Resp

Question 1

what are the signs of respiratory distress?

Answer 1

grunting, intercostal + subcostal recession ie use of accessory muscles bc lung compliance is poor or airway resistance is high, tracheal tug, abdominal breathing, nasal flaring (increases upper airway diameter and reduces resistance and work of breathing), tachypnoea > 60/min, use of accessory muscles, head bopping.

Question 2

what is stridor?

Answer 2

harsh inspiratory musical sound resulting from partial upper airway obstruction in the larynx and upper trachea.

Question 3

what is wheeze? What are the common causes?

Answer 3

due to partial obstruction/abnormal narrowing of the intrathoracic airways (large + small) resulting in a musical note during EXPIRATION.
Common causes- mucosal (ie resp mucosal lining) inflammation + swelling (Bronchiolitis); bronchospasm (Asthma); mucus/ FB obstruction, anaphylaxis (recurrent), CF.

Question 4

What are the causes of bronchiolitis?

Answer 4

RSV (80%)
Adenovirus
Rhinovirus
Parainfluenza virus

Question 5

What are the clinical features of bronchiolitis?

Answer 5

Appearance: Signs of Respiratory Distress e.g. Subcostal + intercostal recession due to obstruction causing increased airway resistance, sternum prominent due to hyperinflation of lungs.
Bedside: O2 sats monitor, O2 cannula
Auscultation: Prolonged expiration (due to hyperinflation)/ high pitched Wheeze (partic expiration) due to obstruction of small airways.
Fine end-inspiratory crackles - creps
Palpation: Displaced liver (due to hyper inflation of lungs)

Question 6

What is the natural history of bronchiolitis?

Answer 6

Affects infants up to age ~1 years old.
coryzal (common cold- nasal discharge+ blockage) symptoms precede dry cough and increased SOB.
Feeding is often affected due to increased SOB.

Question 7

Who might be at risk of more severe Bronchiolitis? How is this prevented?

Answer 7

pre-term infants partic if have bronchopulmonary dysplasia/ underlying lung disease e.g. CF,
or CHD, or Immunodeficiency.
Monthly injections of Pavalizumab IM providing exogenous immunity to RSV during first 2 winters of life.

Question 8

What is the physiology behind infants grunting?

Answer 8

self-induced auto-PEEP (positive end expiratory pressure), which allows infants to keep their smaller airways and alveoli open (-ve pressure causes collapse).
The noise results from the sudden closure of the glottis during expiration in an attempt to maintain Functional Residual Capacity which prevents alveolar atelectasis (collapse) maintaining area for gas exchange.

Question 9

what is the pathophysiology of bronchiolitis?

Answer 9

The virus infects the respiratory epithelial cells of the small airways, leading to necrosis, inflammation, oedema, and mucus secretion. The combination of cellular destruction and inflammation leads to obstruction of the small airways.
The physiological and clinical results consist of hyperinflation (due to obstruction), atelectasis (obstruction prevents air replenishment in these spaces and residual air is absorbed by vessels quicker than it is replaced leading to collapse), and wheezing (secondary to obstruction). In severe cases, interstitial inflammation and alveolar infiltrates also develop.

Question 10

How is acute bronchiolitis managed?

Answer 10

Supportive measures
Admitted if: Apnoea, persistent O2 sats below 90%, inadequate fluid intake 50-75% normal, severe respiratory distress eg. RR > 70, grunting, marked chest recession.
1. Humidified Oxygen via cannula/ head box concentration guided by sats to maintain ~ 90%
2. Hydration try to maintain feeding, if drops, can use NGT or IV hydration.
Good Hand hygiene, usually about half will go on to have a recurrence of cough + wheeze.

Question 11

what is the natural history of asthma?

Answer 11

interaction of genetics, environment such as allergens, smoking, emotional upset, URTI, cold air and atopy.
Triad of:
bronchial inflammation- oedema, excess mucus, immune cell infiltration
bronchial hyperresponsiveness- exaggerated bronchoconstriction in response to inhaled allergens
airway narrowing- reversible airway obstruction

Over time, airway remodelling occurs secondary to chronic inflammation ***

Question 12

what are interval symptoms?

Answer 12

1. night time cough
2. SOB on exertion
3. wheeze
   in the absence of a viral illness.

Question 13

How would you manage a severe acute exacerbation of asthma?

Answer 13

1. 15L of O2 via non re-breathe mask
2. Nebs of Salbutamol (2.5 mg under 8/ 5mg over 8)+ Ipratropium (125mg under 5/ 250mg over 5) (Can give up to 4 times of the two if req)
3. Oral corticosteroids (Inhaled are NOT indicated in this instance)
4. IV Mg2+/ Salbutamol/ Aminophylline/ Steroids
5. Transfer to HDU

Question 14

During the first 3 years of life how is wheeze categorised?

Answer 14

viral wheeze- wheeze only in the context of viral illness
multi trigger wheeze- wheeze caused by multiple things e.g. allergens + viral, more likely to develop into asthma and benefit greatly from asthma therapies.
asthma- rarely diagnosed at this age bc inappropriate.

Question 15

What is multi trigger wheeze?

Answer 15

wheeze triggered by viruses, cold air, dust mites, exercise, animal hair. When viral wheeze is associated with interval symptoms - ie night time cough, SOB on exertion and wheeze in absence of virus, and evidence of allergies to inhaled allergens eg. pollen, it is called ‘atopic asthma’.
Remember atopy is strongly assoicated with eczema, hayfever (rhinoconjunctivitis) and food allergy.

Question 16

What is the stepwise management of asthma?

Answer 16

Step 1. Short-Acting Inhaled B2 Agonist e.g. Salbutamol 100-200mcg (1-2puffs) before exercise/ every 4-6 hours + Very Low dose Inhaled Corticosteroid e.g. Beclometasone Dipropionate 50mcg 2 puffs BD OR if <5 years old, Leukotriene R Antagonist e.g. Montelukast

Step 2. Short-Acting Inhaled B2 Agonist PRN (same dosage/freq as above) + Very low dose Inhaled Corticosteroids + (if <5years) Leukotriene R Antagonist e.g. Montelukast 4mg OD OR (if >5years) Long-Acting Inhaled B2 Agonist e.g. Salmetarol

Step 3. Options- if no response to LABA, Stop LABA + increase ICS to low dose (100mcg 2 puffs BD); OR if some response, maintain LABA+ increase ICS to low dose; OR maintain LABA + ICS dosage + Add LTRA

Step 4. Increase ICS to Medium dose Inhaled Corticosteroid e.g. Beclometasone Dipropionate 200mcg two puffs BD OR consider adding SR Theophylline + Refer to specialist services

Step 5. Daily oral steroid tablets + Medium dose ICS + Consider other tx options to minimise oral steroid

Question 17

What are the indicators of acute severe asthma?

Answer 17

Can’t complete sentences in one breath or too breathless to talk or feed
SpO2 <92%
PEF 33–50% best or predicted
Heart rate >140/min in children aged 1–5 years
>125/min in children >5 years
Respiratory rate >40/min in children aged 1–5 years >30/min in children >5 years

Question 18

What is the stepwise management of asthma?

Answer 18

Step 1.
Short-Acting Inhaled B2 Agonist e.g. Salbutamol 100-200mcg (1-2puffs) before exercise/ every 4-6 hours

Step 2.
Add Very Low dose Inhaled Corticosteroid e.g. Beclometasone Dipropionate 50mcg 2 puffs BD OR if <5 years old, consider Leukotriene R Antagonist e.g. Montelukast

Step 3.
Add (if <5years) Leukotriene R Antagonist e.g. Montelukast 4mg OD or consider increasing ICS to 100mcg 2 puffs BD
Add (if >5years) Long-Acting Inhaled B2 Agonist e.g. Salmetarol and assess response:
§ if no response to LABA, Stop LABA + increase ICS to low dose (100mcg 2 puffs BD) or (200mcg 2 puffs BD in teens) + consider LTRA and/or SR Theophylline
§ if some response, maintain LABA+ increase ICS to low dose
§ good response- maintain LABA

Step 4.
In <5 years old: Refer
In 5-12 years old: Increase ICS to Medium dose Inhaled Corticosteroid e.g. Beclometasone Dipropionate 200mcg two puffs BD (or 400mcg two puffs BD in teens) + consider adding SR Theophylline/ LTRA

Refer to specialist services

Step 5.
In 5-12 years old: Maintain ICS at Medium dose Inhaled Corticosteroid e.g. Beclometasone Dipropionate 200mcg + Daily oral steroid tablets (lowest possible dose) + Refer
In teens: Maintain ICS at 400mcg dose Inhaled Corticosteroid + Daily oral steroid tablets (lowest possible dose) + refer

Question 19

What features of the history suggest asthma?

Answer 19

symptoms worse at night and early in the morning
symptoms with no viral trigger
interval symptoms between acute exacerbations
personal/ family hx of atopy
response to asthma therapy

Question 20

what is your ddx for asthma?

Answer 20

GOR, CF, VIW, Bronchiolitis, Croup

Question 21

what clinical signs suggest asthma?

Answer 21

normal examination between exacerbations.
long standing may find hyperinflated chest + exp wheeze + prolonged expiratory phase.
wet cough + finger clubbing/ poor growth might think of bronchiectasis/ CF. loose cough w/o wheeze persistent bacterial bronchitis.
Peak Flow- diurnal variation, worse in morning than in evening and day to day variation if not controlled.

Question 22

to assess the severity of asthma, what questions are imp to include?

Answer 22

frequency of symptoms, triggers, impact on sport/ gen activities, sleep disturbed?, severity of interval symptoms?, missed school, how exacerbations are managed

Question 23

what are the clinical features of pneumonia?

Answer 23

fever, cough and tachypnoea (>60). sometimes preceded by URTI.
Lethargy + poor feeding.
Signs=
tachypnoea (>60) **

Question 24

What is croup? What are the features?

Answer 24

Coryza + fever followed by:
Hoarseness (inflammation vocal cords)
Inspiratory Stridor
Barking Cough (tracheal oedema + collapse)
Chest recession + increased work of breathing
Symptoms often worse at night.
Caused by: Viruses - parainfluenza, rhinovirus, RSV
Ages: 6m- 6y but peak at 2y.

Admission if <12m (narrower airway), less parental confidence, severity of obstruction (stridor- at rest/ biphasic more severe + chest recession)

Question 25

what are the common causes of pneumonia? (By ages list 2-3). What is the physiology behind some of the key clinical signs?

Answer 25

= Newborns: Genital tract- GBS, G-ve enterococci + bacilli
= Infants + young children: Many viral (e.g. RSV), Strep pneumoniae, chlamydia trachomatis, B. pertussis
= Older children: mycoplasma pneumoniae, strep pneumoniae, chlamydia pneumoniae
= consider mycobacterium tuberculosis in any age

Intra-alveolar exudates. Crackles are caused by the “popping open” of small airways and alveoli collapsed by fluid, exudate, or lack of aeration during expiration. Consolidation- dull to percussion bc of exudate

Question 26

How is pneumonia managed?

Answer 26

Most can be managed at home but if O2 sats <92% on air or poor oral intake, recurrent apnoeas, grunting admission required.
At home
paracetamol + ibuprofen for pain + temp control
Oral Amoxicilin if discharged home
Return if Temp not settled within 48h/ not tolerate Oral Abx, or child still unwell
In Hospital
Oral Amoxicilin (unless particularly unwell/ v young/ lung disease)
CXR. Physiotherapy has no place.
Bloods not indicated unless IV Abx if so- FBC, culture
O2 for hypoxia,
Adequate oral intake or NGT (IV only if req)
Paracetamol/ Ibuprofen
IV Abx- Benzylpenicillin/ Cefuroxime

Question 27

what is the aetiology + natural history of pertussis?

Answer 27

bacteria bordatella pertussis v infectious.
3 phases:
1. Catarrhal- corzya (1 week)

2. Paroxysmal- paroxysmal (sudden attack)/ sporadic cough followed by inspiratory whoop. Cough worse at night and may cause vomitting. Whoop may be absent in infants but apnoeas common. Red/ blue in face while coughing is common. (up to 3 months)
3. Convalescent- cough improving

Question 28

what is the aetiology + natural history of pertussis?

Answer 28

bacteria bordatella pertussis v infectious. Pregnant mums vaccinated anytime after 16/52. Babies vaccinated at 2,3,4 months. High mortality rate.
3 phases:
1. Catarrhal- corzya (1 week)

2. Paroxysmal- paroxysmal (sudden attack)/ sporadic cough followed by inspiratory whoop. Cough worse at night and may cause vomitting. Whoop may be absent in infants but apnoeas common. Red/ blue in face while coughing is common. (up to 3 months)
3. Convalescent- symptoms gradually decrease but can take months.

Question 29

What investigations + management is required for pertussis?

Answer 29

Ix: Pernasal swab culture/ PCR
FBC marked lymphocytosis.
Tx: Macrolides but only effective in symptom management during catarrhal stage.
Immunization reduces risk of contracting + severity but does not guarantee protection
Immunization/ macrolide prophylaxis of close contacts
if severe attacks + cyanotic episodes require admission to hospital .

Question 30

what are the clinical features of epiglottitis?

Answer 30

Acute swelling of epiglottis + surround tissues assoc with septicaemia
Drooling
Quiet Stridor
Reluctance to feed/ drink/ cry
acute onset over hours, with no preceding coryza
Caused by Haemophillus Influenzae
No cough or v little
V toxic child with fever >38.5
muffled cry
Severe sore throat, increased difficulty breathing
child sits up immobile with open mouth to optimise airway
Require immediate intubation by senior ENT, IV abx once airway secured.

Question 31

How do you manage croup?

Answer 31

1. Oral Dex/ Pred reduce severity + duration.

2. Neb Adrenaline + O2 improves symptoms dramatically in severe obstruction

Question 32

what is your ddx for upper airway obstruction? What is the predominant symptom?

Answer 32

Stridor + chest retraction (none, on crying, at rest). Degree of stridor- none, on crying, at rest, biphasic. Severe obstruction- tachycardia, agitation, tachypnoea
Epiglottitis
Viral Croup 
Anaphylaxis
Laryngeal/ oesophageal foreign body
Smoke inhalation
Diphtheria
Bacterial tracheitis
Hypocalcaemia

Question 33

how do you distinguish epiglottitis from viral croup?

Answer 33

Croup onset slower (days vs hours)
Croup has preceding coryza, none in epiglottitis
Croup has severe barking cough, epiglottitis (none/ slight)
In Croup can still tolerate drinking
Epiglottitis drooling
Both appear unwell but perhaps more unwell Epi
Fever <38.5 croup, >38.5 Epiglottitis
Harsh stridor croup, soft in epiglottitis
Hoarse cry in croup, reluctant to cry epiglottitis

Question 34

what are the main causes of coryza?

Answer 34

viruses- coronavirus, rhinoviruses, RSV

Question 35

what are the main causes of coryza? What is the best management?

Answer 35

viruses- coronavirus, rhinoviruses, RSV

Simple paracetamol/ ibuprofen

Question 36

what are the clinical features of tuberculosis? How is it tx?

Answer 36

Primary infection: 90% asymptomatic. Symptoms: fever, anorexia + weight loss, cough, CXR changes, then latency.
Reactivation: Localized/ miliary to joints, kidneys, CNS. TB meningitis is imp thing to rule out in kids.

Gastric washings, Mantoux test, urine, CSF, LN tissue to culture TB may be appro.
Tx: Triple or quadruple therapy (rifampicin, isoniazid,
pyrazinamide, ethambutol for 2m then Rifampicin + isoniazid for 4/ more months. steroids if TB meningitis.
If asymptomatic (ie latent primary infection)- rifampicin and isoniazid for 3 months or isoniazid alone for 6 months

Question 37

What are the clinical features of pharyngitis?

Answer 37

Inflammation of pharynx + soft palate
Tender local LN
Viral causes- adenovirus, enterovirus. Older kids- Group A Strep

Question 38

What are the clinical features of tonsillitis?

Answer 38

Inflammation + enlargement of tonsils +/- purulent exudate
painful throat, diff swallow, pyrexia, halitosis, lymphadenopathy
Common cause Group A Strep + EBV
Bacterial causes often present with headache, cervical LN tenderness, white exudate, abdo pain

Question 39

What are the clinical features of tonsillitis?

Answer 39

Inflammation + enlargement of tonsils +/- purulent exudate
painful throat, diff swallow, pyrexia, halitosis, lymphadenopathy
Common cause Group A Strep, H. influenzae + EBV
EBV charavteristic grey/ white exudate.
Req analgesia, Abx penicilin/ erythromycin
Common complications- Febrile convulsions, quinsy - peritonsillar abscess