Respiratory Flashcards
1
Q
Define stridor
A
Added inspiratory noise on due to partial obstruction of upper airway
2
Q
Physiology of stridor
A
On inspiration there is negative pressure in intrathoracic cavity with increased intrathoracic volume
There is Atmospheric pressure in extrathoracic airway, causing collapse of upper airways
When there is URT narrowing, obstruction on inspiration is exaggerated and added sounds produced due to turbulent air flow
3
Q
Types of upper airway infections
A
Coryza
Pharyngitis, tonsillitis
Acute otitis media
Sinusitis
4
Q
Clinical features of coryza
A
Clear or mucopurulent nasal discharge
Nasal blockage
Cough - up to 4 weeks
5
Q
Aetiology of coryza
A
Rhinovirus
Coronavirus
Respiratory syncytial virus
6
Q
Management of coryza
A
Reassurance and education
Analgesia - Paracetamol, ibuprofen
7
Q
How to assess severity of upper airway obstruction/stridor
A
Stridor: None Only on crying - mild At rest Biphasic
Degree of chest retraction (subcostal, intercostal, sternal):
None
Only on crying
At rest
Level of consciousness Cyanosis Drooling saliva Barking cough Agitation Increased RR, HR O2 sats
8
Q
Causes of upper airway obstruction
A
Viral laryngotracheobronchitis (croup)
Epiglottitis Bacterial tracheitis Foreign body Allergic laryngeal angiooedema Inhalation of smoke in fires Trauma to throat Retropharyngeal abscess Severe lymph node swelling Hypocalcaemia Measles Diphtheria
8
Q
Define croup
A
Symptoms due to partial obstruction of upper airways as a result of generalised inflammation due to viral infection
Most common cause of stridor
8
Q
Aetiology of croup
A
Parainfluenza virus
Rhinovirus
RSV
Influenza
9
Q
Epidemiology of croup
A
6 months - 6 years, peak at 2 years
Autumn
10
Q
Clinical features of croup
A
Preceding Coryza + fever: nasal discharge, congestion, cough
Hoarseness (vocal cords) Barking cough (tracheal collapse) Harsh Stridor Difficulty breathing - recession Symptoms worse at night
11
Q
Management of croup
A
Mild:
No stridor at rest
Dexamethasone (single dose)
supportive
Moderate: Stridor at rest Corticosteroid (dexamethasone PO/IM single dose) Nebulised adrenaline Supportive
Severe: Stridor at rest + agitation or lethargy Corticosteroid (nebulised budesonide, PO, IM) Nebulised epinephrine Oxygen (8-10L/min by blow-by)
12
Q
Define acute epiglottitis
A
Cellulitis of supraglottis and epiglottis, with potential to cause airway compromise
13
Q
Aetiology of epiglottitis
A
Haemophilus influenza type b (Hib)
14
Q
Epidemiology of epiglottitis
A
Age 1-6 years
15
Q
Clinical features of epiglottitis
A
V acute onset (hours) Intensely painful throat - prevents speaking, swallowing Soft stridor Respiratory difficulty Tripod position: place neck and head anteriorly with hands on knees, to optimise airflow Toxic appearance Fever >38.5 Agitation Drooling Muffled voice Decreased oral intake Absent cough
16
Q
Management of epiglottitis
A
Secure airway:
Do not attempt examination - can precipitate obstruction
Clinical diagnosis - no investigations preclude management
Transfer to ICU/anaesthetic room
Direct rigid laryngoscopy and intubation
IV Abx: cefuroxime
17
Q
Define bacterial tracheitis
A
Bacterial croup
Due to bacterial super-infection in child with immune dysfunction
18
Q
Clinical features of bacterial tracheitis
A
High Fever
Toxic appearance
Rapidly progressive airway obstruction (sudden deterioration of croup)
Poor response to treatment with Nebulised epinephrine
19
Q
Management of bacterial tracheitis
A
IV antibiotics
Endotracheal intubation
21
Q
Define wheeze
A
Added respiratory sound on inspiration due to lower airway obstruction
23
Q
Physiology of wheeze
A
On expiration, there is recoil of diaphragm and decreased intrathoracic volume
Leads to compression of lower airways and airflow from alveoli to upper airways down pressure gradient
If there is lower airway narrowing, obstruction on expiration exaggerated causing added respiratory sound
24
Q
Define cystic fibrosis
A
Severely life-shortening autosomal recessive disease resulting from abnormalities in cystic fibrosis transmembrane conductance regulator
25
Epidemiology of cystic fibrosis
Caucasians
Incidence 1 in 2500 births
Carrier rate 1 in 25
26
Aetiology of cystic fibrosis
Mutation in CFTR gene
In chromosome 7
Many different gene mutations cause disease
Most common in UK is F508delta
Different class of gene mutations cause different severity of disease (class I = no protein synthesised, class VI = shortened half-life of protein)
27
Pathophysiology of CF
CFTR is chloride ion channel found in apical membrane of epithelial cells
Mutations in CFTR result in abnormal ion transport across epithelial cells and sticky thick secretions
In airways: impaired ciliary function, mucus retention, chronic infection, parenchyma destruction
In intestines: thick meconium/stools, meconium ileus, blockage
In pancreas: blockage of exocrine ducts, pancreatic destruction, malabsorption
In sweat glands: excessive sodium and chloride in sweat
28
What is the newborn screening for CF
Heel-prick blood test
Raised immunoreactive trypsinogen
If positive IRT, confirmatory testing with:
Sweat test
Genetic testing for two disease-causing mutations
29
Clinical features of CF
Newborn:
Positive newborn screen
Failure to pass meconium / meconium ileus
```
Infant:
Prolonged neonatal jaundice
Failure to thrive
Recurrent chest infections -
Chronic ‘wet’ cough
Malabsorption, steatorrhoea
```
```
Young child:
Bronchiectasis
Nasal polyp
Chronic sinusitis
Rectal prolapse
```
```
Adolescent:
Allergic bronchopulmonary aspergillosis
Diabetes
Cirrhosis + portal hypertension
Distal intestinal obstruction
Pneumothorax / recurrent haemoptysis
Sterility in males
```
30
Organisms of chronic chest infection in CF
Initially Staph aureus
H influenzae
Pseudomonas aeruginosa
Burkholderia cepacia
31
Respiratory features in CF
```
Persistent wet cough
Hyperinflation
Coarse inspiratory crepitations
Expiratory wheeze
Finger clubbing
```
(Chronic infection -> bronchiectasis -> abscess formation)
32
Investigations for CF
Sweat test:
Diagnostic
Sweat chloride >60 positive
Genetic testing:
Positive = presence of 2 disease-causing mutations
IRT test:
Screening test to identify newborns at increased risk of CF
NOT diagnostic, requires confirmatory testing If positive
33
Respiratory management of CF
A) Chest physiotherapy
B) inhaled bronchodilator
C) inhaled mucolytic: Dornase Alfa
+/-
Inhaled tobramycin: if chronic P aeruginosa colonisation
Inhaled steroid: if allergic bronchopulmonary aspergillosis or asthma
Anti-inflammatory agents: azithromycin, ibuprofen, oral steroid
CFTR Modulators: Ivacaftor (>12 months), Lumacaftor/ivacaftor (>2 years), Tezacaftor (>12 years)
Lung transplantation
34
Management of acute pulmonary exacerbation in CF
Assess severity by: increased cough, sputum, decreased activity, malaise, dyspnoea, changes in chest sounds, FEV1, imaging changes
Mild: oral abx +/- inhaled tobramycin
Severe: IV aminoglycoside (tobramycin)
Monitoring of serum aminoglycoside Levels: due to increased clearance in CF, higher and prolonged doses
35
Nutritional management in CF
Monitoring: appetite, stool habits, presence of GORD
Insatiable appetite, large number of stools - fat and calorie malabsorption
Decreasing number of stools - obstruction
Therapy:
Pancreatic enzymes
Oral calorific supplements
Gastrostomy tube
36
Management of pancreatic insufficiency in CF
Pancreatic enzyme supplements - pancreatin
Fat soluble vitamin supplements - A/retinol, D/colecalciferol, E, K/phytomenadione
+/- H2 antagonists: alkaline enviro for pancreatic enzyme supplements enzymatic function
37
Management of liver disease in CF
Ursodeoxycholic acid - improve flow of bile
| Liver transplant
38
Types of CFTR Modulators and their indications
Ivacaftor: >12 months, NOT F508del
Lumacaftor/Ivacaftor: >2 years, F508del mutation
Tezacaftor/Ivacaftor: >12 years, F508del mutation
39
Route of transmission of TB and risk factors for transmission
Respiratory droplets
Close proximity
Large infectious load in index case
Immunodeficiency
40
Pathophysiology and Types of TB infection
Inhalation of respiratory droplets
Alveolar Macrophages phagocytosis, release of bacilli and immune response activated
Clearance of infection
Latent TB - containment of infection by cellular immune system; T cells and macrophages form caseating granuloma and granulation tissue
Active TB - primary active TB, or Re-activation of latent TB; infection not contained by cellular immune system and active replication of bacilli with spread by lymphatic system
41
Clinical features of active TB infection
```
Fever (Low grade)
Night sweats
Weight loss
Anorexia
Cough - >2 weeks, initially dry later productive
Malaise
```
Chest pain - pleuritic or costochondritis from cough
Auscultation - crackles, bronchial breath sounds
Check arm for BCG vaccine
Lymphadenopathy - cervical, axillary, groin
42
Differentials for pulmonary TB
Pneumonia
Lung cancer
Other - sarcoidosis
43
Types of active Tb in children
```
Pulmonary - 75%
TB lymphadenitis
Osteoarticular TB
Genitourinary TB
TB meningitis
```
44
Diagnostic tests for TB
CXR - fibronodular opacities in upper lobes +/- cavitation, hilar lymphadenopathy
FBC - leukocytosis, Anaemia of chronic disease, oanchtopenia
Sputum acid-fast bacilli smear - three specimens 8hrs apart with one early morning, Ziehl-Nielsen stain
Sputum culture - takes 3-8 weeks
NAAT - used on sputum, allows rapid diagnosis
Gastric aspirate - in children bc unable to produce sputum, for overnight collection of bronchial secretions in stomach
Tuberculin skin test - induration >5mm, purified protein derivative of tuberculin injected to look for delayed hypersensitivity response to detect exposure to TB
IFN-Gamma release assays - assess response of T cells to in vitro stimulation with TB antigens, does not distinguish Latent vs Active
45
Treatment of TB
Intensive phase: Rifampicin, isoniazid, pyrazinamide, ethambutol 8 weeks
Continuation phase: isoniazid, rifampicin 4 months
Asymptomatic children with latent infection:
rifampicin and isoniazid for 3 months
+ pyridoxine - in adolescents to prevent peripheral neuropathy
46
Prevention of TB
BCG immunisation at birth of high risk children
Contact tracing:
Children infected w TB - screen other family members
Children exposed to pulmonary TB - screen for latent infection w TST/IGRA and children <2 start prophylactic isoniazid
47
TB Drugs side effects
Rifampicin: orange coloured urine, rash, jaundice, vomiting, confusion, generalised purpura, shock and purpura
Isoniazid: burning sensation in feet, rash, jaundice, vomiting and confusion
Pyrazinamide: joint pains, jaundice, vomiting and confusion
Ethambutol: visual impairment
48
Causes of recurrent/persistent wheeze in children
```
Bronchiolitis
Asthma
Viral episodic wheeze
Multiple trigger wheeze
Recurrent anaphylaxis
Chronic aspiration
Cystic fibrosis
Bronchopulmonary dysplasia
Tracheo-bronchomalacia
```
49
Definitions of cough
Subacute: 3-8 weeks
Chronic: >8 weeks
50
Causes of acute cough
Wet:
- lower respiratory tract infection/mucus secretion
Dry:
- sensation of mucus in throat = upper airway
- barking = tracheal
- wheeze = lower airway narrowing
51
Define whooping cough
Upper respiratory tract infection with Bordetella pertussis
52
Epidemiology of Whooping Cough
Occurs in epidemics every 3-4 years
| Infants susceptible to severe infections
53
Aetiology of whooping cough
Transmission by respiratory droplets - highly infectious
54
Clinical features of whooping cough
```
Catarrhal Phase: 1 week of coryza
Paroxysmal Phase:
- paroxysms of cough followed by vomiting/inspiratory whoop
- 3 months
- cyanosis during paroxysms
- worse at night
- in infants: apnoea
- associated with epistaxis, subconjunctival haemorrhage
```
55
Risk factors for whooping cough
<6 months (incomplete vaccination)
Maternal infection at >34 weeks gestation
Close/household contact
56
Complications of whooping cough
Pneumonia
Seizures
Bronchiectasis
57
Investigations for whooping cough
Nasopharyngeal aspirate / swab culture
Nasopharyngeal sample PCR
Serology
FBC - raised WCC
58
WHO diagnostic criteria for whooping cough
Clinical:
>2 weeks cough with post-cough vomiting/whoop/paroxysms of cough
Laboratory:
+ve PCR
Isolation on culture
Serology
59
Management of whooping cough
Macrolides - clarithromycin/erythromycin, only effective during catarrhal phase
Prophylaxis of contacts - vaccination, prophylactic macrolide
60
Causes of chronic cough in children
Recurrent respiratory infections - most common
Specific respiratory infections - RSV, Pertussis, Mycoplasma
Unresolved lobar collapse after pneumonia
Persistent bacterial bronchitis
TB
Suppurative lung disease - CF, primary ciliary dyskinesia, immunodeficiency
Asthma
structural airway abnormalities
Other: recurrent aspiration, inhaled FB, habit cough, cigarettes smoking
61
Aetiology of pneumonia in children
Newborn: GBS, Gram -ve bacilli (E Coli), Gram -ve enterococcal
(Maternal genital tract)
Infants: RSV, Resp viruses, strep pneumoniae, H influenzae, bordatella pertussis, chlamydia trachomatis, staph aureus (rare, serious)
>5: Mycoplasma pneumoniae, strep pneumoniae, chlamydia pneumoniae
62
Clinical features of pneumonia in children
Tachypnoea - most sensitive
Localised chest pain, neck stiffness, abdominal pain - bacterial
Localised chest signs - bacterial
Classical signs often absent - dullness, bronchial breathing, reduced breath sounds
Cough non-productive - children <6 swallow sputum
63
Management of pneumonia in children - admission, antibiotics
Admission: <92%, recurrent apnoea, grunting, inability to maintain fluid/feed intake
Antibiotics:
Neonate - IV Broad spectrum
Infant - PO amoxicillin
>5 - PO amoxicillin or erythromycin
64
Complications of pneumonia
Small parapneumonic effusions - 33%, resolves
Pleural effusion - drainage If persistent fever after 48hrs abx, USS-guided drainage with small bore chest drain and regular installation of fibrinolytic agent
65
Causes of chronic lung infection
Persistent bacterial bronchitis
| Bronchiectasis
66
Define persistent bacterial bronchitis and pneumonia
Persistent Bacterial bronchitis: lower respiratory tract/bronchial infection, leading to inflammation
Pneumonia: infection of lung parenchyma, leading to consolidation
67
Causes of persistent bacterial bronchitis
H influenzae
| Moraxella catarrhalis
68
Management of persistent bacterial bronchitis
Referral - may lead to bronchiectasis
Diagnosis - isolation from sputum/bronchial lavage culture
Treatment - co-amoxiclav + PT
69
Causes of bronchiectasis
```
Generalised:
CF
Primary ciliary dyskinesia
Chronic aspiration
Immunodeficiency
```
Focal/Single lobe:
Previous severe pneumonia
Obstruction by foreign body
Congenital lung abnormality - tracheo-bronchomalacia, tracheo-oesophageal fistula
