Respiratory Flashcards
A 5-year-old boy was diagnosed with asthma aged 3 years. He presented to accident and emergency with shortness of breath, increased work of breathing and a 1-week history of coryzal illness and fever. On examination he is tachypnoeic 60/ min, tachycardia 160 bpm and has minimal air entry bilaterally. He has intercostal recession, tracheal tug and is too breathless to complete a sentence. Oxygen saturation is 90 per cent in air. What is the initial management of this boy?
A. Immediate intubation and ventilation
B. High flow oxygen through non-rebreather mask
C. IV salbutamol and magnesium sulphate infusion
D. Back to back salbutamol and Atrovent though oxygen driven nebuliser
E. Trial of continuous positive airway pressure support
D. Back to back salbutamol and Atrovent though oxygen driven nebuliser
1 DAsthma management follows the British Thoracic Society guidelines which have a step-wise approach to the management of both chronic and acute asthma. According to his symptoms he has life-threatening asthma, but initial management still requires the use of back to back salbutamol nebulizers (D). He is hypoxic in room air, so giving oxygen driven nebulizers will be of benefit compared to inhalers or oxygen alone (B). If after three doses of salbutamol and one of Atrovent nebulizer he is not improving, he may require IV salbutamol or aminophylline and magnesium sulphate, but not first line (C). Although he does require high flow oxygen, this alone will not help the underlying problem. If he is not responding to intravenous therapy then intubation and ventilation will be required with intensive care support (A). Continuous positive airway pressure (E) is not used in the management of asthma, as it does not provide ventilatory support.
A 3-year-old child presents to the GP with a chronic cough for the last month. He had previously been fit and well since he suffered a severe pertussis infection when he was 1 month of age. He has subsequently been fully immunized but was noted to be on the 0.4th centile for height. What is the most likely cause for his cough?
A. Cystic fibrosis
B. Recurrent pertussis infection
C. Habit
D. Asthma
E. Bronchiectasis
E. Bronchiectasis
2 E A severe respiratory infection in early childhood can present later in life with bronchiectasis (E) caused by dilatation and poor mucociliary clearance, predisposing to further infection. Any chronic illness may impact on the growth and development of a child. Other important causes of chronic cough include (D) asthma (though usually associated with nocturnal cough, atopy and eczema) and (A) cystic fibrosis (can present with respiratory and gastrointestinal involvement due to pancreatic insufficiency), and a thorough history is needed, but bronchiectasis (E) is still more likely given the history. Once the initial pertussis infection is treated it is unlikely that he will have further infections (B), and having been immunized this provides some protection, though immunity does wane with time and infected adults are likely the carriers of this disease. Coughs may become habitual (C) but his must be a diagnosis of exclusion.
A 15-year-old boy attends his GP with a week of cough productive of yellow sputum, fever to 39°C and chest pain on the right side of the chest on coughing. There is no history of foreign travel or unwell contacts. On examination there is reduced air entry in the right lower zone with crepitations and bronchial breathing. You diagnose a right-sided chest infection. What is the most likely causative organism?
A. Staphylococcus aureus
B. Mycobacterium tuberculosis
C. Streptococcus pneumoniae
D. Mycoplasma pneumoniae
E. Chlamydophila pneumoniae (Chlamydia pneumoniae)
D. Mycoplasma pneumoniae
3 DThe causative organisms of pneumonia can be categorized into typical
(Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, Moraxella catarrhalis) or atypical (Mycoplasma pneumoniae, Legionella spp., Chlamydia spp.). Streptococcus pneumoniae (C) is the most common typical cause and would be more likely in under 4 year olds. Mycoplasma pneumoniae (B) is more common in older children presenting with pneumonia. The presentation of a lobar pneumonia and a short history is not consistent with tuberculosis (B) which may present with systemic features of weight loss, loss of appetite and a more indolent course. Staphylococcus aureus (A) and Chlamydia pneumonia (E) are possible but are less likely causes epidemiologically.
A 4-year-old girl has recently moved to the area and is registering with you, her new GP. She has had a diagnosis of primary ciliary dyskinesia (PCD) made last week and the parents wish to know more about the complications. Which of the following is not a complication of PCD?
A. Pancreatic insufficiency
B. Infertility
C. Sinusitis
D. Bronchiectasis
E. Dextrocardia
A. Pancreatic insufficiency
4 A(A) Pancreatic secretions are not reliant on cilia for the expulsion of enzymes and pancreatic fluids. They travel along the pancreatic duct and are joined by biliary secretions in the ampulla of Vater. The respiratory tract (C) and (D) and reproductive organs (B) are both lined by cilia to ensure the movement of particles. Cilia are also necessary for the determination of the sites of the internal organs during development. These children can have dextrocardia alone or situs inversus (E).
A 26 week, premature baby was born by emergency caesarean section due to maternal pre-eclampsia. He required ventilation until age 38 weeks corrected gestation and is still requiring oxygen to maintain his saturations. At 12 months of age he has poor vision and neurodevelopmental function, requires home oxygen and was admitted for a recent respiratory syncytial virus (RSV) bronchiolitis. What is the underlying diagnosis of his respiratory problems?
A. Respiratory distress syndrome (hyaline membrane disease)
B. Chronic lung disease (bronchopulmonary dysplasia)
C. Cystic fibrosis
D. Diaphragmatic hernia
E. Pulmonary hypoplasia
B. Chronic lung disease (bronchopulmonary dysplasia)
5 B Chronic lung disease is by definition an oxygen requirement at 36 weeks corrected gestation or at 28 days post-term (B). It occurs in premature babies as a consequence of barotraumas or volutrauma during the ventilation, surfactant deficiency and oxygen therapy, though the pathophysiology is complex. It can be minimized by using the lowest possible pressure and volume settings to optimize respiratory function in premature infants, but despite this there can be long-term consequences. These children are at risk of respiratory tract infections, particularly RSV for which the preventative paluvizumab monocloncal antibody can be given. (A) Respiratory distress syndrome is due to surfactant deficiency and may be present soon after birth; however, if the clinical manifestations persist, these children may also develop chronic lung disease. (C) Cystic fibrosis does not present in this way, and is more likely to cause meconium ileus or prolonged jaundice in the neonatal period. (D) Diaphragmatic hernia and renal abnormalities can both result in pulmonary hypoplasia (E) and then respiratory difficulties at birth.
John is a 2-year-old boy whose mother has been concerned about a cough for the last 2 weeks which started out of the blue. He has been previously fit and well with no respiratory or cardiac problems from birth. There is no family history of illness. He is thriving and eating as normal, but has a persistent cough, recently productive of yellow and slight blood stained sputum. You suspect that John may have a pneumonia and lung collapse secondary to an inhaled foreign body. Which is the most likely location of this boy’s foreign body?
A. Left lower lobe
B. Right upper lobe
C. Right middle lobe
D. Left upper lobe
E. Right lower lobe
C. Right middle lobe
6 C The right middle lobe is the terminal one of the three branches of the right main bronchus (the other being the right upper lobe and right lower lobe). The right main bronchus is the widest, shortest and most vertical of the bronchi and hence the most likely for a foreign body descent (path of least resistance). The right middle lobe is the most direct anatomically likely location for the foreign body; therefore (A), (B), (D) and (E) are incorrect.
A couple who are known to both be carriers of cystic fibrosis ask to see you. They had genetic counselling but declined antenatal diagnostic testing and their baby has now been born and is ready to be discharged home. The parents are now keen to get the baby tested so that if treatment is required it can be initiated early on. What initial test do you suggest for the baby?
A. Newborn blood spot screening
B. Chest x-ray
C. Faecal elastase
D. Genetic testing
E. Sweat test
A. Newborn blood spot screening
7 A Newborn blood spot screening (NBSS) is a national screening programme
to target early diagnostic testing for cystic fibrosis, hypothyroidism, phenylketonuria (and sickle cell disease and medium chain acyl dehydro-genase deficiency in some areas). The NBSS (A) is a blood spot sample and
for cystic fibrosis tests for immune reactive trypsin; if positive, the sample will be sent for further genetic analysis to try to identify the gene mutation (D). The child will then require a sweat test, the gold standard test, to confirm the diagnosis (E). A chest x-ray in the newborn will not be useful (B). Faecal elastase (C) is useful to detect pancreatic insufficiency secondary to cystic fibrosis, but not all children will have pancreatic involvement so is not a diagnostic test.
A 5-week-old baby was admitted today to the children’s ward with bronchiolitis. The nasopharyngeal aspirate identified respiratory syncitial virus. He was saturating to 96 per cent in air this morning and was feeding two-thirds of his usual amount of formula milk. You are asked to review him as his work of breathing is worsening now it is night time. He has nasal flaring, intercostal and subcostal recession, tachypnoea and crepitations and wheeze heard bilaterally. What do you expect his capillary blood gas to show?
A. pH 7.16 PCO2 kPa 3.1 PO2 10.0 kPa BE –8 HCO–3 18 mmol/L
B. pH 7.38 PCO2 kPa 5.5 PO2 12.0 kPa BE +1 HCO–3 25 mmol/L
C. pH 7.20 PCO2 kPa 8.2 PO2 8.3 kPa BE +2 HCO–3 26 mmol/L
D. pH 7.40 PCO2 kPa 1.2 PO2 7.5 kPa BE +5 HCO–3 28 mmol/L
E. pH 7.47 PCO2 kPa 6.3 PO2 11.0 kPa BE +10 HCO–3 35 mmol/L
C. pH 7.20 PCO2 kPa 8.2 PO2 8.3 kPa BE +2 HCO–3 26 mmol/L
8 CHe has increased work of breathing causing him to tire. He has an infective process in his lungs resulting in inflammation and an inability to oxygenate effectively. Therefore he will develop type 2 respiratory failure as seen in (C) with hypoxia and hypercapnia producing respiratory acidosis. The blood gas in (D) may represent his situation before he becomes exhausted, with hyperventilation resulting in low PCO2 and hypoxia, but with metabolic compensation. (A) is a metabolic acidosis which may be secondary to sepsis. (B) is a normal blood gas. (E) is a metabolic alkalosis.
Clara is a 14-year-old girl who was diagnosed with muscular dystrophy when she was younger. She now mobilizes in a wheelchair and other co-morbidities include a scoliosis and cardiomyopathy. She is being seen for her annual review in clinic. Which of these would best represent the respiratory complications of muscular dystrophy?
A. Normal FVC, low FEV1/FVC ratio
B. Flattened diaphragms on chest x-ray
C. Morning dips in peak expiratory flow rate
D. Extrathoracic obstruction on flow-volume loops
E. Reduced FVC, normal FEV1/FVC ratio
E. Reduced FVC, normal FEV1/FVC ratio
9 E Muscular dystrophy causes a restrictive pattern of respiratory disease (E). This may be due to weak intercostals and diaphragmatic muscles and scoliosis, resulting in a reduced capacity for lung and chest wall expansion. Spirometry can be used in a clinic setting to assess lung function. (A) is an obstructive pattern as may be seen with asthma, and morning dips (C) are characteristic of asthma. Flattening of the diaphragms is typical of hyperinflation and air trapping, for example bronchiolitis (B). There is no indication from the history of an extrathoracic obstruction (D), for example chest pain, cough, or lymphadenopathy.
A 10-month-old baby boy is brought to accident and emergency with inconsolable crying. His mother says he is a miserable baby and even after feeding he does not settle. He has recently started to cruise around furniture, but is not yet walking. His crying has been worse today and both his parents had been awake all night due to his incessant crying. On examining the baby, you note that he is more upset when being handled and is a bit better when lying on his front. You do a chest x-ray which shows three posterior rib fractures; his mother states he fell down some steps yesterday. What is the likely diagnosis and appropriate management strategy?
A. Birth trauma; no intervention necessary as they will heal spontaneously
B. Accidental injury; ensure no pneumothorax present, reassure and discharge home
C. Accidental injury; ensure no pneumothorax present and admit for observation
D. Non-accidental injury (NAI); advise the parents you will refer to social services and discharge home
E. NAI; discuss with social services and paediatric consultant and admit the child to a place of safety
E. NAI; discuss with social services and paediatric consultant and admit the child to a place of safety
10 E Posterior rib fractures are highly suspicious of NAI, hence (B) and (C) are less likely to be correct. This child is 10 months old and the injuries he has sustained are not consistent with his development or proposed mechanism. The baby may be inconsolable, particularly after feeding, if he has symptoms of gastro-oesophageal reflux. It may be inferred that the parents in their fatigue and frustration may be responsible for the injuries. If you suspect NAI, then a detailed history and examination are needed, discussion with a senior paediatrician and social services to fully investigate the situation to safeguard the child (E) while (D) is not a safe protocol to follow. Birth should not result in rib fractures (A), though clavicular fractures can be seen after shoulder dystocia or forceps deliveries.
