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PAEDS RESPIRATORY Flashcards

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1
Q

RESP OVERVIEW
What are some causes of respiratory infections in children?

A

80-90% viral –
- Respiratory syncytial virus (RSV), rhinoviruses, metapneumovirus, parainfluenza
Bacterial –
- Strep. pneumoniae, h. influenzae, moraxella catarrhalis, bordatella pertussis

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2
Q

RESP OVERVIEW
What are some risk factors for respiratory infections?

A
  • Parental smoking
  • Poor socioeconomic status
  • Male gender
  • Immunodeficiency
  • Underlying lung disease
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3
Q

RESP OVERVIEW
Cough is a very common symptoms with many causes.
What are some of the causes of cough?

A
  • Recurrent colds, allergic rhinitis (post-nasal drip)
  • Infections
  • Reflux (aspiration)
  • Passive smoking
  • CF, bronchiectasis, asthma
  • TB
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4
Q

URTI
What is the most common presentation of an upper respiratory tract infection (URTI)?

A
  • Combination of nasal discharge + blockage
  • Fever, sore throat, earache
  • Cough
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5
Q

URTI
How does coryza present?

A

Clear or mucopurulent nasal discharge + blockage

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6
Q

URTI
What are some complications of URTIs?

A
  • Difficulty feeding + breathing
  • Febrile convulsions
  • Acute exacerbations of asthma
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7
Q

URTI
What is coryza?

A
  • Commonest infection in childhood (rhinoviruses, coronaviruses, RSV)
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8
Q

URTI
What is the management of coryza?

A
  • Conservative (paracetamol, ibuprofen, fluids)
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9
Q

OTITIS MEDIA
How would you investigate otitis media?

A
  • Tympanic membrane bright red + bulging with loss of normal light reflection
  • May be pus visible with hole in TM in acute perforation
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10
Q

LARYNX/TRACHEAL ISSUES
What are laryngeal + tracheal infections characterised by?

A
  • Stridor (rasping sound on inspiration)
  • Hoarseness of voice (inflamed vocal cords)
  • Barking cough
  • Variable degree of dyspnoea
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11
Q

LARYNX/TRACHEAL ISSUES
What are some causes of stridor?

A
  • Croup
  • Epiglottitis
  • Laryngomalacia
  • Inhaled foreign body
  • Tracheitis
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12
Q

LARYNX/TRACHEAL ISSUES
How can the severity of upper airway obstruction be clinically assessed in laryngeal and tracheal infections?

A
  • Chest recession (none, only on crying, at rest)
  • Degree of stridor (none, only on crying, at rest or biphasic)
  • Tracheal tug (none, present)
  • Sternal wall retractions (present or marked)
  • Lethargy or agitation + RD = severe
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13
Q

LARYNX/TRACHEAL ISSUES
What is the main issue with laryngeal and tracheal infections?
How can this be avoided?

A
  • Mucosal inflammation + swelling can rapidly cause life-threatening obstruction
  • Do NOT examine throat, keep calm
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14
Q

CROUP
What is the epidemiology?

A
  • Peak incidence 2y (6m–3y), commonly Autumn
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15
Q

CROUP
What are the causes?

A
  • Parainfluenza viruses (#1), less so RSV, metapneumovirus, influenza
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16
Q

CROUP
What is croup (laryngotracheobronchitis)?

A
  • URTI causing oedema in larynx, oedema of subglottis dangerous (narrow trachea)
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17
Q

CROUP
What is the clinical presentation of croup?

A
  • Initial low grade fever + coryza start and are worse at night
  • Barking (seal-like) cough, harsh stridor + hoarseness
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18
Q

CROUP
When would you admit a patient to hospital?

A
  • Mod-severe croup, <6m or upper airway issues (laryngomalacia)
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19
Q

CROUP
How do you assess croup severity?

A

Westley score for severity
(chest wall retractions, stridor, cyanosis, air entry + consciousness)

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20
Q

CROUP
What are the investigations for croup?

A
  • Clinical but if CXR done PA view shows subglottic narrowing (steeple sign)
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21
Q

CROUP
What is the management of croup?

A
  • PO dexamethasone 0.15mg/kg 1st line, can repeat at 12h
  • Nebulised budesonide (steroid)
  • High flow oxygen + nebulised adrenaline (more severe/emergency cases)
  • Monitor closely with anaesthetist + ENT input, intubation rare
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22
Q

ACUTE EPIGLOTTITIS
What is acute epiglottitis?

A
  • Life-threatening emergency as high risk of obstruction due to intense swelling of epiglottis + surrounding tissues associated with septicaemia
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23
Q

ACUTE EPIGLOTTITIS
What causes it?

A
  • Haemophilus influenza B (HiB), most common 1–6y
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24
Q

ACUTE EPIGLOTTITIS
What is the clinical presentation of acute epiglottitis?

A
  • Rapid onset, no preceding coryza
  • High fever in an ill, toxic looking child
  • Intensely painful throat (can’t drink, speak, drooling saliva)
  • Soft inspiratory stridor with absent or minimal cough
  • ‘Tripod’ position > optimise airway by leaning forward + extending neck
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25
ACUTE EPIGLOTTITIS What is the investigation for acute epiglottitis?
- Clinical Dx but if CXR done lateral view show epiglottis swelling = thumb sign
26
ACUTE EPIGLOTTITIS What is the management of epiglottitis?
- Prevention HiB vaccine, rifampicin prophylaxis for close household contacts - Do NOT examine throat, anaethetist, paeds + ENT surgeon input - Intubation if severe, may need tracheostomy - IV ceftriaxone + dexamethasone given once airway secured
27
BRONCHIOLITIS What is the epidemiology of bronchiolitis?
90% aged 1–9m, less common after 1, common in the winter
28
BRONCHIOLITIS What is bronchiolitis?
- Inflammation + infection of bronchioles
29
BRONCHIOLITIS What are the causes of bronchiolitis?
- RSV #1, others = adenovirus, metapneumovirus + Mycoplasma - Adenovirus associated with bronchiolitis obliterans (perm damage due to scarring, Rx steroids)
30
BRONCHIOLITIS What are some risk factors for bronchiolitis?
- Premature babies - CHD - Cystic fibrosis - Immune deficiency
31
BRONCHIOLITIS What is the clinical presentation of bronchiolitis?
- Coryzal Sx precede a sharp, dry cough with increasing breathlessness - Feeding difficulty associated with increasing dyspnoea - Respiratory distress
32
BRONCHIOLITIS What are some signs of respiratory distress seen in bronchiolitis?
- Subcostal + intercostal recession, apnoea - Hyperinflation of chest - Accessory muscles - Nasal flaring - Fine end-inspiratory crackles - Tracheal tug - Head bobbing - Grunting - High pitched wheezes - Tachypnoea, tachycardia - Low grade fever
33
BRONCHIOLITIS What are some investigations for bronchiolitis?
- Nasopharyngeal secretions PCR for RSV (immunofluorescence) - CXR may show hyperinflation due to small airways obstruction, air trapping + foetal atelectasis - Blood gas (capillary) if severe + ?ventilation > falling O2, rising CO2 + pH
34
BRONCHIOLITIS What is the mainstay of management for bronchiolitis?
- Supportive - Most recover 2w, some have recurrent episodes of cough + wheeze
35
BRONCHIOLITIS What are some criteria for admission?
- Apnoea - Severe resp distress (RR>60, marked chest recession, grunting) - Central cyanosis - SpO2 < 92% - Dehydration - 50–75% usual intake
36
BRONCHIOLITIS What is the inpatient management of bronchiolitis?
- Saline nasal drops - Small feed (NG 1st or IV if cannot tolerate) - Humidified oxygen via nasal cannula - Suction if excessive secretions - Assisted ventilation by CPAP or fully mechanical (rare)
37
BRONCHIOLITIS What can be given as prevention against bronchiolitis? Who would be given this?
- Monoclonal Ab to RSV = palivizumab as monthly IM - Reduces hospital admissions in high-risk infants (preterm, cystic fibrosis, congenital heart disease)
38
PNEUMONIA What is pneumonia?
- Infection + inflammation of the lung parenchyma
39
PNEUMONIA What are the common causes of pneumonia in neonates?
group B strep (gram -ve enterococci)
40
PNEUMONIA What are the common causes of pneumonia in infants + young children?
RSV most common, pneumococcus #1 bacterial, H. influenzae, Bordatella pertussis, chlamydia trachomatis (S. aureus rarely but = serious)
41
PNEUMONIA What are the common causes of pneumonia in children >5?
Pneumococcus, mycoplasma pneumoniae, chlamydia pneumoniae
42
PNEUMONIA What are the common causes of pneumonia in immunocompromised?
Pneumocystis jiroveci or TB
43
PNEUMONIA What is the clinical presentation of pneumonia?
- Fever + difficult breathing common presenting Sx - Often preceded by URTI - Productive cough, poor feeding, lethargy - Mycoplasma can present extra-pulmonary (erythema multiforme)
44
PNEUMONIA What are some clinical signs of pneumonia?
- Tachypnoea + tachycardia - Nasal flaring + chest indrawing, head bobbing - End-inspiratory focal coarse crackles - Other signs (dull percussion, bronchial breathing) can be absent in young
45
PNEUMONIA What are indications for hospital admission?
- SpO2 <92%, severe tachypnoea, grunting, apnoea, not feeding, family unable to provide appropriate care
46
PNEUMONIA What are some investigations for pneumonia?
- SpO2 may be low - FBC, CRP ± blood cultures + sputum culture - CXR to confirm diagnosis
47
PNEUMONIA How can CXR indicate what the causative organism may be?
- Lobar consolidation (dense white area in a lobe) = pneumococcus - Rounded air-filled cavities (pneumatoceles) + multi-lobar = S. aureus
48
PNEUMONIA What is a complication of pneumonia?
- May have pleural effusion which can lead to empyema - Suspect if persistent fever, foul smelling mucus - Surgical drainage ± chest drain
49
PNEUMONIA What is the prophylaxis for pneumonia?
- Prophylaxis PCV vaccine with 13 common pneumococcus serotypes + HiB vaccine
50
PNEUMONIA What is the management of pneumonia?
- Newborns = IV broad-spec Abx - Older = PO amoxicillin with broad-spectrum Abx (co-amoxiclav) if unresponsive or influenza - Macrolides (erythromycin) to cover for mycoplasma, chlamydia or if unresponsive
51
VIRAL INDUCED WHEEZE What is the epidemiology?
- M>F, usually resolves by 5 as airway size increases
52
VIRAL INDUCED WHEEZE What are the two types of viral induced wheeze?
- Episodic viral = only wheezes when viral URTI + Sx free inbetween - Multiple trigger = as well as viral URTIs, other triggers (exercise, smoke)
53
VIRAL INDUCED WHEEZE What is a wheeze?
- Expiratory, polyphonic breathing sound created by air being forced through narrow air passage
54
VIRAL INDUCED WHEEZE What are some risk factors?
Maternal smoking during/after pregnancy + prematurity
55
VIRAL INDUCED WHEEZE What causes viral induced wheeze?
- Often decreased lung function from birth from small airway diameter so more likely to narrow + obstruct due to inflammation from viral URTI
56
VIRAL INDUCED WHEEZE How is it different to asthma?
- Preschool (1-3y), - no atopy - only during viral infections
57
VIRAL INDUCED WHEEZE What is the clinical presentation of viral induced wheeze?
- SOB, - signs of respiratory distress, - widespread expiratory wheeze
58
VIRAL INDUCED WHEEZE What is the management?
1st line = PRN salbutamol 2nd line = Montelukast or ICS or both
59
ASTHMA What is asthma?
- Chronic inflammatory airway disease causing episodic exacerbations of bronchoconstriction due to smooth muscle contraction of the airways (bronchi)
60
ASTHMA how does acute asthma present?
Worsening dyspnoea, use of accessory muscles, tachypnoea, symmetrical expiratory wheeze, reduced air entry
61
ASTHMA What are the characteristics of asthma?
- Airflow limitation due to bronchospasm (reversible spontaneously or with Tx) - Airway hyperresponsiveness to various triggers - Bronchial inflammation
62
ASTHMA What is the consequence of bronchial inflammation?
- Oedema - Excessive mucus production - Infiltration with cells (eosinophils, mast cells, neutrophils, lymphocytes)
63
ASTHMA What are some risk factors for asthma?
LBW, FHx, bottle fed, atopy, male, pollution
64
ASTHMA What are the 2 main classifications of asthma?
Allergic/atopic asthma – - T1 hypersensitivity IgE mediated reaction (mast cells + histamine) - PMH/FHx of atopy (eczema, hayfever, food allergies), persistent Sx Non-allergic asthma – - Idiopathic but triggers
65
ASTHMA What are some triggers of non-allergic asthma?
- Smoking, allergens, exercise, cold/damp air, animals, beta-blockers, NSAIDs, occupations
66
ASTHMA What is the clinical presentation of asthma?
- Dry cough, SOB, chest tightness - Bilateral widespread polyphonic wheeze - Episodic Sx with diurnal variability (worse at night + early morning)
67
ASTHMA What are some investigations for asthma?
- Clinical Dx (RCP3 Qs) - FBC = eosinophilia (atopy) - Fractional exhaled nitric oxide >40ppb = inflamed airways - Peak expiratory flow rate diary - Spirometry - Atopy (skin prick or IgE showing ≥1 allergen + constant wheeze) - ?CXR to exclude other causes (hyperinflation)
68
ASTHMA What are the RCP3 questions and what are they used for?
Assessing asthma severity – Recent waking in the night? – Usual asthma Sx in the day? – Interference with ADLs?
69
ASTHMA What is purpose of a peak expiratory flow rate diary?
- 2 readings a day will show diurnal variation >20% on ≥3d/week - Will show bronchodilator responsiveness too
70
ASTHMA What is the purpose of spirometry?
- Obstructive pattern = FEV1 <80%, FEV1/FVC < 70% - Bronchodilator responsiveness = FEV1 ≥12% improvement
71
ASTHMA What is some conservative management for asthma?
- Inhaler technique - Avoid triggers - Monitor peak flow diary - Yearly flu jab + asthma review - Asthma self-management programme
72
ASTHMA Name 6 potential treatments that can be used in asthma
- SABA = salbutamol, terbutaline "reliever" - ICS = beclomethasone "preventer" - LABA = salmeterol, formoterol - Leukotriene receptor antagonists = montelukast - Theophylline = aminophylline - Maintenance + reliever therapy = combined low dose ICS + fast acting LABA
73
ASTHMA What is the mechanism of action for SABAs?
- Adrenaline acts on smooth muscles of airways > dilation, - acts fast but lasts only few hours
74
ASTHMA What are the important side effects of SABAs?
Hypokalaemia, tremor
75
ASTHMA What is the mechanism of action for ICS?
Reduces inflammation + reactivity of airways
76
ASTHMA What are the important side effects of ICS?
Oral thrush, adrenal + growth suppression, DM, osteoporosis
77
ASTHMA What is the mechanism of action for LABA?
Same as SABA but longer effects, useful in exercise-induced asthma
78
ASTHMA What is the mechanism of action for LTRA?
Leukotrienes produced by immune system > inflammation, bronchoconstriction + mucous secretion in airways so blocks this
79
ASTHMA What is the mechanism of action for MART?
Replaces all other inhalers as preventer + reliever
80
ASTHMA What is the mechanism of action for theophyllines?
Relaxes bronchial smooth muscle + reduces inflammation
81
ASTHMA What are the important side effects of theophylline?
Vomiting, insomnia, headaches
82
ASTHMA What is the stepwise management of chronic asthma in <5y? (BTS guidance)
- 1 = PRN SABA - 2 = Low dose ICS OR PO montelukast - 3 = Other option from 2 - 4 = refer to specialist
83
ASTHMA What is the stepwise management of chronic asthma >5y? (BTS guidance)
- 1 = PRN SABA - 2 = SABA + low dose ICS - 3 = SABA + low dose ICS + LABA (only continue if good response) - 4 = increase ICS dose (?LTRA or PO theophylline) - 5 = PO steroids in lowest tolerated dose - May need immunosuppression or immunomodulation therapy with specialist referral
84
ASTHMA What is the management of asthma in <5 year olds (NICE guidance)
1. PRN SABA 2. SABA + 8 week trial of moderate ICS 3. SABA + low ICS + LTRA 4. Stop LTRA and refer to specialist
85
ASTHMA What is the management for children >5yrs old? (NICE guidance)
1. SABA 2. SABA + low dose ICS 3. SABA + low dose ICS + LTRA 4. SABA + low dose ICS + LABA 5. SABA + MART (including low dose ICS) 6. SABA + MART (including mod dose ICS) / LABA + moderate dose ICS 7. SABA + high dose ICS / theothylline + refer to specialist
86
ASTHMA What are some reasons for failure to respond to treatment for asthma?
ABCDE – - Adherence (#1) - Bad disease (dose inadequate for severity) - Choice of drug/device (different pts respond differently) - Diagnosis (?correct) - Environment (?trigger)
87
ASTHMA What is acute asthma? What can cause it?
- Acute exacerbation of asthma characterised by rapid deterioration in Sx - Any of typical asthma triggers
88
ASTHMA What is classed as a severe asthma exacerbation?
- PEFR 33–50% predicted - Unable to complete full sentences - RR>50 (2-5y), or >30 (>5y) - HR >130 (2-5y) or >120 (>5y) - Signs of resp distress (chest recessions) - SpO2 <92%
89
ASTHMA What is classed as a life-threatening asthma exacerbation?
- PEFR 33% predicted - Exhaustion/cyanosis - Poor respiratory effort - Altered consciousness, hypotension - Silent chest (airways so tight no air entry) - SpO2 <92%
90
ASTHMA What are some investigations for exacerbation of asthma?
- Monitor RR, peak flow, SpO2, chest auscultation - ECG monitoring for arrhythmias (low K+ from SABA + steroids) - ABG = initial resp alkalosis as tachypnoea causes drop in CO2, normal pCO2 or hypoxia concerning as indicates exhaustion, resp acidosis from high CO2 very bad sign
91
ASTHMA What is the management of exacerbations of asthma?
O SHIT ME – - Oxygen (SpO2 94–98%) - Salbutamol (spacer or neb B2B, IV if no response to this + ipratropium as 2nd line) - Hydrocortisone IV or PO pred - Ipratropium bromide (neb if poor response to salbutamol) - Theophylline (IV) - Magnesium sulfate (IV) - Escalate early > ICU if not improving for ventilation ± intubation
92
CYSTIC FIBROSIS What is cystic fibrosis?
- Mutation in gene encoding cystic fibrosis transmembrane conductance regulator (CFTR) on chromosome 7 which is a cAMP dependent Cl- channel on cell membranes of lungs, pancreas, GI + reproductive tract
93
CYSTIC FIBROSIS What is the pathophysiology of cystic fibrosis?
- Decreased Cl- excretion into airway lumen + increased reabsorption of Na+ into epithelial cells means less excretion of salt (+ so water) > increased viscosity of airway secretion
94
CYSTIC FIBROSIS What is the impact of cystic fibrosis in the various parts of the body?
- Thick pancreatic + biliary secretions = blockage of ducts > lack of digestive enzymes in GI tract - Lungs = reduction in air surface liquid layer + impaired ciliary function = reduced airway clearance, bacterial colonisation + infections - Abnormal function of sweat glands = Na+ + Cl- in sweat (saltier)
95
CYSTIC FIBROSIS What is the aetiology and epidemiology of cystic fibrosis?
- Autosomal recessive condition - Most common mutation is deltaF508 deletion, more commonly in caucasians - 1 in 25 carriers + 1 in 2500 have CF
96
CYSTIC FIBROSIS How does cystic fibrosis present in neonates?
- Meconium ileus (SBO from thick intestinal secretions) - Failure to thrive, malabsorption, steatorrhoea - Prolonged neonatal jaundice - Recurrent chest infections
97
CYSTIC FIBROSIS What is meconium ileus? How does it present on imaging?
- Not passing meconium in 24h, vomiting + abdo distension - Meconium pellets + microcolon on contrast enema - AXR will show dilated loops of bowel
98
CYSTIC FIBROSIS How does cystic fibrosis present in young children?
- Chronic cough with thick sputum production - Bronchiectasis - Rectal prolapse - Nasal polyps + sinusitis
99
CYSTIC FIBROSIS How does cystic fibrosis present in older children + adolescents?
- DM (pancreatic insufficiency) - Cirrhosis + portal HTN - Distal intestinal obstruction - Pneumothorax or recurrent haemoptysis - Sterility in males as absent vas deferens
100
CYSTIC FIBROSIS What are some signs of cystic fibrosis?
- Low weight or height on growth charts - Hyperinflation due to air trapping - Coarse inspiration crepitations ± expiratory wheeze - Finger clubbing
101
CYSTIC FIBROSIS What are some complications of cystic fibrosis?
- Respiratory tract infections - Cholesterol gallstones - Malabsorption + maldigestion due to pancreatic insufficiency (failure to thrive, steatorrhoea) - Biggest cause of death is respiratory failure
102
CYSTIC FIBROSIS What are some typical causes of respiratory tract infections in cystic fibrosis?
- S. aureus - H. influenzae - Pseudomonas aeruginosa - Bulkholderia cepacia associated with increased morbidity + mortality
103
CYSTIC FIBROSIS What are some investigations for cystic fibrosis?
- Guthrie test = raised immunoreactive trypsinogen - Sweat test = gold standard - Low faecal elastase = pancreatic insufficiency - Genetic testing for CFTR gene during pregnancy with amniocentesis or CVS
104
CYSTIC FIBROSIS What is the sweat test? What result is diagnostic?
- Pilocarpine on patch of skin, attach electrodes + induces sweat - Diagnostic Cl- >60mmol/L (normal 1–30mmol/L)
105
CYSTIC FIBROSIS Who is involved in the care of a patient with cystic fibrosis?
- Resp paeds + GP - Physio - Specialist nurses - Dietician - Genetic counsellor for family
106
CYSTIC FIBROSIS How is the respiratory aspects of cystic fibrosis managed?
- Chest physio ≥BD for airway clearance - Rescue Abx when needed (may have portacath) + long-term prophylactic flucloxacillin (S. aureus) – avoid other CF pts - Bronchodilators - Nebulised hypertonic saline - Nebulised DNase - Oxygen + CPAP - Heart + lung transplant
107
CYSTIC FIBROSIS What is DNase?
- Enzyme that can break down DNA material in respiratory secretions to decrease sputum viscosity + increase clearance
108
CYSTIC FIBROSIS What is the nutritional management of cystic fibrosis?
- High calorie, high fat diet - Pancreatic enzyme replacement therapy (Creon) with all food - Gastrostomy for overnight feeding - Fat soluble (ADEK) vitamins
109
SLEEP BREATHING ISSUES What is the management of sleep related breathing disorders?
- Adeno-tonsillectomy (if adeno-tonsillar hypertrophy) often curative - Nasal or facemask CPAP or BiPAP may be required at night
110
RESP PHARMACOLOGY Give an example of a SABA
Salbutamol
111
RESP PHARMACOLOGY Give an example of a LABA
Salmeterol
112
RESP PHARMACOLOGY Give an example of a LAMA
tiotropium
113
RESP PHARMACOLOGY Give an example of an LTRA?
montelukast
114
RESP PHARMACOLOGY Give an example of an ICS
Beclometasone

My Phase 3a Revision (27 decks)

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