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Respiratory Flashcards

1
Q

What are the main symptoms of asthma?

A

Wheeze, cough, chest tightness, breathlessness

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2
Q

What are the environmental triggers of asthma?

A

URTI, allergens (dust, pollens, pets etc), smoking, cold air, exercise, emotional upset or anxiety

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3
Q

Describe asthma?

A

IgE mediated disease of chronic airway inflammation, bronchial hyper-reactivity & reversible
airway obstruction.

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4
Q

What percentage of kids does asthma affect?

A

15-20%

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5
Q

When does asthma typically present?

A

Before the age of 10 and difficult to make diagnosis in toddler below the age of 3

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6
Q

Describe asthma to a parent?

A

It is a REVERSIBLE obstructive condition of the breathing pipes which happens in a response to various triggers (give examples) causing narrowing of the breathing pipes, inflammation (like an allergy or a reaction) and a production of mucus all making it difficult for the child to breathe. Very common, FH likely, worse at night and first thing in morning etc etc

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7
Q

What is the appearance and sound of a child’s chest with chronic asthma?

A

hyperinflation of the chest, generalised polyphonic expiratory wheeze & prolonged expiratory phase

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8
Q

What are harrison’s sulci?

A

These are depressions at the base of the thorax, associated with chronic obstructive disease in childhood

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9
Q

What are the reliever therapies for asthma?

A

Short acting beta agonists (salbutamol and terbutaline) and long acting beta agonist (salmeterol).

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10
Q

What are the preventative therapies for asthma?

A

Inhaled corticosteroids (beclometasone and fluticasone), Add leukotrine antagonist (montelukast) OR combination inhaler containing inhaled corticosteroid and beta agonsit (USED WITH BETA AGONIST NOT INSTEAD OF), theophylline (bronchodilator) and oral steroids (e.g. prednisolone).

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11
Q

What are the side effects of long term steroid use in children?

A

Impaired growth, make sure they’re growing, shoe size, height etc
Adrenal suppression
Oral cadidiasis
Altered bone metabolism
Oral steroids only work locally and therefore only side effect is oral thrush, reassure parents.

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12
Q

When should parents seek medical attention?

A

If their child is requiring 10 or more puff of reliever more than every 4 hours OR when
RR >50 in 2-5s or >30 in >5s, tachycardia, breathlessness, use of accessories etc.

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13
Q

Describe a severe asthma attack.

A

Too breathless to talk or feed, use of accessory NECK muscles, oxygen sats <92%, resps >50 2-5s and >30 >5s, Pulse >130 2-5s and >120 over 5s, peak flow <50% predicted value.

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14
Q

In a life-threatening asthma attack, whats the peak flow saying?

A

<33% of predicted value

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15
Q

In a moderate asthma attack what is the treatment?

A

Short acting beta agonist via spacer, 2-4 puffs every 2 minutes increasing by 2 puffs every 2 mins to 10 puffs if necessary. Consider oral pred and reassess in 1 hour.

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16
Q

How do you manage a severe asthma attack?

A

Short acting beta 2 10 puffs via spacer or nebuliser, oral pred or IV hydrocortisone, nebulised ipratropium bromide if poor response, repeat bronchodilators every 20-30 mins.

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17
Q

How do you manage a life-threatening asthma attack?

A

Nebulised beta 2 salbut or terbutaline plus ipratropium bromide, IV hydrocortisone and if poor response transfer to HCU or PICU, consider chest X-ray and blood gases , IV salbutamol or amyophylline (caution if already using theophylline and consider IV bolus of magnesium sulphate.

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18
Q

How many days after a severe or moderate asthma exacerbation should you continue oral pred?

A

3 days

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19
Q

How do you know if you are breathing correctly into an inhaler?

A

It will make a clicking noise, if not it will make a whistling noise.

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20
Q

Inhalation technique:

A

Child standing (to make full use of diaphragm)
Shake MDI
Place it into spacer
Place device in mouth, FIRM SEAL
Breathe in and out normally until normal rhythm established
Once this has happened activate device and continue breathing 5 times, if second does is needed repeat

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21
Q

What causes bronchiolitis in 80% of cases?

A

RSV (single stranded RNA).

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22
Q

What happens in RSV?

A

The virus invades the lower airways and causes increase mucous production, desquamation & bronchiolar obstruction

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23
Q

What age does bronchiolitis mainly occur in?

A

1-9 months, rare after 12 months

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24
Q

What are the remaining 20% of cases of bronchiolitis caused by?

A

Human metapneumovirus (joint infection with RSV causing severe bronchiolitis), parainfluenza virus, influenza, rhinovirus, mycoplasma pneumoniae, adenovirus

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25
Although unhelpful what does a chest x ray in a kid with bronchiolitis show?
Hyperinflation of the lungs with a flattened diaphragm, horizontal ribs and increased hilar bronchial markings.
26
Which children are at increased risk of bronchiolitis?
Congenital HDs, chronic lund disease of prematurity, immunodeficiency etc.
27
What can you hear on auscultation in a kid with bronchiolitis?
Fine end inspiratory crackles
28
How do you test for RSV?
Nasopharyngeal swab
29
How do you manage RSV?
Humidified oxygen via nasal canula to achieve SaO2>92%, NG tube if tachypnoea, limit oral feeds and use NGT, bronchodilators for wheeze. (0.15mg/kg) and 15 mins later nebuliser dexamethasone (0.6mg/kg IM). Altlhough little evidence that beta agonists work in kids this young as underdeveloped beta agonist receptor,
30
What is croup?
Inflammation and increased secretions and obstruction anywhere from the nose to the lower airway (larynx, trachea, bronchi).
31
What age group does croup normally affect?
6 months- 6 years with peak incidence at 2 years
32
What causes croup?
95% due to viral cause. Influenza/parainfluenza, as well as RSV.
33
What are the typical features of croup?
Barking cough, harsh stridor (Airflow is usually disrupted by a blockage in the larynx (voice box) or trachea (windpipe). It's most noticeable when breathing in, though it can sometimes be heard when breathing out.), hoarseness, coryza, fever. Symptoms start at night usually and develop over days
34
What is a dangerous feature of croup?
Oedema in the sub glottic area that may result in critical narrowing of the trachea.
35
How is croup normally managed?
Can be managed at home but low threshold for admission in <12 months. Oral dexamethasone, prednisolone & nebulised steroids reduce severity & duration of croup 􃱺reducing need for hospitalisation. If sats <93%- warm humidified oxygen can be given <2% require tracheal intubation.
36
What age group does epiglottis usually affect?
1-6 years
37
How does epiglottitis usually present?
Very acute onset, associated with high fever, ill and toxic looking child, DROOLING, soft inspiratory stridor, child immobile, upright with airway open, minimal or absent cough
38
How could you differentiate between croup and epiglottitis?
No cough in epi, child can still drink in croup, child is toxic looking in epi, rapid onset in epi, (in sever croup sometimes nebuliser adrenaline is given and initiates response, this would have no response in epiglottitis)
39
In what condition would you see a steeple sign on AP chest x ray?
Croup- this is when subglottic tracheal narrowing produces the shape of a church steeple
40
In what condition would you see thumb print sign on lateral x-ray?
Epiglottitis, (looks like a thumb print laterally).
41
How do you manage epiglottitis?
Child must be intubated immediately, only after ETT can bloods be taken and venous access for IV antibiotics
42
What antibiotics are used in epiglottitis?
Cefuroxime, ceftriaxone and cefatxime IV for 7-10 days.
43
Random but which antibiotic is used for gonorrhoea?
Ceftriaxone plus doxy or azith.
44
What prophylaxis should be given to people in close contact with epiglottitis?
Rifampicin.
45
When does the incidence of pneumonia peak?
Infancy and old age.
46
What pathogens are the likely cause of pneumonia in newborns?
Group B strep, e.coli, klibsiella and staph aureus.
47
What pathogens are the likely cause of pneumonia in infants?
Strep pneumonia (MOST COMMON), RSV, chlamydia.
48
What pathogens are the likely cause of pneumonia in >5s?
Strep pneumonia , staph aureus, group A strep, bordatella pertussis, mycoplasma pneumonia (most common?), chlamydia, gonorrhoea.
49
Which kids are at higher risk of acquiring pneumonia?
Congenital lung cysts, chronic lung disease of prematurity, CF, PCD, sickle cell, immunodeficiency, if they have a tacheostomy in situ.
50
What are the clinical features seen in kids with pneumonia?
Possible URTI, temp of more than 38.5, SoB, productive cough in children >7.
51
What is seen on examination in kids with pneumonia?
Tachypnoea, grunting, intercostal recession, sats <92% indicate severe resp disease, lungs are dull to percussion, crackles and decreased air entry with bronchial breathing.
52
What is grunting?
Exhalation against a partially closed glottis
53
Investigations for pneumonia?
Sputum → may be of limited value • Nasopharyngeal swab → for viral investigation in infants • Blood cultures → should be performed in children with severe bacterial pneumonia • CxR → not routine, however may show areas of consolidation or effusion • Pleural fluid → performed in presence of significant pleural effusion; aspirate sample should be tested
54
Management of pneumonia?
Amoxicillin, anti-pyretics, IV fluids, supplementing oxygen (maintain sats at 92%), chest drain (if fluid collection).
55
What treatment would you give in sever pneumonia?
Co-amoxiclav, cefotaxime, cefuroxime.
56
What is an empyema?
This is when pus gathers in the pleural cavity, is usually preceded by pneumonia.
57
What are the usual microbiological causes of pharyngitis?
Virally, usually adenovirus (dsDNA), enterovirus (ssRNA) and rhinovirus (ssRNA) and bacterial causes are usually group A strep.
58
What bacteria usually causes tonsillitis?
Group A strep or EBV.
59
How do you manage upper respiratory tract infections?
Fever- paracet/ ibuprofen, antibiotics- penicillin or erythromicin in pen allergic.
60
If a URTI is caused by EBV, which antibiotic should be avoided?
Avoid amoxicillin in EBV as causes rash.
61
What is a wheeze?
This is a breath sound heard during expiration and it is associated with prolonged expiration.
62
What does a wheeze indicate?
An obstruction of air flow from within the thorax.
63
Where do high and low pitched wheezes come from?
High = small airway obstruction and low= large airway obstruction
64
What does a polyphonic wheeze indicate?
A wheeze originating from several airways.
65
What are the 2 patterns of wheeze?
Transient early wheeze and persistent and recurrent wheeze.
66
What are the clinical features of a transient early wheeze?
Viral induced wheeze in pre-school age children, result from obstruction of smaller airways, episodic symptoms with no interval symptoms, and ABSENCE of strong history of atopy and risk factors include maternal smoking and prematurity.
67
What are the clinical features of a recurrent wheeze?
Frequent wheeze triggered by stimuli, IgE response, evidence of allergy which can be confirmed by skin prick test or IgE blood test
68
Name some other causes of a wheeze?
Non-atopic wheezing can follow a LRTI, cardiac failure causing resp distress heart murmur and hepatomegaly, and inhaled body wheeze (choking), aspiration of feeds usually associated with a neuromuscular disorder.
69
What is cystic fibrosis caused by?
Autosomal recessive disorder leading to a defect in the CF transmembrane protein (CFTR), most common deletion is F508- this results in defective ion transport in exocrine glands.
70
What organs are affected in CF?
In the lungs- there is abnormal sodium and ion transport causing thickening of respiratory mucus which the lungs cannot adequately clear leading to chronic bacterial infection and lung injury. Pancreas- cyst formation here and fibrosis leading to pancreatic insufficiency (maldigestion, malabsorption and diabetes) Can also affect the liver and cause infertility in males,
71
How common is CF?
It is the most common life-limiting autosomal recessive condition in caucasians and the incidence is 1 in 2500 live births.
72
What is the carrier rate of CF?
1 in 25, however much less common in other ethnic groups
73
What is the average life expectancy in someone with CF?
40s
74
What are the clinical features of CF in infancy?
Meconium ileus (due to thick mucus in the ileum and ingestion of meconium causes intestinal obstruction and vomiting- common first presentation. Can also cause prolonged NEONATAL JAUNDICE, chronic infection in airways due to (staph/haem influ etc) Failure to thrive • Malabsorption & steatorrhoea
75
Why does CF cause neonatal jaundice?
Due to extrahepatic biliary obstruction from bile of increased density, with secondary intrahepatic bile stasis.
76
Why is there failure to thrive in CF patients?
Pancreatic insufficiency causes maldigestion & malabsorption
77
What are the clinical features of CF in the young child?
``` • Bronchiectasis (widening of the bronchi due to increased volume of mucous → more prone to infection) • Rectal prolapse • Nasal polyp • Sinusitis ```
78
What are the clinical features of CF in older children/adolescents?
Diabetes → due to pancreatic insufficiency • Liver cirrhosis & portal hypertension • Pneumothorax & recurrent heamoptysis • Allergic bronchiopulmonary aspergillosis • Persistent loose cough, producing purulent sputum • Sterility in males
79
What does a chest x ray look like in a patient with CF?
Hyperinflation, marked peribronchial shadowing, bronchial wall thickening and ring shadows.
80
On examination what is found with CF?
Hyperinflation of the chest (air trapping) • Course inspiratory crepitations • Finger clubbing • Perform full respiratory & GI examination; Growth & development
81
How is CF screened for?
Guthrie test performed at 8 days old, also CF sweat test determines the conc of chloride in the sweat. Lung function- obstructive lung disease, decreased FVC and increased lung volume.
82
Which professionals are involved in CF team?
``` Paediatric pulmonologist Primary care team Physiotherapists Teachers Dieticians Psychologist Nurse liaison ```
83
How often is physio needed in CF?
Twice a day
84
Which medications do patients with CF require?
Oral antibiotics when child is well but when unwell may require IV, through portacath for permanent access possibly. They also need lactulose to treat intestinal obstruction They also require pancreatic supplements and vitamins
85
RECAP
Decreased secretion of chloride and increased reabsorption of sodium with water following inside the cell causes mucus to build up extracellularly.
86
What bacteria usually causes an atypical pneumonia and how is this treated?
Mycoplasma pneumonia and oral azithromicin.
87
When is a cough considered chronic?
When it persists for 8 weeks or more.
88
Causes of coughs in children;
Bordatella pertussis, tonsilitis, sinusitis, tracheo-pesophageal fistula, foreign body, bronchiectasis from chronic condition, gord, CF, psychogenic cough, tourettes.
89
What is bronchiectasis?
Permanent dilatation and thickening of the airways characterised by chronic cough, excessive sputum production, bacterial colonisation, and recurrent acute infections. It may be widespread throughout the lungs (diffuse) or more localised (focal). It is caused by chronic inflammation of the airways, and is associated with, or caused by, a large number of diseases e.g. CF
90
Which bronchus is a medium object likely to be stuck in a toddler?
Right main bronchus
91
What is likely to happen if an object is lodged in the bronchioles?
Infection- pneumonia which doesn't resolve with antibiotics.
92
Chest sounds:
If object stuck in trachea- stridor | If stuck in bronchus- wheeze
93
What are the signs of an inhaled foreign object?
Decreased air entry on affected side, deviated trachea away from object, hyperinflation of unaffected side. (view with bronchoscopy)
94
What are the common pathogens of a middle ear infection?
Pneumococcus, group A strep, H. influenzae, | Moraxella
95
Who are middle ear infections most common in?
Children aged 6-12 months
96
What are the risk factors for middle ear infections in children?
Parental smoking, male, structural abnormalities
97
What may be seen on examination with otitis media?
- Discharge - Tympanic membrane may not be intact - Bright red & bulging eardrums - Loss of light reflex
98
How do you treat middle ear infections?
Co-amoxoclav
99
What are the clinical features of TB?
4- 6 weeks- Febrile illness, night sweats, anorexia and weight loss, erythema nodosum, cough, Phlyctenular conjunctivitis 6-9 months- Effusion: lesion may rupture in to pleural space • Cavitation: lesion may rupture in to bronchus • Miliary spread (wide dissemination throughout the body) • May eventually cause extensive scarring throughout the lung
100
What is phyuctenular conjunctivitis?
Phlyctenular keratoconjunctivitis is a nodular inflammation of the cornea or conjunctiva that results from a hypersensitivity reaction to a foreign antigen
101
NB:
50% of infants & 90% of children will experience minimal symptoms if any with TB. However the disease remains latent & can develop in to active disease later on. A positive Mantoux test in these children is enough evidence to initiate treatment.
102
Why might a mantoux test be positive?
Note: This may be positive because of past vaccination (BCG) rather than TB infection; therefore vaccination history must be taken.
103
What is the management of TB?
Isoniazid, rifampicin & pyrazinamide
104
What causes whooping cough?
Bordatella pertussis
105
What is the epidemiology of whooping cough?
It is endemic with epidemics every 3-4 years.
106
What are the clinical features of whooping cough?
A week of coryza • Characteristic paroxysmal cough, followed by inspiratory whoop • Spasms of cough are usually worse at night & may cause vomiting • During cough, child may go red or blue & mucous will flow from mouth & nose • Child may develop epistaxis & sub-conjunctival haemorrhages due to excessive cough • Infants may not exhibit the ‘whoop’ but have apnoea instead • Symptoms last 3-6 weeks & gradually improve with time
107
What is the management of whooping cough?
Infants: admission required for those with apnea, cyanosis or significant cough. • Close monitoring required due to risk of seizures, encephalopathy & death Isolation: should be isolated for 5 days after starting abx Antibiotics: Erythromycin for 14 days will reduce infectivity but not minimise cough Pregnant women are now also offered a vaccination that increases the infants immunity against disease until it can be immunised
108
When does immunisation against pertussis occur?
2 and 3 months and decrease likelihood of developing it by 90%
109
What should close contacts of people with pertussis receive?
Erythromicin prophylaxis
110
How do you confirm pertussis in kids?
Per nasal swab
111
How can you prevent RSV in kids who are prem, immunocompromised or have lung or heart problems?
Palivizumab is a monoclonal antibody which is used to prevent respiratory syncytial virus (RSV) in children who are at increased risk of severe disease.

Paediatrics (23 decks)

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