Respiratory Disease in Childhood

Question 1

What is the most common respiratory problem in premature babies?

Answer 1

Respiratory Distress Syndrome - relative surfactant deficiency results in high surface tension and can cause lung collapse

Inverse relationship with gestation

Question 2

What is surfactant?

Answer 2

A phospholipid secreted by child at 30-32/40 weeks
Lack of surfactant results in atelactasis (partial collapse/incomplete inflation of lungs) and impairment of gas exchange

Question 3

Clinical presentation of respiratory distress syndrome?

Answer 3

High RR (in children, normal is 60 breaths/min)
Sternal recession
Grunting
No breath sounds on side of chest affected

Question 4

Prophylactic treatment of respiratory distress syndrome?

Answer 4

Mother in premature labour is given steroid injection, to stimulate surfactant production by child

Question 5

Complications of respiratory distress syndrome?

Answer 5

Ventilation - can cause problems so must ensure it is gentle and not for too long
Sudden deterioration - can cause increase O2 requirement

Question 6

Iatrogenic cause of problems in respiratory distress syndrome?

Answer 6

Pneumothorax (air in pleural space) - risk factors include RDS and increased incidence with IPPV (Intermittent Positive Pressure Ventilation), CPAP (Continuous Positive Airway Pressure) and ventilation

Question 7

Non-iatrogenic causes of pneumothorax in babies?

Answer 7

Spontaneous - occurs in ~1% vaginal deliveries and 1.5% of caesarian sections

Question 8

What is chronic neonatal lung disease classified as?

Answer 8

AKA bronchopulmonary dysplasia (BPD)

O2 requirement beyond 36 weeks corrected gestation + evidence of pulmonary parenchymal disease on CXR

Question 9

When does chronic neonatal lung disease occur in neonates?

Answer 9

Generally, follows RDS

Question 10

Clinical presentation of chronic neonatal lung disease?

Answer 10

Barotrauma - lung damage due to pressure changes
Volume trauma
High inspired oxygen

Question 11

Healing of chronic neonatal lung disease?

Answer 11

Associated with continued lung growth over 2-3 years - often wheezy

Question 12

Diaphragmatic hernia in neonate?

Answer 12

Diaphragm not formed properly do gut goes through and so lungs do not develop properly (associated pulmonary hypoplasia)

Question 13

Commonest diaphragmatic hernia in neonate?

Answer 13

Posterolateral (Bochdalek) that is left-sided

Question 14

Treatment of a diaphragmatic hernia?

Answer 14

Avoid bag-mask IPPV (do not want to blow up the gut more)
Respiratory support
Surgical

Question 15

Key points in examination of older children?

Answer 15

Weight and height plotted - growth may be stunted due to energy usage in illness
Finger clubbing
Chest shape - pestus excavatum (sternal recession), Harrison’s sulcus (horizontal groove along the lower border of the thorax corresponding to the costal insertion of the diaphragm)
Auscultation

Question 16

Diagnosis of respiratory problems in children?

Answer 16

Spirometry - difficult with young kids, could potentially do it in 7+ years of age

Question 17

What is cystic fibrosis?

Answer 17

Autosomal recessive genetic disorder due to mutations in CFTR gene on chromosome 7 (most common mutation is Δ508)

Question 18

Incidence of cystic fibrosis?

Answer 18

Now becoming an adult problem due to increased life expectancy

All kids in Scotland get heel prick test measuring IRT (immunoreactive trypsin) which is raised in those with CF; if +ve result, repeat; if +ve again, then do CF genetics

Question 19

Clinical presentation of CF?

Answer 19

Respiratory infections are recurrent and prominent
Absorption problems - pancreas makes sticky secretions so:
Growth stunted
Salty on skin

Question 20

Differential diagnosis with CF?

Answer 20

CF
Immune deficiency
Ciliary dyskinesia?
Asthma
Kartagener's/immotile cilia syndrome - rare

Question 21

Care of CF patient?

Answer 21

Physiotherapist - exercises to remove sticky secretions
Clinical psychologist - CF impacts on mental health (patients not allowed to meet one another due to risk of attaining infection from one another = isolation)
Dietician - too thin/overweight can impair lung function further

Question 22

Clinical features that increase asthma probability?

Answer 22

One or more:
Wheeze - tends to be atopic wheeze that is recurrent; not every kid with wheeze has asthma
Cough
Chest tightness
Difficulty breathing
Atopy (personal/family history), e.g: asthma
WIDESPREAD WHEEZE ON AUSCULTATION
Response to treatment (Rx - prescription)

Question 23

What to do with low, intermediate and high probabilities of asthma?

Answer 23

Low - consider Ix (investigation) and referral
Intermediate - watchful waiting, spirometry (response), Rx and evaluate
High - diagnosis of asthma likely so trial of Rx; further Ix if poor response

Question 24

Spirometry curve in asthma?

Answer 24

Scallop-shaped:
Flow decreases with increasing volume
ADD PICTURE

Question 25

Management of childhood asthma?

Answer 25

Stage 1: Treat with inhaled beta-agonists when needed
Stage 2: Treat with regular inhaled steroids
Stage 3A: Regular inhaled steroids + Long Acting Beta Agonists
Stage 3B: Stage 3A + Leukotriene Antagonists

Question 26

Passive smoking effect on children?

Answer 26

Reduces birth weight 
Perinatal mortality increase
Teratogenic - airways, cleft lip/palate
Glue ear
Carcinogenic
Increased likelihood of asthma attack if living with parents that smoke

Question 27

Treatment of acute problems in children?

Answer 27

Oxygen
Nebulised bronchodilator
Oral prednisolone
i.v salbutamol
i.v aminophylline
i.v magnesium
Ventilatory support

Question 28

Pathological changes during an asthma attack

Answer 28

Muscle walls of airways (bronchi and bronchioles) bronchoconstrict
Increased mucous secretion
Inflammation of alveolar linings causes further narrowing of airway diameter

Question 29

Bronchiolitis in children?

Answer 29

Bronhciolitis is a lower RTI that occurs in children usually under 18 months old
Usually caused by a virus - commonly Respiratory Syncitial Virus (RSV)

Question 30

When is bronchiolitis more severe?

Answer 30

In younger babies, ex-premature babies, family of smokers

Question 31

Clinical presentation of bronchiolitis?

Answer 31

Tachypnoea
Poor feeding
Irritating cough
Apnoea (suspension of external breathing) in small babies

Increased incidence of wheezing episodes in next 10 years

Question 32

Treatment of bronchiolitis?

Answer 32

Supportive

Question 33

Pneumonia bacterial causes in neonates?

Answer 33

GBS (Group B Strep.), E.coli, Klebsiella, Staph. aureus

Question 34

Pneumonia bacterial causes in infants?

Answer 34

Strep. pneumoniae, Chlamydia

Question 35

Pneumonia bacterial causes in school age children?

Answer 35

Strep. pneumoniae, Staph.aureus, GRA (Group A Strep.), Bordetella, Mycoplasma, Legionella

Question 36

What is croup?

Answer 36

AKA laryngotracheobronchitis
Childhood condition that affects trachea, bronchi and larynx
Usually triggered by an acute viral infection of the upper airway

Question 37

Clinical presentation of croup?

Answer 37

Stridor

Barking cough

Question 38

Treatment of croup?

Answer 38

Oral steroid to reduce inflammation

Question 39

Describe pulmonary TB

Answer 39

Caused by Mycobacterium tuberculosis

Spread by droplet infection

Question 40

Prevention of TB?

Answer 40

BCG

Question 41

Drug treatment of TB?

Answer 41

2 months - Isoniazid, Rifampicin, Pyrazinamide
4 months - Isoniazid, Rifampicin

6 months total treatment

Question 42

Common respiratory problems in children?

Answer 42

Infant Respiratory Distress Syndrome
CLD
Congenital diaphragmatic hernia
Cystic fibrosis 
Asthma
Bronchiolitis
Childhood pneumonias
Croup
Tuberculosis