Paeds - Resp

Question 1

A 3year old boy presents to you with a barking cough, hoarse voice and stridor - where is his infection if it is caused by an infection?

Answer 1

Barking cough, hoarse voice and stridor are due to laryngeal/tracheal infections.

Question 2

A 2 year old boy presents to you with a barking cough, hoarse voice and stridor.
What are your differentials for an infective cause? And give the other symptoms he would be experiencing with each of them

Answer 2

1) Croup - preceded by low-grade fever and coryza, worse at night and when crying
2) Bacterial tracheitis - very high fever, toxic looking child, worsening obstruction, copious thick secretions
3) Acute epiglottitis - High fever, ill, painful to swallow

Question 3

A 2 year old girl presents with a barking cough, she has a hoarse voice, stridor that are all worse at night. She has been unwell for the past few days with cold like symptoms.
What could be the pathogens responsible?

Answer 3

Sounds like viral croup
Parainfluenza
Human metaneumovirus
Respiratory syncytial virus

Question 4

A 2 year old girl presents with a barking cough, she has a hoarse voice, stridor that are all worse at night. She has been unwell for the past few days with cold like symptoms.
How do you asses the severity of her illness/airways obstruction?

Answer 4

RR, HR, WOB - tracheal tugs and chest wall retractions, degree of stridor, altered mental state (confused/agitated)

Question 5

A 2 year old girl presents with a barking cough, she has a hoarse voice, stridor that are all worse at night. She has been unwell for the past few days with cold like symptoms.
How do you treat?

Answer 5

You suspect mild/mod viral croup

Oral prednisolone

Viral - x abx
cause is inflammatory - reduce that with steroids

Question 6

A 2 year old girl presents with a barking cough, she has a hoarse voice, stridor that are all worse at night. She has been unwell for the past few days with cold like symptoms. O/E she has increased WOB, with tracheal tug and a high pitched stridor, the child is very unwell with raised RR.
How would you treat?

Answer 6

You suspect severe viral croup

Nebulised adrenaline
Oral prednisolone

Question 7

A 4 year old girl has a high fever, is toxic looking and getting worse - she has a barking cough, hoarse voice and stridor with thick secretions.
What is the cause and how would you treat?

Answer 7

A 4 year old girl has a high fever, is toxic looking and getting worse - she has a barking cough, hoarse voice and stridor with thick secretions.
Bacterial tracheitis
Staph Aureus
Penicillin

Question 8

Describe the presentation for a child with acute epiglottis

Answer 8

High fever, toxic/very ill, acute onset - hours, stridor, hoarse voice,
sitting up with mouth open, not drinking - painful throat
Life threatening

Question 9

A 5 year old boy has acute epiglottitis - how do you treat?

Answer 9

Intubate
IV cefuroxime - against H. influenza B
Prophylaxis - rifampicin to house hold contacts

Question 10

What is coryza?

Answer 10

Coryza
= the common cold
Irritation and swelling of the mucous membranes in the nose
Commonly caused by rhinovirus, coronavirus or RSV

Question 11

A 8 year old boy complains of a sore throat - O/E he has enlarged lymph nodes.
What advise would you give?

Answer 11

Sore throat - pharyngitis
Usually viral cause - adenovirus, enterovirus and rhinovirus - abx not of use
Will ease in the next few days - reassurance

Question 12

What are the causes of tonsillitis?

Intense inflammation of the tonsils with purulent exudate

Answer 12

Group A haemolytic strep

Epstein-bar virus

Question 13

A 6 year old girl complains of a sore throat, headache, feeling tired with a bit of tummy ache. O/E you see surface exudates on inflamed tonsils and cervical lymphadenopathy
What do you think is the cause and how would you treat her?

Answer 13

Suspect bacterial cause of tonsillitis.
Group A strep
- give penicillin

Question 14

A 10 month old presents very upset and with a fever.
O/E she has no respiratory signs and had bright red tympanic membranes that are red and bulging with no light reflection.
What do you think is the diagnosis and what is the cause?

Answer 14

Acute otitis media = acute infection of the middle ear.
Usually viral - Respiratory syncytial virus, rhinovirus
Or if bacterial - pneumococcus or H.influenzae

Question 15

A 10 month old presents very upset and with a fever.
O/E she has no respiratory signs and had bright red tympanic membranes that are red and bulging with no light reflection.
What do you think is the diagnosis and how would you treat?

Answer 15

Acute otitis media = acute infection of the middle ear.
Advise regular pain relief with paracetamol/ibuprofen (may be needed for up to a week)
May give prescription for amoxicillin if no improvement for 3 days

Question 16

How do you confirm otitis media with effusion ?

Answer 16

<4 - flat trace on tympanometry with evidence of conductive loss on pure tone audiometry

or reduced hearing on a distraction hearing test if older

Question 17

What is the most common cause for conductive hearing loss in children?

Answer 17

Otitis media with effusion

Question 18

How can otitis media with effusion be treated?

Answer 18

Abx - only reduce duration of pain, not hearing loss

Grommets - ventilation tubes

Question 19

What is whooping cough?

Answer 19

It is a highly contagious bacterial respiratory infection caused by Bordetella Pertussis

Question 20

Explain the course of disease for whooping cough

Answer 20

Intubation period - Up to 3 weeks intubation period before onset of any symptoms

Catarrhal stage - coryzal like symptoms, nasal congestion - 2 weeks

Paroxysmal stage - 1-10 weeks, paroxysmal coughing out bursts, followed by quick inspiration (whoop) lots of snot, may vomit, worse at night

Convalescent stage - up to 2 months - chronic cough, becoming less violent

Question 21

A 3 year old presents at 10pm due to having a very bad and loud cough for the past couple of days, it comes in busts and is a spasmodic cough followed by a funny noise. He vomited at home just after he coughed. He has been unwell for over a week with runny nose, and sneezing.
What investigations do you request and what is your working diagnosis?

Answer 21

ABC - okay

Nasal and throat swab
FBC - lymphocytosis

Working diagnosis = Bordetella Pertussis/whooping cough

Question 22

A 3 year old presents at 10pm due to having a very bad and loud cough for the past couple of days, it comes in busts and is a spasmodic cough followed by a funny noise. He vomited at home just after he coughed. He has been unwell for over a week with runny nose, and sneezing.
What treatment do you give?

Answer 22

Suggests he is in the paroxysmal phase - less effect of abx
Give erythromycin - reduces contagiousness and severity of symptoms slightly

Macrolide abx for the GNB bordetella pertussis

Question 23

A 4 year old girl presents with a paroxysmal cough followed by inspiratory wheeze, its worse at night and she has vomited because of it. She has also had a week of cold like symptoms.
You suspect that she has whooping cough caused by bordetella pertussis
She has a 3 month old sister - what are your concerns here?

Answer 23

Vaccinations complete at 4 months old
in the 6 in 1 vaccine given at 2,3 & 4 months

sister has reduced immunity so may have more severe reaction, sister is an infant so more likely to get apnoea instead of paroxysm cough which is more dangerous

Close contacts get prophylactic erythromycin

Question 24

Whooping cough/bordetella pertussis is included in the 6 in 1 (previously 5 in 1) vaccine schedule given at 2, 3 and 4 months.
What other diseases are included in the vaccine?

Answer 24

Diptheria 
Tetanus 
Polio 
Hib 
Hep B

Question 25

Explain the pathology of bronchiolitis and how it leeds to the symptoms

Answer 25

Viral infection causing inflammation in the wall of the bronchioles. Reduced air flow due to this inflammation and increased mucosal secretions and SM tightening around bronchioles. Causes air to be trapped in alveolar leading to hyperinflation. Dry cough - irritation in airways Wheeze - due to air way obstruction SOB - due to reduced airflow and over inflation

Question 26

Explain the signs you would see in an infant with bronchiolitis

Answer 26

Hyperinflation - prominent sternum, downwardly displaced liver Sub costal and intercostal recessions Fine end inspiratory crackles and wheeze

Question 27

Is there a vaccine available for bronchiolitis?

Answer 27

There is a vaccine available for premature high risk babies - monoclonal abs palivizumab for RSV. It has to be given monthly as its only passive immunity

Question 28

What can cause bronchiolitis?

Answer 28

``` Respiratory syncytial virus RSV Human metapnuemovirus Parainfluenzae influenzae adenovirus ```

Question 29

A 5 month old present with increased WOB and a dry cough O/E you see sub and intercostal recessions, and a tracheal tug. He has a prominent sternum, fine end inspiratory crackles and wheeze. What do you suspect is the diagnosis and how would you treat?

Answer 29

Bronchiolitis Treat with humidified O2 via a nasal cannula

Question 30

What is the difference between stridor and wheeze?

Answer 30

Stridor is a high-pitched noise from turbulent air from the upper air ways - usually inspiratory. Wheeze is expiratory coarse whistling sounds - usually lower airways

Question 31

What are the pathogens that cause pneumonia in children?

Answer 31

New borns - Group B strep Younger - Viral > Bacterial = RSV + strep pneumoniae Older - Bacterial > Viral = Strep pneumonia, chlamydia pneumonia + mycoplasma pneumoniae

Question 32

What are the principles of treatment for CAP in paeds?

Answer 32

Are they hypoxic? O2 therapy if <92% <2 exectant + supportive as more likely viral cause >2 amoxicillin Severe/suspected mycoplasma or chlamydia pneumoniae the cause add a macrolide - erythromycin

Question 33

A 6 year old presents with a cough, and difficulty breathing and being generally unwell. She has a fever. You suspect that she has CAP What examinations would you find to confirm this diagnosis?

Answer 33

``` Raised temperature Increased respiratory rate >40 Nasal flaring Bronchial breathing Chest recessions End inspiratory coarse crackles may be heard over the infected area ```

Question 34

A 3 year old presents with difficulty breathing, she has a wheeze is showing signs of increased work of breathing. What are your treatment options?

Answer 34

>5 wheeze 1st line = montelukast - leukotrine receptor antagonist 2nd line = salbutamol - SABA 3rd line = ipotropium bromide - anticholinergic

Question 35

A 2 year old presents to hospital with a wheeze and shortness of breath - he has been admitted twice in the past with similar symptoms. You suspect that it is a viral induced wheeze but what are in your differentials?

Answer 35

Tracheobronchomalacia/laryngo malacia CF Ciliary dyskinesia

Question 36

Give 2 examples of reliever inhalers that can be used for asthma

Answer 36

Relievers: SA beta agonists = salbutamol Anticholinergic = ipotropium bromide

Question 37

Give examples of preventers that can be used to treat asthma

Answer 37

``` ICS = beclomethasone, budesomide LABA = salmeterol, formoterol Leukotrine inhibitors = montelukast Methylxanthines = Theophylline Oral steroids = prednisolone ```

Question 38

A 8 year old present to you in A&E in a drowsy state. His mum tells you he has had problems breathing and has asthma. He is showing a poor respiratory effort and has02 sats of 90%. He is having a life threatening asthma attack. How would you treat?

Answer 38

O SHITME ``` O2 Salbutamol Nebs Ipratropium bromide IV hydrocortisone Theophylline ```

Question 39

Explain the pathophysiology that causes asthma

Answer 39

Genetics + atopy + trigger Cause bronchial inflammation - oedema, increased mucus secretion and infiltration of cells - and bronchial hyper responsiveness Lead to airways narrowing (reversible) Causing symptoms: wheeze, cough, SOB, tight chest

Question 40

What are the side effects of steroids?

Answer 40

Adrenal suppression - less adrenal stimulation due to less ACTH --> fatigue, wt loss and appetite, N/V/D, depression Stunted growth - only in the short term - no affect on adult height

Question 41

A 2 year old boy presents with a cough. From the history you elicit that he has suffered from many chest infections and has had a 'wet' cough for a few months now. You suspect that he has had a chronic lung infection. What could be the cause?

Answer 41

``` Causes of chronic lung infection: CF Ciliary dyskinesia Immune deficiency Chronic aspiration ```

Question 42

Explain the pathology behind CF especially in the lungs

Answer 42

Autosomal recessive disease due to faulty CFTR gene on chromosome 7. Faulty CFTR proton pump on cell membranes leading to problems with Cl- ion transport. Problems in Lungs, sweat glands, pancreas, liver, bowel, and reproductive organs. In the lungs: Cl- not transported out of cells into the airways - greater negative charge inside of cells - sodium and water drawn into cells - increased viscosity of mucus in airways - decreased mucociliary transport - accumulation of mucus - increased bacterial infections - inflammation - damage to lungs.

Question 43

Explain the problem that CF causes in the pancreas

Answer 43

``` Less Cl in the pancreatic juices - increased viscosity - remains in pancreas - activation of pancreatic proteolytic enzymes causes damage to pancreas Exocrine enzymes (proteases, lipases & amylase) fail to reach bowl for digestion - steatorrea and malabsorption Endocrine enzymes - insulin - DM ```

Question 44

How is CF diagnosed?

Answer 44

Sweat test