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Paediatrics > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Define stridor

A

Added inspiratory noise on due to partial obstruction of upper airway

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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

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3
Q

Types of upper airway infections

A

Coryza
Pharyngitis, tonsillitis
Acute otitis media
Sinusitis

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4
Q

Clinical features of coryza

A

Clear or mucopurulent nasal discharge
Nasal blockage
Cough - up to 4 weeks

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5
Q

Aetiology of coryza

A

Rhinovirus
Coronavirus
Respiratory syncytial virus

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6
Q

Management of coryza

A

Reassurance and education

Analgesia - Paracetamol, ibuprofen

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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
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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
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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

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8
Q

Aetiology of croup

A

Parainfluenza virus
Rhinovirus
RSV
Influenza

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9
Q

Epidemiology of croup

A

6 months - 6 years, peak at 2 years

Autumn

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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
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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)
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12
Q

Define acute epiglottitis

A

Cellulitis of supraglottis and epiglottis, with potential to cause airway compromise

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13
Q

Aetiology of epiglottitis

A

Haemophilus influenza type b (Hib)

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14
Q

Epidemiology of epiglottitis

A

Age 1-6 years

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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
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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

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17
Q

Define bacterial tracheitis

A

Bacterial croup

Due to bacterial super-infection in child with immune dysfunction

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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

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19
Q

Management of bacterial tracheitis

A

IV antibiotics

Endotracheal intubation

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21
Q

Define wheeze

A

Added respiratory sound on inspiration due to lower airway obstruction

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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

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24
Q

Define cystic fibrosis

A

Severely life-shortening autosomal recessive disease resulting from abnormalities in cystic fibrosis transmembrane conductance regulator

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25
Q

Epidemiology of cystic fibrosis

A

Caucasians
Incidence 1 in 2500 births
Carrier rate 1 in 25

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26
Q

Aetiology of cystic fibrosis

A

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)

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27
Q

Pathophysiology of CF

A

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

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28
Q

What is the newborn screening for CF

A

Heel-prick blood test
Raised immunoreactive trypsinogen
If positive IRT, confirmatory testing with:
Sweat test
Genetic testing for two disease-causing mutations

29
Q

Clinical features of CF

A

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
Q

Organisms of chronic chest infection in CF

A

Initially Staph aureus
H influenzae
Pseudomonas aeruginosa
Burkholderia cepacia

31
Q

Respiratory features in CF

A 
Persistent wet cough
Hyperinflation 
Coarse inspiratory crepitations
Expiratory wheeze 
Finger clubbing

(Chronic infection -> bronchiectasis -> abscess formation)

32
Q

Investigations for CF

A

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
Q

Respiratory management of CF

A

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
Q

Management of acute pulmonary exacerbation in CF

A

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
Q

Nutritional management in CF

A

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
Q

Management of pancreatic insufficiency in CF

A

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
Q

Management of liver disease in CF

A

Ursodeoxycholic acid - improve flow of bile

Liver transplant

38
Q

Types of CFTR Modulators and their indications

A

Ivacaftor: >12 months, NOT F508del
Lumacaftor/Ivacaftor: >2 years, F508del mutation
Tezacaftor/Ivacaftor: >12 years, F508del mutation

39
Q

Route of transmission of TB and risk factors for transmission

A

Respiratory droplets

Close proximity
Large infectious load in index case
Immunodeficiency

40
Q

Pathophysiology and Types of TB infection

A

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
Q

Clinical features of active TB infection

A 
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
Q

Differentials for pulmonary TB

A

Pneumonia
Lung cancer
Other - sarcoidosis

43
Q

Types of active Tb in children

A 
Pulmonary - 75%
TB lymphadenitis
Osteoarticular TB
Genitourinary TB
TB meningitis
44
Q

Diagnostic tests for TB

A

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
Q

Treatment of TB

A

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
Q

Prevention of TB

A

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
Q

TB Drugs side effects

A

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
Q

Causes of recurrent/persistent wheeze in children

A 
Bronchiolitis 
Asthma
Viral episodic wheeze 
Multiple trigger wheeze 
Recurrent anaphylaxis 
Chronic aspiration 
Cystic fibrosis
Bronchopulmonary dysplasia
Tracheo-bronchomalacia
49
Q

Definitions of cough

A

Subacute: 3-8 weeks
Chronic: >8 weeks

50
Q

Causes of acute cough

A

Wet:
- lower respiratory tract infection/mucus secretion

Dry:

  • sensation of mucus in throat = upper airway
  • barking = tracheal
  • wheeze = lower airway narrowing
51
Q

Define whooping cough

A

Upper respiratory tract infection with Bordetella pertussis

52
Q

Epidemiology of Whooping Cough

A

Occurs in epidemics every 3-4 years

Infants susceptible to severe infections

53
Q

Aetiology of whooping cough

A

Transmission by respiratory droplets - highly infectious

54
Q

Clinical features of whooping cough

A 
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
Q

Risk factors for whooping cough

A

<6 months (incomplete vaccination)
Maternal infection at >34 weeks gestation
Close/household contact

56
Q

Complications of whooping cough

A

Pneumonia
Seizures
Bronchiectasis

57
Q

Investigations for whooping cough

A

Nasopharyngeal aspirate / swab culture
Nasopharyngeal sample PCR
Serology
FBC - raised WCC

58
Q

WHO diagnostic criteria for whooping cough

A

Clinical:
>2 weeks cough with post-cough vomiting/whoop/paroxysms of cough

Laboratory:
+ve PCR
Isolation on culture
Serology

59
Q

Management of whooping cough

A

Macrolides - clarithromycin/erythromycin, only effective during catarrhal phase
Prophylaxis of contacts - vaccination, prophylactic macrolide

60
Q

Causes of chronic cough in children

A

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
Q

Aetiology of pneumonia in children

A

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
Q

Clinical features of pneumonia in children

A

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
Q

Management of pneumonia in children - admission, antibiotics

A

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
Q

Complications of pneumonia

A

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
Q

Causes of chronic lung infection

A

Persistent bacterial bronchitis

Bronchiectasis

66
Q

Define persistent bacterial bronchitis and pneumonia

A

Persistent Bacterial bronchitis: lower respiratory tract/bronchial infection, leading to inflammation
Pneumonia: infection of lung parenchyma, leading to consolidation

67
Q

Causes of persistent bacterial bronchitis

A

H influenzae

Moraxella catarrhalis

68
Q

Management of persistent bacterial bronchitis

A

Referral - may lead to bronchiectasis
Diagnosis - isolation from sputum/bronchial lavage culture
Treatment - co-amoxiclav + PT

69
Q

Causes of bronchiectasis

A 
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

Paediatrics (15 decks)

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