The infant or child with breathing difficulties

Question 1

Most common cause of wheezy child-coryza, breathless, cough (3)

Answer 1

URTI
Asthma
Bronchiolitis

Question 2

Causes of ‘chestiness’ (10) and important features

Answer 2

Bronchiolitis
Asthma
Pneumonia
Heart failure
Viral induced wheeze
Foreign body
Whooping cough
Croup
TB

Traumatic->pneumothorax, hemothorax
DKA, acidosis, deH, anxiety
Peritonsillar abscess
Spontaneous pneumothorax of teenager
Cough without breathlessness

Question 3

Causes of cough without breathlessness (5)

Answer 3

GORD
Post nasal drip
Tracheoesophageal fistula
Passive smoking
Cystic fibrosis

Question 4

History

Answer 4

Evidence of infection- fever, poor feeding
Previous history of wheezing- recurrent asthma
Atopic- eczema, hay fever
Known history of disease which may +risk of developing bronchiolitis- congenital heart disease, prematurity
Relevant family history- TB, CF, CHD

Question 5

Examination

Answer 5

Signs of respiratory distress->grunting, intercostal recession, nasal flaring
Are there additional noises->whooping, stridor, barking cough
Signs of chronic respiratory conditions->clubbing, chest wall deformities
Cyanosis?
Pyrexial?
Evidence of congenital heart disease?
Evidence of consolidation
Can the child talk in full sentences?
Is the PEFR normal?

Question 6

Investigations and importance

Answer 6

CXR->consolidation (lobar/diffuse), collapse, heart failure, hyperinflation
FBC->leukocytosis (penumonia), lymphocytosis (TB)
Nasopharyngeal swab->viral immunoflurescence
Sputum->acid fast bacilli
Perinasal swab->Bordetella pertussis
Viral titres->atypical pneumonia (Mycoplasma)
Blood cultures->S pneumonia if bacterial pneumonia
Mantoux test->TB
Bronchoscopy->Removal of foreign bodies

Question 7

Viral causes of pneumonia

Answer 7

RSV
Parainfluenza
Influenza
Adenovirus
Coxsackie

Question 8

Bacterial causes of pneumonia

Answer 8

S. Pneumonia
Haemophilus influenza
S. Aureus
Mycoplasma pneumonia

GBS in newborn

Question 9

Which infectious agents more common in those with underlying respiratory disease

Answer 9

Pseudomonas

Staphylococcus aureus

Question 10

Predisposing factors in penumonia

Answer 10

Congenital anomaly of respiratory tract
Aspiration
Foreign body
Immunosuppressioin
CF

Question 11

First line treatment for lobar pneumonia

Answer 11

Penicillin

Question 12

Complications of pneumonia

Answer 12

Empyema
Septicemia
Pleural effusion
Abscess

Question 13

Cause of bronchiolitis

Answer 13

Most commonly RSV

Parainfluenza
Adnovirus

Question 14

Clinical features of bronchiolitis

Answer 14

Coryza
Cough
Respiratory distress
Wheeze

Question 15

Examination findings in bronchiolitis

Answer 15

Widespread wheeze
Fine crackles
Hyperinflation

Patchy collapse/consolidation on CXR

Question 16

How is RSV diagnosed

Answer 16

Nasopharyngeal aspirate

Question 17

Indications for hospitalisation in bronchiolitis

Answer 17

++Respiratory distress
Need for oxygen
Poor feeding
Apnoea

Question 18

How long does RSV usually last

Answer 18

7-10 days

Question 19

Mortality in RSV

Answer 19

1-2%

Question 20

Prophylaxis for those at high risk of RSV in winter months

Answer 20

Pavilizumab

Monoclonal antibody against RSV

Question 21

How if bordatella pertussis cultured

Answer 21

Peri-nasal swab

Question 22

How long can the paroxysms of cough last in whooping cough

Answer 22

Months

100 day cough

Question 23

Age typically affected by croup, causative agent, signs of severe

Answer 23

6 months to three years
Parainfluenza
+work of breathing, cyanosis and restlessness

Question 24

How does epiglottitis present

Answer 24

Sepsis
Inability to swallow or talk
Lean forward
Drool saliva

Question 25

Confirmation of diagnosis

Answer 25

Laryngoscopy- cheer red swollen epiglottitis

Question 26

Causes of apnea

Answer 26

Bronchiolitis
Pertussis
Sepsis
Meningitis
Fits

Question 27

When should apnea be considered

Answer 27

Floppy and cyanosis

Question 28

Red flags

Answer 28

Choking
Apnea
Status asthmaticus

Question 29

What is status asthmaticus

Answer 29

When does not respond to three + medications, requiring repeated nebulisers.

Question 30

Differential of cyanosis in a newborn

Answer 30

Cyanotic heart disease
-TGA
-TOF
Pulmonary atresia
RDS
Transient tachypnea of the newborn
PPHN
Pneumothorax
Aspiration pneumonia
Pulmonary edema
Congenital diaphragmatic hernia
Upper airway obstruction
Polycythemia
Asphyxia
met-Hb
Hypoglycemia
Neonatal sepsis

Question 31

If cyanosis does not improve when given oxygen, likely explanation

Answer 31

Congenital heart disease with left to right shunt

Question 32

How does cardiac failure present in neonates and infants

Answer 32

Symptoms - sweating, poor feeding due to breathlessness (ultimately poor weight gain)
Signs - tachycardia, tachypnoea, hepatomegaly
Note: basal crepitations and dependent oedema are very late signs in childhood.

Question 33

Common differential for cough

Answer 33

Pneumonia
Asthma
URTI
Bronchiolitis
Croup
Whooping cough
Inhaled foreign body

Question 34

Common differential for wheeze

Answer 34

Bronchiolitis
Asthma
Heart failure
Inhaled foreign body

Question 35

Common differential of stridor

Answer 35

Acute:
Croup
anaphylaxis
inhaled foreign body
epiglottitis

Chronic:
Laryngomalacia
laryngeal anomalies

Question 36

When to suspect bronchiectasis symptoms and signs

Answer 36

Indigenous child
Symptoms:
chronic cough
excessive sputum production
clubbing
suboptimal weight gain

Signs:
chest deformity
persistent crepitations and wheeze on
auscultation.

Question 37

Differences in respiratory system in pediatrics

Answer 37

Up to 6/12 obligate nasal breathers
Smaller
Trachea and rib cage more cartilaginous
Larynx at cervical spine 2-3, more difficult to view with laryngoscope
Cricoid ring narrowest
Short trachea->ETT can pop out

Question 38

Sinus anatomy

Answer 38

1. maxillary->first to develop, 3 & 7-8 years
2. ethmoid
3. Frontal
4. Sphenoid