Respiratory - Chest Infections and CF

Question 1

What is bronchiolitis?

Answer 1

most common serious respiratory infection in infancy infants are admitted to hospital each year during the annual winter epidemics mostly between 1-9 months old RSCV is pathogen in 90%

Question 2

What is the natural history of bronchiolitis?

Answer 2

Coryzal symptoms precede a dry cough and increasing breathlessness
Feeding difficulty associated with increasing dyspnoea is often the reason for hospital admission
Recurrent apnoea is a serious complication
Most infants recover in 2 weeks - however half will have recurrent episodes of cough and wheeze

Question 3

What are the clinical features of bronchiolitis?

Answer 3

dry wheezy cough 
tachypnoea and tackycardia
subcostal and intercostal recession 
hyperinflation of the chest 
fine end expiratory crackles 
high pitched wheezes - 
expiratory > inspiratory

Question 4

How is acute bronchiolitis treated?

Answer 4

Supportive treatment
Humidified oxygen us either delivered via nasal cannula or using a head box
Infant is monitored for apnoea
Fluids may be given by NG tube or intravenously
Assisted ventilation in the form of non invasive respiratory support - CPAP or mechanical ventilation may be required in a small number of children

Question 5

How should you advise parents to care for a child with bvrochiolitis?

Answer 5

Keep child upright - makes breathing easier
Drink plenty of fluids
Keep air moist
Smoke free environment
Relieving a fever - paracetamol/ibuprofen
Saline nasal drops

Question 6

Which babies are at risk of severe bronchiolitis?

Answer 6

Premature babies who develop bronchopulmonary dysplasia
Babies with underlying lung disease (CF)
Babies with congenital heart disease

Question 7

What are the common causative organisms of pneumonia in newborns?

Answer 7

Newborn - organisms from the mothers genital tract are common –> group B strep, gram negative enterococci and bacilli

Question 8

What are the common causative organisms of pneumonia in infants and young children?

Answer 8

Infants and young children - RSV (most COMMON), Also - Strep. pneumoniae or H.influenza. Bordetella pertussis and Chlamydia trachomatis

Question 9

What are the common causative organisms of pneumonia in children over 5 years?

Answer 9

Mycoplasma pneumoniae, Streptococcus pneumonia and Chlamydia pneumonia are the main causes

Question 10

What other organism should be considered when thinking about pneumonia in children of all ages?

Answer 10

Mycobacterium tuberculosis

Question 11

What are the presenting symptoms of pneumonia?

Answer 11

MOST COMMON:
fever 
cough 
rapid breathing 
usually preceding URTI OTHER:
lethargy 
poor feeding 
"unwell" child 
localised chest/abdo/neck pain is a feature of pleural irritation and is a sign of a bacterial infection

Question 12

What is seen on examination in pneumonia?

Answer 12

Nasal flaring
Tachypnoea
Chest indrawing
Respiratory rate increase is an important sign of pneumonia
End inspiratory course crackles of affected area
Consolidation signs - dull percussion, decreased breath sounds and absent bronchial breathing
Low oxygen sats

Question 13

What investigations are used in pneumonia?

Answer 13

Chest X-ray Nasopharyngeal aspirate to differentiate between bacterial and viral pneumonia

Question 14

How are children with pneumonia treated?

Answer 14

most can be managed at home but hospital admission is required in some cases (o2 sats <92%, recurrent apnoea, grunting and inability to maintain fluids/feeds intake) 
IV fluids to correct dehydration 
Oxygen for hypoxia 
Analgesia for pain 
Physio has no proven role 
Antibiotics

Question 15

Which antibiotics should be given in pneumonia in children of different ages?

Answer 15

Newborns: Broad spectrum IV Abx

Older infants: oral amoxicillin with broad spectrum reserved for unresponsive pneumonia

Children over 5 years: amoxicillin or oral macrolide (erythromycin) Oral treatment is used for mild/moderate pneumonia

Question 16

When is a pleural collection suggested in pneumonia?

Answer 16

persistent fever despite 48 hours of antibiotics

Question 17

How should you advise patients to care for a child with a chest infection?

Answer 17

encourage child to drink milk
paracetamol and ibuprofen
nasal drops,
upright position for nose steam inhalation?

Question 18

What is pertussis?

Answer 18

Whooping cough

Highly contagious respiratory infection caused by Bordetella pertussis

Question 19

How does pertussis present?

Answer 19

paroxysmal cough followed by inspiratory whoop and vomitting; in infants, apnoea rather than whoop, which is potentially dangerous

Question 20

How does immunisation effect the presentation on pertussis?

Answer 20

reduces the risk and severity of disease but does not guarantee protection reimmunization by mothers during pregnancy reduces the risk of pertussis

Question 21

What are the clinical features of tuberculosis in children?

Answer 21

Primary infection can lead to symptomatic presentation (active TB) or asymptomatic presentationactive TB symptoms are often non specific, such as prolonged fever, malaise, anorexia, weight loss, focal signs of infection (lymph node swelling)

Question 22

How is TB treated in children?

Answer 22

Triple or quadruple therapy (rifampicin, isoniazid, pyrazinamide, ethambutol) is recommended initial combination
This is then decreased to rifampicin and isoniazid alone after 2 months
Treatment is 6 months in uncomplicated TB
Older children should be given pyridoxine to prevent peripheral neuropathy associated with isoniazid therapy
Asymptomatic children who test positive should be given 3 months of rifampicin and isoniazid and isoniazid for 3 months alone

Question 23

What is cystic fibrosis?

Answer 23

most common life limiting autosomal recessive condition life expectancy is 30-40 years it is caused by a defective protein called the CF transmembrane conductance regulator (CFTR)

Question 24

What are the clinical features of cystic fibrosis?

Answer 24

newborns: diagnosed through newborn screening, meconium ileus

Infancy: prolonged neonatal jaundice, growth faltering, recurrent chest infections, malabsorption, steatorrhoea

Young child: bronchiectasis, rectal prolapse, nasal polyp, sinusitis

Older Children and adolescent: allergic bronchopulmonary aspergillosis, DM, Cirrhosis, portal HTN, distal intestinal obstruction, pneumothorax or recurrent hamoptysis, sterility in males

Question 25

How is CF managed?

Answer 25

• MDT management
• Respiratory symptoms should be monitored through symptoms in younger children and spirometry in older children - Physiotherapy should be at least twice a day
• Continuous prophylactic antibiotics oral antibiotics (flucloxacillin) with additional oral rescue antibiotics
  IV therapy to limit lung damage if persisting symptoms
• Chronic pseudomonas infection is associated with more chronic decline which is slowed through daily nebulized antiseudomonal antibiotics
• Nebulized DNase or hyaline saline may be helpful at increasing sputum clearance- Azithromycin can be used to decrease respiratory exacerbations do to immunomodulatory effect
• More severe CF requires regular IV antibiotics and central venous catheter may need to be inserted
• Bilateral sequential lung trasnplantation is only therapeutic option for end stage CF disease

Question 26

How is physio uses to treat CF?

Answer 26

Children should have physiotherapy for at least twice a day to clear airway secretions In younger patients parent are taught to perform airway clearance a home using chest percussion and postural drainage Older patients perform controlled deep breathing exercises and use a variety of physio devices

Question 27

What are the indications for hospital admission in bronchiolitis?

Answer 27

apnoea episodes
intake <50% normal in preceeding 24 hours 
cyanosis 
severe resp distress (grunting, nasal flaring) 
congenital heart disease
significant hypotonia (trisomy 21) 
survivor of extreme prematurity 
social factors