Respiratory Abnormalities

Question 1

When does a child’s cough become chronic?

Answer 1

Acute cough is < 3 weeks presentation

Chronic cough is > 6 weeks

Question 2

What differentials should be considered for a chronic cough?

Answer 2

• In a normal child this could simply be recurrent respiratory infections, a long-lasting cough after specific infections such as RSV, pertussis and mycoplasma, atelectasis following infection or persistent bacterial bronchitis.
• Minor persistent cough due to post nasal drop
• Asthma syndrome
• Long term illness such as CF, PCD (primary ciliary dyskinesia), TB and immunodeficiency
• Recurrent aspiration/inhalation/reflux due to swallowing incoordination, GOR or FB
• Congenital abnormalities such as trachea-laryngomalacia or TOF
• Habit cough

Question 3

What’s the difference between monophasic and biphasic stridor?

Answer 3

Note stridor can be monophasic or biphasic i.e. on inspiration or both inspiration and expiration. This helps identify where the problem is. Biphasic stridor occurs because of problems below the vocal cords whilst monophasic means the problems is around the vocal cords.

Question 4

What can cause a chronic wheeze?

Answer 4

Most common - asthma, viral episodic wheeze
Broncho-pulmonary dysplasia or bronchiolitis obliterans
Bronchitis and bronchiectasis
Cystic fibrosis
Oesophageal foreign body
Recurrent aspiration
Structural – trachea-bronchomalacia, tracheal stenosis/web
Vocal cord dysfunction

Question 5

What are the clinical features of bronchiectasis?

Answer 5

Wet cough
Poor growth
Clubbing
Excessive sputum

Question 6

What causes bronchiectasis?

Answer 6

Post infection from TB, measles, pertussis and pneumonia 
Cystic fibrosis 
Immune deficiency 
Allergic bronchopulmonary aspergillosis 
Ciliary dyskinesia

Question 7

How should bronchiectasis be investigated?

Answer 7

CXR
High res CT chest
FBC
Sputum culture

Question 8

How is bronchiectasis managed?

Answer 8

Treat cause if possible
Physical training and postural drainage
Antibiotics for exacerbation and long term in severe cases
Bronchodilators in specific cases
Immunisations
Surgery for localised disease or transplant

Question 9

What organisms most commonly cause infections in bronchiectasis?

Answer 9

Hemophilus influenzae
Pseudomonas aeruginosa
Klebsiella
Streptococcus Pneumoniae

Question 10

What is laryngomalacia?

Answer 10

Commonest cause of stridor in an infant. Congenital softening of supra-glottic larynx resulting in a dynamic supra-glottic collapse on inspiration and so intermittent upper airway obstruction and stridor.

Question 11

How does laryngomalacia present?

Answer 11

4 weeks old with stridor
Brassy, barking cough
Noisy breathing (stridor) worse when agitated, feeding, crying or lying on back.
Feeding difficulties, choking, poor weight gain.
Frequently associated with GORD

Question 12

What investigation can be used to diagnose laryngomalacia?

Answer 12

Bronchoscopy

Question 13

What is choanal atresia?

Answer 13

Blockage at back of nasal passage due to congenital abnormality – bone or soft tissue. Neonates are obligate nose breathers so potentially serious. Nasal catheter won’t pass through the pharynx. Associated with other congenital malformations e.g. coloboma.

Question 14

How does choanal atresia present?

Answer 14

Clinical features
Poor feeding
Cyanotic episodes that improve with crying but are worse when feeding
Very good cry
If unilateral can go unnoticed, bilateral babies with present early

Question 15

How is choanal atresia treated?

Answer 15

Fenestration procedure designed to restore patency

Question 16

What is congenital lobar over inflation?

Answer 16

Formerly called Congenital lobar emphysema. Developmental anomaly of lower respiratory tract characterised by hyperinflation of one or more lobes (most commonly upper lower lobe).

Question 17

How does congenital lobar over inflation present?

Answer 17

Presentation variable; symptomatic at birth or later, usually around 3 months (up to 2 years).