xray = thumb sign
Tx of Epiglottitis?
ABCDE
O2 = Good, Intubation or tracheostomy = bad
IV ceftriaxone +/- nebulised adrenaline
What is given to close contacts of epiglottitis?
what is given as prophylaxis?
Rifampicin
HiB vaccine (>99% reduction)
What is bronchiolitis?
Inflammation and infection of the bronchioles causing atelactesis (partial collapse / impaired filling of lung), mucous hypersensitivity, obstruction
what % of Px with bronchiolitis need hospital admission?
what is the cause of it in older kids?
2-3%
S.Pyogenes = 20-30% older kids
Bronchiolitis:
what ages does it affect?
which age most?
cause?
what does it cause?
what time of year?
3 months - 1 year old
-6 months
RSV
Widespread wheeze
Winter and spring
RF of bronchiolitis?
CHD
Preterm
CF
Winter
Immunocompromised
why are <1 year olds affected by bronchiolitis?
<1y = smaller airway therefore minor bronchiole inflammation = big effect on lumen size + work of breath
Sx of bronchiolitis?
Resp distress Sx
Coryza
Mild fever (<39c) - high grade = suspect Ddx
Apnoea
Wet nappies less
around 9 days of Sx, day 5 peak
Dx of bronchiolitis?
Clinical
widespread wheeze
Cap blood gas = severe
Chest xray = hyperinflated +/- atelactesis
Nasopharyngeal PCR
Tx for bronchiolitis?
Supportive
Consider CPAP/O2 if severe (most cases self resolve)
eg. <90% O2 sats, 50-75% fluid intake, RR>70
What prophylaxis is given in bronchiolitis and to who?
IM Palivizumab - for high risk
eg. premature, CHD, CF, Lung defect, Immunocompromised
Monthly injection for passive immunity - not vaccine
what protects a baby against RSV?
Maternal IgG vs RSV protects baby vs that
What is a complication of bronchiolitis?
Bronchiolitis obliterans
what is bronchiolitis obliterans?
Dx?
(post transplant or recurrent infection)
scarring / permanent narrowing of airways - FEV1:FVC 16-20%
HRCT (High resolution CT) = Mosaic pattern
What is pharyngitis?
Inflammation of the pharynx (sore thorat) - mucous membranes of the oropharynx +/- tonsils (tonsillitis) +/- Local lymphadenopathy
What are the causes of pharyngitis?
Viral:
EBV (Glandular fever) - MC
Rhinovirus, adenovirus
Bacterial:
S.Pyogenes
S.pneumo
Who does S.pyogenes affect and %?
what may it cause and Sx?
20-30% older kids
may cause Scarlett fever - strawberry tongue
Sx of pharyngitis?
FEVER PAIN
Fever >38c
Purulent exudate
Attend rapidly
Inflamed tonsils <72hrs
No/mild cough
With the Sx, how many would you need to consider and give Antibiotics?
2-3 = consider Abx
4 or more = Give Abx
(62-65% bacterial)
Dx of pharyngitis?
Clinical
Can do bloods (ASO titres)
Viral PCR swab
EBV monospot test - heterophile Ab vs EBV
Tx of viral pharyngitis?
EBV = Supportive
Tx of bacterial pharyngitis?
dosages for each age?
PO Phenoxymethylpenicillin
1-5y = 250mg BD
6-12y = 500mg BD
12+y = 1000mg BD
With EBV causing pharyngitis, what must be safety netted to the Px and why?
How long does it take to resolve?
Must safety net to AVOID contact sports for at least 4 weeks due to risk of splenic rupture
Self resolving in 6-8 weeks
what are some post strep complications?
Rheumatic fever
post strep glomerularnephritis
Scarlett fever
Invasive gas
Necrotising fascitis
SSSS
Toxic shock
what may happen of you give a patient with EBV penicillin and why?
may cause a macropapular rash, EBV causes transient beta lactam hypersensitivity
what is a complication of pharyngitis?
quinsy
what is quinsy? Tx? what can it cause?
(complication of pharyngitis)
Peritonsillar abscess
IV Abx and drain
Causes jugulodiagastric LNadenopathy
what are adenoids?
when do they usually regress?
lymphatic supratonsillar masses
Regress usually <7y
what happens if adenoids persist?
Sx they can cause?
Tx?
Can cause Obstructive sleep apnoea
(adenotonsillarhypertrophy)
consider surgery
what is a viral wheeze?
Viral Infection, inflammation of airway, transient viral induced wheeze in 5 or under due to lung immaturity (more likely obstruction)
RF of a viral wheeze?
trigger?
maternal smoking
prematurity
Viral and multiple trigger (asthma like) - occurs only during infection
what is a viral wheeze triggered by?
Otherwise?
viral infection
otherwise systemically well, no diurnal variation, minimal FHx
Tx of a viral wheeze?
- SABA - 4 hourly (max), 10 puffs PRN with spacer
- ICS (Paed low dose) trial for 8 weeks eg. 200-400mg beclomethasone then escalate
- consider LTRA
What is asthma?
Chronic reversible airway obstruction characterised by mucus hypersecretion, airway hyperresponsiveness, bronchial inflammation
RF of asthma?
FHx
atopy
PHx atopy
samters triad (asthma, nasal polyps, aspirin sensitivity)
Hygiene hypothesis
Pathology of asthma?
allergen, hypersensitive smooth muscle, constriction
allergic and non allergic causes of asthma?
Allergic = T1 IgE mediated
Non allergic =
Triggers - cold, exercise, infection, allergen, mould, smoking
Sx of asthma?
persistent, recurrent, diurnal variation (worse at night + in morning)
Resp distress with wheeze
Harrison sulci = muscle insertions at diaphragm visible
what could be the causes of poor control of asthma?
ABCDE
Adherence + technique
Bad disease
Choice of drug
Diagnosis incorrect
Environment
What does total control of asthma mean?
No daytime Sx
No acute attacks
No exercise limit
No night waking asthmatic episodes
Dx of asthma?
<5y?
>5y?
<5y = clinical
>5y =
-PEF diary >20% variability in 2-4 weeks
-Chest xray = hyper inflated lungs
FEV1:FVC <0.8
-Bronchodilator >12% reversibility with 4 puffs SABA
-FeNO >35ppb
Tx for asthma <5y?
same as viral wheeze
Tx for asthma >5y?
- SABA with spacer PRN
- SABA + ICS (Low dose)
- SABA + ICS + LTRA
- SABA + ICS + LABA
- SABA + MART (low ICS)
- SABA + MART (mod ICS)
- SABA + MART (High ICS)/Mod ICS + theophylline
what is MART?
Maintenance and Reliever Therapy
ICS and Fast acting LABA eg. seretide, formeterol
How is baseline status of asthma assessed?
Asthma control questionnaire /25
(measures control over last month)
what are the 4 severities of asthma attacks?
mild - mod
severe
life threatening
fatal
what is a mild-moderate asthma attack?
PEFR 50-75%
Breathlessness
what is a severe asthma attack?
PEFR 33-49%
Can’t complete a sentence without breathlessness
what is a life threatening asthma attack?
PEFR <33%
Silent chest, altered GCS, Hyperventilation, low effort to breathe
what is a fatal asthma attack?
Lifethreatening + hypercapnic (T2 resp failure)
In an acute exacerbation of asthma in a 2-17y/o, what assessment is done?
Paediatric resp assessment measure (PRAM)
Tx of an asthma attack?
- Nebulised SABA (10 puffs + spacer) + PO prednisolone (3 or less days) + O2 if SpO2 <94%
- Nebulised ipatropium +/- MgSO4
- IV Aminophylline
what is ICS?
examples?
How often is it taken?
Inhaled corticosteroids (ICS)
beclometasone, budesonide, ciclesonide, fluticasone, and mometasone
Taken regularly 2x day
what is a spacer used for and what are some pros of it?
Increases bioavailability of drug by keeping it nebulised in vacuum for longer
-prevents thrush
-easier to administer
-avoid breathing medication too fast
what is cystic fibrosis?
autosomal recessive
delta F508 mutation in CFTR gene on chromosome 7
Low CFTR expression
High Na+ and Cl- retention
Less watery secretions
how many people are affected by CF?
How many people have CFTR mutation?
1/2500 affected
1/25 in UK have CFTR mutation
Pathology of CF and organs it affects?
Lungs = Impaired mucociliary clearance
GIT = Impaired absorption due to thicker secretions
Pancreas = Beta islet damage + low enzyme secretion
Liver = Biliary stasis
Sx of CF in neonates?
Failure to pass meconium within 48hrs birth
Sx of CF in infant?
Jaundice
Failure to thrive
Recurrent chest infections (P.aurug - adult, ciprofloxacin), S.aureus - kids, mycoplasma)
Sx of CF in children?
Bronchiectasis
Nasal polyps
sinusitis
Sx of CF in older kids?
Congenital vas deferens absence (infertile)
Bronchopulmonary aspergillosis (allergic reaction to fungus)
Complications of CF?
High risk of bowel cancer, T2DM, Pneumothorax, Cor pulmonale, liver cirrhosis, infertility
Dx of CF?
Guthrie heel prick (d5-9 post birth) - serum innumoreactive trypsin
GS = Sweat test >60mmol/L Cl-
Genetic test
Resp Tx for CF?
MDT
Chest physio 2x daily (clearance)
Breathing techniques
LL = Lung transplant (CI in burkholderia infection)
Mucoactive agents: Dornase alfa, lumacaftor, hypertonic saline, prophylactic Abx
Pancreatic Tx for CF?
Creon + OGTT annually >10y/o
GI Tx for CF?
High calorie high fat diet
Liver Tx for CF?
LFT annual screen
what advice would be given to CF Px?
advice CF Px not to play/sit together
(intertransmission)
MC cause of death in CF Px?
Resp
Prognosis of CF Px?
49.1y median
what is laryngomalacia?
Tx?
congenital floppy larynx
self resolving
GORD
Must Tx eg,. PPI
What is kartagener syndrome?
Auto recessive
-1^ ciliary dyskinesia (immotility)
-Situs inversus (organs on opposite side of body)
-Dextrocardia (heart on R instead of L)
Triad of bronchiectasis, sinusitis and situs inversus
