Respiratory Flashcards
If an infant has a chronic cough, what should be considered?
A congenital abnormality or aspiration of stomach contents (particularly if related to meal times)
What age group does viral wheeze commonly affect?
6months-3years
Under what circumstances would a child need to be hospitalised for viral wheeze? How would they be managed?
RR>60, SpO2 <92 and/or signs of severe respiratory distress
Management = high flow oxygen with salbutamol nebuliser
What type of allergic reaction is asthma?
Type 1 hypersensitivity - IgE activated eosiniphils/mast cells which release inflammatory mediators
What would the peak flow be in a severe asthma attack? What if it progressed to become life threatening?
Severe = >33-<50% Life-threatening = <33%
Why are bronchodilators of little help in an infant experiencing an asthma (or asthma like) attack?
Their airways are already very narrow and so the main problems with the airway are due to secretions and mucosal oedema
In a 6 year old child’s asthma is not well controlled and they are currently using a brown inhaler and a brown inhaler, what is the next stage of treatment?
Add on a LABA - Salmeterol
What might you see on CXR in a child with asthma?
Flattened hemi-diaphragms
Hyperinflation
Atelectasis
What is the management for an severe acute asthma attack?
- O2 15L via NRBM
- Nebulised salbutamol + Ipratropium bromide 250mcg (Back to back if needed)
- Steroids - oral prednislone or IV hydrocrotisone
- Consider nebulised magnesium sulphate (give with each ipratropium bromide + B2 agonist)
- If severe and unresponsive = IV salbutamol 15mcg/kg over 10 mins
- Aminophylline if unresponsive to bronchodilators and steroids
In a 4 year child what is the next step to add on if they are requiring a their salbutamol inhaler 4 times a week?
Add a very low dose ICS or LRTA (montelukast)
What should you do fora 7-year-old child who uses their blue inhaler once a week and is on a LABA and Medium dose ICS?
Consider stepping down their management to a low dose ICS dose
How should you clean a inhaler spacer?
With warm soapy water - do not dry with a towel as this will create static that the powder will stick to
What most commonly causes bronchiolitis?
RSV
What prodrome is bronchiolitis usually preceded by? for how long?
1-3 days of coryza
Criteria for hospital referral from a GP with an infant with bronchiolitis?
Severe respiratory distress - signs (tracheal tug, nasal flaring, inter/subcostal recession), RR>60, SpO2 <92%
Cyanosis
Apnoea (observed or reported)
Reduced fluid/feed intake (<50% normal)
If a child with bronchiolitis is not feeding how should this be managed?
Naso-gastric tube - 90-150mls/hr
or TPN/IV fluids
What is an important differential for suspected croup?
Acute epiglottitis - soft stridor, fever (>38.5), drooling, absent/v. mild cough, can’t drink
When do you give a child with croup steroids?
Regardless of how severe give single dose oral dexamethasone (15mg/kg)
+/- inhaled steroids and adrenaline
What usually causes croup?
Parainfluenza virus
What age group are prone to epiglottis?
2-6 yrs (more common in travelling community as they may not be up to date with their immunisation - HiB)
What drug should be given prophylactically to family members when a child is diagnosed with epiglotittis?
Rifampicin
What immediate management is required for epiglotittis?
Intubation by experienced anaesthetist
If this fails do a tracheostomy
What group of antibiotics should be used to treat epiglotittis?
3rd generation cephs = cefotaxime or cefuroxime
What pathogen causes pneumonia in newborns?
group B strep
What signs would indicate a bacterial cause of pneumonia?
Localising chest signs, abdominal pain or neck stiffness,
What Abx treatment should be given first line in children >5yrs for bacterial pneumonia? If it is complex?
1st line = amoxicillin + erythromycin
Complex = co-amxoiclav
What is the cause of CF?
(usually change in F508 gene) on Ch 7 which codes for CFTR protein
What gastroenterology problems can CF patients have?
Meconium ileus (10-20%) can present in later life as distal intestinal obstruction syndrome Steatorrhoea and jaundice Biliary cirrhosis Pancreatic insuffuciency (FTT) IDDM
What respiratory problems can a CF patient have?
Lifelong chronic bronchiectasis
Infections - esp pseudomonas
Pneumothorax
Nasal polyps
What are the signs of CF?
Clubbing
nasal polyps
Hyperinflation of the lungs and end-respiratory crackles
Rectal prolapse
When instructing a parent on inhaler technque what should be advised in regards to:
- using a new (unused inhaler)
- How many breaths for each puff in a spacer
- How many puffs of salbutamol before they get medical help?
- How to minimise effects of inhaled steroids?
- Shake well before use and prime 4 times
- 6 slow and even breaths in a spacer per puff
- 10 - can have more but need to get help at this point
- wash mouth out to avoid oral thrush
For CF patients are females or males more affected by infertility?
males - vas deferens gets blocked (in females fallopian tubes can get blocked as well but less common)
What level of Cl- in a sweat test would be diagnostic of CF?
> 60mmol/L fro all age groups
30-50 = possible CF (40-59 in infants <6mo) <30 = unlikely
How are CF patients managed nutritionally?
High calorie diet
CREON (pancreatic enzymes)
Vitamins - A, D, E, K
What are the conditions URTI presents as?
Common Cold
Sore throat - pharyngitis (including tonsillitis)
Otitis media
Sinusitis
What is the usual cause of pharyngitis?
Virus - adenovirus, enterovirus, rhinovirus
In older children = group A B-haemolytic strep
What is the CENTOR criteria?
Determines risk of tonsillitis being bacterial in origin:
- Age (+1 if 3-14yrs)
- Fever (+1)
- Absent cough (+1)
- Tonsillar exudate (+1)
- Cervical tenderness/swelling (+1)
If total ≥3 - likely to be group A B-haemolytic strep
What is the management of bacterial tonsillitis?
Penicillin or erythromycin - 2 tablets a day for 10 days (extended course of abx to prevent rheumatic fever)
Never give amoxicillin because it will result in widespread rash if tonsillitis is in fact EBV in origin
What age group is most affected by acute OM? Why is this?
6-12 months
Their eustachian tubes a short, horizontal and function poorly
What is glue ear?
(Usually recurrent) otitis media with effusion (OME) - often asymptomatic apart from decreased hearing
Tympanic membrane will look dull and retracted
Common in 2-7yrs
If chronic secretory >3 months - will require audiometry investigations and may requrie grommets
What antibiotic is often given for acute OM?
Amoxicillin but parents may be advised only to give after 2-3 days if symptoms haven’t improved with supportive management
Common viral and bacterial causes of acute OM?
viral = RSV and rhinovirus Bacterial = pneumococci, H, influezae and moraxella catarrhalis
Where is a medium sized object most likely to become lodged when inhaled by a child? What would the clinical presentation be?
right main bronchus
Tachypnoea and dyspnoea
Wheeze
Chest tightness/pain
Respiratory distress
Management in a conscious child who has inhaled a foreign body and has ineffective cough?
5 back blow and 5 abdominal thrusts (chest thrusts in infant)
Severe signs of inhaled foreign body?
Rapid LoC Silent coughing attempts Wheeze Cyanosis U/L monophonic wheeze
Management of an unconscious child who has inhaled a foreign body?
In community - open airway and do CPR
In hospital - 15L O2 NRBM and bronchoscopy to remove foreign body
Pathogen which causes whooping cough?
Bordetella pertussis
Comes in epidemics - every 3-4 years
Incubation period 10-14 days
Symptoms of whooping cough?
Catarrhal phase = up to 1 week of coryza
Paroxysmal and spasmodic cough with characteristic ‘whoop’ inspiratory sounds afterwards (may be apnoea in infants) - typically worse at night
Child may go red/blue whilst coughing
May culminate in vomiting, sub-conjunctival haemorrhage, epistaxis, exhaustion
Lasts around 3-6 weeks
Investigations for whooping cough?
Swab culture (per-nasal) = diagnostic (can also do PCR) Bloods - raised WCC (>15 x 10^9) Ophthalmology - sub-conjunctival haemorrhage
Management of whooping cough?
Hospitalize if having severe attacks/cyanotic attacks
Erythromycin for 14 days or clarithromycin for 7 days
Give prophylactic abx to family
Isolate for 5 days post abx treatment
Sequalae of TB disease?
= TB primary infection
4-8 weeks:
Febrile
Erythema nodusum
Conjunctivitis
6-9mths:
Progressive healing of primary focus (majority)
or
Effusion: focus perforates into pleural space
and/or
Cavitation: focus perforates into bronchi
Symtpoms of pulmonary TB?
prolobged fever (+/- night sweats) malaise Anorexia, weight loss Silent or cough +/- haemoptysis focal signs of infection
What would be a positive mantoux test?
Skin lesion >15mm after sub-dermal injection of tuberculin
What would be seen on CXR in TB?
Hilar lymphadentopathy Ghon's focus - focal opacity/calcification Consolodiation Cavitation Pleural effusion
Management of pulmonary TB?
Triple therapy:
Isoniazid + Rifampicin + Pyrazinamide for 2 months
Then 4 months of rifampacin + isoniazid
Presentation of epiglottitis?
Rapid onset
High temperature
Stridor
Drooling
