Respiratory and ENT Flashcards
How can asthma be broadly split into two types?
1) Extrinsic - definitive external cause identified, most common in atopic individuals
2) Intrinsic / cryptogenic - no causative agent identified, usually late onset (middle aged)
What is the pathophysiology of asthma?
Increase in circulating IgE causes increased allergic atopic reactions
Reversible inflammatory disease of airways that responds to bronchodilators
List three features of asthma
1) Bronchial muscle contraction
2) Mast cell and basophil degranulation = inflammation
3) Increased mucus sectetion
List some triggers for asthma (5)
1) Drugs
- Beta-blockers = vasodilation and bronchoconstriction
- NSAIDS
2) Pollution / environmental allergens / dust
3) Cold air
4) Viruses
5) Physical exertion
List some risk factors for asthma (7)
1) Personal hx atopy
2) FH atopy
3) Triggers (eg pollen), dust, exercise, viruses, chemicals etc
4) Prematurity and low birth weight
5) Viral infections in early childhood
6) Maternal smoking
7) Early exposure to broad-spectrum abx
Breast feeding = protective
What is the triad of asthma symptoms?
Recurrent episodes of
1) Cough = worse at night
2) SOB
3) Wheeze
Ddx for wheeze:
Present from birth (3)
Shortly after birth (5)
Sudden onset in a previously well child (4)
Wheeze present from birth:
1) Presents immediately, constant wheeze without variation = structural abnormality eg bronchogenic cyst, vascular ring
2) Weak cry, stridor = laryngeal abnormality
3) Signs of HF = congenital heart disease
Wheeze shortly after birth:
4) Hx of prematurity or ventilation = bronchopulmonary dysplasia
5) Recurrent bacterial infections and FTT = immunodeficiency
6) Persistent cough and FTT, FH of chest disease = CF
7) Persistent nasal discharge and OM = ciliary dyskinesia
8) Vomitting and aspiration = GORD
Sudden onset in a previously well child:
9) Hx choking, unilateral reduced breath sounds = foreign body
10) Persistent wet cough = CF, bronchiectasis, recurrent aspiration, immunodeficiency, GORD
11) Finger clubbing, purulent sputum = CF, bronchiectasis
12) Focal signs in chest = developmental anomaly, post-infection, bornchiectasis, TB, foreign body
List the features of moderate acute asthma in a child <2yr
Moderate acute asthma:
- Able to talk in sentences
- SpO2 =/> 92%
- Peak flow =/> 50% best or predicted
- HR =/> 140bpm aged 2-5yr or 125 over 5yr
- RR =/> 40 aged 2-5yr or 30 over 5yr
List the features of severe acute asthma in a child <2yr
Severe acute asthma:
- Can’t complete sentences in one breath or too breathless to talk / feed
- SpO2 <92%
- Peak flow 33-55% best or predicted
- HR >140bpm aged 2-5yr or >125bpm over 5yr
- RR >40 aged 2-5yr or >30 over 5yr
List the features of life-threatening asthma in a child <2yr
Any one of the following in a child with severe asthma:
- SpO2 <92%
- Peak flow <33% best or predicted
- Silent chest
- Cyanosis
- Poor response effort
- Hypotension
- Exhaustion
- Confusion
What are the normal vital signs for:
1) Infant
2) 1-2yrs
3) 2-5yrs
4) 5-12yrs
5) >12yrs
1) Infant
HR: 110-160bpm
Systolic BP: 80-90mmHg
RR: 30-40
2) 1-2yrs
HR: 100-150bpm
Systolic BP: 85-95mmHg
RR: 25-35
3) 2-5yrs
HR: 95-140
Systolic BP: 85-100mmHg
RR: 25-30
4) 5-12yrs
HR: 80-120bpm
Systolic BP: 90-100mmHg
RR: 20-25
5) >12yrs
HR: 60-90bpm
Systolic BP: 100-140mmHg
RR: 14-18
What investigations should be performed for asthma? (6)
1) PEFR
2) Spirometry
3) Allergy testing
4) Exercise test
5) Bloods - Raised IgE and eosinophils
6) CXR
What is the stepwise management of asthma in children <12yrs?
1) Inhaled SABA
2) Inhaled corticosteroid (ICS): 200mcg / day
3) Add inhaled LABA (5yrs or over)
Add leukotreine receptor antagonist (LRTA) (<5yrs)
4) If only partial benefit: inc ICS to 400mcg / day
If no response: stop LABA and increase ICS to 400mcg / day
If control still inadequate: try LTRA
5) Increase ICS to 800mcg / day
OR consider addition of 4th drug eg theophylline
- Refer to respiratory paediatrician
6) Daily oral steroids = refer to respiratory paediatrician
Consider moving up ladder if using 3 or more doses of SABA per week
What is the stepwise management of asthma in children 12 yrs or over?
1) Inhaled SABA Inhaled corticosteroid (ICS) - 400mcg / day
2) Add inhaled LABA (usually combined inhaler with ICS and LABA)
If only partial benefit: increase ICS to 800mcg / day
If no response: stop LABA and increase ICS to 800mcg / day
If control still inadequate, try LRTA
3) Consider increasing ICS to 2000mcg
Or addition of 5th drug: LRTA, theophylline
4) Daily oral steroid and refer to specialist
What is the management of acute asthma in children?
O SHIT ME
Oxygen 15L/min Salbutamol NEB b2b Hydrocortison IV 4mg / kg Ipatropium NEB b2b Theophylline PO (or aminophylline IV) Magnesium sulphate IV Escalate
List types of bronchodilators and examples
1) Beta 2 agonist
- Salbutamol = Short acting
- Salmeterol = long acting
2) Anticholinergics
- Ipatropium
- Triotropium
3) Leukotriene receptor agonist
- Montelukast
4) Xanthines
- Theophylline = PO
[aminopyhlline is theophylline + ethylenediamine, given IV]
What is bronchiolitis? What age does It affected?
Acute viral infection of LRTI
Mostly ages 3-6 months (1/3rd have before age 1)
M>F
What is the cause of bronchiolitis?
80% due to respiratory syncytial virus (RSV)
What is the pathophysiology of bronchiolitis?
Initial URTI spreads to LRT = infection of bronchiolar respiratory cells and ciliated epithelial cells causes increased mucus secretion, cell death, lymphocytic infiltration and submucosal oedema
Mucus and oedema causes narrowed small airways and V/Q mismatch - leading to hypoxia
What are some risk factors for bronchiolitis? (9)
Un/under developed lungs + immune system most common:
1) Premature birth
2) Chronic lung disease eg CF or bronchopulmonary dysplasia
3) Congenital heart disease
4) Neurological disease with hypotonia and pharyngeal disco ordination
5) Immunocompromise
6) Tobacco smoke exposure
7) Non-breast fed
8) Contact with multiple children eg nursery, older siblings
9) Down’s syndrome
How may bronchiolitis present?
<2yr with 1-3 day hx of coryzal symptoms followed by:
1) Persistent cough AND
2) Either tachypnoea or chest recession (or both); AND
3) Either wheeze or crackles (or both)
Other features include low grade fever (under 39 degrees Celsius) and poor feeding
What are some other signs of hypoxia / increased work of breathing?
1) Tracheal tug
2) Cyanosis
3) Tachypnoea
4) Sub-costal recession
5) Nasal flare
What features may make you consider a pneumonia over bronchiolitis?
Higher temperature and focal crackles
Describe features of bronchiolitis vs viral induced wheeze
Bronchiolitis:
- Younger = 2-12mnths
- Hx of a viral illness followed by a wheeze
- Salbutamol ineffective (too young)
- Treated symptomatically
- Chest sounds of wheeze and crackles
Viral wheeze:
- Older = 1-3yrs
- Shorter hx, wheeze develops in hours-day
- Salbutamol effective
- Chest sounds clear cut wheeze
- Treated same as asthma
NB said that asthma cannot be accurately diagnosed before age 5 (but viral wheeze treated as asthma)
What features may make you consider a viral induced wheeze over bronchiolitis?
Wheeze with no crackles, episodic symptoms and/or a FH of atopy
How may young infants present with bronchiolitis?
May be lone apnoea
What investigations are performed for bronchiolitis? (4)
1) Full examination inc CRT, RR, HR, chest signs
2) Pulse oximetry - hypoxia
3) Nasopharyngeal swab fluorescent antibody test - RSV +ve
4) CXR - non specific: maybe hyperinflation, atelectasis, consolidation
What features require immediate referral to secondary care for bronchiolitis? (5)
1) Apnoea (observed or reported)
2) Marked chest recession or grunting
3) RR >70
4) Central cyanosis
5) O2 sats <92%
Or clinical judgement that the child looks severely unwell
What treatment is given for moderate acute bronchiolitis?
Usually mild, self-limiting illness that can be managed at home
Supportive treatment focussing on fluid input, nutrition and temperature control
Advise parents that symptoms peak between 2-5 days of onset
If awaiting referral to hospital, give supplementary oxygen if sats are persistently <92%
What treatment is given for severe bronchiolitis?
Admission in severe cases, symptomatic treatment:
1) Oxygen - achieve >92%
2) CPAP / intubation and ventilation
3) Fluids - limit oral needs, use NG tube or IV depending on severity (may need intermittent feeding as may vomit)
NB salbutamol ineffective = too young to have adrengergic receptors
What prophylactic treatment can be given for bronchiolitis?
Palivizumab = monoclonal antibody to RSV can be given to high risk groups my monthly IM injection
ie those with bronchopulmonary dysplasia due to premature birth, congenital heart disease or immunodeficiencies
What is croup also known as?
Acute laryngotracheitis
Acute laryngotracheobronchitis
Which ages are mostly affected by croup?
Typically 6 months - 6 years
Peak incidence at 2 years
What is the aetiology of croup?
Most commonly: Parainfluenza viruses types I, II, III and IV (approx 80%)
What is the pathophysiology of croup?
Viral URTI causes nasopharyngeal inflammation that may spread to the larynx and trachea, causing sub glottal inflammation, oedema and compromise of the airway at is narrowest portion
Movement of vocal chord impaired = characteristic cough
How may croup present?
Initially nonspecific symptoms of viral URTI eg coryzal symptoms, fever, cough (12-72hrs)
This progresses to characteristic seal barking cough and hoarse cry (worse at night)
+/- stridor
Decreased chest sounds if severe airflow limitation
+/- respiratory distress - tachypnoea, intercostal recession etc
What is the natural course of croup?
3-7 days but can persist for up to 2 weeks
Usually mild and self limiting, but the distressing symptoms can mean parents present to GP/A&E
Severe cases can compromise upper airway
What is the scoring system for the severity of croup?
Westley scoring system
What features to the Westley scoring system involve?
1) Inspiratory stridor
Not present = 0
When agitated/active = 1
At rest = 2
2) Intercostal recession Not present = 0 Mild = 1 Miderate = 2 Severe = 3
3) Air entry
Normal = 0
Mildly decreased = 1
Severely decreased = 2
4) Cyanosis
None = 0
When agitated/active = 4
At rest = 5
5) Level of consciousness
Normal = 0
Altered = 5
Scoring / 17
0-3 = mild
4-6 = moderate
>6 = severe
Most children will have mild croup which can be managed at home. When is immediate assessment in hospital required?
Moderate or severe croup, or impending respiratory failure
Any suspicion of epiglottis, bacterial tracheitis, quinsy, retrophayngeal abscess or laryngeal diptheria eg suspicion of severe infection
Also if <6months, immunocompromised etc
What investigations may be performed for croup? (5)
1) Pulse oximetry (<95% = significant respiratory impairment)
Risk vs benefit of distressing child for:
2) CXR
3) Bloods
4) Rapid influenza A throat swab
NB DO NOT EXAMINE THROAT
What is the management of croup?
Single dose PO dexamethasone 0.15mg / kg ASAP
Adrenaline NEB:
For patients in moderate to severe distress
What are some complications of croup?
Complications rare
Bacterial superinfection may result in pneumonia or bacterial tracheitis = S aureus (most common)
Pulmonary oedema
Pneumothorax
Lymphadenitis
OM
What is “spasmodic croup?”
Barking cough with no apparent respiratory symptoms
How common is epiglottitis? What ages are affected
Rare since introduction of Haemophilus Influenza type B (Hib) vaccine in 1992
2-5yrs
What is the aetiology of epiglotttis?
Mostly strep
HSV
Candida and aspergillus in immunocompromised
Non-infectious causes include thermal eg steam / crack cocaine smoking, foreign bodies etc
Reactive epiglottitis can occur as a result of head and neck chemo
How may epiglottitis present? (10)
1) Sore throat
2) Odynophagia
3) Inability to swallow secretions = drooling in children
4) Muffled ‘hot potato’ voice
5) Fever
6) Tachycardia
7) Anterior neck tenderness over hyoid bone
8) Ear pain
9) Cervical lymphadenopathy
10) Tripod sign = moves inflamed structures forward, thus easing upper airway obstruction
What is odynophagia?
Painful swallowing
How can epiglottitis be distinguished from croup in children?
Rare for a child to have a cough with epiglottitis
Croup has seal barking cough
What investigations should be done for epilglottitis?
DO NOT EXAMINE THROAT WITH TONGUE DEPRESSOR = risk of laryngeal obstruction, they should be urgently referred for laryngoscopy
Fibre-optic laryngoscopy = gold standard
- Should only be done in theatre as may need to intubate or perform tracheostomy in the event of an upper airway obstruction
- If not possible, lateral neck x-ray can show ‘thumbprint sign’
Throat swabs when airway secure
Blood cultures if systemically unwell
CT or MRI if abscess suspected
How is epilglottitis managed?
IV cefotaxime 25-50mg/kg/8hr
Surgical tracheostomy may be required in pt with severe airway obstruction where intubation is not possible
Drainage of abscess if present
What are some complications of epiglottitis? (5)
1) Abscess formation (25%)
2) Meningitis
3) Sepsis
4) Pneumothorax
5) Pneumo-mediastinitis (v rare)
Differentiate between croup and epiglottitis
Croup: Time course - days Prodrome - coryza Cough - barking Feeding - can drink Mouth - closed Toxic - no Fever - <38.5 Stridor - rasping Voice - hoarse
Epiglottitis: Time course - hours Prodrome - none Cough - none (or slight) Feeding - none Mouth - drooling saliva Toxic - yes Fever - >38.5 Stridor - soft Voice - weak / silent
Failure for croup to improve on steroids/nebulisers indicates what?
Bacterial tracheitis
What is bacterial tracheitis?
Thick mucopurulent exudate and tracheal mucosal sloughing that is not cleared by coughing, risks include occluding the airway
Often hx of viral infection (like croup) with an acute deterioration
Pronounced tracheal tenderness may be present
What is the aetiology of childhood pneumonia? <2yrs Neonates Infants School age
Viral more common in <2yrs:
- RSV
- Adenovirus
- Influenza
- Parainfluenza
- Hib in immunocompromised
Bacterial (most are strep peumoniae):
- Neonates = GBS, E coli, kiebsiella, s aureus
- Infants = s pneumoniae (lobar pneumonia), chlamydia
- School age = s pneumoniae, s aureus, GAS, Bordetella peruses, mycoplasma pneumoniae
What are some risk factors for child pneumonia?
Immunodeficiency
CF
Sickle cell disease
Tracheostomy in situ
What are some signs for childhood pneumonia?
1) Fever
2) Cough
3) Malaise
4) Respiratory distress eg tachypnoea, cyanosis, intercostal recession, use of accessory muscles
Hx of preceding URTI very common
What is defined as tachypnoea in:
1) 0-5 months
2) 6-12 months
3) Over 12 months
1) 0-5 months = >60/min
2) 6-12 months = 50/min
3) Over 12 months >40/min
What are some complications of childhood pneumonia?
Persistent pneumonia after 48hr treatment could be effusion or empyema
A fluid sample should be taken by chest drain:
- Empyema diagnosed if acidic pH and protein +++
- Fluid should be allowed to drain from chest drain and not removed until dry for 48hr
What may childhood pneumonia show on examination?
1) Dullness to percussion
2) Inspiratory crackles
3) Diminished breath sounds`
Audible wheezing is not seen very often in LRTI, however when is it more common?
Diffuse infections such as mycoplasma pneumoniae and bronchiolitis
What pneumonia may be accompanied by conjunctivitis in the newborn? When?
Chlamydial pneumonia may be accompanied by chlamydial conjunctivitis
Second or third week
Which pneumonia is particularly concerning in first 24 hours of life?
Streptococcal sepsis and pneumonia
What type of pneumonia may present with abdominal pain in toddlers?
Lower lobe pneumonia
What investigations may be done in pneumonia?
Not required in a CAP with child going home
1) FBC - raised WCC
1) Blood cultures - rarely positive in pneumonia (fewer than 10% are bacteraemic in pneumococcal disease)
2) Sputum culture / nasopharyngeal aspirate
3) CXR
Often hard to distinguish between viral / bacterial
What should be tested for in recurrent childhood pneumonia? How?
CF - Sweat test
When should admission be considered for a childhood pneumonia? (9)
1) O2 sats <92%
2) RR >70 (or 50 in older child)
3) Significant tachycardia
4) Prolonged CRT
5) Difficulty breathing shown by intermittent apnoea, grunting, not feeding
6) Presence of comorbidity eg congenital heart disease / CF
7) Age <6 months
8) Those in which abx have failed - should see improvement within 48hrs PO abx
9) Pleuritic pain
What is the treatment of childhood pneumonia?
Mostly managed at home with fluids, antipyretics and abx if bacterial
<5yrs = amoxicillin >5yrs = amoxicillin / macrolide eg clarithromycin Severe = Coamoxiclav / IV cephaloposporin (cefotaxime, cefuroxime)
What is the Centor Criteria?
Give up to 50% predictive power for bacterial cause of URTI
What features are included in the Centor Criteria?
One point for each criterion met:
1) Fever >38 degrees celcius
2) Tonsillar exudate
3) Absent cough
4) Anterior cervical lymphadenopathy
5) Age 3-14
- Bacterial cause <3 is rare
- >45 = -1
What is mesenteric adenitis?
Intermittent abdo pain caused by inflamed lymph glands usually due to viral infection
Adenitis = inflamed lymph glands
What should be included on examination of URTI?
ENT examination:
- Ear discharge
- Bulging ear drum
Cervical lymphadeopathy
Purulent tonsillar exudate
- Seen in GABH or EBV
Check there is no difficulty breathing in infants / neonates
What is the treatment of an URTI?
Mostly symptomatic
Sale drops/gentle suction can remove obstructing mucus
Abx only if swab +ve for GABH:
- Penicillin V
or erythromycin for 10 days
Why should you avoid amoxicillin when treating an URTI?
Can cause an itchy maculopapular rash if the cause is EBV
What may an URTI precipitate in a child?
Febrile convulsions
What is a viral induced wheeze?
Wheeze related to viral UTI
Reversible obstruction = responds to bronchodilators
Admit if needing inhalers more
than 4hrly or needing oxygen
Often “grow out of it” but may develop into asthma
No role for steroids
Occasionally use montelukast or ICS if recurrent
Beware of foreign body !
What genes are involved in CF
Autosomal recessive disease caused by mutation of CFTR on Chr7
List the features of CF
1) High sodium sweat
2) Pancreatic insufficiency
3) Biliary disease
4) GI disease
5) Respiratory disease
When does CF present? What is the most common presentation?
Normal digestive function possible with <5% pancreatic function = CF can present at any age
Most common presentation its recurrent LRTI with chronic sputum production
What screening is performed for CF?
Immunoreactive trypsinogen (IRT) measured on a dried spot of blood obtained on the Guthrie card at day 6 of life
Samples with raised IRT will undergo CFTR mutation screening
How is CF diagnosed antenatally?
Amniocentesis / CVS
US demonstration of bowel perforation / hyperchogenic bowel (bright bowel) = 4% due to CF
How is CF diagnosed perinatally?
How may it present?
Screening
Bowel obstruction with meconium ileus (bowel atresia)
Haemorrhagic disease of the newborn
- Vit K deficiency due to malabsorption of fat soluble vitamins due to pancreatic insufficiency (but rare as vit K given after birth)
Prolonged jaundice
- Extrahepatic biliary obstruction from bile of increased density with secondary intrahepatic bile stasis
What is meconium ileus?
Obstruction of the terminal ileum by abnormally thick / adherent meconium
Symptoms include bilious vomiting, abdo distention and failure to pass meconium in the first few days of life
How may CF present in infancy and childhood?
1) Recurrent RTI
2) Diarrhoea
3) FTT
4) Rectal prolapse
- Frequent coughing or hard-to-pass stools
5) Nasal polyps = in children this is nearly always due to CF
6) Acute pancreatitis
7) Portal HTN and variceal haemorrhage
8) Electrolyte abnormality
- Can develop Pseudo-Bartter’s syndrome
9) Hypoproteinaemia and oedema
What signs may be observed with CF?
1) Finger clubbing
2) Cough with purulent sputum
3) Crackles
4) Wheeze - mainly upper lobes
5) FEV1 shows obstruction
NB babies with CF usually have no signs / symptoms
What investigations are done for CF?
Sweat test = 98% sensitive
- Chloride >60mmol/L with sodium concentration lower than that of chloride on 2 separate occasions
Molecular genetic testing for CFTR gene
Sinus X-ray / CT scan = opacification of sunless
CXR / CT thorax
Lung funcitoning test - spirometry unreliable <6yr
Sputum microbiology
What is most of the morbidity and mortality with CF in respiratory disease related to?
Chronic infection and inflammation lead to bronchiectasis, progressive airflow obstruction, cor pulmonate and death
+ Inc bacterial resistance esp p aeruginosa
What interventions are used to prevent and treat respiratory problems related to CF?
Mucus clearance, preventing infection nd maintaining good lung function are main aims
Chest physiotherapy twice daily (inc with infective exacerbations)
Regular sputum samples sent for culture
Prophylactic abx to reduce s aureus in children and to prevent secondary bacterial infections when pt has presumed acute viral RTI
Patient with P. aeruginosa have 2/3 inc risk of death >8yr:
- Given combination of PO, NEB and IV abx
Bronchodilators:
- LABA / SABA
Dornase alfa NEB
- Reduces sputum viscosity
High-dose ibuprofen may slow progression of lung diseases
Azithromycin may reduce inflammation
Hypertonic saline by NEB given for osmotic action
How are nasal polyps treated in CF? What is recurrence rate?
Steroids initially
Polypectomy if fails
50% require repeat within 2 yrs
How may pancreatic insufficiency present in CF?
Meconium ileus
FTT
Steatorrhoea
Malnutrition
Which can lead to:
Anaemia
Vit deficiency
Sometimes obstruction
Which can cause: Rectal prolapse Intussusception Volvulus Obstruction
How is pancreatic insufficiency diagnosed in CF?
Confirm with stool elastase = presence of unsplit fat globule in stool or 2-3 days stool collection of fatal fat
How is adequate weight maintained in CF?
High energy + protein
Enteric coated enzymes before meals + adjust to achieve normal stools
Vitamin supplements
?acid lowering meds
What proportion of children and adolescents with CF develop diabetes?
2% children
19% adolescents
(40-50% adults)
What is the treatment of CF-related DM?
Insulin replacement usually required with dose adjusted to match high dietary intake
What other systems are affected by CF?
Liver disease - 30% of adults will develop
- Check LFTs
- Usually seen hepatosplenomegaly
- USS
- Liver transplant in liver failure if good lung function
Osteoporosis - 33% adults
- Take calcium, vit D, bisphosphonates as required
- Regular DEXA scans
What follow up is required for CF pts?
Recommended to be seen twice yearly by MDT working in specialist centre
Investigations performed at regular intervals:
1) Pulmonary function tests
2) DEXA scan
3) Blood glucose
4) Respiratory cultures
5) Liver USS
6) Vit D levels
What vaccines are offered in CF populations?
1) Annual influenza
2) Pneumococcal
+ varicella antibodies checked for and varicella vaccine offered to children who need it
What is the estimated survival for a child born with CF?
40-50yrs
