Child Health Respiratory

Question 1

Croup epidemiology

Answer 1

peak incidence at 6 months - 3 years

more common in autumn

Question 2

Croup sx

Answer 2

stridor which is caused by a combination of laryngeal oedema and secretions

barking cough (worse at night)
fever
coryzal symptoms

Question 3

Croup causative organism

Answer 3

Parainfluenza viruses account for the majority of cases.

Question 4

Features of mild croup

Answer 4

Occasional barking cough
No audible stridor at rest
No or mild suprasternal and/or intercostal recession
The child is happy and is prepared to eat, drink, and play

Question 5

Features of moderate croup

Answer 5

Frequent barking cough
Easily audible stridor at rest
Suprasternal and sternal wall retraction at rest
No or little distress or agitation
The child can be placated and is interested in its surroundings

Question 6

Features of severe croup

Answer 6

Frequent barking cough
Prominent inspiratory (and occasionally, expiratory) stridor at rest
Marked sternal wall retractions
Significant distress and agitation, or lethargy or restlessness (a sign of hypoxaemia)
Tachycardia occurs with more severe obstructive symptoms and hypoxaemia

Question 7

CKS suggest admitting any child with moderate or severe croup. Other features which should prompt admission include:

Answer 7

< 6 months of age
known upper airway abnormalities (e.g. Laryngomalacia, Down’s syndrome)
uncertainty about diagnosis

Question 8

Croup the vast majority of children are diagnosed clinically

Answer 8

true

Question 9

Croup CXR would show

Answer 9

a posterior-anterior view will show subglottic narrowing, commonly called the ‘steeple sign’

in contrast, a lateral view in acute epiglottis will show swelling of the epiglottis - the ‘thumb sign’

Question 10

Croup mx

Answer 10

single dose of oral dexamethasone (0.15mg/kg) to all children regardless of severity

prednisolone is an alternative

Emergency treatment -high-flow oxygen, nebulised adrenaline

Question 11

Bronchiolitis is a condition characterised by acute bronchiolar inflammation causative organism is?

Answer 11

Respiratory syncytial virus (RSV) is the pathogen in 75-80% of cases

other causes: mycoplasma, adenoviruses

Question 12

Bronchiolitis epidemiology?

Answer 12

most common cause of a serious lower respiratory tract infection in < 1yr olds

higher incidence in winter

Question 13

Maternal IgG provides protection to newborns against RSV

Answer 13

true

Question 14

Bronchiolitis is more serious if?

Answer 14

bronchopulmonary dysplasia (e.g. Premature), congenital heart disease or cystic fibrosis

Question 15

Bronchiolitis sx

Answer 15

coryzal symptoms (including mild fever) precede:
dry cough
increasing breathlessness
wheezing, fine inspiratory crackles (not always present)
feeding difficulties associated with increasing dyspnoea are often the reason for hospital admission

Question 16

Bronchiolitis NICE recommend immediate referral (usually by 999 ambulance) if they have any of the following:

Answer 16

apnoea (observed or reported)
child looks seriously unwell to a healthcare professional
severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute
central cyanosis
persistent oxygen saturation of less than 92% when breathing air.

Question 17

Bronchiolitis NICE recommend that clinicians ‘consider’ referring to hospital if any of the following apply:

Answer 17

a respiratory rate of over 60 breaths/minute
difficulty with breastfeeding or inadequate oral fluid intake (50-75% of usual volume ‘taking account of risk factors and using clinical judgement’)
clinical dehydration.

Question 18

Bronchiolitis ix

Answer 18

immunofluorescence of nasopharyngeal secretions may show RSV

Question 19

Bronchiolitis mx

Answer 19

Management is largely supportive

humidified oxygen is given via a head box and is typically recommended if the oxygen saturations are persistently < 92%

nasogastric feeding may be needed if children cannot take enough fluid/feed by mouth
suction is sometimes used for excessive upper airway secretions

Question 20

Whooping cough (pertussis) is an infectious disease caused by

Answer 20

Gram-negative bacterium Bordetella pertussis.

Question 21

Whooping cough (pertussis)infants are routinely immunised at

Answer 21

2, 3, 4 months and 3-5 years.

Question 22

Whooping cough (pertussis)immunisation results in lifelong protection

Answer 22

false
neither infection nor immunisation results in lifelong protection - hence adolescents and adults may develop whooping cough despite having had their routine immunisations

Question 23

Whooping cough (pertussis) sx

Answer 23

Features, 2-3 days of coryza precede onset of:
coughing bouts
inspiratory whoop
infants may have spells of apnoea
persistent coughing may cause subconjunctival haemorrhages or even anoxia leading to syncope & seizures

symptoms may last 10-14 weeks* and tend to be more severe in infants
marked lymphocytosis

Question 24

Whooping cough (pertussis)Diagnostic criteria

Answer 24

Whooping cough should be suspected if a person has an acute cough that has lasted for 14 days or more without another apparent cause, and has one or more of the following features:

Paroxysmal cough.
Inspiratory whoop.
Post-tussive vomiting.
Undiagnosed apnoeic attacks in young infants.

Question 25

Whooping cough (pertussis)Diagnosis

Answer 25

PCR and serology

Question 26

Whooping cough (pertussis)Management

Answer 26

infants under 6 months with suspect pertussis should be admitted an oral macrolide (e.g. clarithromycin, azithromycin or erythromycin) is indicated if the onset of the cough is within the previous 21 days to eradicate the organism and reduce the spread

Question 27

Whooping cough (pertussis) in the UK pertussis is a notifiable disease

Answer 27

true

Question 28

Whooping cough (pertussis) household contacts should be offered antibiotic prophylaxis

Answer 28

true

Question 29

Whooping cough (pertussis) school exclusion?

Answer 29

48 hours after commencing antibiotics (or 21 days from onset of symptoms if no antibiotics )

Question 30

Whooping cough (pertussis) complications?

Answer 30

subconjunctival haemorrhage pneumonia bronchiectasis seizures

Question 31

Snoring in children | Causes

Answer 31

``` obesity nasal problems: polyps, deviated septum, hypertrophic nasal turbinates recurrent tonsillitis Down's syndrome hypothyroidism ```

Question 32

episodic viral wheeze is?

Answer 32

only wheezes when has a viral upper respiratory tract infection (URTI) and is symptom free inbetween episodes

Question 33

multiple trigger wheeze is

Answer 33

as well as viral URTIs, other factors appear to trigger the wheeze such as exercise, allergens and cigarette smoke

Question 34

Episodic viral wheeze is not associated with an increased risk of asthma in later life although a proportion of children with multiple trigger wheeze will develop asthma.

Answer 34

true

Question 35

Episodic viral wheeze mx

Answer 35

treatment is symptomatic only first-line is treatment with short acting beta 2 agonists (e.g. salbutamol) or anticholinergic via a spacer next step is intermittent leukotriene receptor antagonist (montelukast), intermittent inhaled corticosteroids, or both

Question 36

Multiple trigger wheeze mx

Answer 36

trial of either inhaled corticosteroids or a leukotriene receptor antagonist (montelukast), typically for 4-8 weeks

Question 37

Acute epiglottitis is rare but serious infection caused by

Answer 37

Haemophilus influenzae type B.

Question 38

Acute epiglottitis sx

Answer 38

``` rapid onset high temperature, generally unwell stridor drooling of saliva 'tripod' position: the patient finds it easier to breathe if they are leaning forward and extending their neck in a seated position ```

Question 39

Acute epiglottitis Diagnosis is made by direct visualisation

Answer 39

true

Question 40

Acute epiglottitis mx

Answer 40

immediate senior involvement, including those able to provide emergency airway support (e.g. anaesthetics, ENT) endotracheal intubation may be necessary to protect the airway if suspected do NOT examine the throat due to the risk of acute airway obstruction oxygen intravenous antibiotics

Question 41

Causes of stridor in children include:

Answer 41

Croup Acute epiglottitis Inhaled foreign body Laryngomalacia

Question 42

Laryngomalacia Infants typical present at 4 weeks of age with:

Answer 42

stridor

Question 43

most likely causative agent of a bacterial pneumonia in children

Answer 43

S .pneumoniae

Question 44

bacterial pneumonia in children mx

Answer 44

Amoxicillin is first-line for all children with pneumonia Macrolides may be added if there is no response to first line therapy Macrolides should be used if mycoplasma or chlamydia is suspected In pneumonia associated with influenza, co-amoxiclav is recommended

Question 45

Asthma - definitions of what constitutes a low, moderate or high-dose ICS have also changed. In contrast to the BTS guidelines NICE also have different definitions for adults and children. For children:

Answer 45

<= 200 micrograms budesonide or equivalent = paediatric low dose 200 micrograms - 400 micrograms budesonide or equivalent = paediatric moderate dose > 400 micrograms budesonide or equivalent= paediatric high dose.

Question 46

Children aged less than 5 years asthma mx

Answer 46

1. SABA 2. SABA + an 8-week trial of paediatric MODERATE-dose inhaled corticosteroid (ICS) 3. SABA + paediatric low-dose ICS + leukotriene receptor antagonist (LTRA) 4. refer

Question 47

Asthma mx Children and young people aged 5 to 16

Answer 47

1. SABA 2. SABA + paediatric low-dose inhaled corticosteroid (ICS) 3. SABA + paediatric low-dose ICS + leukotriene receptor antagonist (LTRA) 4. SABA + paediatric low-dose ICS + long-acting beta agonist (LABA) 5. SABA + switch ICS/LABA for a maintenance and reliever therapy (MART), that includes a paediatric low-dose ICS 6. SABA + paediatric moderate-dose ICS MART OR consider changing back to a fixed-dose of a moderate-dose ICS and a separate LABA 7. SABA + one of the following options: increase ICS to paediatric high-dose, either as part of a fixed-dose regime or as a MART a trial of an additional drug (for example theophylline) seeking advice from a healthcare professional with expertise in asthma

Question 48

Children between 2 and 5 years of age acute asthma attack severity scale?

Answer 48

Moderate attack SpO2 > 92% No clinical features of severe asthma ``` Severe attack SpO2 < 92% Too breathless to talk or feed Heart rate > 140/min Respiratory rate > 40/min Use of accessory neck muscles ``` ``` Life-threatening attack SpO2 <92% Silent chest Poor respiratory effort Agitation Altered consciousness Cyanosis ```

Question 49

Children greater than 5 years of age acute asthma attack severity scale?

Answer 49

``` Moderate attack SpO2 > 92% PEF > 50% best or predicted No clinical features of severe asthm ``` ``` Severe attack SpO2 < 92% PEF 33-50% best or predicted Can't complete sentences in one breath or too breathless to talk or feed Heart rate > 125/min Respiratory rate > 30/min Use of accessory neck muscles ``` ``` Life-threatening attack SpO2 < 92% PEF < 33% best or predicted Silent chest Poor respiratory effort Altered consciousness Cyanosis ```

Question 50

For children with mild to moderate acute asthma:

Answer 50

Bronchodilator therapy give a beta-2 agonist via a spacer (for a child < 3 years use a close-fitting mask) give 1 puff every 30-60 seconds up to a maximum of 10 puffs if symptoms are not controlled repeat beta-2 agonist and refer to hospital Steroid therapy should be given to all children with an asthma exacerbation treatment should be given for 3-5 days

Question 51

Cystic fibrosis (CF) is an autosomal dominant disorder

Answer 51

false | recessive

Question 52

Cystic fibrosis (CF) is due to

Answer 52

increased viscosity of secretions (e.g. lungs and pancreas). It is due to a defect in the cystic fibrosis transmembrane conductance regulator gene (CFTR), which codes a cAMP-regulated chloride channel

Question 53

Organisms which may colonise CF patients

Answer 53

Staphylococcus aureus Pseudomonas aeruginosa Burkholderia cepacia* Aspergillus

Question 54

Cystic fibrosis: features | neonatal sx

Answer 54

meconium ileus, less commonly prolonged jaundice

Question 55

Cystic fibrosis | sx

Answer 55

recurrent chest infections (40%) malabsorption (30%): steatorrhoea, failure to thrive other features (10%): liver disease

Question 56

Cystic fibrosis assoc short stature

Answer 56

true

Question 57

Cystic fibrosis | PMH

Answer 57

``` diabetes mellitus delayed puberty rectal prolapse (due to bulky stools) nasal polyps male infertility, female subfertility ```

Question 58

Cystic fibrosis: diagnosis

Answer 58

Sweat test patient's with CF have abnormally high sweat chloride normal value < 40 mEq/l, CF indicated by > 60 mEq/l

Question 59

Cystic fibrosis: diagnosis | Causes of false positive sweat test

Answer 59

``` malnutrition adrenal insufficiency glycogen storage diseases nephrogenic diabetes insipidus hypothyroidism, hypoparathyroidism G6PD ectodermal dysplasia ```

Question 60

Cystic fibrosis: diagnosis | Causes of false negative sweat test

Answer 60

skin oedema, often due to hypoalbuminaemia/ hypoproteinaemia secondary to pancreatic exocrine insufficiency.

Question 61

Cystic fibrosis: management | physio

Answer 61

regular (at least twice daily) chest physiotherapy and postural drainage. Parents are usually taught to do this. Deep breathing exercises are also useful

Question 62

Cystic fibrosis: management | diet

Answer 62

high calorie diet, including high fat intake vitamin supplementation pancreatic enzyme supplements taken with meals

Question 63

Cystic fibrosis: management patients with CF should try to minimise contact with each other to prevent cross infection with Burkholderia cepacia complex and Pseudomonas aeruginosa

Answer 63

true

Question 64

Cystic fibrosis: management | CF-specific contraindication to lung transplantation

Answer 64

chronic infection with Burkholderia cepacia

Question 65

Cystic fibrosis: management | what is used to treat cystic fibrosis patients who are homozygous for the delta F508 mutation

Answer 65

Lumacaftor/Ivacaftor (Orkambi)