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Question 1

Signs of Respiratory Distress

Answer 1

Raised respiratory rate
Use of accessory muscles of breathing, such as the sternocleidomastoid, abdominal and intercostal muscles
Intercostal and subcostal recessions
Nasal flaring
Head bobbing
Tracheal tugging
Cyanosis (due to low oxygen saturation)
Abnormal airway noises

Question 2

Bronchiolitis management

Answer 2

humidified optiflow
saline nasal drops and suctioning
pavalizumab - monthly (ex prem and chd)

monitor cbgs (co2 and ph)

Question 3

Viral Induced Wheeze or Asthma?

Answer 3

Presenting before 3 years of age
No atopic history
Only occurs during viral infections

Asthma can also be triggered by viral or bacterial infections, however it also has other triggers, such as exercise, cold weather, dust and strong emotion

Question 4

VIW Presentation

Answer 4

Evidence of a viral illness (fever, cough and coryzal symptoms) for 1-2 days preceding the onset of:

Shortness of breath
Signs of respiratory distress
Expiratory wheeze throughout the chest

Neither viral induced wheeze or asthma cause a focal wheeze. If you hear a focal wheeze be very cautious and investigate further for a focal airway obstruction such as an inhaled foreign body or tumour.

Question 5

VIW and Acute Asthma management - Moderate

Answer 5

Nebulised beta-2 agonists (i.e. salbutamol 5mg repeated as often as required)

Nebulised ipratropium bromide

Steroids. Oral prednisolone or IV hydrocortisone. These are continued for 5 days

Antibiotics if there is convincing evidence of bacterial infection

Question 6

VIW and Acute Asthma management - Severe

Answer 6

Oxygen if required to maintain sats 94-98%

Aminophylline infusion

Consider IV salbutamol

Question 7

VIW and Acute Asthma management - Life threatening

Answer 7

IV magnesium sulphate infusion

Admission to HDU / ICU

Intubation in worst cases – however this decision should be made early because it is very difficult to intubate with severe bronchoconstriction

Question 8

Asthma post treatment

Answer 8

Monitor serum potassium

Optimise asthma control after an acute attack. Discharge patients with an “asthma action plan” -

reducing regime of salbutamol to continue at home, for example 6 puffs 4 hourly for 48 hours then 4 puffs 6 hourly for 48 hours then 2-4 puffs as required

Finish the course of steroids if these were started (typically 3 days total)
Provide safety-net information about when to return to hospital or seek help

prescribing a “rescue pack” or steroids for the person to initiate in the future if they have another exacerbation of asthma

NICE suggest referral to a respiratory specialist after 2 attacks in 12 months

Question 9

Grading Acute Asthma

Moderate

Answer 9

PEFR 50 – 75% predicted

Question 10

Grading Acute Asthma

Severe

Answer 10

PEFR 33-50% predicted
Resp rate >25
Heart rate >110
Unable to complete sentences

Question 11

Grading Acute Asthma

Life-threatening

Answer 11

PEFR <33%
Sats <92%
Becoming tired
No wheeze. This occurs when the airways are so tight that there is no air entry at all. This is ominously described as a “silent chest”.
Haemodynamic instability (i.e. shock)

Question 12

Chronic asthma investigations

Answer 12

intermediate or high probability of asthma - a trial of treatment

intermediate probability of asthma or diagnostic doubt:

Spirometry with reversibility testing (in children aged over 5 years)
Direct bronchial challenge test with histamine or methacholine
Fractional exhaled nitric oxide (FeNO)
Peak flow variability measured by keeping a diary of peak flow measurements several times a day for 2 to 4 weeks

Question 13

Asthma Medical Therapy in Under 5 Years

Answer 13

salbutamol
low dose steroid inh or montelukast (oral)
add other option from step 2
specialist

Question 14

Asthma Medical Therapy in 5-12 Years

Answer 14

salbutamol prn
low dose steroid inh
laba e.g. salmeterol (take off if not good response)
medium dose steroid inh
monteulkast/theophylline
high dose steroid inh
specialist - oral steroids??

Question 15

Asthma Medical Therapy Aged Over 12 Years (Same as Adults)

Answer 15

salbutamol prn
low dose steroid inh
salmeterol
med dose steroid inh
trial montelukast/theophyllin/inh tiotropium
high dose inh corticosteroid
combine alt therapies
oral salbutamol
oral steroids (start low) under specialist guidance

Question 16

Recurrent Lower Respiratory Tract Infections Ix

Answer 16

Full blood count

Chest xray

Serum immunoglobulins -
Test immunoglobulin G to previous vaccines (i.e. pneumococcus and haemophilus). Some patients are unable to convert IgM to IgG, and therefore cannot form long term immunity to that bug. This is called an immunoglobulin class-switch recombination deficiency.

Sweat test to check for cystic fibrosis.

HIV test, especially if mum’s status is unknown or positive.

A thorough history (including family history) and examination is needed to assess for reflux, aspiration, neurological disease, heart disease, asthma, cystic fibrosis, primary ciliary dyskinesia and immune deficiency.

Question 17

Pneumonia ix

Answer 17

CXR
Sputum cultures
Throat swab
viral pcr
cbg - monitor blood lactate and metabolic acidosis

Question 18

Pneumonia tx

Answer 18

Amoxicillin is often used first line

Adding a macrolide (erythromycin, clarithromycin or azithromycin) will cover atypical pneumonia

Question 19

characteristic chest signs of pneumonia

Answer 19

Bronchial breath sounds.
Focal coarse crackles
Dullness to percussion

Question 20

croup presentation

Answer 20

Increased work of breathing
“Barking” cough, occurring in clusters of coughing episodes
Hoarse voice
Stridor
Low grade fever

Question 21

croup tx

Answer 21

Supportive and sit up

Stepwise options in severe croup to get control of symptoms:

Oral dexamethasone
Oxygen
Nebulised budesonide
Nebulised adrenalin
Intubation and ventilation

Question 22

Presentation Suggesting Possible Epiglottitis

Answer 22

Patient presenting with a sore throat and stridor
Drooling
Tripod position, sat forward with a hand on each knee
High fever
Difficulty or painful swallowing
Muffled voice
Scared and quiet child
Septic and unwell appearance

Question 23

Epiglotttitis ix

Answer 23

lateral xray of the neck shows a characteristic “thumb sign” or “thumbprint sign

excludes FB

!!! - If the patient is acutely unwell and epiglottitis is suspected then investigations should not be performed.

Question 24

Epiglotttitis TX

Answer 24

alert the most senior paediatrician and anaesthetist available

ensuring the airway is secure - preparations need to be made to perform intubation at any time - needs to be performed in a controlled environment with facilities available to do a tracheostomy

IV antibiotics (e.g. ceftriaxone)
Steroids (i.e. dexamethasone)

Question 25

Pertussis ix

Answer 25

nasal swab - pcr or culture

if over 2 wks - antibody

Question 26

Pertussis management

Answer 26

Pertussis is a notifiable disease

Macrolide antibiotics such as azithromycin, erythromycin and clarithromycin can be beneficial in the early stages (within the first 21 days) or vulnerable patients. Co-trimoxazole is an alternative to macrolides.

Close contacts with an infected patient are given prophylactic antibiotics if they are in a vulnerable group,

The symptoms typically resolve within 8 weeks, however they can last several months. It is also known as the “100-day cough” due to the potential long duration of the cough. A key complication of whooping cough is bronchiectasis.

Question 27

CF Presentation

Answer 27

Meconium ileus
recurrent lower respiratory tract infections,

failure to thrive

pancreatitis

Chronic cough
Thick sputum production
Recurrent respiratory tract infections
Loose, greasy stools (steatorrhoea) due to a lack of fat digesting lipase enzymes
Abdominal pain and bloating
Parents may report the child tastes particularly salty when they kiss them, due to the concentrated salt in the sweat
Poor weight and height gain (failure to thrive)

Question 28

CF Signs

Answer 28

Low weight or height on growth charts
Nasal polyps
Finger clubbing
Crackles and wheezes on auscultation
Abdominal distention

Question 29

CF Tests

Answer 29

pilocarpine sweat test

Question 30

CF Management

Answer 30

Chest physiotherapy

Exercise

High calorie diet

CREON tablets to digest fats in patients with pancreatic insufficiency

Prophylactic flucloxacillin

Treat chest infections when they occur

Bronchodilators such as salbutamol inhalers

Nebulised DNase

Nebulised hypertonic saline

Vaccinations including pneumococcal, influenza and varicella

Pseudomonas colonisation can be treated with long term nebulised antibiotics such as tobramycin. Oral ciprofloxacin is also used.

Patients with cystic fibrosis are managed and followed up in specialist clinics, typically every 6 months. They require regular monitoring of their sputum for colonisation of bacteria like pseudomonas. They also need monitoring and screening for diabetes, osteoporosis, vitamin D deficiency and liver failure.

Question 31

Primary Ciliary Dyskinesia - Kartagner’s Triad

Answer 31

Paranasal sinusitis
Bronchiectasis
Situs Inversus