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Child Health > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Aetiology of asthma

A

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

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2
Q

Asthma pathophysiology

A

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

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3
Q

Asthma presentation and history

A

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

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4
Q

Asthma differential diagnosis

A

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

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5
Q

Asthma investigations

A

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

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6
Q

Chronic asthma initial management plan

A

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?

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7
Q

Acute asthma initial management

A

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

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8
Q

Coryza classical features + treatment

A

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

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9
Q

Coryza pathogens

A

Viruses = commonest
Rhinovirus
Coronaviruses
Respiratory syncytial virus

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10
Q

Common causative organisms of pharyngitis

A

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

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11
Q

Pharyngitis clinical presentation and common pathogens

A

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

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

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12
Q

Tonsillitis common causative organisms

A

Group A beta-haemolytic strep

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

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13
Q

Tonsillitis presentation

A

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

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14
Q

Markers of bacterial tonsillitis, and treatment

A

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

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15
Q

URTI clinical presentation + complications

A 
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

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16
Q

Acute otitis media clinical presentation + complications

A

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

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17
Q

Acute otitis media initial management plan

A

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

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18
Q

Types of wheezing patterns

A

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

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19
Q

Beta2-agonist examples and mechanism of action

A

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

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20
Q

Anti-muscarinic examples and mechanism of action

A

Ipratropium bromide

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

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21
Q

Methylxanthines examples and mechanism of action

A

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

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22
Q

Corticosteroids examples and mechanism of action

A

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

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23
Q

Leukotriene inhibitor examples and mechanism of action

A

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

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24
Q

Anti-IgE injections example and mechanism of action

A

Omalizumab

Monoclonal antibody designed to target IgE and prevent atopic reaction

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25
Q

Bronchiolitis aetiology

A

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

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26
Q

Bronchiolitis risk factors

A 
Older siblings
Nursery attendance
Passive smoking (particularly maternal)
Prematurity/low birth weight
Chronic lung disease: CF, bronchopulmonary dysplasia
Immunocompromised

Breast-feeding = protective

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27
Q

Bronchiolitis presentation

A

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

28
Q

Bronchiolitis on CXR

A 
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
29
Q

Acute bronchiolitis management

A

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

30
Q

Common bacterial causes of pneumonia

A

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

31
Q

Pneumonia presentation

A

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

32
Q

Pneumonia investigations

A

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

33
Q

Abx therapy for a child with pneumonia <5yo

A

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

34
Q

Abx therapy for a child with pneumonia >5yo

A

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

35
Q

Pertussis causative organisms, phases and according symptoms

A

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

36
Q

Pertussis investigations

A

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

37
Q

Pertussis management

A

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

38
Q

TB pathological sequence

A

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

39
Q

Asymptomatic TB prevalence and explanation

A

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

40
Q

TB presentation

A 
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

41
Q

What is a ghon focus?

A

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

42
Q

TB treatment

A

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

43
Q

CF aetiology

A

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

44
Q

CF pathophysiology

A

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)

45
Q

CF clinical features in infancy

A

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

46
Q

CF clinical features in young children

A 
Bronchiectasis
Rectal prolapse
Nasal polyps
Sinusitis
Anorexia
47
Q

CF clinical features in older children/adolescents

A 
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
48
Q

CF chronic chest infection consequences

A

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

49
Q

CF pancreatic exocrine insufficiency consequences

A

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

50
Q

CF investigations

A 
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
51
Q

CF pulmonary management

A

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

52
Q

CF GI management

A

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)

53
Q

Epiglottitis aetiology

A

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

54
Q

Epiglottitis presentation

A

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

55
Q

Epiglottitis management

A

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

56
Q

Otitis media causative organisms

A

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

57
Q

Secretory otitis media features

A

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)

58
Q

Childhood fever red flags

A

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

59
Q

Septic screen components

A 
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)
60
Q

Pyrexia treatment

A

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

61
Q

Croup causative organisms

A 
Croup = laryngotracheobronchitis
Viral croup (>95%): parainfluenza viruses, human
metapneumovirus, RSV, influenza
62
Q

Croup presentation

A

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

63
Q

Croup management

A

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

64
Q

Bacterial tracheitis clinical features & management

A

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

65
Q

Smoke inhalation symptoms

A

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

66
Q

Smoke inhalation management

A

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

Child Health (15 decks)

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