Respirology Flashcards
Length of “Acute cough”
• Acute cough <3 weeks
Length of “chronic cough”
• Chronic cough >4-8 weeks
How long can a cough last after a viral infection?
Persistenceofcough after viral infection:
– 10 days: 50%
– 16 days: 25%
– 25 days: 10%
How often is there a choking history with aspiration?
Clinical choking history in ~40-85% of cases
How old are most kids with FBA?
• Majority of cases <3 years of age
Symptoms of FBA?
• Symptoms of presentation – Cough – Wheeze/stridor – Dyspnea/Respiratory distress – Asymptomatic
CXR findings for FBA?
Radiologic findings – Localized emphysema – Pneumonia – Atelectasis – Normal
if you have a foreign body in a mainstem bronchi you can breathe air IN but it is hard to breathe out/ Hyperinflation of affected lung
Consequences of missed foreign body:
– Recurrent pneumonia
– Bronchiectasis
- Cardiac Arrest
Investigations if cough >4 weeks
CXR
PFTs
Differential for chronic cough
Healthy Children
• Frequent viral respiratory tract infections
• Postviral cough
• Pertussis/Pertussis like cough
Chronic Cough • Cough variant Asthma • Chronic Rhinitis • Persistent Bronchitis • GERD • Psychogenic Cough • Non-specific Isolated Chronic Cough
Potentially Serious Lung Disorder • Cystic Fibrosis • Immunodeficiency • Primary Ciliary Dyskenesia • Foreign Body Aspiration • Recurrent Pulmonary Aspirations • Tuberculosis • Anatomic Disorder • Interstitial Lung Diseases
What is a honking cough that disappears with sleep?
psychogenic cough
What has a Dry cough, dyspnea, restrictive spirometry
Interstitial Lung Disease
What has Progressive cough, weight loss, fevers,
TB, Malignancy
Red flag symptoms for chronic wet cough
Concerning features – Year round – Starting at early age – Not responsive to therapies – Specific pointers to other illnesses
Chronic Wet Cough differential
- Cystic Fibrosis
- Primary Ciliary Dyskinesia
- Immunodeficiency
- Bronchiectasis
- Persistent Bacterial Bronchitis
- Missed Foreign body
- Chronic Infections
- Asthma+/- AllergicRhinitis
- Recurrent Viral Infections
How does CF present in infancy
Infancy • Failure to thrive • Meconium ileus • Recurrent respiratory symptoms – Wheeze, cough, bronchiolitis • Hyponatremic, hypochloremic metabolic alkalsosis • Prolonged Jaundice • Severe pneumonia
How does CF present in childhood/adolescence
• Recurrent respiratory symptoms
– Cough, pneumonia, wheeze poorly controlled asthma etc..
• Failure to thrive
• Recurrent rectal prolapse
• Clubbing
• Bronchiectasis
• Nasal polyps/sinus disease nasal polyps in children are CF until proven otherwise
• Chronic Pseudomonas aeroginosa colonization
Diagnosis of CF
Prenatal: CVS with DNA analysis/ amnio
Postnatal:
– Newborn Screening: IRT (immunoreactive trypsinogen level)
• Sweat Chloride – ≥60mEq/L – Normal: • <30 1st 6 months • >40 after 6 months • CFTR analysis may be misleading should not do without first having SCT – >1900 associated mutations – >160 disease causing mutations • Newborn Screen programs may miss up to 5% of classic CF
Diagnostic criteria —
Both of the following criteria must be met to diagnose CF:
1) Clinical symptoms consistent with CF in at least one organ system
OR
Positive newborn screen
OR
Having a sibling with CF
AND
Evidence of cystic fibrosis transmembrane conductance regulator (CFTR) dysfunction (any of the following):
Elevated sweat chloride ≥60 mmol/L
OR
Presence of two disease-causing mutations in the CFTR gene, one from each parental allele
OR
Abnormal NPD (nasal potential difference)
Treatment of CF
• Multidisciplinary Clinic
– Nurse,Physiotherapy, Dietician, Social Worker, Psychologist
• Aggressive treatment of infections, airway secretion clearance, nutrition
• Novel therapies aimed at underlying CFTR mutations
– $$$$$
Maintain normal lung function
- Regular chest physiotherapy
- Treat chronic infections with oral or inhaled Abx
- Treat acute infections with oral or IV Abx
- Use mucolytics
Maintain normal nutrition & growth
- High fat/high energy diet
- Pancreatic enzymes, vitamin supplements
- Supplements/g-tube feeds
Regular follow-up with multi-D team
Educate patient and family about CF
Why do we do genetic testing in CF?
To help with various treatment options
Median survival age for CF?
Median survival age: 50.9
– Median age of death: 34
Prognostic factors for CF?
Male > female – Lung disease • FEV1 • Burkohlderia Cepacia • Pneumothorax – Nutritional status*** • Weight/height • Diabetes
Clinical Presentation of PCD?
Clinical – Year round daily wet cough – Year round nasal congestion – Recurrent Otitis media – Neonatal Respiratory distress - male infertility – Laterality defects (situs inverses totalis)
Diagnosis of PCD?
Electron Microscopy
Nasal nitric oxide
Genetic testing
What is protracted bacterial bronchitis?
• Emerging (controversial) diagnosis
– >3-4 weeks of chronic wet cough
– Resolution of cough with antibiotic treatment
– Associated with significant pus and neutrophils on bronchoscopy
How old are kids who get protracted bacterial bronchitis?
Most common in children <5 years of age
Most common pathogens in protracted bacterial bronchitis
H influenza
S. Pneumo
S. Aureus
M Catarrhalis
When should you consider a diagnosis of laryngeal cleft?
• Associated with direct aspiration on swallowing (recurrent aspirations) • Videoflouroscopy • Rigid bronchoscopy required to rule out – Grade1-4 • Consider with syndromes – VACTRL – CHARGE – OpitzFrias – MidlineDefects
What conditions pre dispose you to recurrent aspirations?
– Choking/coughing with feeds, especially liquids
– Neurologic abnormalities
– Previous intubations
– Syndromes associated with anatomic malformations (VACTRL)
How to diagnose a H type fistula?
Rigid Bronchocopy is gold standard
Characteristics of psychogenic cough?
usually do not look distressed
more often in the daytime, goes away at night
often starts with viral infection + cough —> turns into psychogenic cough can be successful to get them to drink water every time they need to cough can last years in some children
Treatment of Non specific chronic cough?
• Medium dose Inhaled corticosteroids
– Especially if positive family or atopic history, wheezing or other signs of asthma
• Intranasal corticosteroids +/- anti-histamines
– Especially if other signs and symptoms of chronic
rhinitis and/or upper airway symptoms
• Always look for red flags and give a time defined treatment trial
Chronic Wet cough should have what investigations?
Strong consideration for children with a chronic wet cough should include:
- CXR
- PFT with bronchodilator
- sweat chloride
• Further investigations based on above +/- trial of treatment
What is asthma
- paroxysmal or persistent symptoms such as dyspnea, chest tightness, wheezing, sputum production, and cough
- associated with variable airflow limitation and airway hyperresponsiveness to endogenous and exogenous stimuli.
- Inflammation and it’s resultant effects on airway structure are considered the main mechanisms leading to the development and persistence of asthma.
What are the symptoms of good asthma control?
Daytime Symptoms: <4 days/week Nighttime Symptoms: <1 night/week Physical Activity: Normal Exacerbations: Mild, Infrequent Absence from work/school: None Fast acting B-agonist use: <4 doses/week* FEV1 or PEF: ≥90% personal best PEF diurnal variation: <10-15% Sputum eosinophils (adults): <2-3%
Diagnosis of Asthma
Clinical symptoms \+ Diagnosis of Asthma • Objective evidence – Spirometry: obstruction (↓FEV1/FVC) + bronchodilator response (↑FEV1 by ≥12%) – Peak Flow: increase by ≥20% following bronchodilator – Methacholine Challenge: • +ve: <4 mg/mL • Borderline: 4-16 mg/mL • Negative: >16mg/mL
What ages should use an aerohamber?
All!!
But can switch to mouth piece at 5 years of age
Management pathway for asthma for kids 6-11 years of age
Low Dose Inhaled Corticosteroid Low-Medium Dose Inhaled Corticosteroid THEN Medium Dose Inhaled Corticosteroids (201-400 mcg/day) THEN Add a LABA or Add a LTRA THEN add the other THEN Medium Dose Inhaled Corticosteroids + LABA + LTRA
