Respiratory Flashcards
1
Q
What is asthma?
A
Airway hyperresponsiveness - various triggers for bronchial smooth muscle contraction
Bronchial inflammation - immune cell infiltration causing oedema, smooth muscle hypertrophy, mucus plugging, epithelial damage
Airflow limitation - reversible
2
Q
How can asthma present?
A
Symptoms induced by weather, exercise, and ill-health, and nocturnal symptoms
Wheeze - heard by bedside or on auscultation
An absent wheeze can suggest narrowed airways
Expiratory wheeze
Cough
Increased WOB
Atopy
3
Q
What signs might suggest increased WOB?
A
Head bobbing Tripoding Nasal flaring Tracheal tug Use of abdominal muscles, sternocleidomastoid IC recession Grunting or gasping Chest expansion Cyanosis RR
4
Q
What is the long term management of asthma?
A
Step 1 - SABA PRN Step 2 - regular low dose ICS Step 3 - < 5 leukotriene receptor antagonist - > 5 LABA Step 4 - increase ICS dose, add in LRA Step 5 - regular oral steroids
5
Q
What suggests acute asthma?
A
33 92 CHEST
- < 33% PEFR
- < 92% sats
- Cyanosis
- Hypotension
- Exhaustion
- Silent chest
- Tachycardia
- Respiratory acidosis on ABG
6
Q
How is acute asthma treated?
A
OH SHIT Me!
- Oxygen
- Hydrocortisone
- Salbutamol nebs or 10 puffs via INH or IV
- Ipratropium bromide
- Theophylline
- Magnesium sulphate
7
Q
How does VIW tend to present?
A
Pre-school children Symptoms associated with chest infection Symptom free between infections Not worse at night Inhalers useful during symptoms No benefit for oral steroids during exacerbation
8
Q
What is bronchiolitis?
A
Inflamed and mucus plugging of bronchioles
9
Q
What is the most common cause of bronchiolitis?
A
RSV
Adenovirus
Rhinovirus
10
Q
How does bronchiolitis present?
A
Dry cough followed by vomiting Increased WOB Low grade pyrexia Poor feeding Apnoea when sleeping
11
Q
How is bronchiolitis investigated?
A
NPA - nasopharyngeal aspirate
Blood gas
CXR - if lung examination asymmetrical then might want to rule out superimposed pneumonia or pneumothorax or lobar collapse
U&E to look at hydration status
12
Q
When should you use a SABA in bronchiolitis?
A
FHx or atopy
Co-existing eczema
Over 6 months - babies don’t have beta-2 receptors
13
Q
What bacteria can cause pneumonia in children?
A
Strep pneumonia
Staph aureus
HiB
Mycoplasma
14
Q
What viruses can cause pneumonia in children?
A
Adenovirus
Rhino virus
RSV
15
Q
How does pneumonia present?
A
Cough Increased WOB Pyrexia Poor feeding and dehydration Auscultation - crepitations, reduced AE
16
Q
What investigations should you do for pneumonia?
A
CXR - focal consolidations
Raised WCC and CRP
Sputum cultures
Blood cultures
17
Q
How is pneumonia managed?
A
Oral antibiotics unless expecting sepsis
First line amoxicillin
Add macrolide if suspecting atypical infection or mycoplasma - clarithromycin
18
Q
What are the complications of pneumonia?
A
Sepsis Parapneumonic effusions Lung abscess Empyema Dehydration
19
Q
What bacteria can cause tonsilitis?
A
Group A strep
20
Q
When might you suspect bacterial tonsilitis?
A
Fever
Tender swollen anterior cervical lymphadenopathy
Tonsillar exudate
Absent of cough
21
Q
How do you manage bacterial tonsilitis?
A
10 days pen V
If stertor and dysphagia then IV antibitoics, IVI and corticosteroids
22
Q
What is quinsy and how does it present?
A
Peritonsillar abscess Trismus Hot potato voice Drooling Odynophagia
23
Q
How is quinsy managed?
A
I+D of abscess
IV antibiotics
24
Q
What causes croup?
A
Most commonly influenza and parainfluenza virus in < 2
25
How does croup present?
Coryzal prodrome followed by barking cough
| Mucosal inflammation of airway can result in inspiratory stridor, increased WOB, reduced AE, cyanosis, and LOC
26
How is croup managed?
Adrenaline nebs
| Steroids
27
What does stridor sound like?
High-pitched, single tone
Caused by blockage in throat/larynx - upper airway obstruction
Often heard on inspiration
28
What does wheeze sound like?
Continuous, coarse, whistling sound produced in respiratory airways during breathing, musical
Caused by small airway narrowing
Often heard on expiration
29
What are the differentials for a child with stridor?
```
Croup
Foreign body inhalation
Epiglottitis
Laryngitis
Anaphylaxis
Bacterial tracheitis
Trauma to the throat
Diphtheria
Laryngomalacia
```
30
How might epiglottitis present?
Severe sore throat, pain when swallowing, drooling, looks very unwell, tripoding, acute onset
31
How might croup present?
Low-grade fever
Barking cough
Stridor
32
Why might you not examine a child with stridor?
May precipitate complete airway obstruction
33
What are the main causes of croup?
Parainfluenza virus
RSV
Other respiratory viruses
34
What time of year is croup most common?
Autumn
35
What age is croup most common?
3 months - 6 years
| Peak at 2 years
36
What is the first line treatment of croup?
Oral dexamethasone 150mg/kg
37
What could be some differential diagnoses of bronchiolitis?
```
Asthma (depends on age)
Pneumonia
Croup
Whooping cough
Viral induced wheeze
Covid
Heart failure
CF
```
38
What question can you ask to find out a child's risk of whooping cough?
Did mother have whooping cough vaccine during pregnancy?
| Child up to date with imms?
39
What can cause bronchiolitis?
RSV - most common
Adenovirus
Influenza virus
Parainfluenza virus
40
What factors can increase risk of bronchiolitis?
```
Premature
Underlying heart/lung conditions
Suppressed immune system
Exposure to tobacco smoke
Infant < 3 years
Winter months
Bronchopulmonary dysplasia
Attending nursery
Older sibling with infections
```
41
How is bronchiolitis treated?
```
Supportive treatment
Fluids if dehydrated
Anti-pyrexials if feverish
O2 if low sats
NG tube
Nasal suction
Don't give nebulisers - often doesn't help
```
42
How can bronchiolitis be prevented?
Vaccination
| Antibody injection monthly for children with chronic lung disease/congenital heart disease/congenital muscular dystrophy
43
What investigations would you order to help confirm your diagnosis?
```
Throat swab and viral PCR
Pulse oximetry
Mucus sample test
Blood gas
CXR but only if suspect bacterial infection
```
44
Why would you do a throat swab for bronchiolitis?
Helps stop passing on different viruses, cohort areas of ward
45
What is the guthrie test?
Heel prick neonatal screening test
46
What conditions are picked up on the guthrie test?
```
CF
Sickle cell disease
Congenital hypothyroidism
Galactosaemia
Inherited metabolic diseases
- Phenyloketonuria
- Medium chain acyl-CoA dehydrogenase deficiency
- Maple syrup urine disease
- Isovaleric acidaemia
- Glutaric aciduria type 1
- Homocystinuria
```
47
How is CF inherited?
Autosomal recessive
48
What is the pathophysiology of CF?
Mutation in CFTR gene (CF transmembrane conductance regulator) protein produced by gene regulates movement of chloride and sodium ions across epithelial membranes
49
What happens in the respiratory system due to CF?
Cells absorb too much Na and water so thick secretions
Reduced muco-ciliary clearance
Frequent infections
Scarring of lungs
50
What happens in the digestive system due to CF?
Sticky mucus blocks pancreatic ducts preventing pancreatic enzymes digesting food
Rectal prolapse
Meconium ileus (babies)
Diabetes
51
How does CF affect the reproductive system?
Vas deferens doesn't develop, male infertility
52
How does CF present in newborns?
Bowel obstruction - failure to pass meconium
53
What is the definition of wheeze?
Wheezing/whistling sounds
Breathlessness
Persistent troublesome cough
Severely affecting the well-being of infant or child
54
Why might you get recurrently wheezing children?
```
Persistent infantile wheeze - small airways/smoking/viruses
Viral episodic wheeze - no infantile symptoms/URI triggered
Asthma - persistent symptoms/FH/atopy
Other causes
- CF
- Chronic lung disease
- Tracheo-bronchomalacia
- Ciliary dykinesia
- GORD
- Chronic aspiration (potentially due to neurodisability)
- Immune deficiency
- Persistent bacterial bronchitis
```
55
What can cause transient early wheeze in children?
Small airways
Mother smoking
Early viruses
Preterm
56
What can cause viral episodic wheeze?
RSV/other LRTI
| Airway hyper-reactivity
57
What can cause IgE associated asthma?
Atopy
| Airway hyper-reactivity
58
What might the course of viral episodic wheeze look like?
```
No interval symptoms
No excess of atopy
Likely to improve with age
No benefit from regular inhaled steroids
Use bronchodilators
May use oral steroids in severe exacerbations
```
59
How do you manage an acute asthma exacerbation?
ABC
O2 if needed
Beta agonist
Prednisolone 1mg/kg oral (or IV hydrocortisone)
IV salbutamol bolus
Aminophylline +/- MgSO4 +/- salbutamol infusion
60
What are the primary medications for asthma?
Preventers
Relievers
Add on therapies
61
What preventers are there for asthma?
```
Inhaled steroids
- Beclomethasone
- Budesonide
- Fluticasone
(Inhaled cromones)
- Sodium cromoglycate
- Nedocromil sodium
```
62
What relievers are there for asthma?
Beta agonists
- Salbutamol
- Terbutaline
Ipratropium bromide (muscarinic antagonist, atrovent)
63
What add on therapies are there for asthma?
```
Long acting beta-agonists
- Salmeterol
- Formeterol
Leukotriene receptor antagonists - montelukast
Theophyllines
Omalizumab (anti-IgE)
Protexo (high IgE)
```
64
What is important to consider when prescribing inhaled steroids?
Lowest effective dose
Minimise oral deposition
Minimise GI absorption
65
What is important to consider when prescribing relievers?
Age-appropriate device
Easy to use
Portable
Dosage not critical
66
What is step 1 of asthma management in children aged 5-12?
Mild intermittent asthma
| - Inhaled short acting beta-agonist PRN
67
What is step 2 of asthma management in children aged 5-12?
Regular preventer therapy
| - Add inhaled steroid 200-400mcg/day
68
What is step 3 of asthma management in children aged 5-12?
Add on therapy
- Add inhaled long-acting beta-agonist
- Assess asthma control
- Good response from LABA
- Benefit from LABA but control still inadequate so increase steroid
- No response to LABA - stop LABA and increase steroid dose
69
What is step 4 of asthma management in children aged 5-12?
Persistent poor control
| - Increase inhaled steroid up to 800mcg/day
70
What is step 5 of asthma management in children aged 5-12?
Continuous or frequent use of oral steroids
- Refer to resp paediatrician
- Use daily steroid tablet to lower dose providing adequate control
- Maintain high dose inhaled steroid at 800mcg/day
71
What could be causes of failure to respond to medication in asthma?
```
Adherence
Bad disease
Choice of drugs/devices
Diagnosis
Environment - parent still smoking, sensitised to animal that child won't keep away from
```
72
What are the possible risks of inhaled corticosteroids?
Adrenal suppression
| Growth suppression - brief
73
How can you minimise risk of inhaled corticosteroids?
Discuss issues with parent/patient
Minimise dose and maximise targeting
Monitor growth in children
74
Name 3 types of URTI
```
Rhinitis
Otitis media
Pharyngitis
Tonsilitis
Laryngitis
```
75
Name 3 types of LRTI
```
Bronchitis
Croup
Epiglottitis
Tracheitis
Bronchiolitis
Pneumonia
```
76
What respiratory tract infections are generally caused by viral infection?
```
Rhinitis
Pharyngitis
Laryngitis
Croup
Bronchiolitis
```
77
What respiratory tract infection are generally caused by bacterial infection?
Epiglottitis
78
How common is RSV?
```
Annual epidemics
60%+ of infants
20-30% LRTI
0.5-2% infants hospitalised
Mean admission 3 days UK
Mortality v low
Long term morbidity
```
79
What acute URTI can RSV cause?
Rhinitis
Otitis media
Pharyngitis
80
What acute LRTI can RSV cause?
```
Bronchitis
Acute bronchiolitis
Pneumonia
Viral associated wheeze
Exacerbation of asthma
Croup
```
81
What is the difference between URTI and LRTI caused by RSV?
Increased viral load
82
What are the two main causes of acute stridor?
Croup
| Acute epiglottitis
83
What are the S&S of croup?
```
Viral - usually parainfluenza
More common in spring/autumn
Self-limiting
Worse at night
Barking seal-like cough
Stridor
Recessions
Steroids
```
84
What causes acute epiglottitis?
HiB
| Severe acute illness
85
What RTI can pneumococcus cause?
Otitis media - acute/chronic
Sinusitis
Bacterial bronchitis
Pneumonia - acute/chronic
86
What is pneumonia?
Respiratory disease characterised by inflammation of the lung parenchyma (excluding bronchi) with congestion caused by viruses or bacteria or irritants
WHO - history of cough and/or difficulty breathing < 14 days with increased RR
87
What do the cells look like in pneumonia?
Congestion
Red hepatisiation
Grey hepatisation
Resolution
88
What is an increased RR for children aged under 2 months?
> 60/min
89
What is an increased RR for children aged 2-11 months?
> 50/min
90
What is an increased RR for children aged over 11 months?
> 40/min
91
What does a pneumonia CXR look like?
Dense/fluffy opacity that occupies portion or whole of a lobe or lung that may or may not contain an air bronchgram
Consolidation
92
How is pneumonia diagnosed?
Consider in children aged up to 3 years when fever > 38.5 together with chest recession and RR > 50/min
For older children history of difficulty in breathing more helpful than clinical signs
Chest radiography not performed routinely in children with mild and uncomplicated acute LRTI
Radiographic findings poor indicators of aetiology
93
What bacteria can cause pneumonia?
```
Pneumococcus 30-50%
HiB 10-30%
S aureus
K pneumoniae
TB
```
94
What viruses can cause pneumonia?
```
RSV 15-40%
Influenza A and B
Parainfluenza
Human metapneumovirus
Adenovirus
```
95
What can cause pneumonia in immunosuppression eg HIV?
Bacterial infection
Pneumocysitis jiroveci
TB
96
What other organisms can cause pneumonia?
```
Mycoplasma pneumoniae
Chlamydia spp
Pseudomonas spp
E coli
Measles
Varicella
Histoplasmosis
Toxoplasmosis
```
97
What is the difference between bacterial bronchitis and pneumonia?
Pneumonia affects lung parenchyma and alveoli
| Bronchitis 3 specific organisms, form biofilms, chronic cough
