Respiratory disorders Flashcards
1
Q
What is the most common chronic disease of childhood
A
asthma
2
Q
what are the signs of moderate respiratory distress
A
1) Tachypnea 2) Tachycardia 3) Nasal flarring 4) Use of accessory respiratory muscle 5) Use of accessory muscles 6) Intercostal and subcostal recession 7) head traction 8) inability to feed
3
Q
What are the signs of severe resp distress
A
1) cyanosis 2) tiring bc of increased work 3) decreased conscious level 4) O2 sats <92% despite oxygen therapy
4
Q
Who is particularly susceptible to respiratory distress?
A
- ex preterm infant w BPD
- hemodynamically significant cong. HD
- disorders causing muscle weakness
- CF
- immunocompromised
5
Q
What are the physiology of stridor
A
- Extrathoracic airway obstruction in trachea and larynx
- Inspiration is an active process that generate negative pressure and suck air into the lungs
- A degree of invard collapse during inspiration
- Obstruction to extrathoracic airway is worse during inspiration
6
Q
What is the physiology of wheeze
A
- Intrathoracic airway obstruction
- Predominantly expiratory
- During expiration recoil pressure of chest wall generate a positive pressure which push air out and distending extra thoracic airways
- Obstruction to intrathoracic airway is worse during expiration
7
Q
What diseases are included in URI
A
- common cold
- sore throat, pharyngitis, tonsilitis
- acute otitis media
- sinusitis (relatively uncommon)
8
Q
When is hospital admission needed w URI
A
- Difficulty in feeding (nose are blocked and obstructs breathing)
- Fluid intake is inadequate
9
Q
Common cold is
A
the most common inf of childhood
10
Q
features of coryza
A
1) clear or mucopurulent nasal discharge 2) blokage
11
Q
most common pathogens of coryza
A
- Rhinovirus
- Coronavirus
- Respiratory syncytial virus
12
Q
mx coryza
A
- Health education , no curative tx
- Pain: paracetamol, ibux
- Cough: may persist up to 4 w after, cough sirup
13
Q
what is pharyngitis
A
- Pharynx and sof palate is inflamed
- local LN are enlarged and tende
14
Q
cause pharyngitis
A
Usually viral, adenovirus, enterovirus, rhinovirus. In older child: beta hemolytic streptococcus is a common pathogen
15
Q
what is tonsillitis
A
A form of pharyngitis where there is intense inflammation of the tonsils
16
Q
sx tonsillitis
A
- Purulent discharge of tonsils,
- constitutional disturbance( headache, apathy, abdominal pain), white tonsillar exudate and cervical lymphadenopaty. is more common w bacterial
17
Q
Causes of tonsilitis
A
- Group A betahemolytic streptococcus
- EBV (mononucleosis)
18
Q
mx of pharyngitis and tonsillitis
A
- ABs penicillin and erythromycin, but only 1/3 is of bacterial origin. It is to eradicate and prevent rheumatic fever, at least for 10 day.
19
Q
which AB should be avoided in sore throat
A
Amoxicillin because it may cause maculopapular rash if tonsillitis is due to EBV
20
Q
What does sore throat consists of
A
Pharyngitis and tonsillitis
21
Q
What is scarlet fever
A
- Caused by group A strep
- most common age 5-12yrs
- after headache and tonsillitis by 2-3 days
- the only childhood exanthema caused by a bacteria
22
Q
what does scarlet fever look like
A
- sandpaperlike maculopapular rash
- flushed cheeks
- perioral sparing
- white and coated tongue that may be swollen or sore (strawberry tongue)
23
Q
mx scarlet fever
A
penicillin V or erythromycin
24
Q
what is the complications of scarlet fever
A
Acute glomerulonephritis and rheumatic fever
25
what is most common age of otitis media
6- 12m
26
why are young children prone to AOM
- Short eustachian tubes
- They are horizontal,
- They function poorly
27
Presentation of AOM
- pain in ear
- fever
- tympanic membrane is bright red and bulging w loss of normal light reflex or perforation
- Pus
28
what are the pathogens of AOM
- Virus: RSV and Rhino
| - Bacteria: pneumococcus, H. influenzae, Moraxella catharrhalis
29
what are the complications of AOM
1) mastoiditis 2) meningitis 3) conductive hearing loss
| but they are uncommon
30
mx of AOM
- analgesics
- most resolve spontaneously
- give prescription but not use unless child remains unwell after 2-3 days
- Amoxicillin
- adenectomy, grommet insertion
31
Tonsillectomy indications
1) recurrent severe tonsillitis 2) peritonsillar abscess (quinsy) 3) onstructive sleep apnea
32
Adenectomy indications
1) recurrent OM w effusion w hearing loss
| 2) obstructive sleep apnea (absolute)
33
sinusitis
- Not common in first decade of life bc frontal sinuses is not developed
- In paranasal sinus w viral inf
- Sometimes secondary bacterial inf: 1) pain 2) swelling 3) tenderness over the check from maxillary sinus
- tx is analgesics and ABs
34
what does stridor sound like
A harsh musical sound
35
what is obstructed w stridor
trachea and larynx
36
what is the most common cause of stridor
Laryngeal or tracheal infection
37
how is severity of stridor assessed
1) none
2) only on crying
3) at rest
4) biphasic
38
What is croup?
= laryngotracheobronchitis / falsk krupp
39
cause of croup
1) parainfluenza 2) rhino 3) RSV 4) influenza
40
age group typical for croup
6m- 6yrs, peak is 2 yrs
41
at what time croup is more common
Autumn
42
Clinical features of croup
1) hoarseness 2) barking cough 3) harsh stridor 4) difficulty w breathing 5) sx often start at night and are worse at night 6) coryza
43
mx of croup
- usually at home, but low threshold for admission <12 m due to narrow airway
- Oral dexamethasone, oral prednisolone ...nebulized steroids (budesonide): reduce severity and duration, 1st line tx w chest recession at rest
- In severe obstruction: nebulized epinephrine w oxygen by facemask
- observation for 2-3hrs
44
what is acute epiglottitis
- "Strupelokksbetennelse
- Intense sweeping of epiglottis and surrounding tissues
- Life threatening emergency due to high risk of resp obstruction
- Caused by H. influenza type B (Hib)
- Most common in age 1-6yrs, but affects all age groups
45
presentation epiglottis
- Acute onset, over hrs
- High fever in vey ill toxic looking child
- Intense painfull throat, prevents from speaking, eating
- Saliva drools from chin
- Soft inspiratory stridor
- Sitting immobile, upright, w open mouth
- Cough is minimal or absent
- Fever > 38 C
46
mx epiglottitis
1. Urgent admisson and tx -> ICU
2. Intubation or tracheostomy, remove after 24h
3. IV ABs, cefuroxime for 3-5days
4. Prophylaxis w Rifampicin to close contacts
47
Ddx of stridor
- Croup
- Epiglottitis
- Bacterial tracheitis
- Laryngeal or esophageal foreign body
- Allergic laryngeal angioedema (anaphylaxis and recurrent croup)
- Inhalation of smoke and hot fumes in fires
- Trauma to throat
- Retropharyngeal abscess
- Hypocalcemia
- Severe LN swelling (TB, mono, malignancy)
- Mesles
- Diphteria
- Psychological, vocal cord dysfunction
48
Bacterial tracheitis
- "pseudomembraneous croup, trakeitt, akutt trakeitt"
- Rare but dangerous, similar to epiglottitis
- 1) fever 2) appear very ill 3) rapidly progressive airways obstruction 4) copious thick airway secretions
- Caused på Staph. aureus
- mx: IV ABs, intubation and ventilation if needed
49
Laryngomalacia
- Most common airway anomaly, and most frequent cause of chronic stridor in infants and children
- Collapse of supraglottic structures during inspiration
- Starts in first 2w, sx increase up to 6m and is exacerbated by exertion
- dx w laryngoscopy, bronchoscopy
- tx is supportive, or surgery w supraglottoplasty
50
Subglottic stenosis
2nd most common cause of chronic stridor. Presentation w 1) recurrent/persistent croup 2) stridor (no difference w supine and prone). Dx w CXR and laryngoscopy. Tx w surgery, cricoid split or reconstruction.
51
Vocal cord paralysis
Is 3rd most common cause of chronic stridor. Often ass w meningomyelocele, Chiari malf., hydrocephalus. May be acquired after surgery (CHD, TEF repair).
If bilateral: airway obst., high pitched insp. stridor
If unilateral: aspiration, cough, choking, weak cry
Dx w flexible bronchoscopy. TX usually resolves in 6-12m, temporary tracheostomy
52
What causes a wheeze
Due to partial obstruction of the intrathoracic airways from mucosal inflammation and swelling or brochoconstriction
53
What is the most common serious resp inf of infancy?
Bronchiolitis
54
Pathogen bronchiolitis
1) RSV (80%) 2) Parainfluenza 3) Rhinovirus 4) Adenovirus 5) Influenza virus 6) metapneumovirus (often co-inf w RSV)
55
Age in brochiolitis
90% are 1-9m
56
Presentation of bronchiolitis
1) Dry wheezy cough 2) TP, TC 3) Subcostal and intercostal recession 4) Hyperinflation of the chest 5) Fine end inspiratory crackles 6) High pitched wheezes, exp > insp 7) Feeding difficulties, often reason for admission
57
What are indications for hospital admission in bronchiolitis
1. Apnea
2. Sats < 90% on air
3. Inadequate fluid intake (50-70% of usual volume)
4. Severe resp distress
58
mx bronchiolitis
- Supportive: fluids, ventilation (CPAP)
- Inf. control measures
- Most recover from acute inf within 2w
- 1/2 wil have recurrent episode of cough and wheese
59
what are a rare complication of adenovirus bronchiolitis?
Permanent damage to airways, "bronchiolitis obliterates"
60
What are the patterns of wheezing in asthma
1. Viral episodic wheezing
2. Multiple trigger wheeze
3. Asthma
61
Viral episodic wheezing (asthma)
Wheeze only in response to viral inf
62
Multiple trigger wheeze
In response to multiple triggers, more likely to develop asthma over time. Triggers are virus, cold air, dust, animal dander, exercise. When evidence of allergy to one or more allergens (inhaled) dx of atopic asthma. Ass w eczema, rhino conjunctivitis, food allergy
63
Etiology of asthma
- Genetic
- Atopy
- Environmental trigger
64
Bronchial inflammation in asthma w ?
Edema, excessive mucus, infiltration of cells (eosinophils, mast cell, neutrophils, lymphocyte)
65
What is bronchial hyper responsiveness in asthma
Exaggerated twitchiness to inhaled stimuli
66
Sx asthma
1) cough 2) breathlessness 3) chest tightness
67
What are clinical features of circumstantial properties of asthma, underlining dx
1) FH w atopy 2) wheeze on more than one occasion 3) sx worse at night / early in the morning 4) nonverbal trigger 5) Interval sx 6) positive response to tx 7) Harrison sulci
68
What does wet cough or sputum production, finger clubbing and poor growth suggest?
Chronic inf, eg in CF or bronchiectasis
69
Dx of asthma
- Skin prick test for allergens, atopy and triggers
- CXR is usually normal, exclude other conditions
- PEFR: peak expiratory flow (less sensitive to changes)
- Spirometry to check FEV1 (forced expiratory volume). W bronchodilator an improvement >_ 12 % in FEV1
70
MX in asthma
- Bronchodilator tx:
1. inhaled B2-agonist, short acting, salbutamol (ventolin) and terbutalin. Effective for 2-4hrs
2. LABA: salmeterol, formeterol. Effective for 12h, not in acute asthma, useful in exercise induced
- Inhaled corticosteroids (Solu-Cortef): most effective prophylaxis. Decrease inflammation. W inhaled LABA or leukotriene antagonist
- Anti -IgE
- Avoid allergen
71
what is 1st choice add-on tx in asthma
> 5 yrs LABA, <5yrs leukotriene antagonist (montelukast)
72
Anti-Ig E tx in asthma
Omalizumab
73
Monitoring in steroid tx in asthma
- Growth
| - But also consider other SE: adrenal suppression, altered bone metabolism
74
Acute asthma criteria for admission
1. Do not respond adequately to high-dose tx
2. Are becoming exhausted
3. Still a reduction in PEF and FEV1
4. Sats < 92% on air
5. CXR w unusual features eg. asymmetry, inf
6. ABG: life- threatening or refractory case. Often normal until extremes
75
DDX of recurrent or persisting wheezing in childhood
- Viral episodic wheeze
- Multiple trigger wheeze
- Asthma
- Recurrent anaphylaxis (eg. food allergy)
- Chronic aspiration
- CF
- BPD
- Bronchiolitis obliterans
- Tracheo-bronchomalacia
76
DDX of breathlessness in older child
- Asthma
- Pneumonia or lower resp tract inf
- Foreign body
- Anaphylaxis
- Pneumothorax
- Metabolic acidosis, DKA, IEM, lactic acidosis
- Severe anemia
- HF
- Panic attacks (hyperventilation)
77
Inhaler corrected for ages
- Pressureized metered dose inhaler and spacer: 0-2 yrs, spacer and facemask >3yrs. Acute attack
- Breath-actuated metered dose inhalers: 6+ yrs
- Dry powder inhaler: 4+ yrs. Less good in attack.
- Nebilizer: any age, when oxygen in needed in acute, in addition to inhaled drugs
78
How to differentiate cough
- Dry
- Moist
- Barking
79
Dry cough
W prolonged expiratory phase. Caused by narrowing of the small- moderate sized airways
80
Barking cough
A degree of tracheal inflammation, narrowing or collapse
81
Moist cough
Either increased mucus secretion or inf of lower airway
82
Cough reflex
Expel unwanted material below the glottis. Most commonly due to tracheobronchial spread of URTIs by the common cold virus
83
What is whooping cough
"Kikhoste" is a highly contagious resp inf caused by broadtail pertussis. Is endemic every 3-4yrs
84
Presentation whopping cough
- 1w w coryza (catarrrhal phase)
- Paroxysmal/spasmodic cough, worse at night
- Chough followed by "whop" (paroxysmal phase)
- Cough may culminate vomiting
- Child goes red/blue in face during paroxysms
- Epistaxis and subconjunctival hemorrhage after cough
- Sx gradually decrease
85
Complications of whooping cough
1) Pneumonia 2) Seizures 3) Bronchiectasis, are uncommon but w significant mortality, esp w/o vaccine
86
admission whopping cough if
1) suffering severe spasms 2) cyanotic attack
87
dx whooping cough
Culture from prenatal swab, PCR (more sensitive), lymphocytosis >15x10^9
88
Whooping cough mx
Macrolides, decrease sx only if taken in catharral phase. Close contacts should receive vaccine, and ABs. Reimmunization of mothers during pregnancy decrease risk.
89
Persistent or recurrent cough
- Is most commonly series of resp inf. Some cough for months w pertussis, RSV or mycoplasma.
- Other causes: 1) asthma 2) persisten lobar collapse following pneumonia 3) recurrent aspiration +/- GER 4) Inhaled foreign body 5) cigarette smoking (active/passive) 6) habit cough 7) Airway anomalies
90
Persistent cough definition
>8w lasting or not improving for 3-4w. Absence of recurrent URTI
91
What can persistent cough might indicate?
1) unresolved lobar collapse 2) bacterial bronchitis 3) suppurative lung disease. 4) TB should be considered.
92
Pneumonia age
Incidence peak in infancy and old age but relatively high in childhood. Major cause of death in low and middle income countries
93
Pneumonia pathogens
- In 50% no pathigen identyfied
- Virus is most common in younger child, bacteria in older child
- Newborn: from mothers GU tract, group B strep, mag neg. enterococci and bacilli
- Infant/young child: RSV, S.pneumonia, H.influenzae, B.pertussis , C.trachomatis, S. aureus (infrequent)
- Child >5yrs: Mycoplasma, S.pneumonia, C. pneumonia
- At all ages: TB
94
Presentation of pneumonia
1) Fever 2) Cough 3) TP 4) recurrent URTI 5) lethargy 6) poor feeding 7) unwell child 8) localized chest/abd/neck pain (pleural irritation often bacterial) 9) Nasal flaring 10) chest indrawing 11) end-inspiratory crackles over affected area 12) dullness on percussion 13) decreased breath sounds 14) Decreased sats
95
Dx of pneumonia
- CXR, may confirm but not differentiate btw viral/ bacterial
- Nasopharyngeal aspirate for viral causes
- Blood: CBC and acutephase reactant
96
MX pneumonia
- Supportive w O2 and analgesia, IV fluids
- ABs, newborn: broad spectrum, older infant: amoxicillin, >5 yrs amoxicillin or macrolide
- W persisten fever >48hrs, pleural collection that requires drainage + fibrinolytic agent (break down fibrin strands)
97
Admission pneumonia
1. Sats <92%
2. Recurrent apnea
3. Grunting
4. inabillity to feed/ fluid intake
98
what is CF
Most common life-limiting AR condition in Caucasians. Incidence 1 in 2500 births, carrier rate of 1 in 25. Life-Expectancy is mid 30s (40s). Defective protein called the CF transmembrane conductance regulator (CFTR)
99
what is CFTR
CF transmembrane conductance regulator. A cyclic Amp-dependent chloride channel found in membranes of cells. Are on chr. 7, over 900 mutations discovered. Most frequent is F508. Some are milder.
100
Pathophysiology of CF
- Multisystem disorder
- Abnormal transport across epithelial cells
- Airway: decrease in surface liquid layer + consequent impaired ciliary function + retention of mucopurulent secretion = chronic endobronhial inf
- Immune: dysregulation of inflammation and defense
- GI: thick viscid meconium is produced, meconium ileus in 10-20 %
- Pancreas: ducts are blocked by thick secretions which cause enzyme deficiency and malabsorption
- Sweat: abnormal function, excessive concentrations of Na and Cl in sweat
101
Different classes of mutation in CF
1. Nonsense/frameshift - no protein synth
2. Incorrect folding, cannot traffic membrane
3. Channel opening defect
4. Pore abnormality, cause decreased conductance
5. Splicing abn, reduced protein synth
6. Shortened half-life of protein
102
Clinical in newborn CF
All newborns are screened. Meconium ileus
103
Clinical infancy CF
1) prolonged neonatal jaundice 2) growth faltering 3) recurrent chest inf 4) malabsorption, steatorrhea
104
Clinical young child CF
1) bronchiectasis 2) rectal prolapse 3) nasal polyp 4) sinusitis
105
Clinical older child/adolescent CF
1) allergic bronchopulmonary aspergillosis 2) DM 3) cirrhosis and portal HT 4) distal intestinal obstruction (meconium ileus equivalent) 5) Pneumothorax or recurrent hemoptysis 6) sterility in males
106
What are the chronic inf w bacteria in CF
S. aureus, H.influenza, Pseudomonas, Bukholderia spp
107
What are the typical clinical signs in CF
Wet cough, air trapping, insp. crepitations, exp. wheeze, clubbing
108
dx CF
- The sweat test: Cl is elevated 60-120mm/dl (10-40 in normal child. Stimulated by pilocarpine, collected in capillary tube. Error if nor enough volume
- Gene testing, abn CFTR protein
109
mx CF
- Physio x 2 a day, clear secreations (percussion, postural, deep breathing exercise)
- Prophylactic ABs: flucloxacillin
- Nebulized DNase or hypertonic saline
- Transplant: end stage
- Pancreas: oral entericcoated replacement tx
- High caloric diet
- Teens: regular ursodeoxycholic acid (bile flow), liver transplant, laxatives, psychological support
110
what is primary ciliary dykinesia
Congenital abnormaity in the structure or function of cilia lining resp tract. Leads to impaired mucociliary clearance. Have recurrent URT LRT. May lead to severe bronchiectasis
111
presentation of PCD
1) recurrent productive cough 2) purulent nasal discharge 3) chronic ear inf 4) 50% have dextrocardia and situs inversus (Kartagener sd)
112
dx PCD
Examination of the structure of the cilia. Nasal epithelial cells brushed from nose
113
mx PCD
Daily physic to clear secretions. Proactive tx of inf w ABs. Appropriate ENT follow up
114
Tracheomalacia
A floppy trachea due to lack of structural integrity of tracheal wall. May not extend around circumference, be absent or present, but damaged. Can result in excessive collapse, most pronounced during exp.
115
tracheomalacia presentation
1) tracheoesophageal fistula 2) bony dysplasia sd 3) acquired from mechanical ventilation 4) may be exacerbated by viral inf (exp wheezing and barley cough5) may be mistaken for asthma/ bronchiolithis / croup 6) cyanotic episode w apnea
