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Coovadias Paediatrics > Respiratory disorders > Flashcards

Respiratory disorders Flashcards

1
Q

What cells make up the lining of the respiratory tract?

A

Pseudostratified columnar epithelium

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2
Q

What should you ask on respiratory history?

A 
URTI:
Blocked nose
Itching
Sneezing
Rhinorrhoea

LRTI:
Coughing (acute vs chronic, dry vs productive, colour, hyperresponsiveness)
Fever
Noisy breathing (stridor, snoring, wheezing, crackles)
Attacks (infection/asthma)

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3
Q

What is the clinical manifestation of nasal itching?

A

Allergic salute

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4
Q

Name complications of allergic rhinitis

A 
Recurrent sinusitis
Recurrent OM 
Grommets 
Snoring (adenoid hypertrophy)
Recurrent snore throat
Dental malocclusion (braces)
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5
Q

What do you suspect in a child with a hoarse voice and stridor?

A

Croup

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6
Q

What do you look for generally in a direct respiratory examination?

A

Clubbing
Lymph nodes
Anthropometry
Upper resp tract (facies, nose, ear, throat)

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7
Q

What is tachypnoea

A 
0-2m = >60
2-12m = >50
1-3 y = >40
4-10y = >35
>10y = >30
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8
Q

Name patterns of respiratory distress and what they entail

A 
Subcostal recession = bronchiolitis/asthma
Intercostal recession = pneumonia
Tracheal tug (UA obstruction)
Alar flaring (severe)
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9
Q

In which direction can a child’s trachea naturally deviate slightly?

A

Right

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10
Q

What could be a respiratory cause of a palpable P2 and LPH?

A

Pulmonary hypertension -> RVH

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11
Q

What do you look for on inspection in a direct respiratory examination?

A

Scars (thoracotomy, stenotomy)
Chest expansion
Shape
Pattern of resp distress

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12
Q

What do you look for on palpation in a direct respiratory examination?

A

Trachea position
Apex beat
LPH
Palpable P2

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13
Q

What do you look for on percussion in a direct respiratory examination?

A

Front (upper lobes)
Right axilla (right middle lobe) and left axilla (lingular segment)
Back (lower lobes)
Heart and upper border of liver

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14
Q

What are you percussing in the left axilla?

A

Lingular segment of upper left lobe

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15
Q

What is dullness in the right middle lobe a sign of?

A

Atelectasis eg asthmatic

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16
Q

What is dullness in the lower lobes a sign of? And if this dullness is stony dull?

A

Free fluid

Stony dull = pleural effusion

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17
Q

What do you look for on auscultation in a direct respiratory examination?

A

Mouth (snoring)
Trachea (stridor)
Breath sounds
Crackles

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18
Q

What are signs of acute illness?

A

Respiratory distress
Dehydration
Seizures
Wasting

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19
Q

What are signs of chronic illness?

A

Deformities
Stunting
Wasting
Contractures

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20
Q

How does the mechanism of central cyanosis differ to peripheral cyanosis

A 
Central = saturation issue
Peripheral = circulation issue
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21
Q

Name causes of clubbing

A 
Suppurative lung disease
Cystic fibrosis
IE
Liver cirrhosis
Ulcerative colitis
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22
Q

Name signs of respiratory distress

A

Recessions
Accessory muscle use
Nostril flaring
Head bobbing

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23
Q

What is Hoover sign indicative of?

A

Hyperinflation -> peripheral airway disease

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24
Q

What is a chronic Hoover sign known as?

A

Harrison sulcus

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25
Q

What is stertor and what is it a sign of?

A

Stertor = snoring, low pitched sound

Indicates obstruction in nasal, nasopharyngeal or oropharyngeal areas

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26
Q

What is stridor and what is it a sign of?

A

Stridor = musical sound on inspiration

Indicates obstruction of upper airway

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27
Q

What is wheezing and what is it a sign of?

A

Wheezing = musical sound on expiration

Indicates obstruction of distal airways

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28
Q

What is grunting and what is it a sign of?

A

Grunting = expiratory sound due to exhalation against partially closed glottis
Indicates severe resp distress 2nd to lower airway disease

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29
Q

Name causes of a pectus carinatum

A

Idiopathic lung disease
Chronic lung disease
Rickets
Connective tissue disease

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30
Q

Name causes of a pectus excavatum

A

Idiopathic tissue disease
Connective tissue disease
Neuromuscular
Repaired diaphragmatic hernia

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31
Q

Name reasons for a hyperresonant lung

A

Hyperinflation
Pneumothorax
Amphysema

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32
Q

Name reasons for a dull lung

A

Consolidation
Collapse
Pleural thickening
Fibrosis

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33
Q

How can you check if the lung sounds are simply transmitted sounds?

A

Listen over cheek/mouth

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34
Q

Practice video on respiratory distress in paediatrics fifth year at 42minutes

A

x

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35
Q

What are the 2 criteria for acute otitis media?

A

Hyperaemia

Bulging tympanic membrane

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36
Q

Which frontal view is more common in older child and adult?

A

Posteroanterior

AP used in non-cooperative children

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37
Q

How do you decide the inspiration on a CXR?

A

Normal = 8/9 posterior rib OR 5-6 anterior rib
Hyperinflation = >9 post OR >6 anterior
Poor inspiration = <8 posterior ribs

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38
Q

Discuss the systematic review of a CXR

A
  1. Trachea and bronchi
  2. Hilar structures
  3. Mediastinum
  4. Heart
  5. Lungs/pleural cavities
  6. Diaphragms/costophrenic angle
  7. Below diaphragm
  8. Bones
  9. Soft tissue
  10. Hidden areas
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39
Q

Which hilum is slightly higher?

A

Left hilum is slightly higher than the right hilum

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40
Q

Define an acute asthma attack

A

Progressive increase in typical asthma symptoms not responding to its usual bronchodilator therapy

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41
Q

Define near fatal asthma

A

Acute asthma attack assoc w/ respiratory arrest/hypercapnia

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42
Q

Name clinical signs of moderate asthma exacerbation

A

Able to talk in sentences
Pulse rate normal
RR normal
PEFR>50%

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43
Q

Name clinical signs of severe asthma exacerbation

A 
Tachypnoea
Tachycardia
Accessory mm use
Agitation
Unable to complete sentences in 1 breath
Too breathless to feed
PEFR 33-50%
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44
Q

Name clinical signs of life-threatening asthma

A 
Silent chest
Cyanosis
Poor resp effort
Hypotension
Exhaustion
Confusion
Drowsiness
Bradycardia (preterminal event!)
PEFR <33%
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45
Q

Discuss management of an acute asthma attack

A
  1. High flow oxygen
  2. SABA
    - 2 puffs every 2min up to 10puffs and repeat every 20-30min
    - salbutamol 2.5-5mg dilute w/ saline to volume of 4ml and repeat every 20-30min
  3. Corticosteroid
    - oral prednisone 1mg/kg/day x 3-5 days
    OR
  4. SAMA
    - IB 250mcg to normal SABA dose
  5. IV magnesium sulphate
    - 50mg/kg/hr if poor tx response
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46
Q

How long does steroid treatment take to work in acute asthma attack?

A

After 4 hours

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47
Q

What can you give to help the child/parents remember how to control their asthma?

A

Asthma plan

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48
Q

What sign will you look for on CXR for croup?

A

Steeple sign

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49
Q

What is croup also known as?

A

Laryngotracheobronchitis

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50
Q

What is the most common cause of LTB?

A

Parainfluenza virus

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51
Q

Name the clinical signs of LTB

A

Barking cough
Hoarseness
Stridor

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52
Q

What setting does croup usually present?

A

Age 6-24m
Autumn/early winter
At night

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53
Q

Classify the severity of croup

A

Grade 1: inspiratory stridor
Grade 2: + passive expiratory stridor
Grade 3: + active expiration w/ access mm + pulsus paradoxus
Grade 4: cyanosis, marked retractions, impending apnoea

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54
Q

How do you treat croup?

A

Grade 1: steroids
Grade 2: steroids and adrenaline nebs
Grade 3-4: steroids and adrenaline nebs + intubate

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55
Q

Name clinical signs of epiglottitis

A

High fever
Tripod position
Drooling

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56
Q

What is the junior and adult dose for adrenaline epipen?

A 
Jnr = 0.15mg
Adult = 0.3mg
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57
Q

What is the dose of adrenaline for anaphylaxis?

A

10mcg/kg (max 500mcg)

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58
Q

Name common URTIs

A 
Viral rhinitis
Rhinosinusitis
Otitis media
Mastoiditis
Tonsillitis
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59
Q

What is the most common cause of viral rhinitis?

A

Rhinovirus

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60
Q

Name clinical features of viral rhinitis

A 
Nasal stuffiness
Nasal discharge
Throat irritation
Fever
Cough w/o tachypnoea
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61
Q

Why is acute bacterial rhinosinusitis uncommon in children younger than 5 years old?

A

Sinuses are not fully developed

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62
Q

Name clinical features of acute bacterial rhinosinusitis

A 
Common cold gets worse
Headache
Purulent nasal discharge
Pain/tenderness over sinuses
Fever
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63
Q

What is the treatment for acute bacterial rhinosinusitis?

A

45mg/kg/dose 12hrly for 5 days

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64
Q

Which sinuses are present at birth?

A

Maxillary

Ethmoid

65
Q

When does the sphenoid sinus develop?

A

4 years old

66
Q

When does the frontal sinus develop?

A

6 years old

67
Q

Name complications of bacterial rhinosinusitis

A

Orbital

  • preseptal periorbital cellulitis
  • postseptal periorbital cellulitis

Intracranial

  • meningitis
  • abscess
  • cavernous sinus thrombosis
68
Q

How do you treat the complications of bacterial rhinosinusitis?

A

REFER!

Admit -> IV ceftriaxone 50-80mg/kg daily

69
Q

Differentiate preseptal vs postseptal cellulitis

A 
Preseptal = normal eye examination
Postseptal = abnormal eye examination
70
Q

What will be anormal on the eye examination in a patient with postseptal orbital cellulitis?

A 
Erythema
Chemosis
Proptosis
Vision loss
Ophthalmoplegia
71
Q

Name pathogens that cause acute otitis media

A

Strep pneumo

Haemophilus influenza

72
Q

Name clinical features of acute otitis media

A 
Fever
Earache
Irritability lying down
Pulling of ear
Acute purulent otorrhoea
73
Q

What is the treatment of acute otitis media?

A

Children >6mo wait 72hours
45mg/kg amoxicillin 12hrly (strep pneumo) x 5d
Augmentin (haemophilus influenza) x 5d

74
Q

When do you refer otitis media with effusion to ENT for grommets?

A

Persistent OM (>3m)

75
Q

What are clinical features of mastoiditis?

A

Swelling/redness in postauricular area

Pinna down and forwards

76
Q

How do you treat mastoiditis?

A

REFER!

Admit -> IV ceftriaxone 50-80mg/kg daily

77
Q

How do you treat tonsillitis?

A

Phenoxymethylpenicillin oral for 10 days
Benzathine benzylpenicillin, IM , single
Amoxicillin, oral, 50 mg/kg daily for 10 days

78
Q

Name complications of tonsillitis

A

Peritonsillar abscess
Parapharyngeal abscess
Retropharyngeal abscess

79
Q

How do you treat complications of tonsillitis?

A

REFER!

Admit -> IV augmentin

80
Q

Name causes of stertor

A 
Allergic rhinitis
Choanal atresia
Adenoid hypertrophy
Hypotonia
Tonsillitis
81
Q

What are consequences of nose obstruction in the infant?

A

Difficulty feeding
Poor growth
Apnoea

82
Q

What are consequences of nose obstruction in older children?

A 
Neurological
- lethargy
- irritability
- ADHD
- poor school performance
Cardiac
- hypoxia -> PH -> cor pulmonale -> cardiac failure
Enuresis nocturia
83
Q

How can you diagnose OSA in children?

A

Polysomnograph
Standardized questionnaire
Nocturnal saturation monitoring
Video recorded by parents

84
Q

How do you treat OSA in children?

A

Nasal steroid spray

Continues? REFER

85
Q

What conditions are assoc with OSA in children?

A 
Obesity
Craniofacial abnormalities
Midface hypoplasia
Muscle weakness
Tone weakness
86
Q

Which children can have midface hypoplasia?

A

Down syndrome

87
Q

How do you test for choanal atresia?

A

Try to pass suction catheter through the nose

88
Q

Name causes of acute onset stridor

A 
Supraglottic:
Anaphylaxis
Epiglottitis
Retropharyngeal abscess
Paratracheal gland enlargement
FB
LTB
Trauma
Bacterial tracheitis
89
Q

Name organisms other than parainfluenza virus that are known for causing LTB

A

HSV
Measles
Candidiasis (HIV+)

90
Q

What is the management of epiglottitis?

A

Secure airway

IV ceftriaxone

91
Q

Where do FBs often get lodged?

A

Between vocal cords and cricoid cartilage

92
Q

Name causes of chronic stridor

A 
Laryngomalacia
Laryngeal web
Laryngeal cyst
Subglottic stenosis
Vascular compression
Laryngeal papillomatosis
93
Q

Name clinical features of laryngomalacia

A

> 14 days old

Inspiratory stridor that improves when prone

94
Q

Name clinical features of pertussis

A

Paroxysmal cough w/ inspiratory whoop
Vomiting
Subconjunctival haemorrhage

95
Q

How do you diagnose pertussis?

A

Leucocytosis
PCR
Serology

96
Q

How do you treat pertussis?

A

Azithromycin

97
Q

What is the likely organism in an otitis media that doesn’t respond to augmentin?

A

Pseudomonas -> give fluoroquinolone

98
Q

Name common LRTIs

A 
Pneumonia
Brochiolitis
Bronchitis
Bronchiectasis
Tracheitis
Non-infectiou
99
Q

Name pathogens that cause LRTIs

A 
Bacterial
Viral
Atypical
Fungal
PJP
100
Q

Name complications of LTRIs

A 
Pleural effusion -> empyema
Necrotising pneumonia -> pneumotocele
Pneumothorax
Hypoxia
Resp failure
101
Q

What are the 3 signs of LRTI?

A

Fever
Cough
Tachypnoea

102
Q

Name clinical signs of pneumonia

A

Crackles
Bronchial breathing
Dull percussion
Indrawings

103
Q

Differentiate coarse vs fine crackles

A 
Coarse = fluid in large airway
Fine = fluid in alveoli
104
Q

Name kinds of indrawings and explain why they occur

A 
Subcostal
Tracheal tug
Supraclavicular
Intercostal
Paradoxical breathing

Alveoli close on expiration due to fluid -> need more negative pressure to open up collapsed alveoli -> body compensates

105
Q

Why does grunting occur?

A

Alveoli close on expiration due to fluid -> body tries to increase PEEP

106
Q

Why does bronchial breathing occur?

A

Alveoli not opening up -> loss of vesicular breathing -> bronchial breathing

107
Q

What investigations can you do when you suspect pneumonia?

A

CRP
Procalcitonin (more specific and sensitive but expensive)
WCC

108
Q

Name the common causative organisms of pneumonia in newborns

A

GBS

Enteric gram -

109
Q

Name the common causative organisms of pneumonia in children 1-3m

A

Chlamydia trachomatis
Ureaplasm
Viruses
Bordatella pertussis

110
Q

Name the common causative organisms of pneumonia in children 3-12m

A 
Viruses
Strep pneumo
Haemo influenza
Staph aureus
Moraxella catarrhalis
111
Q

Name the common causative organisms of pneumonia in children 1-5y

A

Viruses
Strep pneumo
Mycoplasmia pneumo
Chlamydia pneumo

112
Q

Name the common causative organisms of pneumonia in children >5y

A

Strep pneumo
Mycoplasma pneumo
Chlamydia pneumo

113
Q

Name the common causative organisms of pneumonia in HIV positive children

A 
Strep pneumo
Staph aureus
Haemo influenza
E coli
Salmonella
Klebsiella
Pseudomonas
Mycobacterium tuberculosis
114
Q

What is the treatment for pneumonia?

A 
Amoxicillin 80mg/kg/day twice daily x 5 days
Aminoglycoside for gram -
- neonates
- severe acute malnutrition
- HIV +

Severe pneumonia
- ampicillin + gentamycin

Atypicals
- macrolides

Necrotising
- cloxacillin (staph aureus)

115
Q

Why should you consider augmentin for pneumonia in Pretoria?

A

High incidence of beta lactamase producing haemophilus influenza

116
Q

What is normal oxygen saturation?

A

94% sea level

92% Gauteng

117
Q

When should you give oxygen in pneumonia?

A

Oxygen

118
Q

What are complications of oxygen use?

A

Ciliary clearance reduced (dry, cold O2)
Mucus plugs
Dry secretions -> obstruction
Radicals

119
Q

Give a differential diagnosis for pneumonia

A 
URTI
PCP
Asthma
Pulmonary TB
Chronic suppurative lung disease
120
Q

Name causative pathogens of bronchiolitis

A 
RSV
Rhinovirus
Adenovirus
Influenza
Parainfluenza
Metapneumovirus
Coronavirus
Enterovirus
121
Q

Discuss the pathogenesis of bronchiolitis

A

Virus uses TLR-4 to enter epithelial cells -> inflammation -> epithelial cell necrosis -> ciliary destruction -> mucus plug -> bronchiolar narrowing -> air trapping

122
Q

How do we treat bronchiolitis?

A

Oxygen therapy
Nasal decongestion
Feeding
No ABs!

123
Q

Name clinical signs of PCP

A 
Cough
SOB
Hypoxia
High LDH
High beta D glucan
PJP on sputum
124
Q

Name causative organisms of PCP

A

Pneumocystis jeruvicii

CMV

125
Q

Discuss management of PCP

A

Supportive

  • Oxygen
  • CPAP
  • Invasive ventilation

Pharmacological

  • bactrim
  • gancyclovir
  • systemic steroids
126
Q

Name clinical signs of asthma

A

Recurrent

  • cough
  • wheeze
  • SOB
127
Q

Name clinical signs of pulmonary TB

A

Chronic

  • cough
  • weight loss
  • night sweats
  • lymphadenopathy
128
Q

Name clinical signs of chronic suppurative lung diseases

A

Wet cough
Clubbing
Harrison’s sulcus

129
Q

What should you suspect in a patient with recurrent pneumonias (>2/year)

A

Primary immune deficiency

130
Q

Name red flags of chronic lung disease

A

Signs

  • stunting/wasting
  • hypoxia
  • clubbing
  • allergic face
  • chest wall deformity
  • persistent abnormalities on auscultation

Symptoms

  • cough >3w
  • productive cough
  • cough/choking on feeding
  • noisy breathing
  • dyspnoea
  • exercise intolerance
  • recurrent LRTIs
131
Q

Name chronic lung diseases

A 
Asthma
Bronchiectasis
Cystic fibrosis
Primary immunodeficiency
Primary ciliary dyskinesia
HIV assoc
Lymphoma
Mediastinal mass
Congenital d/o 
Diaphragmatic hernia
Cystic lung
CLD of prem
GERD
132
Q

What is bronchiectasis

A

Infection -> permanent destruction of bronchial walls and lung tissue -> impaired secretion clearing -> repeated LRTIs -> vicious cycle

133
Q

Name the clinical signs of bronchiectasis

A 
Chronic cough
Productive cough
Halitosis
Haemoptysis
Clubbing
Chest deformities
Hyperinflation
FTT
Stunting
Pulmonary hypertension 
Cor pulmonale
134
Q

Name causes of focal bronchietasis

A

FB

Endobronchial mass

135
Q

Name causes of diffuse bronchiectasis

A 
HIV
TB
Primary ciliary dyskinesia
Aspiration
Mediastinal mass
136
Q

Name causes of aspiration

A

Neuromuscular disease
Cleft lip/palate
Tracheosophageal fistula
GERD

137
Q

Name causes of bronchiectasis

A

Cystic fibrosis vs non-cystic fibrosis

138
Q

Discuss the management of bronchiectasis

A 
PT
Immunisation
Azithromycin 
Lobectomy
Treat acute episodes w/ ABs (augmentin)
Treat underlying cause
139
Q

What is cystic fibrosis?

A

Autosomal recessive defect in CF transmembrane conductance regulator gene on chromosome 7 which is responsible for chloride channel ion transport -> water follows chloride out the cell -> abnormal viscous mucus -> plugs -> recurrent infections

140
Q

What is the most common cystic fibrosis mutation?

A

DeltaF508 (caucasian)

31201GA (african)

141
Q

Which systems does cystic fibrosis impact?

A 
Sinuses
Sweat glands
Pancreas
Lungs
Reproductive system
GIT
142
Q

What is the common, non-pulmonary presentation of cystic fibrosis?

A

Cholestatic jaundice -> fat malabsorption (steatorrhoea) -> ADEK deficiency

143
Q

How is cystic fibrosis diagnosed?

A

Sweat chloride test
Stool faecal elastase
Genetics

144
Q

Discuss treatment of cystic fibrosis

A 
Lungs
- nebulise
- PT
- ABs
- transplant
Pancreatic enzyme replacement
145
Q

Why is azithromycin given in CF and bronchiectasis?

A

Role in immunomodulation

146
Q

Name HIV related chronic lung diseases

A 
Bronchiectasis
Lymphocytic interstitial pneumonitis
T and B cell lymphoma
Pulmonary TB
Kaposi's sarcoma
147
Q

What is lymphocytic interstitial pneumonitis?

A

Chronic lymphocytic infiltrative disease due to dysregulated immune response to HIV/EBV interaction

148
Q

Name clinical signs of lymphocytic interstitial pneumonitis

A 
Chronic cough
SOB
Recurrent pneumonia
FTT
Clubbing
Lympadenopathy
Parotid enlargement
HSM
Barrel chest
Diffuse crackles
149
Q

How do we treat lymphocytic interstitial pneumonitis?

A

ARVs

Prednisone 2mg/kg for 30 days (symptomatic)

150
Q

What are typical features of lymphocitis interstitial pneumonitis and what is this confused with?

A

Peribronchiolar lymphoid follicles
Lymphocytic infiltration of alveolar spaces

Miliary TB

151
Q

What are clinical features of pulmonary TB

A 
Chronic cough
Weight loss
Night sweats
Poor appette
Haemoptysis
152
Q

How do you diagnose pulmonary TB?

A

CXR
AFB+ gene Xpert (sputum)
Mantoux test

153
Q

How do you treat pulmonary TB

A

RIPES

2nd line = kanamycin, amikacin, ofloxacin, levofloxacin (KOAL)

154
Q

What are clinical features of bronchiolitis obliterans

A

Hyperinflation
Wheeze
Crackles

155
Q

How do you treat bronchiolitis obliterans?

A

ARVs

156
Q

What is primary ciliary dyskinesia

A

Autosomal recessive disorder -> defects of cilia -> impaired mucous clearance

157
Q

What do you suspect in a patient with primary ciliary dyskinesia and situs inversus?

A

Kartagener syndrome

158
Q

Name clinical features of primary immunodeficiency diseases

A 
Recurrent ENT infections
Resp infections
Bronchiectasis
FTT
Severe eczema
Intractable diarrhoea
Pyogenic infection
159
Q

How do you treat primary immunodeficiency diseases

A

Treat underlying condition
Vaccination
Prophylaxis
Immunoglobulin therapy

Coovadias Paediatrics (10 decks)

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