Respiratory

Question 1

Aetiology of asthma

Answer 1

Affects 15-20% of children
Genetic predisposition may be a factor
40% of children who suffer with asthma are atopic
Presence of one allergic disease increases the risk of another
The majority of asthma exacerbations are triggered by rhinovirus infection
Other triggers: URTIs, allergens, smoking, cold air, exercise, emotional upset/anxiety, chemical irritants

Question 2

Asthma pathophysiology

Answer 2

Genetic predisposition/atopy/triggers leads to:
Bronchial inflammation: oedema, excessive mucus production, infiltration with eosinophils, mast cells, neutrophils, lymphocytes, oedema
Bronchial hyper-responsiveness: to inhaled stimuli
Airway narrowing: reversible airway obstruction
Symptoms: wheeze, cough, breathlessness, tight chest

Question 3

Asthma presentation and history

Answer 3

Recurrent polyphonic wheeze
Symptoms worse at night and early AM
Symptoms with triggers (e.g. cold air, pets, dust)
Interval symptoms: symptoms between acute exacerbations
Personal/FH of atopy
Reversibility of symptoms with beta-2-agonist
Chest exam usually normal between attacks
Harrison’s sulci if onset in early childhood (depression at base of thorax)
Barrel chest & hyperinflation

Question 4

Asthma differential diagnosis

Answer 4

Look for: evidence of eczema, allergic rhinitis
Wet cough/sputum production/clubbing/poor growth = indicates chronic infection such as cystic fibrosis/bronchiectasis
Bronchiolitis
Foreign body in the airway
Croup: inspiratory stridor and wheeze
Vocal chord dysfunction: mimics steroid refractory asthma
Ciliary dyskinesia
Post-nasal drip
Sinonasal manifestations of CF

Question 5

Asthma investigations

Answer 5

Skin-prick testing for allergens/atopy
CXR: usually normal - rule out other conditions. Hyperinflation, flattened hemi-diaphragm, peribronchial cuffing, atelectasis
Peak flow: if uncertainty
Spirometry: check reversibility with beta-agonist, PEFR<80% predicted
FEV1/FVC <80% predicted

Question 6

Chronic asthma initial management plan

Answer 6

Step-up/step-down approach:

1) short acting beta-2 agonist, consider very low-dose ICS
2) SABA + regular very low-dose ICS
3) SABA + low-dose ICS + LTRA(<5y)/LABA(>5y)
4) increase doses, theophylline?

Question 7

Acute asthma initial management

Answer 7

Up to 10 puffs of a SABA (through nebuliser if )2 sats <92%)
Oral prednisolone (3d)/ i.v. hydrocortisone
Nebulised ipratropium bromide if poor response (anti muscarinic)
Repeat bronchodilators every 20-30m
Severe attack not responding: IV aminophylline

Question 8

Coryza classical features + treatment

Answer 8

Clear/mucopurulent nasal discharge
Nasal blockage
Fever/pain: treat with paracetamol + ibuprofen
Unlikely to be bacterial in origin so antibiotics not indicated

Question 9

Coryza pathogens

Answer 9

Viruses = commonest
Rhinovirus
Coronaviruses
Respiratory syncytial virus

Question 10

Common causative organisms of pharyngitis

Answer 10

Adenoviruses
Entenoviruses
Rhinoviruses
Older children: group A beta-haemolytic streptococcus

Question 11

Pharyngitis clinical presentation and common pathogens

Answer 11

Sore throat
Inflamed pharynx and soft palate
Enlarged/tender local lymph nodes

Adenovirus, enterovirus, rhinovirus. group A beta-haemolytic strep

Question 12

Tonsillitis common causative organisms

Answer 12

Group A beta-haemolytic strep

Epstein-Barr virus –> infectious mononucleosis (glandular fever)

Question 13

Tonsillitis presentation

Answer 13

Form of pharyngitis with intense inflammation of the tonsils, often with a purulent exudate

Question 14

Markers of bacterial tonsillitis, and treatment

Answer 14

Headache, apathy, abdominal pain, white tonsillar exudate, cervical lymphadenopathy

Treatment: penicillin/erythromycin (if penicillin allergy)
Amoxicillin avoided: causes widespread maculopapular rash if tonsillitis is due to infectious mononucleosis
Recurrent severe tonsillitis –> tonsillectomy? Reduces tonsillitis episodes by 1/3

Question 15

URTI clinical presentation + complications

Answer 15

Nasal discharge + blockage/sinusitis
Fever
Pharygitis/tonsillitis/sore throat
Acute otitis media/ear ache
Cough

Complications:
Infants may find feeding difficult if noses are blocked
Febrile convulsions
Acute exacerbation of asthma

Question 16

Acute otitis media clinical presentation + complications

Answer 16

Most common at 6-12m of age
Ear pain + fever (check tympanic membranes of every child with a fever)
Tympanic membrane is bright red and bulging with loss of normal light reflection
Occasionally acute tympanic membrane perforation with pus visible in external canal

Complications: mastoiditis, meningitis
Recurrent infections: otitis media with effusion - most common cause of conductive hearing loss in children

Question 17

Acute otitis media initial management plan

Answer 17

Pain: paracetamol/ibuprofen
Most cases resolve spontaneously
Amoxicillin may be prescribed, only to be used if no improvement within 2-3d

Question 18

Types of wheezing patterns

Answer 18

Transient early wheezing: begins in infants with respiratory infection, result of small airways being
more likely to narrow and obstruct due to inflammation/aberrant immune response to viral infection

Recurrent persistent wheezing: triggered by a stimuli and presence of IgE in response to inhaled allergens, persistent symptoms, decreased lung function, association to other atopic diseases

Question 19

Beta2-agonist examples and mechanism of action

Answer 19

Salbutamol/Terbutaline (SABA)
Salmeterol/Formoterol (LABA)
Act on beta receptors to directly –> bronchodilation
Less effective in very young children as they have fewer active beta receptors

Question 20

Anti-muscarinic examples and mechanism of action

Answer 20

Ipratropium bromide

Similar effect to beta-agonists, but act via a different receptor to achieve their affect: sympathetic system

Question 21

Methylxanthines examples and mechanism of action

Answer 21

Aminothylline or Theophylline
Pathway that leads to the relaxation of bronchiole smooth muscle
ADRs: vomiting, sleep disturbance, headaches, poor concentration, arrhythmias

Question 22

Corticosteroids examples and mechanism of action

Answer 22

Budesonide/Beclometasone/Fluticasone (inhaled) Prednisolone (oral)
Prevent the creation of inflammatory proteins –> reduce IgE response
ADRs: impaired growth, adrenal suppression, oral candidiasis, altered bone metabolism

Question 23

Leukotriene inhibitor examples and mechanism of action

Answer 23

Montelukast or Zafirlukast
Taken orally in children <5yrs instead of LABA
Antagonist that blocks the action of leukotriene –> reduces bronchoconstriction

Question 24

Anti-IgE injections example and mechanism of action

Answer 24

Omalizumab

Monoclonal antibody designed to target IgE and prevent atopic reaction

Question 25

Bronchiolitis aetiology

Answer 25

90% occur in 1-9month olds Most common in winter months and urban areas RSV: 80% of cases. Remainder = Human metapneumovirus, Parainfluenza virus, Rhinovirus, Adenovirus, Influenza virus, Mycoplasma pneumoniae Severe bronchiolitis: associated with combined RSV & human metapneumovirus

Question 26

Bronchiolitis risk factors

Answer 26

``` Older siblings Nursery attendance Passive smoking (particularly maternal) Prematurity/low birth weight Chronic lung disease: CF, bronchopulmonary dysplasia Immunocompromised ``` Breast-feeding = protective

Question 27

Bronchiolitis presentation

Answer 27

Mild rhinorrhea, cough and fever, dry cough, increasing breathlessness Feeding difficulties associated with dyspnoea Apnoeas: especially young children Sharp, dry cough Tachypnoea Subcostal and intercostal recession Hyperinflation of the chest: prominent sternum or liver displaced downwards Fine end-inspiratory crackles or prolonged expiration High-pitched wheezes: expiratory > inspiratory Tachycardia Cyanosis or pallor

Question 28

Bronchiolitis on CXR

Answer 28

``` Only performed if there is a diagnostic uncertainty or an atypical course Non-specific and patchy infiltrates Focal atelectasis Air trapping Flattened diaphragm Increased anteroposterior diameter Peribronchial cuffing ```

Question 29

Acute bronchiolitis management

Answer 29

Supportive: primary care & at home --> fluid input, nutrition, temp control Secondary care if: Poor feeding, lethargy, apnoeas, >70 breaths/min, nasal flaring or grunting, severe chest wall recession, cyanosis, saturations <94% Humidified oxygen via nasal cannulae Monitored for apnoea Fluids: NG tube or IV If assisted ventilation is required: nasal/facemask CPAP/full ventilation

Question 30

Common bacterial causes of pneumonia

Answer 30

Neonates: organisms from mother’s genital tract: group B streptococcus, E.coli, Klebsiella, Staph. Aureus (Gram –ve enterococci) Infants: Strep. pneumoniae, Chlamydia trachomatics, Haemophilus influenzae (more commonly RSV) School age: Strep pneumoniae, Staph aureus, group A streptococcus, Bordetella pertussis, Mycoplasma pneumoniae

Question 31

Pneumonia presentation

Answer 31

Recent URTI, fevers, SOB, increased WOB, cough, lethargy, poor feeding Localised chest pain: indicative of pleuritic irritation from bacterial infection Temp>38.5 Signs of respiratory distress: tachypnoea, grunting, intercostal recession, nasal flaring Desaturation: <92 in air Dullness to percussion, tactile vocal fremitus Auscultation: coarse crackles, decreased breath sounds, bronchial breathing

Question 32

Pneumonia investigations

Answer 32

CXR: confirm diagnosis, cannot differentiate between bacterial/viral Nasopharyngeal aspirate: identify viral causes Bloods & acute phase response markers may not differentiate between bacterial/viral

Question 33

Abx therapy for a child with pneumonia <5yo

Answer 33

Supportive: O2 & analgesia, IV fluids, correct electrolytes Newborns: broad spectrum IV Abx <5yrs: Strep. Pneumoniae is most common 1st line = oral amoxicillin 2nd line = Co-amoxiclav or Cefaclor for typical cases Erythromycin, clarithromycin or azithromycin for atypical cases

Question 34

Abx therapy for a child with pneumonia >5yo

Answer 34

Supportive: O2 & analgesia, IV fluids, correct electrolytes >5 yrs: Mycoplasma pneumoniae is most common 1st line = oral Amoxicillin or macrolide (Erythromycin) if mycoplasma/chlamydia suspected 2nd line = if Staph. Aureus is suspected consider using macrolide or combination of Flucloxacillin with Amoxicillin Severe pneumonia = Co-amoxiclav, Cefotaxime or Cefuroxime IV

Question 35

Pertussis causative organisms, phases and according symptoms

Answer 35

Caused by Bordetella parapertussis Other causes = Mycoplasma pneumoniae, Chlamydia or adenovirus Catarrhal phase (1-2 weeks): mild symptoms with fever, cough and coryza Paroxysmal phase (2-6 weeks): develops characteristic paroxysmal or spasmodic cough followed by a inspiratory whoop Convalescent phase (2-4 weeks): symptoms gradually decrease, but may persist for many months

Question 36

Pertussis investigations

Answer 36

Eyes: subconjunctival haemorrhage CXR: pneumonia sometimes develops Blood count: leucocytosis and lymphocytosis Diagnosis: culture nasal swab, marked lymphocytosis on blood film

Question 37

Pertussis management

Answer 37

Erythromycin for 14 days (or Clarithromycin for 7 days): reduce infectivity Severe spasms of cough or cyanotic attack should be admitted to hospital and isolated from other children Erythromycin started in the catarrhal phase: can reduce symptoms and eradicate pertussis organisms Immunisation: reduces the risk of developing pertussis & severity

Question 38

TB pathological sequence

Answer 38

4-8 weeks: Febrile illness Erythema nodosum: red swellings in fat tissue Phlyctenular conjunctivitis: allergic conjunctivitis 6-9 months: Progressive healing of primary complex Effusion: ghon focus may rupture into pleural space Cavitation: focus may rupture into bronchus Coin lesion on CXR: focus may enlarge Regional lymph nodes may obstruct bronchi or erode into bronchus/pericardial sac Miliary spread

Question 39

Asymptomatic TB prevalence and explanation

Answer 39

50% of infants and 90% of older children show minimal signs & symptoms Local inflammatory reaction limits the progression of infection --> disease remains latent and therefore may develop into active disease at a later time Mantoux test may be positive = sufficient evidence to initiate treatment

Question 40

TB presentation

Answer 40

``` Host response fails to contain the inhaled bacilli --> spread to regional lymph nodes Fever Anorexia and weight loss Cough CXR changes: ghon focus, miliary TB ``` Local enlargement of peribronchial lymph nodes: bronchial obstruction, lung consolidation & collapse Organs that may be involved: gut, skin, superficial lymph nodes (caseate forming cold abscess_ Post-primary TB: local disease or widely disseminated miliary TB to bones, joints, kidneys, pericardium and CNS: tuberculous meningitis

Question 41

What is a ghon focus?

Answer 41

Lung lesions + infected lymph node = ‘Ghon or primary complex’

Question 42

TB treatment

Answer 42

Triple/quadruple therapy: decreased to 1st 2 drugs after 2m Rifampicin, Isoniazid, Pyrazinamide, Ethambutol Pulmonary/lymph node TB: 6m treatment Disseminated TB/TB meningitis: >6m treatment TB meningitis: 1m course of dexamethasone Latent TB treatment: 3m rifampicin & isoniazid

Question 43

CF aetiology

Answer 43

Autosomal recessive, annually 1/2500 live births and 1/25 carriers Projected life expectancy for current newborns: 40s Defective membrane protein = cystic fibrosis transmembrane conductance regulator (CFTR): cyclic AMP-dependent chloride channel CFTR gene = chromosome 7: most common defect is delta-F508 Additional factors important in determining the severity of lung disease: microbial pathogens, passive smoking, social deprivation and other ‘modifier’ genes

Question 44

CF pathophysiology

Answer 44

Airways: reduction in airway surface mucus layer, impaired ciliary function, retention of mucopurulent secretions Chronic endobronchial infections: Pseudomonas aeruginosa Dysregulation of inflammation and defence against infection Intestine: meconium ileus in 10-20% of infants Pancreatic ducts: blocked by thick secretions --> pancreatic enzyme deficiency and malabsorption Sweat glands: excessive concentrations of sodium & chloride in sweat (salty)

Question 45

CF clinical features in infancy

Answer 45

Meconium ileus: inspissated meconium causes intestinal obstruction, vomiting, abdominal distension, failure to pass meconium for the 1st few days Prolonged neonatal jaundice Failure to thrive Recurrent chest infections: Staphylococcus aereus, Haemophilus influenzae, Pseudomonas aeruginosa, Burkholderia Malabsorption: steatorrhoea Hypoproteinaemia and oedema

Question 46

CF clinical features in young children

Answer 46

``` Bronchiectasis Rectal prolapse Nasal polyps Sinusitis Anorexia ```

Question 47

CF clinical features in older children/adolescents

Answer 47

``` Allergic bronchopulmonary aspergillosis (ABPA) Diabetes mellitus Cirrhosis and portal hypertension Distal intestinal obstruction (DIOS): meconium ileus equivalent Pneumothorax/recurrent haemoptysis Sterility in males Arthropathy Psychological problems ```

Question 48

CF chronic chest infection consequences

Answer 48

Results in viscous mucus in the smaller airways leading to damage of the bronchial wall, bronchiectasis and abscess formation --> may have persistent, loose cough and productive purulent sputum O/E: chest hyperinflation due to air trapping, coarse inspiratory crepitations and/or expiratory wheeze, finger clubbing

Question 49

CF pancreatic exocrine insufficiency consequences

Answer 49

Insufficient lipase, amylase and proteases -->m maldigestion and malabsorption --> failure to thrive and passing frequent steatorrhoea Diagnosis: low elastase in faeces Meconium ileus: treated with gastrografin enemas

Question 50

CF investigations

Answer 50

``` Newborn screening (heel-prick) Sweat test: increased chloride levels (>60mmol/L) CXR: hyperinflation, increased AP diameter, bronchial dilation, cysts, linear shadow and infiltrates Lung function: obstructive pattern with decreased FVC and increased lung volume ```

Question 51

CF pulmonary management

Answer 51

b.d. physiotherapy: chest percussion, postural drainage, self-percussion, deep breathing exercises, flutter/acapello device Antibiotic therapy When well: oral Abx (flucloxacillin) against Staphylococcus aureus & Haemophilus influenzae Acute exacerbations: 14 day course of IV Abx through an indwelling long-line Chronic Pseudomonas aeruginosa infection: nebuliser Other therapies: annual flu vaccine, bronchodilators, mucolytics (before physio) and oral azithromycin

Question 52

CF GI management

Answer 52

Distal intestinal obstruction: Lactulose (1mL/kg/day) Oral acetylcysteine solution (prophylaxis 15mL of 10%/day in <7yrs or 30mL in >7yrs, treatment doses 2-3x larger) Gastrografin: single oral dose treatment + fluid intake encouraged Pancreatic insufficiency: oral enteric-coated pancreatic supplements (Creon) taken will all meals and snacks, Ranitidine/omeprazole may be useful High calorie diet: 120-150% of normal energy intake Salt supplements: salt depletion is risk in 1st year and summer months Fat-soluble vitamin supplements: multivitamins, vitamin E and vitamin K (liver disease)

Question 53

Epiglottitis aetiology

Answer 53

Life-threatening swelling of the epiglottis and septicaemia Haemophilus influenzae type B infection Most commonly in children 1-6yrs Rare due to routine HiB immunisation

Question 54

Epiglottitis presentation

Answer 54

Pyrexic: ill, toxic-looking child Intensely painful throat that prevent swallowing or speech: saliva drools down chin Soft inspiratory stridor and rapidly increasing respiratory difficulty over hours Child sits immobile, upright and with an open mouth to optimise the airway

Question 55

Epiglottitis management

Answer 55

ICU after endotracheal intubation Blood cultures and IV antibiotics 2nd or 3rd generation Cephalosporin IV for 7-10: Cefuroxime, Ceftriaxome or Cefotaxime Rifampicin prophylaxis to close contacts

Question 56

Otitis media causative organisms

Answer 56

RSV and rhinovirus Pneumococcus Group A beta-haemolytic streptococcus Haemophilus influenza

Question 57

Secretory otitis media features

Answer 57

Middle ear effusion without symptoms and signs of acute otitis media Course: months Effusions: serious, mucoid or purulent O/E: the drum may be retracted, does not move easily, with fluid effusions visible behind the tympanic membrane (opaque)

Question 58

Childhood fever red flags

Answer 58

Fever: >38oC if <3 months or >39oC if 3-6 months Pale, mottled, blue Level of conscious: neck stiffness, bulging fontanelle, status epilepticus, focal neurological signs or seziures Significant respiratory distress: recession, stridor Bile-stained vomiting: obstruction Severe dehydration or shock Non-blanching rash

Question 59

Septic screen components

Answer 59

``` Blood culture FBC: including differential WCC Acute phase proteins: CRP Urine sample CXR LP Rapid antigen screening (blood/urine/CSF), meningococcal/pneumococcal PCR (blood/CSF) or virus PCR for HSV or enterovirus (CSF) ```

Question 60

Pyrexia treatment

Answer 60

Parenteral abx stat. if seriously unwell: 3rd-generation cephalosporin (cefotaxime or ceftriaxone) and ampicillin Aciclovir is given if HSV encephalitis is suspected Antipyretics: paracetamol or ibuprofen Not thought to prevent febrile seizures, but are in NICE guidelines

Question 61

Croup causative organisms

Answer 61

``` Croup = laryngotracheobronchitis Viral croup (>95%): parainfluenza viruses, human metapneumovirus, RSV, influenza ```

Question 62

Croup presentation

Answer 62

6m to 6 years: peak incidence 2yrs old in the autumn Barking cough, harsh stridor and hoarseness Usually preceded by fever and coryza Start and are worse at night

Question 63

Croup management

Answer 63

Close observation at home, rest Oral dexamethasone, oral prednisolone and nebulised steroids (budesonide): reduce severity and duration of croup, and the need for hospitalization Severe cases with severe upper airway obstruction: nebulised adrenaline & oxygen provides transient improvement Beware rebound symptoms after 2hrs Only a few children require tracheal intubation Link between recurrent croup and atopy

Question 64

Bacterial tracheitis clinical features & management

Answer 64

Similar to severe croup + high fever, appears toxic and has rapidly progressive airway obstruction due to thick airway secretions Staphylococcus aureus Management: IV antibiotics and intubuation/ventilation if required

Question 65

Smoke inhalation symptoms

Answer 65

Cough: becomes useless to remove particulate matter SOB Sore throat Headache Confusions Mucosal oedema: hot smoke burning the mouth and throat Cyanosed: asphyxia due to deposition of smoke in the lower alveoli Increased RR accordingly

Question 66

Smoke inhalation management

Answer 66

high flow and humidified oxygen: 100% oxygen helps to remove CO from blood quickly and reduces any poisoning affect CO is the leading cause of cardiac arrest and death before patients reach hospital 50% of patients will need intubation and PEEP to maintain the airway