Respiratory Flashcards
Define Apnoea
Cessation of respiratory airflow
Note: short breathing pauses of 5-10 seconds are normal and common in preterms
Define Apnoea of Prematurity
Cessation of breathing for >20 seconds, or <20 seconds with a drop in SpO2 and bradycardia
Give 3 causes of Apnoea of Prematurity
Immaturity of breathing responses to changes in O2 and CO2
Collapse of airways due to poor tone
Nasal Obstruction (neonates are obligate nasal breathers)
Define OSA and give some causes
Snoring associated with periods of ineffective breathing
Adenotonsillar Hypertrophy, Obesity, Macroglossia, Micrognathia
How might OSA present in a child?
Snoring and sleep disturbance
Daytime sleepiness
Enuresis
How would you investigate and manage OSA?
Ix - Sleep Study, CXR, EEG
Mx - CPAP, ?Weight Loss, ?Adenotonsillectomy
What is Expiratory Apnoea Syncope? (AKA Blue Breath Holding Spells)
Precipitated by anger/crying
Cannot catch breath (stuck in expiration)
Goes blue, stiff then limp with rapid recovery
Name three investigations for Apnoea
Lumbar Puncture
CXR
Bloods (U&Es, Glucose, Culture)
Define Wheeze
High pitched musical respiratory sound usually heard on expiration. Associated with airway narrowing and limitations.
Give 5 causes of acute wheeze
Viral Episodic Wheeze Bronchiolitis/Bronchitis Bacterial tracheitis Foreign Body Aspiration Anaphylaxis
Give two structural and two functional causes of chronic wheeze
Structural - Tracheobronchomalacia, Tracheal Web
Functional - Asthma, CF
How is a Wheeze managed?
Treat underlying cause
Beta Agonists and Steroids
Oxygen
Define Stridor
Harsh respiratory sound produced by turbulent flow in narrow upper airways, affected by severity of narrowing
What three associated symptoms with Stridor or should you ask about as a priority?
Fever
Drooling (Secure Airway, ENT referral)
Barking Cough (Dexamethasone, Intubate and Admit)
Give 5 causes of Acute Stridor
Croup (Laryngotracheobronchitis) Epiglottitis Bacterial Tracheitis Peritonsillar Abscess Anaphylaxis
Give two congenital causes and two acquired causes of Chronic Stridor
Congenital - Laryngomalacia, Subglottic Stenosis
Acquired - Vocal cord paralysis, Tumours
In an Acute Stridor or you should avoid looking at the throat until resus equipment is at hand. How else could you assess severity?
Only on crying? At rest? Chest Retraction? Cyanosis? Tachypnoea/Tachycardia?
Define Cyanosis
Bluish/Purplish discolouration of tissues due to increased concentration of deoxygenated haemoglobin in capillary beds
Mostly appreciated in lips/nail beds/mucous membranes
Can be central or peripheral
Give three AIRWAY causes of Cyanosis
Choanal Atresia
Laryngomalacia
Pierre Robin Syndrome
Give three BREATHING causes of Cyanosis
Hypoventilation/Apnoea
Pneumonia
Congenital Diaphragmatic Hernia
Give three CIRCULATION causes of Cyanosis
Anaemia
Methaemaglobinaemia
Cyanotic CHD
State five categories of a cough history
Onset (Any preceding symptoms) Duration Nature (Dry or Wet) Triggers Associated Sx
Give 3 viral causes of Acute Cough
URTI (Cold)
Laryngotracheobronchitis
Bronchiolitis
Give 2 bacterial causes of Acute Cough
Epiglottitis
Bacterial Pneumonia
How would an inhaled foreign body appear on a CXR?
The object may be visible on the CXR
Hyperinflation on affected side due to air trapping
Give three Pulmonary causes of a chronic cough
Asthma
Post Infectious
CF
Give three Extra - Pulmonary causes of a chronic cough
Post Nasal Drip
Cardiac
GORD
Define Protracted Bacterial Bronchitis
Chronic Wet Cough as a diagnosis of exclusion
Resolves with 2-6 weeks of treatment
State the boundaries for Tachypnoea in Neonates/Infants/Children/Adolescents
Neonates - >60
Infants - >50
Child - >40
Adolescent - >30
State 5 red flags of a Cough
Sudden Onset (choking) Weight Loss Night Sweats Cyanosis Clubbing
Define Breathlessness
Laboured or increased work of breathing from increased airway resistance, characterised by nasal flaring, grunting, and usage of accessory muscles
Give four differentials for breathlessness in a child
Airway obstruction
DKA
Pneumonia
CHD
What would point to a Cardiac cause of breathlessness in a child?
Squatting when fatigued
Poor weight gain
Hepatomegaly
Oedema
Asthma is the most common chronic condition in children. State the definition
Reversible and paroxysmal constriction of the airways
Early features include inflammatory exudate, and late features include airway remodelling
Asthma is a multifactorial disease in which susceptible individuals have an exaggerated response to various stimuli. Describe the classical pathophysiology.
Driven by TH2 cells which release cytokines resulting in activation of humoral system
Humoral system causes increased proliferation of mast cells/eosinophils/dendritic cells
Leukotrienes cause cytotoxicity and histamine causes exudate production
Give four risk factors for Asthma
Genetic (trend of atopy)
Prematurity
Parental Smoking
Early Viral Bronchiolitis
There are various triggers that affect Asthma, what effects do NSAIDs have?
Shunts the arachadonic pathway towards leukotriene production which is cytotoxic
How could you describe the pattern of wheezing in asthmatic individuals?
Infrequent - discrete episodes lasting a few days with no interval sx
Frequent - occurring 2 to 6 times weekly
Persistent - occurring most days and may occur at night
What is Pre- School Wheeze?
50% have at least one significant wheeze by their 5th Birthday
Asthma is normally a clinical diagnosis, what are the two main investigations that could be carried out?
Spirometry - if child is over 6, should be normal in between exacerbations if well controlled
PEFR - if over 5y/o
What are Bronchial Provocation Tests?
A test used in uncertain cases to assess airway hyper responsiveness to histamine or metacholine
How is the Exhaled Nitric Oxide investigation used?
Produced in bronchial epithelial cells, and it’s production is increased with TH2 driven inflammation
Positive result is >35ppb
Note: Also raised in hay fever
What investigations could be done to rule out differentials of Asthma?
Oesophageal pH Bronchoscopy Chlorine Sweat Test Nasal Brush Biopsy (exclude PCD) HRCT
How would you manage Asthma in children under 5 on a day to day basis?
Treat without investigation
Inhalers via Metered Dose Inhaler with spacer
1) SABA as reliever therapy
2) + 8 week trial of ICS
3) + Leukotriene Antagonist (eg Montelukast - beware of behavioural issues)
How would you manage Asthma in children 5-16 on a day to day basis?
1) SABA reliever
2) add low dose ICS
3) SABA + ICS + Leukotriene antagonist
4) Stop Leukotriene, start ICS and LABA and SABA
5) MART regimen (Maintenance and Reliever therapy)
6) Higher steroid dose MART regime
7) Increase ICS/Add Theophylline/Oral Steroids/Biologics
What are the contents of a Fostair combined inhaler?
Beclametasone
Formeterol
What are the contents of a Seretide combined inhaler?
Fluticasone and Salmeterol
What are the contents of a Symbicort combined inhaler?
Budesonide
Formeterol
Describe the features of Mild/Mod Asthma Exacerbation
SpO2>92% Resp Rate under 30(>5) or (<5) Minimal accessory muscle use Full Sentences Wheeze
Describe the features of Mod/severe Asthma Exacerbation
SpO2<92% PEFR 33-50% predicted Resp Rate over 30(>5) or 40 (<5) Incomplete Sentences Tachycardia Accessory Muscles and Wheeze
Describe the features of Life Threatening Asthma Exacerbation
SpO2<92% PEFR <33% predicted Silent Chest and Poor Resp Effort Altered consciousness Cyanosis
How is an Asthma Exacerbation managed?
1) If O2<94% give O2
2) Nebulised Salbutamol
3) 3d Oral Prednisolone
4) +/- Ipratropium Bromide
Consider IV Salbutamol or MgSO4 if severe
What is involved in an Asthma discharge bundle?
SpO2>94% on air Assessed inhaler technique Four hourly bronchodilators Written asthma management plan GP follow up 2d
Define Bronchiectasis
Abnormal dilation of airways associated with destruction of bronchial tissue. Secondary to an inflammatory response to infection causing structural damage and dilation
What are the 5 broad causes of Bronchiectasis?
Post Infectious Immunodeficiency Primary Ciliary Dyskinesia Post Obstructive Congenital
Give four immunodeficiencies that could result in Bronchiectasis
Hypogammaglobulinaemia
CVID
IgA/IgG specific
Ataxia Telangiectasia
Give three of the most common genetic causes of Bronchiectasis
Kartageners (Sinusitis, Bronchiectasis, Situs Inversus)
Young’s (Sinusitis, Bronchiectasis, Infertility)
Yellow Nail Syndrome (Pleural Effusions, Lymphoedema, Dystrophic Nails)
Describe the possible CXR findings of Bronchiectasis
Bronchial Wall Thickening
Airway Dilation
Or normal
Describe the HRCT findings of Bronchiectasis
Bronchial Wall Thickening
Visible Peripheral Bronchi
Signet Sign
CF - bilateral upper lobe
Post TB - Unilateral upper lobe
What tests could you do to determine the underlying cause of Bronchiectasis?
Chloride Sweat Test
Immunoglobulin panel
Ciliary Brush Biopsy
WCC differential
How is Bronchiectasis managed?
Chest Physio Exacerbations managed Vaccinations Bronchodilators Regular Follow Ups
Define Bronchiolitis
Viral infection of the Bronchioles usually caused by RSV
AKA Viral LRTI
Describe the pathophysiology of Bronchiolitis
Excess Mucous (Goblet Cell Proliferation) Inflammation (IgE type 1 allergic response) Bronchiolar Constriction
Ball Valve effect resulting in hyperinflation, airway resistance, atelectasis and VQ mismatch
Give three risk factors and one protective factor
Smoke Exposure, Siblings Nursery Attendance, Prematurity
Breast Feeding
How does a baby with Bronchiolitis present?
Coryzal symptoms for 2-5 days
Poor feeding
OE - Tachypnoea, Grunting, Recessions, Wheeze, Crackles
Give three differentials for Bronchiolitis
Pneumonia
Croup
Heart Failure
How would you investigate suspected Bronchiolitis
Lab - Nasopharyngeal Aspirate, if pyrexia then blood and urine culture
Imaging - CXR (if diagnostic uncertainty or atypical course)
Describe some red flags of Bronchiolitis
RR>60 or Apnoea
Dehydration
Central Cyanosis
O2 Sats <92%
The majority of Brinchiolitis cases are managed supportively at home (resolving in 7-10 days), how are they managed as an inpatient?
Oxygen therapy
Fluids (if required)
?CPAP
Secretions - suction
No role for steroids/dilators/antimicrobial
Define Croup (AKA Laryngotracheobronchitis) and give two risk factors
Viral Upper Respiratory Tract (commonly parainfluenza) with a peak incidence at 2 years characterised by Stridor, Hoarse Voice and Barking Cough
Male, Autumn/Spring
Describe the typical history of a patient with Croup
1-4 day non specific coryza
Progressing to Barking Cough and Hoarseness
Worse at night and associated with fever
Describe the typical examination of a patient with Croup
Stridor?
Respiratory Distress?
What is the severity scoring system for Croup and what are the parameters?
Westly Scoring System
Consciousness, Cyanosis, Stridor, Air Entry, Retractions
Mild - <4
Mod - >4
Severe - >6
How do you differentiate between Croup and Epiglottitis?
Epiglottitis:
Soft Stridor
More Acute
Drooling
Not necessarily preceded by coryza
When would you consider admission for croup?
Previous history of severe airway obstruction
<6 months old
Immunocompromised
Uncertain Diagnosis
What advice would you give parents concerning Croup?
Usually resolves within 48 hours but can last up to a week
Antibiotics not appropriate
Paracetamol/Ibuprofen for pain/fever
Safety net
Can give a single dose of Oral Dexamethasone if Mild
If inpatient, how is Croup treated?
Steroids
Nebulised Adrenaline
O2 therapy as required
How does Cystic Fibrosis affect the lungs?
Reduces airway surface liquid which normally encourages mucous clearance and serves an immunological function
How does a Cystic Fibrosis affect the Pancreas?
Normally occluded in pancreas which causes permanent damage to exocrine pancreas rendering pancreatic insufficiency
Overtime Endocrine pancreas becomes affected (CF related Diabetes)
How does CF affect GI Tract?
Bowel Obstruction - Meconium Ileus
Cholestasis - Neonatal Jaundice
Dismal Intestinal Obstruction Syndrome
How does CF affect Reproductive Tract?
98% of Men are infertile due to congenital absence of Vas Deferens
Pregnancy associated with deterioration in lung health
How does CF present in Neonates?
Meconium Ileus (distension, bilious vomit) Failure to Thrive Prolonged Jaundice
How does CF present in Infants?
Failure to thrive
Recurrent Chest Infections
Steatorrhoea (Pancreatic Insufficiency)
How does CF present in Childhood and Adolescence?
Nasal Polyps, Sinusitis, Pancreatic Insufficiency, Chronic Lung Disease, Gall Stones
What might be seen OE of a child with Cystic Fibrosis?
Clubbing
Nasal Polyps
Chest (Hyperinflated, Crepitations, Portocath)
Abdomen (Faecal Mass, Ileostomy scar)
How is CF diagnosed?
Fitting Clinical History and Positive Chloride Sweat Test
Chloride Sweat Test - collected by Pilocarpine Iontophoresis, >60mmol/l is suggestive
What should be monitored annually in CF patients?
OGTT
LFTs/Coag/Bone Profile
Faecal Elastase
How should Airway Clearance in CF be managed?
Twice daily physiotherapy
Mucolytics (DNAse - decreases viscosity by digesting DNA, Hypertonic Saline)
How should Nourishment and Exercise in CF be managed?
Exercise should be encouraged
Creon taken before or with meals containing fats
Fat soluble vitamin supplements
Monitor growth and weight (may require build up milkshakes)
How should Infection prevention and management in CF be managed?
Prophylactic Abx until age of 3
Infections treated with 14d Abx (even if asymptomatic)
Clinics are split to avoid patient cross contamination
How does CF affect non pancreatic endocrine function?
Delays puberty by around 2 years
Reduces bone mineral density
Whooping Cough is a highly infectious notifiable disease caused by Bordetella Pertussis. What is the vaccine schedule against it?
Given at 2,3, and 4 months
Booster at 3 y 4 m
Immunity wanes after 5-10 years
Describe the clinical features of Whooping Cough (the three phases)
Catarrhal Phase (Generalised URTI)
Paroxysmal Phase (2-8 weeks of Paroxysms followed by gasp/apnoea)
Convalescent Phase (may last up to three months, gradually decreasing cough)
How is Whooping Cough Investigated?
<2 weeks - Nasopharyngeal Aspirate/Swab
> 2 weeks - Anti Pertussis IgG Serology
Lymphocytes is
How is Whooping Cough managed?
Antibiotics don’t alter clinical course but do alter infectivity so only give in first three weeks (Azithromycin or Clarithromycin first line)
Paracetamol/Ibuprofen/Fluids
Avoid school for three weeks (or 5 days with Abx)
When COVID - 19 occurs severely in a child, what is thought to be the cause?
Cytokine Storm Syndrome
Describe the features of Paediatric Inflammatory Multisystem Syndrome
Toxic Shock
Atypical Kawasaki
?Covid
Give two Bacterial/Viral/Atypical causes of LRTI (encompasses Bronchitis, Bronchiolitis, Pneumonia)
Bacterial - Strep Pneumoniae, H Influenza
Viral - Influenza A, RSV
Atypical - Mycoplasma, Legionella
LRTIs present quite typically with grunting and tachypnoea. What are the parameters for Tachypnoea in Children?
0-5 months >60/min
6-12 months >50/min
> 12 months >40/min
How should Community Acquired LRTIs be managed in Children?
Mild/Mod - Amoxicillin (+/- PO Erythromycin)
Severe - IV Co- Amoxiclav (may add PO Erythromycin for atypical cover)
How should Hospital Acquired LRTIs be managed in Children?
Mild/Mod - Co Amoxiclav
Severe - Piperacillin and Tazobactam
Obstructive Sleep Apnoea is a spectrum from snoring - upper airway resistance to apnoea. Give three different aetiologies
Adenotonsillar Hypertrophy
Obesity
Neuromuscular Disease
How does OSA present?
Snoring
Mouth Breathing
Witnessed Apnoeic Episodes (strangles/quiet breathing followed by gasp)
Poor concentration at school (day time sleepiness less common)
How is OSA investigates?
Overnight Polysomnography
Airway Assessment
CT/MRI (structural causes?)
Describe the management options for OSA
Medical - CPAP, Weight Loss
Surgical - Adenotonsillectomy, Tracheostomy
Orthodontic - Mandibular advancement
May just outgrow
Apart from the normal presentation and Ix of Pneumothorax, what can be done in a child?
Trans illumination of Chest Wall
Name a cause of a long standing brassy cough
Airway Malacia
Name a cause of an acute brassy cough
Tracheitis
