Respiratory

Question 1

What is pneumonia?

Answer 1

Infx of lung tissue that causes inflm of lung tissue and sputum filling the airways and alveoli.

Question 2

What are some examples of bacterial and viral causes of pneumonia?

Answer 2

Bacterial:
* Strep pneumonia MC
* Group A strep
* Group B strep - in pre-vax infants, often contracted during birth
* Staph Aureus
* H. influenza

Viral:
* Respiratory syncytial virus (RSV) MC
* Parainfluenza
* Influenza

Question 3

Sx of pneumonia?

Answer 3

Cough (typically wet and productive)
High fever (> 38.5ºC)
Tachypnoea
Tachycardia
Increased work of breathing
Lethargy
Delirium and hypotension (shock)
Hypoxia (low oxygen)

Question 4

What are the characteristic chest sx of pneumonia?

Answer 4

1. Bronchial breath sounds - harsh breath sounds, equally loud on inspiration and expiration
2. Focal course crackles - similar to using straw to blow into a drink
3. Dullness to percussion - consolidation

Question 5

Ix for pneumonia?

Answer 5

CXR - GS
Sputum cultures and throat swabs
If they have sepsis - blood cultures

Question 6

Tx of pneumonia?

Answer 6

• 1st line - amoxicillin
• Add macrolide (erythromycin, clarithromycin or azithromycin) to cover atypical pneumonia
• If penicillin allergy - only give macrolide
• O2 to maintain sats above 92%

Question 7

What presentations suggest moderate asthma attack?

Answer 7

• Peak flow > 50 % predicted
• Normal speech
• No features listed across

Question 8

What presentations suggest severe asthma attack?

Answer 8

• Peak flow < 50% predicted
• Saturations < 92%
• Unable to complete sentences in one breath
• Signs of respiratory distress
• Respiratory rate:
  > 40 in 1-5 years
  > 30 in > 5 years
• Heart rate:
  > 140 in 1-5 years
  > 125 in > 5 years

Question 9

What presentations suggest life threatening asthma attack?

Answer 9

• Peak flow < 33% predicted
• Saturations < 92%
• Normal PaCO2!!
• Exhaustion and poor respiratory effort
• Hypotension
• Silent chest
• Cyanosis
• Altered consciousness / confusion

Question 10

Mx of acute asthma in children?

Answer 10

O2 (if sats <94%)

Bronchodilators (step up):
1. Inhaled or nebulised salbutamol (a beta-2 agonist)
2. Inhaled or nebulised ipratropium bromide (an anti-muscarinic)
3. IV magnesium sulphate
4. IV aminophylline

Steroids - oral prednisone or IV hydrocortisone

If bacterial cx sus = give abx (e.g. amoxicillin)

Question 11

How are mild cases of asthma attacks managed as an outpatient?

Answer 11

Salbutamol inhalers via a spacer (e.g. 4-6 puffs every 4 hours)

Question 12

How are moderate to severe asthma attacks managed?

Answer 12

1. Salbutamol inhalers via a spacer device: starting with 10 puffs every 2 hours
2. Nebulisers with salbutamol / ipratropium bromide
3. Oral prednisone
4. IV hydrocortisone
5. IV magnesium sulphate
6. IV salbutamol
7. IV aminophylline

If at this point you don’t have control then they may need intubation and ventilation

Question 13

Ix for asthma?

Answer 13

Children are usually not diagnosed with asthma until they are at least 2-3 yrs

• Spirometry with reversibility testing (in children aged over 5 years)
• Direct bronchial challenge test with histamine or methacholine
• Fractional exhaled nitric oxide (FeNO)
• Peak flow variability - peak flow diary

Question 14

Medical therapy for asthma in under 5’s?

Answer 14

1. SABA inhaler - as required
2. Add low dose ICS inhaler or LTRA (i.e. oral montelukast)
3. Add other option from step 2
4. Specialist referral

Question 15

Medical therapy for asthma for those aged 5-12 yrs?

Answer 15

1. SABA (e.g. salbutamol)
2. Add low dose ICS
3. Add LABA (e.g. salmeterol)
4. Inc dose ICS to med dose + consider adding LTRA
5. Inc ICS dose to high
6. Specialist referral

Question 16

Medical therapy for asthma for those aged over 12 yrs?

Answer 16

Same as adults
Step 1 → SABA (e.g. salbutamol)
Step 2 → SABA + ICS (e.g. beclomethasone inhaler)
Step 3 → SABA + ICS + LABA (e.g. salmeterol)
Step 4 → SABA + ICS + LABA + LTRA (e.g. montelukast) → if LTRA no tolerated then stop and increase ICS dose instead

Question 17

Sx of resp distress in infants

Answer 17

• Raised respiratory rate
• Use of accessory muscles of breathing, such as the sternocleidomastoid, abdominal and intercostal muscles
• Intercostal and subcostal recessions
• Nasal flaring
• Head bobbing
• Tracheal tugging
• Cyanosis

Question 18

What is a viral-induced wheeze?

Answer 18

Acute wheezy illness caused by a viral infection. The inflammation caused by the virus trigger the smooth muscles of the airways to constrict further narrowing the space in the airway.

Question 19

What’s the difference between a viral induced wheeze and asthma?

Answer 19

In VIW unlike asthma:
* typically presents before 3yrs
* No atopic history
* Only occurs during viral infx

Question 20

Sx of viral induced wheeze?

Answer 20

SOB
Sx of resp distress
Expiratory wheeze throughout chest

Question 21

Tx of viral induced wheeze?

Answer 21

Same as acute asthma attack

O2 (if sats <94%)

Bronchodilators (step up):
1. Inhaled or nebulised salbutamol (a beta-2 agonist)
2. Inhaled or nebulised ipratropium bromide (an anti-muscarinic)
3. IV magnesium sulphate
4. IV aminophylline

Steroids - oral prednisone or IV hydrocortisone

Question 22

What is epiglottitis?

Answer 22

Rapidly progressive infx that leads to inflm of epiglottis and adjacent tissues. The inflm can progress to blockage of upper airway posing a death risk.

MC in children aged 1-6 yrs

Question 23

What is the main bacteria that causes epiglottitis?

Answer 23

Haemophilus influenza B (Hib)

Question 24

Sx of epiglottitis?

Answer 24

• High fevers
• Intense throat pain - prevents speaking or swallowing, leading to drooling
• Soft inspiratory stridor
• Rapid inc in respiratory difficulty over hours
• A tendency to sit upright with an open mouth to optimize airway patency
• Minimal or absent cough

Remember 4 D’s: dysphagia, dysphonia, drooling, and distress

Question 25

Ix for acute epiglottitis?

Answer 25

Laryngoscopy - inflamed epiglottis Culture - identify causative organism

Question 26

Mx of acute epiglottitis?

Answer 26

* Secure airway - endotracheal intubation * IV antibiotics, typically cefuroxime

Question 27

What kind of genetic inheritance is cystic fibrosis and what mutation do people with CF have?

Answer 27

Autosomal recessive CFTR protein mutation

Question 28

What is cystic fibrosis?

Answer 28

A progressive disorder that causes persistent lung infx and limits ability to breathe over time.

Question 29

Sx of CF?

Answer 29

* Meconium ileus * Salty sweat (observed when kissing baby) * Nasal polyps * Recurrent chest infx (persistent productive cough + SOB) * Malabsorption syndrome + steatorrhoea * Delayed onset of puberty ## Footnote * Meconium ileus is a bowel obstruction that occurs when the meconium in your child's intestine is even thicker and stickier than normal meconium

Question 30

Ix for CF?

Answer 30

GS - Sweat test - measures conc of chloride in sweat Initially - neonatal blood spot test done within first few days of life (identify raised blood immunoreactive trypsinogen)

Question 31

Mx of CF?

Answer 31

* Daily chest physio techniques - clear mucus = prevent pneumonia * Prophylactic abx and bronchodilators * Pancreatic enzyme replacement (e.g., Creon) and fat-soluble vitamin supplementation (ADEK) * Regular vax (i.e. influenza and pneumococcal) Bilateral lung transplant if end-stage pul. disease

Question 32

What is a complication of bronchiolitis?

Answer 32

Bronchiolitis obliterans - aka popcorn lung, MC associated w/adenovirus infx