Respiratory disorders Flashcards
What cells make up the lining of the respiratory tract?
Pseudostratified columnar epithelium
What should you ask on respiratory history?
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)
What is the clinical manifestation of nasal itching?
Allergic salute
Name complications of allergic rhinitis
Recurrent sinusitis Recurrent OM Grommets Snoring (adenoid hypertrophy) Recurrent snore throat Dental malocclusion (braces)
What do you suspect in a child with a hoarse voice and stridor?
Croup
What do you look for generally in a direct respiratory examination?
Clubbing
Lymph nodes
Anthropometry
Upper resp tract (facies, nose, ear, throat)
What is tachypnoea
0-2m = >60 2-12m = >50 1-3 y = >40 4-10y = >35 >10y = >30
Name patterns of respiratory distress and what they entail
Subcostal recession = bronchiolitis/asthma Intercostal recession = pneumonia Tracheal tug (UA obstruction) Alar flaring (severe)
In which direction can a child’s trachea naturally deviate slightly?
Right
What could be a respiratory cause of a palpable P2 and LPH?
Pulmonary hypertension -> RVH
What do you look for on inspection in a direct respiratory examination?
Scars (thoracotomy, stenotomy)
Chest expansion
Shape
Pattern of resp distress
What do you look for on palpation in a direct respiratory examination?
Trachea position
Apex beat
LPH
Palpable P2
What do you look for on percussion in a direct respiratory examination?
Front (upper lobes)
Right axilla (right middle lobe) and left axilla (lingular segment)
Back (lower lobes)
Heart and upper border of liver
What are you percussing in the left axilla?
Lingular segment of upper left lobe
What is dullness in the right middle lobe a sign of?
Atelectasis eg asthmatic
What is dullness in the lower lobes a sign of? And if this dullness is stony dull?
Free fluid
Stony dull = pleural effusion
What do you look for on auscultation in a direct respiratory examination?
Mouth (snoring)
Trachea (stridor)
Breath sounds
Crackles
What are signs of acute illness?
Respiratory distress
Dehydration
Seizures
Wasting
What are signs of chronic illness?
Deformities
Stunting
Wasting
Contractures
How does the mechanism of central cyanosis differ to peripheral cyanosis
Central = saturation issue Peripheral = circulation issue
Name causes of clubbing
Suppurative lung disease Cystic fibrosis IE Liver cirrhosis Ulcerative colitis
Name signs of respiratory distress
Recessions
Accessory muscle use
Nostril flaring
Head bobbing
What is Hoover sign indicative of?
Hyperinflation -> peripheral airway disease
What is a chronic Hoover sign known as?
Harrison sulcus
What is stertor and what is it a sign of?
Stertor = snoring, low pitched sound
Indicates obstruction in nasal, nasopharyngeal or oropharyngeal areas
What is stridor and what is it a sign of?
Stridor = musical sound on inspiration
Indicates obstruction of upper airway
What is wheezing and what is it a sign of?
Wheezing = musical sound on expiration
Indicates obstruction of distal airways
What is grunting and what is it a sign of?
Grunting = expiratory sound due to exhalation against partially closed glottis
Indicates severe resp distress 2nd to lower airway disease
Name causes of a pectus carinatum
Idiopathic lung disease
Chronic lung disease
Rickets
Connective tissue disease
Name causes of a pectus excavatum
Idiopathic tissue disease
Connective tissue disease
Neuromuscular
Repaired diaphragmatic hernia
Name reasons for a hyperresonant lung
Hyperinflation
Pneumothorax
Amphysema
Name reasons for a dull lung
Consolidation
Collapse
Pleural thickening
Fibrosis
How can you check if the lung sounds are simply transmitted sounds?
Listen over cheek/mouth
Practice video on respiratory distress in paediatrics fifth year at 42minutes
x
What are the 2 criteria for acute otitis media?
Hyperaemia
Bulging tympanic membrane
Which frontal view is more common in older child and adult?
Posteroanterior
AP used in non-cooperative children
How do you decide the inspiration on a CXR?
Normal = 8/9 posterior rib OR 5-6 anterior rib
Hyperinflation = >9 post OR >6 anterior
Poor inspiration = <8 posterior ribs
Discuss the systematic review of a CXR
- Trachea and bronchi
- Hilar structures
- Mediastinum
- Heart
- Lungs/pleural cavities
- Diaphragms/costophrenic angle
- Below diaphragm
- Bones
- Soft tissue
- Hidden areas
Which hilum is slightly higher?
Left hilum is slightly higher than the right hilum
Define an acute asthma attack
Progressive increase in typical asthma symptoms not responding to its usual bronchodilator therapy
Define near fatal asthma
Acute asthma attack assoc w/ respiratory arrest/hypercapnia
Name clinical signs of moderate asthma exacerbation
Able to talk in sentences
Pulse rate normal
RR normal
PEFR>50%
Name clinical signs of severe asthma exacerbation
Tachypnoea Tachycardia Accessory mm use Agitation Unable to complete sentences in 1 breath Too breathless to feed PEFR 33-50%
Name clinical signs of life-threatening asthma
Silent chest Cyanosis Poor resp effort Hypotension Exhaustion Confusion Drowsiness Bradycardia (preterminal event!) PEFR <33%
Discuss management of an acute asthma attack
- High flow oxygen
- 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 - Corticosteroid
- oral prednisone 1mg/kg/day x 3-5 days
OR - SAMA
- IB 250mcg to normal SABA dose - IV magnesium sulphate
- 50mg/kg/hr if poor tx response
How long does steroid treatment take to work in acute asthma attack?
After 4 hours
What can you give to help the child/parents remember how to control their asthma?
Asthma plan
What sign will you look for on CXR for croup?
Steeple sign
What is croup also known as?
Laryngotracheobronchitis
What is the most common cause of LTB?
Parainfluenza virus
Name the clinical signs of LTB
Barking cough
Hoarseness
Stridor
What setting does croup usually present?
Age 6-24m
Autumn/early winter
At night
Classify the severity of croup
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
How do you treat croup?
Grade 1: steroids
Grade 2: steroids and adrenaline nebs
Grade 3-4: steroids and adrenaline nebs + intubate
Name clinical signs of epiglottitis
High fever
Tripod position
Drooling
What is the junior and adult dose for adrenaline epipen?
Jnr = 0.15mg Adult = 0.3mg
What is the dose of adrenaline for anaphylaxis?
10mcg/kg (max 500mcg)
Name common URTIs
Viral rhinitis Rhinosinusitis Otitis media Mastoiditis Tonsillitis
What is the most common cause of viral rhinitis?
Rhinovirus
Name clinical features of viral rhinitis
Nasal stuffiness Nasal discharge Throat irritation Fever Cough w/o tachypnoea
Why is acute bacterial rhinosinusitis uncommon in children younger than 5 years old?
Sinuses are not fully developed
Name clinical features of acute bacterial rhinosinusitis
Common cold gets worse Headache Purulent nasal discharge Pain/tenderness over sinuses Fever
What is the treatment for acute bacterial rhinosinusitis?
45mg/kg/dose 12hrly for 5 days
Which sinuses are present at birth?
Maxillary
Ethmoid
When does the sphenoid sinus develop?
4 years old
When does the frontal sinus develop?
6 years old
Name complications of bacterial rhinosinusitis
Orbital
- preseptal periorbital cellulitis
- postseptal periorbital cellulitis
Intracranial
- meningitis
- abscess
- cavernous sinus thrombosis
How do you treat the complications of bacterial rhinosinusitis?
REFER!
Admit -> IV ceftriaxone 50-80mg/kg daily
Differentiate preseptal vs postseptal cellulitis
Preseptal = normal eye examination Postseptal = abnormal eye examination
What will be anormal on the eye examination in a patient with postseptal orbital cellulitis?
Erythema Chemosis Proptosis Vision loss Ophthalmoplegia
Name pathogens that cause acute otitis media
Strep pneumo
Haemophilus influenza
Name clinical features of acute otitis media
Fever Earache Irritability lying down Pulling of ear Acute purulent otorrhoea
What is the treatment of acute otitis media?
Children >6mo wait 72hours
45mg/kg amoxicillin 12hrly (strep pneumo) x 5d
Augmentin (haemophilus influenza) x 5d
When do you refer otitis media with effusion to ENT for grommets?
Persistent OM (>3m)
What are clinical features of mastoiditis?
Swelling/redness in postauricular area
Pinna down and forwards
How do you treat mastoiditis?
REFER!
Admit -> IV ceftriaxone 50-80mg/kg daily
How do you treat tonsillitis?
Phenoxymethylpenicillin oral for 10 days
Benzathine benzylpenicillin, IM , single
Amoxicillin, oral, 50 mg/kg daily for 10 days
Name complications of tonsillitis
Peritonsillar abscess
Parapharyngeal abscess
Retropharyngeal abscess
How do you treat complications of tonsillitis?
REFER!
Admit -> IV augmentin
Name causes of stertor
Allergic rhinitis Choanal atresia Adenoid hypertrophy Hypotonia Tonsillitis
What are consequences of nose obstruction in the infant?
Difficulty feeding
Poor growth
Apnoea
What are consequences of nose obstruction in older children?
Neurological - lethargy - irritability - ADHD - poor school performance Cardiac - hypoxia -> PH -> cor pulmonale -> cardiac failure Enuresis nocturia
How can you diagnose OSA in children?
Polysomnograph
Standardized questionnaire
Nocturnal saturation monitoring
Video recorded by parents
How do you treat OSA in children?
Nasal steroid spray
Continues? REFER
What conditions are assoc with OSA in children?
Obesity Craniofacial abnormalities Midface hypoplasia Muscle weakness Tone weakness
Which children can have midface hypoplasia?
Down syndrome
How do you test for choanal atresia?
Try to pass suction catheter through the nose
Name causes of acute onset stridor
Supraglottic: Anaphylaxis Epiglottitis Retropharyngeal abscess Paratracheal gland enlargement FB LTB Trauma Bacterial tracheitis
Name organisms other than parainfluenza virus that are known for causing LTB
HSV
Measles
Candidiasis (HIV+)
What is the management of epiglottitis?
Secure airway
IV ceftriaxone
Where do FBs often get lodged?
Between vocal cords and cricoid cartilage
Name causes of chronic stridor
Laryngomalacia Laryngeal web Laryngeal cyst Subglottic stenosis Vascular compression Laryngeal papillomatosis
Name clinical features of laryngomalacia
> 14 days old
Inspiratory stridor that improves when prone
Name clinical features of pertussis
Paroxysmal cough w/ inspiratory whoop
Vomiting
Subconjunctival haemorrhage
How do you diagnose pertussis?
Leucocytosis
PCR
Serology
How do you treat pertussis?
Azithromycin
What is the likely organism in an otitis media that doesn’t respond to augmentin?
Pseudomonas -> give fluoroquinolone
Name common LRTIs
Pneumonia Brochiolitis Bronchitis Bronchiectasis Tracheitis Non-infectiou
Name pathogens that cause LRTIs
Bacterial Viral Atypical Fungal PJP
Name complications of LTRIs
Pleural effusion -> empyema Necrotising pneumonia -> pneumotocele Pneumothorax Hypoxia Resp failure
What are the 3 signs of LRTI?
Fever
Cough
Tachypnoea
Name clinical signs of pneumonia
Crackles
Bronchial breathing
Dull percussion
Indrawings
Differentiate coarse vs fine crackles
Coarse = fluid in large airway Fine = fluid in alveoli
Name kinds of indrawings and explain why they occur
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
Why does grunting occur?
Alveoli close on expiration due to fluid -> body tries to increase PEEP
Why does bronchial breathing occur?
Alveoli not opening up -> loss of vesicular breathing -> bronchial breathing
What investigations can you do when you suspect pneumonia?
CRP
Procalcitonin (more specific and sensitive but expensive)
WCC
Name the common causative organisms of pneumonia in newborns
GBS
Enteric gram -
Name the common causative organisms of pneumonia in children 1-3m
Chlamydia trachomatis
Ureaplasm
Viruses
Bordatella pertussis
Name the common causative organisms of pneumonia in children 3-12m
Viruses Strep pneumo Haemo influenza Staph aureus Moraxella catarrhalis
Name the common causative organisms of pneumonia in children 1-5y
Viruses
Strep pneumo
Mycoplasmia pneumo
Chlamydia pneumo
Name the common causative organisms of pneumonia in children >5y
Strep pneumo
Mycoplasma pneumo
Chlamydia pneumo
Name the common causative organisms of pneumonia in HIV positive children
Strep pneumo Staph aureus Haemo influenza E coli Salmonella Klebsiella Pseudomonas Mycobacterium tuberculosis
What is the treatment for pneumonia?
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)
Why should you consider augmentin for pneumonia in Pretoria?
High incidence of beta lactamase producing haemophilus influenza
What is normal oxygen saturation?
94% sea level
92% Gauteng
When should you give oxygen in pneumonia?
Oxygen
What are complications of oxygen use?
Ciliary clearance reduced (dry, cold O2)
Mucus plugs
Dry secretions -> obstruction
Radicals
Give a differential diagnosis for pneumonia
URTI PCP Asthma Pulmonary TB Chronic suppurative lung disease
Name causative pathogens of bronchiolitis
RSV Rhinovirus Adenovirus Influenza Parainfluenza Metapneumovirus Coronavirus Enterovirus
Discuss the pathogenesis of bronchiolitis
Virus uses TLR-4 to enter epithelial cells -> inflammation -> epithelial cell necrosis -> ciliary destruction -> mucus plug -> bronchiolar narrowing -> air trapping
How do we treat bronchiolitis?
Oxygen therapy
Nasal decongestion
Feeding
No ABs!
Name clinical signs of PCP
Cough SOB Hypoxia High LDH High beta D glucan PJP on sputum
Name causative organisms of PCP
Pneumocystis jeruvicii
CMV
Discuss management of PCP
Supportive
- Oxygen
- CPAP
- Invasive ventilation
Pharmacological
- bactrim
- gancyclovir
- systemic steroids
Name clinical signs of asthma
Recurrent
- cough
- wheeze
- SOB
Name clinical signs of pulmonary TB
Chronic
- cough
- weight loss
- night sweats
- lymphadenopathy
Name clinical signs of chronic suppurative lung diseases
Wet cough
Clubbing
Harrison’s sulcus
What should you suspect in a patient with recurrent pneumonias (>2/year)
Primary immune deficiency
Name red flags of chronic lung disease
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
Name chronic lung diseases
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
What is bronchiectasis
Infection -> permanent destruction of bronchial walls and lung tissue -> impaired secretion clearing -> repeated LRTIs -> vicious cycle
Name the clinical signs of bronchiectasis
Chronic cough Productive cough Halitosis Haemoptysis Clubbing Chest deformities Hyperinflation FTT Stunting Pulmonary hypertension Cor pulmonale
Name causes of focal bronchietasis
FB
Endobronchial mass
Name causes of diffuse bronchiectasis
HIV TB Primary ciliary dyskinesia Aspiration Mediastinal mass
Name causes of aspiration
Neuromuscular disease
Cleft lip/palate
Tracheosophageal fistula
GERD
Name causes of bronchiectasis
Cystic fibrosis vs non-cystic fibrosis
Discuss the management of bronchiectasis
PT Immunisation Azithromycin Lobectomy Treat acute episodes w/ ABs (augmentin) Treat underlying cause
What is cystic fibrosis?
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
What is the most common cystic fibrosis mutation?
DeltaF508 (caucasian)
31201GA (african)
Which systems does cystic fibrosis impact?
Sinuses Sweat glands Pancreas Lungs Reproductive system GIT
What is the common, non-pulmonary presentation of cystic fibrosis?
Cholestatic jaundice -> fat malabsorption (steatorrhoea) -> ADEK deficiency
How is cystic fibrosis diagnosed?
Sweat chloride test
Stool faecal elastase
Genetics
Discuss treatment of cystic fibrosis
Lungs - nebulise - PT - ABs - transplant Pancreatic enzyme replacement
Why is azithromycin given in CF and bronchiectasis?
Role in immunomodulation
Name HIV related chronic lung diseases
Bronchiectasis Lymphocytic interstitial pneumonitis T and B cell lymphoma Pulmonary TB Kaposi's sarcoma
What is lymphocytic interstitial pneumonitis?
Chronic lymphocytic infiltrative disease due to dysregulated immune response to HIV/EBV interaction
Name clinical signs of lymphocytic interstitial pneumonitis
Chronic cough SOB Recurrent pneumonia FTT Clubbing Lympadenopathy Parotid enlargement HSM Barrel chest Diffuse crackles
How do we treat lymphocytic interstitial pneumonitis?
ARVs
Prednisone 2mg/kg for 30 days (symptomatic)
What are typical features of lymphocitis interstitial pneumonitis and what is this confused with?
Peribronchiolar lymphoid follicles
Lymphocytic infiltration of alveolar spaces
Miliary TB
What are clinical features of pulmonary TB
Chronic cough Weight loss Night sweats Poor appette Haemoptysis
How do you diagnose pulmonary TB?
CXR
AFB+ gene Xpert (sputum)
Mantoux test
How do you treat pulmonary TB
RIPES
2nd line = kanamycin, amikacin, ofloxacin, levofloxacin (KOAL)
What are clinical features of bronchiolitis obliterans
Hyperinflation
Wheeze
Crackles
How do you treat bronchiolitis obliterans?
ARVs
What is primary ciliary dyskinesia
Autosomal recessive disorder -> defects of cilia -> impaired mucous clearance
What do you suspect in a patient with primary ciliary dyskinesia and situs inversus?
Kartagener syndrome
Name clinical features of primary immunodeficiency diseases
Recurrent ENT infections Resp infections Bronchiectasis FTT Severe eczema Intractable diarrhoea Pyogenic infection
How do you treat primary immunodeficiency diseases
Treat underlying condition
Vaccination
Prophylaxis
Immunoglobulin therapy
