Respiratory Flashcards
When in children is asthma worse?
Early morning and at night
At what age, generally, are children investigated using spirometry?
> 6 years old
In terms of spirometry, what degree of reversibility should bronchodilator therapy cause in a child with asthma?
> 12% increase
Which asthma treatments are generally not used in:
- Children under 5?
- Children aged 5 - 12?
- LABA
2. Leukotriene antagonists e.g. montelukast
Give three side effects of long-term steroid inhalers
Sore throat/mouth Hoarse/croaky voice Cough Oral thrush Nose bleeds
In asthma, how does the route of administration change with age?
Nebulisers: < 2 years, children who can’t cooperate and in acute severe asthma attacks
Spacers: Toddlers (2 - 8 years)
Dry powder systems: School age child
Metered dose inhaler: Children > 8 years
How should you advise parents regarding cleaning spacers?
Clean with warm, soapy water and rinse
Do not dry as it will cause static!
Generally, when are children monitored using PEFR?
Over 5 years
After ABCDE, what is the pharmacological management of an acute asthma attack in a child?
In children:
Oral or nebulised salbutamol:
2-4 puffs every 20-30mins in mild attacks; severe may require up to 10 puffs. If failing with inhalers or needing oxygen - give 2.5mg nebulised
Oral prednisolone:
20mg if aged 2 - 5 years; 30-40mg if over 5 years
Maintenence steroids: 2mg/kg, max = 60mg
Repeat if child vomits.
IV salbutamol bolus: 15ug/kg if severe
Nebulised ipratropium bromide: 250mcg mixed with salbutamol, in the first 2 hours or a severe attack
IV aminophylline with severe bronchospasm
IV magnesium sulphate
What is the most common causes of pneumonia in:
- Neonates?
- Infants?
- Older children and adolescents?
- Organisms from the female genital tract
e. g. Group B strep, E. coli, gram -ve bacilli, Chlamydia trachomatis - Bacterial (60%) and Viral (40%)
Bacterial: strep. pneumoniae (90%), staph. aureus, haemophilus influenza
Viral: parainfluenza, influenza, adenovirus, RSV
- As above + atypical organisms such as mycoplasma pneumoniae and chlamydia pneumoniae
What is the most common cause of aspiration pneumonia?
Enteric gram -ve bacteria
Can be strep. pneumoniae or staph. aureus
What are the most common causes of pneumonia in:
- non-immunised children?
- immunocompromised children?
- Haem. influenza, bordatella pertussis, measles
- Viral: CMV, VZV, HZV, measles and adenovirus
Bacterial: pneumocystis carinii, TB
When does the sputum usually appear rusty?
Strep. pneumoniae infection
Give three signs of consolidation.
Decreased breath sounds
Dullness to percussion
Increased tactile/vocal fremitus
Bronchial breathing
Coarse crepitations
Give three signs of respiratory distress in children
Cyanosis (severe)
Grunting
Nasal flaring
Marked tachypnoea
Intercostal and suprasternal recession
Subcostal recession
Abdominal, see-saw breathing
Tripod positioning
Reduced oxygen saturation
What does focal consolidation on a chest x-ray suggest?
Bacterial pneumonia
What does diffuse consolidation on a CXR suggest?
Viral bronchopneumonia
For suspected pneumonia, for which causes would the following investigations be useful:
- Urine culture?
- Blood film?
- Immunofluorescence?
- Legionnaires antigen
- Mycoplasma - RBC agglutination
- RSV on nasopharyngeal exudate
What is the first line management of pneumonia in children?
Oral amoxacillin or erythromycin
If severe, IV cefuroxime +/- erythromycin
What is the antibiotic treatment for aspiration pneumonia?
Metronidazole
What is the most common cause of bronchiolitis?
RSV
At what age does bronchiolitis usually occur?
2 - 6 months old
When is the peak incidence of bronchiolitis?
Winter months
What is the clinical presentation of bronchiolitis?
It usually begins as an upper tract infection (rhinorrhea) and then:
SOB, cough, wheeze and bilateral crepitations
Decreased feeding and irritability
Apnoea
Signs of respiratory distress
Tachypnoea/cardia, fever, dehydration
What is croup usually caused by?
Parainfluenza virus, but all other common viruses can also cause it
Who does croup most commonly affect?
6 months - 2/3 years
More common in boys
What are the clinical features of croup?
Barking cough
Hoarsness
Stridor
Decreased air entry but normal sounds
Respiratory distress
What is the management of croup?
Important to keep patient calm and be as uninvasive as possible to avoid further subglottal inflammation.
Oxygen
Dexamethasone 150ug PO or
Prednisolone 1mg/kg or
Nebulised budesonide
Nebulised adrenaline (if severe)
What is the most important thing to rule out when investigating ?croup?
Epiglottitis
At what age are children more likely to get tonsilitis?
5- 10 years and young adults
Which type of viral tonsillitis causes blisters in the mouth?
Coxsackie virus
What is the most common bacterial cause of tonsillitis?
Group A beta haemolytic streptococcus (group A strep)
When should you prescribe antibiotics in patients with suspected tonsillitis?
Systemic features secondary to acute sore throat
Unilateral peritonsillitis
History of rheumatic fever
Increased risk from acute infection e.g. kids with DM,
3 or more of the centor criteria
Which criteria is used in diagnosing bacterial tonsillitis?
What is it?
Centor criteria:
History of fever
Tonsillar exudates
No cough
Tender anterior cervical lymphadenopathy
What advice should be given for non-pharamacological management of tonsilitis?
Salt water gargles
Antipyretics
In tonsillitis, where can the pain be referred to?
Ears
What is the treatment for bacterial tonsillitis?
What should you not give?
Penicillin V
Erythro-/Clarithro-mycin if peniciilin allergic
You should not give amoxicilin, in case of EBV
Give three complications of tonsillitis
Acute otitis media
Peritonsillar abscess (quinsy)
Cervical abscess
Guttate psoriasis flare-up
Rheumatic fever (delayed)
Acute nephritis (delayed)
When should a child be referred for a tonsillectomy?
Recurrent attacks of tonsillitis (typically streptococcal).
Enlarged tonsils causing obstruction of the airway, which may be the cause of obstructive sleep apnoea.
Possible malignant disease in the tonsils.
What is the most common cause of epiglottitis?
Haemophilus influenzae B, but since the introduction of the Hib vaccination, streptococcus is more common
Who does epiglottitis usually affect?
2 - 5 years
What are the differentiating clinical features of epiglottitis?
Odynophagia
Hot potato voice
Tripod position
Anterior neck tenderness over hyoid bone
Stridor
Drooling
What should you not do in kids with suspected epiglottitis?
Examine the throat with a tongue depressor
What is the management of epiglottitis?
IV fluids
IV ampicillin
Intubation/tracheostomy if airway compromised
When is wheeze heard?
On expiration
What does perinatal wheeze suggest?
Structural abnormalities
What is transient wheezing and what is it caused by?
In infancy, non-atopic infants can get an intermittent wheeze, which usually disappears after the age of 3.
It is most commonly caused by RSV
What is classed as a ‘persistent/recurrent’ wheeze?
Lasting longer than 4 weeks - suggestive of asthma
Which investigations should be done for infants and children with wheeze?
CXR
Sweat test - for CF
Allergy testing
Barium swallow - fistulae
Spirometry (> 6 years)
When is stridor heard?
On inspiration, but if severe can be heard on expiration also
What does biphasic stridor suggest?
Subglottic obstruction
Give three causes of stridor
Croup
Tracheitis: under 3 years
Inhaled foreign body
Abscesses: retropharyngeal or peritonsillar
Anapyhlaxis
Epiglottitis
Give five congential problems that can cause stridor
Laryngomalacia
Vocal cord dysfunction
Subglottic stenosis
Laryngeal disorders
Tracheomalacia
Choanal atresia
Tracheal stenosis
When is the pattern of infection in tracheitis?
Bacterial infection following a viral infection
What different types of abscess can children get and how do their clinical features differ?
Retropharyngeal: < 6 years, pain on neck hyperextension
Peritonsillar: adolescents, trismus, difficulty speaking
Both present with fever and dysphagia
What is the most common cause of stridor in neonates?
Laryngomalacia
It is also the most common cause in early infancy
When is laryngomalacia worst?
Prone position
Crying feeding
What causes subglottic stenosis?
It can be congenital or acquired
It usually occurs as a result of prolonged intubation
What is the most common cause of expiratory stridor?
Tracheomalacia
What is the most common congenital anomaly of the nose?
Choanal atresia: failed recanalisation of the nasal fossae during fetal development
What is the best first line management for any stridor?
Corticosteroids
What mutation causes CF?
What does the mutation result in?
CFTR gene on Chromosome 7
Reduces conductance of chloride ions and increases viscosity of mucus secretions
Which tests are used for CF?
Mouthwash carrier testing
Chorionic villus sampling at 10 weeks
Sweat test (>60mmol/L of NaCl)
Guthrie test (day 5 - 8)
CT head and thorax
Give three signs of CF
Finger clubbing
Cough with purulent sputum
Crackles
Wheezes (mainly in the upper lobes)
Forced expiratory volume in one second (FEV1) showing obstruction
What clinical features are associated with CF perinatally?
Bowel obstruction with meconium ileus (bowel atresia)
Haemorrhagic disease of the newborn
Prolonged jaundice
Failure to thrive
Give five associated features/conditions of CF in infancy and childhood?
DR P5 HF
Diarrhoea and bulky, greasy stools
Recurrent respiratory infections
rectal Prolapse
acute Pancreatitis
Portal hypertension and variceal haemorrhage
Pseudo-Bartter’s syndrome: electrolyte abnormality
nasal Polyps (in children, nearly always due to CF)
Hypoproteinaemia and oedema
Failure to thrive (thriving does not exclude diagnosis)
In CF, what commonly do you have a congenital absence of?
Vas deferens
What is the management of CF?
Chest physio
Prophylactic Abx
Saline nebulisers
SABA/LABA
Pancreatic enzymes (Creon)
What nutritional advice should you give to patients with CF?
High fat and protein diet
Vitamin supplements
150% of normal energy diet
Pancreatic enzyme (Creon)
Give five complications of CF
Respiratory failure
DM
Portal hypertension
Hepatic cirrhosis
Cor pulmonale
Infertility
What is the average life expectancy of a patient with CF?
40 -50 years old
What is TB caused by?
Mycobacterium tuberculosis
By what mode is TB spread?
Droplets
What are the risk factors for TB?
TB contact (obviously)
South Asian
Homelessness
Drug abusers
HIV
Elderly
What are the differentiating features of TB?
Nigh sweats
Fatigue and malaise
Weight loss and anorexia
Purulent +/- blood-stained sputum
How can you diagnose latent TB?
Mantoux test
How do you manage TB?
RIPE:
Rifampicin
Isoniazid
Pyrazinamide
Ethambutol
What is unique about the timing of whooping cough?
It is cyclical; recurring every 3 - 4 years
How long does whooping cough infection usually last for?
6 - 8 weeks
Catarrhal phase followed by 2 weeks of cough
When is whooping cough most infectious?
Towards the end of the catarrhal phase/during the paroxysmal coughing stage (1 - 2 weeks after onset of symptoms)
What is the presentation of whooping cough
Catarrhal phase:
Malaise, conjunctivits, coryzal symptoms, mild fever
Proxysmal coughing phase:
Severe prolonged coughing followed by whoop
Choking/gasping/flailing of extremeties
Cyanosis
How is whooping cough investigated?
Clinical exam
Routine bloods
Nasopharyngeal swabs
Oral fluid testing for IgG antipertussis
PCR if very unwell
Give three complications of whooping cough.
PASO:
Pneumonia
Apnoea
Seizures
Otitis media
