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Respiratory Flashcards

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1
Q

Asthma attack history

A 
Acuity of onset
Potential trigger
Regular medication
Frequency of preventer use and attacks
Frequency of oral steroid use
Previous ED/GP attendances
Social impact
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2
Q

Pathophysiology of asthma

A

Dendritic cells present allergens to Th2 type T-cells
Humoral immune system activated
Mast cells, eosinophils, dendritic cells proliferation
Inflammatory process, bronchoconstriction

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3
Q

Role of leukotriene C4 and histamine in asthma attack

A

Histamine increases production of an exudate

Leukotriene C4 is directly toxic to epithelial cells

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4
Q

Risk factors for asthma

A

Genetic: asthma/atopy in parents or siblings
Environmental factors: low birth weight, prematurity, parental smoking
Viral bronchiolitis in early life
Atopic dermatitis

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5
Q

Precipitating factors for asthma

A 
Cold air and exercise
Atmospheric pollution
NSAIDs increase leukotriene production
BB: prevent bronchodilation through catecholamines 
Exposure to allergens
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6
Q

Pattern of wheeze in asthma

A

Infrequent episodic wheezing lasting a few days, no symptoms at night
Frequent episodic wheezing (2-6weekly)
Persistent wheezing: wheeze and cough most days and disturbed nights

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7
Q

Preschool wheeze clinical patterns

A

RSV
Episodic viral wheeze
Multiple trigger wheeze
Wheezing episode preceded by coryzal symptoms

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8
Q

Asthma diagnosis history

A 
Age at onset of symptoms
Frequency of symptoms
Severity of symptoms: at night, effect on life 
Previous treatments tried
Any hospital attendances 
Presence of food allergies
Triggers 
Disease history 
FH of atopy
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9
Q

Examination of a child with asthma

A

Finger clubbing: CF, bronchiectasis
Chest shape: hyperinflated chest indicates poor asthma control
Chest symmetry
Breath sounds
Presence of crepitations: not suggestive of asthma
Presence of wheeze
Examination of throat to check for tonsillar enlargement

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10
Q

Asthma investigations

A 
Spirometry: FEV1:FVC<0.7 
PEFR
Bronchial provocation tests: histamine or metacholine
Exercise testing
Skin prick testing 
Exhaled nitric oxide 
CXR
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11
Q

What other investigations should be performed if there is doubt of a diagnosis of asthma?

A

Oesophageal pH to assess for GORD
Bronchoscopy to exclude structural abnormality
Chloride sweat test to exclude CF
Nasal brush biopsy to exclude primary ciliary dyskinesia
Serum IgG, IgA and IgM and response to vaccinations
HRCT to exclude bronchiectasis
Sputum culture

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12
Q

Signs of good asthma symptoms control

A 
Full school attendance
No sleep disturbance 
<2/week daytime symptoms
No limitations of daily activities 
No exacerbations 
Using salbutamol <2/week
Maintaining normal lung function
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13
Q

Omalizumab in asthma

A

Monoclonal antibody for IgE
Reduces free IgE in the blood
Given to children with persistent poor control
If evidence of allergic sensitisation to a perineal aeroallergen and a raised serum total IgE

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14
Q

Causes of wheeze in children

A

Respiratory infections: bronchiolitis, bronchiolitis obliterans
Airway abnormalities: bronchomalacia, chronic lung disease of prematurity
Foreign body inhalation

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15
Q

Mild/moderate asthma attack

A 
SpO2 >92%
RR >30 (>5), >40 (<5)
No or minimal accessory muscle use
Feeding well or talking in full sentences
Wheeze
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16
Q

Severe asthma attack

A 
SpO2<92%
PEFR 33-50% predicted 
RR >30 (over 5), >40 (<5)
Too breathless to feed or talk 
HR >125 (>5), >140 (<5)
Use of accessory muscles
Audible wheeze
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17
Q

Life-threatening asthma

A 
SpO2<92%
PEFR <33% predicted
Silent chest
Poor respiratory effort
Altered consciousness
Agitation/ confusion 
Exhaustion
Cyanosis
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18
Q

Immediate management of asthma attack

A

Oxygen, 94-98 aim
Bronchodilators
Ipratropium bromide (anti-muscarinic) if no or poor response to inhaled SABA
Corticosteroids: short 3 day course or steroids should be commenced, oral prednisolone is first line. IV hydrocortisone if child is vomiting lots

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19
Q

Second-line management of asthma attack

A

IV salbutamol

Magnesium sulphate

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20
Q

Safe discharge criteria for asthma

A

Bronchodilators with spacer at intervals of 4-hourly or more
SaO2>94% air
Inhaler technique assessed/taught
Written asthma management plan given and explained to parents
GP should review child 2 days after discharge

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21
Q

Acute cough

A

<4 weeks
Viral, bacterial infection
Pertussis

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22
Q

Prolonged acute cough

A

4-8 weeks
Post-viral cough
Children recovering from complicated pneumonia

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23
Q

DD of chronic wet cough (>8weeks)

A 
Persistent bacterial bronchitis 
Rhinitis and post-nasal drip
GORD
Bronchiectasis (CF vs non-CF)
Primary ciliary dyskinesia (PCD)
Immune problems- recurrent/unusual infections
Recurrent aspiration
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24
Q

Approach to patient with chronic cough

A 
History of infection
Nasal symptoms
Failure to thrive
Wheeze
Response to previous symptoms
Atopy 
CXR
Bloods- immune screen, allergy markers 
SALT
Lung function test
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25
What is involved in an immune screen?
T-cell sub sets Antibody response Ig
26
What are the allergy markers?
Eosinophils IgE SIgE
27
Features and treatment of rhinitis with post-nasal drip?
``` Throat clearing Snoring Blocked nose Bad breath Worse in morning and clears through day ``` Steroid nasal spray Antihistamine
28
GORD features and treatment
Younger child Vomits Better when upright Trial of PPI
29
Protracted bacterial bronchitis
Persistent bacterial infecton in lower airway Presence of wet cough (>4 weeks) Absence of symptoms or signs (i.e. specific cough pointers) suggestive or other causes Cough resolves following a 2-4week course of an appropriate oral antibiotic
30
Symptoms of protracted bacterial bronchitis
Chest pain History suggestive of inhaled foreign body Exertional dyspnoea Failure to thrive Feeding difficulties Cardiac or neuro developmental abnormalities Recurrent sinopulmonary infections Immunodeficiency or epidemiological risk factors for exposure to TB
31
Signs of protracted bacterial bronchitis
Respiratory distress Digital clubbing Chest wall deformity Auscultation crackles
32
Tracheobronchomalacia
Floppy airways: flaccidity of supporting cartilage Congenital, extrinsic compression, acquired Treatment: nothing, prophylactic antibiotics, CPAP, surgery Prognosis very good
33
Causes of bronchiectasis
``` CF Post-infectious Immunodeficiency Ciliary dyskinesia Aspiration ```
34
Diagnosis of bronchiectasis
HRCT
35
Treatment of bronchiectasis
``` Prophylactic Ax Physiotherapy Aggressive LRTI treatment Nutrition Regular monitoring, including lung function ```
36
CF diagnosis
Screening Sweat chloride Genotyping
37
Pathophysiology of CF in lungs
Defective CFTR protein on airway epithelial cells and submucosal glands Decreased secretion of chloride and increased reabsorption of sodium and water Reduced amount of water in secretions Reduced airway surface liquid: important for immunology and mucocilialry escalator Decrease mucus clearance Ideal for bacteria, inflammation
38
CF manifestations
Recurrent chest infections, chronic wet cough Exocrine pancreatic insufficiency Failure to thrive Neonate- meconium ileus, protracted jaundice, electrolyte abnormality Intestinal obstruction Male infertility-blockage of vas
39
Pathophysiology of pancreatic insufficiency in CF
Duct occluded in-utero causing permanent damage to exocrine pancreas CF-related DM
40
GI tract pathophysiology in CF
Small intestine secretes viscous mucus Bowel obstruction in-utero Meconium ileus Cholestasis in biliary tree Neonatal jaundice Later in life: Distal intestinal obstruction syndrome CF-related liver disease
41
Reproductive tract pathophysiology in CF
Congenital abscence of vas deferens
42
Clinical presentation of CF in neonates
Meconium ileus- abdominal distension, delayed passage of meconium and bilious vomiting in first days of life Failure to thrive Prolonged neonatal jaundice
43
Clinical presence of CF in infancy
Failure to thrive Recurrent chest infections Pancreatic insufficiency; steatorrhea
44
Childhood presentation of CF
Rectal prolapse Nasal polyps Sinusitis
45
Adolescent presentation in CF
Pancreatic insufficiency; diabetes mellitus Chronic lung disease DIOS, gallstones, liver cirrhosis
46
History of a patient with CF
Early treatment of infection and optimisation of nutrition Persistent/recurrent productive cough Failure to thrive Complaints of bowel symptoms: steatorrhoea, constipation Rectal prolapse Nasal polyps
47
Examination of a patient with CF
Finger clubbing Nasal polys Hyperinflated chest, crepitations, portacath Faecal mass in abdomen, ileostomy scar from meconium ileus
48
Diagnosis of CF
Fitting clinical history | Positive chloride sweat test
49
Investigations in CF
CXR for hyperinflation and bronchial thickening Chloride sweat test Microbiological assessment, e.g. cough swab/sputum Glucose tolerance test LFT and coagulation Bone profile LFT: spirometry and lung clearance index Faecal elastase to assess pancreatic function Chest CT for bronchiectasis Genetic analysis
50
The chloride sweat test
Measures electrolyte concentration in sweat, >60mmol/L Pilocarpine iontophoresis Need a second positive test or genetic mutation identification to diagnose
51
CF airway clearance and chest symptoms management
Twice-daily physiotherapy Increased airway secretion clearance, will reduce airway obstruction and minimise risk of infection DNase: inhaled and reduces viscosity of mucus by digesting DNA which is abundant in the sputum of patients with CF Hypertonic saline: can aid airway clearance
52
Nourishment and exercise for CF Mx
Pancreatic enzyme supplementation (Creon) with fat meals ADE vitamin supplements Monitor growth Build-up milkshakes Enteral feeding via gastrostomy if needed
53
Managing/ preventing airway infections in children with CF
Common causative organisms; staphylococcus aureus, Haemophilus influenzae, pseudomonas aeruginosa Patients need continual microbiological assessment to identify organisms colonised Sputum cultures Treat infections with 2 weeks of ax Give regular azithromycin Prophylactic ax in <3years Chronic pseudomonas treat with inhaled ax due to biofilms Side room
54
Annual CF review
``` Respiratory paediatrician Dietician Physiotherapist CF specialist nurse Review of clinical symptoms, ax, microbiology Bloods: FBC, renal function, LFTs, vitamines A,D,E, clotting profile, HbA1c LFTs CXR is normally performed >12 oral glucose tolerance test ```
55
Non-resp complications of CF
``` Rectal prolapse DIOS: distal ileal obstruction Cholestasis Gallstones Liver cirrhosis CF-related diabetes Delayed puberty: reduced bone mineral density Arthritis Infertility ```
56
Respiratory complications of CF
``` Allergic bronchopulmonary aspergillosis Bronchiectasis Haemoptysis Pulmonary hypertension and right heart strain Pneumothorax Respiratory failure Nasal polys ```
57
Paediatric long term ventilation
<17 Medically stable Requires a mechanical aid for breathing with invasively by tracheostomy or by non-invasive ask interface for all or part of the 24h day For longer than 3 months
58
Causes of stridor in children
Croup Acute epiglottitis Inhaled foreign body Laryngomalacia
59
Causes of OSA in children
Enlarged tonsils and adenoids Obesity and Down;s syndrome: makes airway more collapsible Abnormal facial structure Narrow, floppy, soft airways (laryngomalacia) Muscular dystrophy or cerebral palsy
60
OSA symptoms
``` Snoring and pauses in breathing followed by gasps or snorts Daytime sleepiness Difficulty putting on weight Mouth breathing Nasal speech Hyperactivity Irritable ```
61
OSA assessment
``` Parental observation Oxygen saturations CO2 levels Breathing movements Heart rate and rhythm Airflow Video and sound recording ```
62
OSA treatment
Adenotonsillectomy | Nasal inhaled corticosteroid sprays or drops
63
What is croup?
Acute laryngotracheobronchitis Common viral childhood illness Harsh barking cough, stridor, hoarseness of voice, fever
64
Epidemiology of croup
6months-3 years | Peak incidence at 2 years
65
Pathophysiology of croup
Mucosal inflammation anywhere between nose and trachea Parainfluenza virus is most common Impaired movement of vocal cords creates characteristic barking cough
66
Potential causative organisms for croup
``` Parainfluenza virus Respiratory syncytial virus Adenovirus Rhinovirus Enterovirus Measles Meta pneumovirus Influenza A and B Mycoplasma pneumoniae ```
67
Risk factors for croup
Male gender Autumn and spring season C/C variant of the CD14 C-159T gene
68
History of a child with croup
1-4 day history of non-productive cough, rhinorrhoea and fever Progressing to a barking cough and hoarseness Symptoms worst at night Red flags for resp failure: drowsiness and lethargy
69
Clinical features from examination of croup
Stridor Decreased airflow Resp distress: tachypnoea, intercostal recession Red flag for respiratory failure: cyanosis, lethargic/decreased level of consciousness, laboured breathing, tachycardia
70
Mild croup
Occasional barking cough No audible stridor at rest No suprasternal, or intercostal recession Child is happy and will drink, eat and play
71
Moderate croup
Frequent barking cough Audible stridor at rest Suprasternal and sternal wall retraction at rest Child isn’t distressed or agitated and will still show interest in surroundings
72
Severe croup
``` Frequent barking cough Prominent inspiratory stridor at rest Marked sternal wall retractions Child will appear distressed/ agitated or lethargic or restless Tachycardia, hypoxaemia ```
73
Croup vs epiglottis
``` Days vs hours Coryza vs no prior features Barking cough vs slight/if any Can drink vs no feeding Mouth closed vs drooling saliva Non toxic vs toxic Fever <38.5 vs >38.5 Rasping stridor vs soft stridor Hoarse voice vs weak or silent ```
74
Investigations for croup
FBC, CRP, U&Es CXR: rule out inhaled foreign body Pulse oximetry
75
When would you consider admission in a croup child?
<6 months Previous history of severe airway obstruction Immunocompromised Have had inadequate fluid intake Have had a poor response to initial treatment The diagnosis is uncertain Significant parental anxiety
76
Advice to parents for home-managed croup:
Symptoms resolve within 48hours but can last to one week Paracetamol or ibuprofen to control pain and fever No Ax needed Ensure that child has adequate fluid intake Seek urgent medical advice if symptoms worsen: high fever, stridor, heart rate (bacterial tracheitis) Call ambulance if signs of respiratory failure
77
When should immediate hospital admission occur for croup?
If child has moderate/severe croup or impending respiratory failure Suspect serious disorder caused by infection, e.g. peritonsillar abscess, laryngeal diphtheria, non-infectious cause (foreign body, angioneurotic oedema)
78
Treatment for croup
Single dose of oral dexamethasone (0.15mg/kg) or oral prednisolone (1-2mg/kg body weight) Nebulised adrenaline to provide temporary symptomatic relief Ensure child is calm Oxygen therapy as required Contact ENT and an anaesthetist if there is need for airway support
79
Complications of croup
``` Lymphadenitis Otitis media Dehydration Bacterial superinfection resulting in pneumonia or bacterial tracheitis Pulmonary oedema Pneumothorax ```
80
When are pertussis vaccines given?
2, 3, and 4 months of age Booster at 3 years and 4months Pregnant women
81
Pathophysiology of pertussis
Bordetella pertussis Gram-negative bacillus Aerosol spread, very contagious Bacteria attach to respiratory epithelium Bacteria produce toxins which paralyse cilia and promote inflammation Impaired clearance of respiratory secretions Cough
82
Risk factors for pertussis
Non-vaccination | Exposure to infected individuals
83
Phases of pertussis
Catarrhal (first) phase lasts 1-2weeks | Paroxysmal (second) phase lasts for 2-8weeks
84
Catarrhal phase of pertussis
``` Rhinitis Conjunctivitis Irritability Sore throat Low-grade fever Dry cough ```
85
Paroxysmal phase of pertussis
Severe paroxysms of coughing, more common at night Then inspiratory gasp, producing the classic whoop sound <3 months, apnoea, vomiting after coughing Conjunctival haemorrhages and facial petechiae due to vigorous coughing
86
Examination of pertussis
Low grade fever Conjunctival haemorrhages and facial petechiae Chest auscultation usually normal
87
Differential diagnosis of paroxysmal cough
``` Bronchiolitis/ viral respiratory infection Mycoplasma pneumonia Bacterial pneumonia Asthma Tuberculosis ```
88
Pertussis investigations
<2 weeks cough: nasopharyngeal aspirate culture or nasopharyngeal swab is recommended >2 weeks and <5: anti-pertussis toxin IgG serology >2 weeks and 5-17: anti-pertussis toxin detection in oral fluid Pertussis vaccine within last year can produce a false positive FBC: lymphocytosis (+/- elevated WCC)
89
Management of pertussis
Macrolides ax when cough <21 days <1 months: clarithromycin >1 months: azithromycin or clarithromycin 2nd line: co-trimoxazole or macrolides inappropriate Supportive management Cough takes 3 months to self-resolve Avoid school or nursery until 21days cough or 5days ax
90
Hospital admission indicated in pertussis
<6months Significant breathing difficulties, e.g. apnoeic episodes, cyanosis, respiratory distress, severe paroxysms of coughing Feeding difficulties Significant complications, e.g. pneumonia or seizures
91
Complications of pertussis
Secondary bacterial pneumonia Seizures Encephalopathy Otitis media
92
Pathophysiology of bronchiolitis
Proliferation of goblet cells: excess mucus IgE-mediated TY1 allergic reaction: inflammation Bronchiolar constriction Infiltration of lymphocytes: submucosal oedema Infiltration of cytokines and chemokines Hyperinflation, increased airway resistance, atelectasis, VQ mismatch
93
Risk factors for bronchiolitis
Breast fed for less than 2 months Smoke exposure Having siblings who attend nursery or school Chronic lung disease due to prematurity
94
History of bronchiolitis
``` Increasing symptoms over 2-5days Low-grade fever Nasal congestion Rhinorrhoea Cough Feeding difficulty ```
95
Examination findings in bronchiolitis
``` Tachypnoea Grunting Nasal flaring Intercostal, subcostal or Supraclavicular recessions Inspiratory crackles Expiratory wheeze Hyperinflated chest Cyanosis or pallor ```
96
Bronchiolitis lab tests
Nasopharyngeal aspirate or throat swab- RSV rapid testing and viral cultures Blood and urine culture if child is pyrexic FBC Blood gas (ABG)- if severely unwell
97
Bronchiolitis CXR features
``` Hyperinflation Focal atelectasis Air trapping Flattered diaphragm Peribronchial cuffing ```
98
Features of bronchiolitis for urgent hospital referral
``` Apnoea Child looks seriously unwell Severe respiratory distress, e.g. grunting, marked recessions, RR>70 Central cyanosis Oxygen sats <92% ```
99
Management steps for bronchiolitis in hospital
If <92% give oxygen Give fluids NG/orogastric if inadequate oral intake CPAP if resp failure Upper airway suctioning if upper airway secretions or apnoea
100
When can u discharge bronchiolitis
Clinically stable Taking adequate oral fluids Maintaining sats >92% for more than 4 hours
101
Complications of bronchiolitis
``` Hypoxia Dehydration Fatigue Respiratory failure Persistent cough or wheeze Bronchiolitis obliterans- airways permanently damaged due to inflammation and fibrosis ```
102
Prognosis of bronchiolitis
7-10days | Most children can cough for up to 6 weeks
103
What is bronchiectasis?
Abnormal dilatation of airways with associated destruction of bronchial tissue Commonly occurs as a result of CF
104
Pathophysiology of bronchiectasis
Inflammatory response to a severe infection Structural damage within bronchial walls, which causes dilatation Scarring from immune response Scarring reduces number of cilia within bronchi
105
Causes of bronchiectasis
``` Streptococcus pneumoniae Staphylococcus aureus Adenovirus Measles Influenza virus Bordetella pertussis Mycobacterium tuberculosis Antibody defects HIV infection Ataxia telangiectasia Primary ciliary dyskinesia Post-obstructive: foreign body Youngs Yellow-nail syndrome ```
106
Primary ciliary dyskinesia
Autosomal recessive genetic defect Reduced efficacy or complete inaction of bronchial cilia Problems in mucociliary clearance Increased susceptibility to low-grade infections and irritation from foreign particles
107
Youngs syndrome
Bronchiectasis Reduced fertility Rhinosinusitis
108
Yellow-nail syndrome
Pleural effusions Lymphoedema Dystrophic nails
109
Bronchiectasis history
``` Chronic, productive cough Purulent sputum expectoration Chest pain Wheeze Breathlessness on exertion Haemoptysis Recurrent or persistent infections of LRTI ```
110
Bronchiectasis examination
Finger clubbing Inspiratory crackles Wheezing
111
Bronchiectasis imaging
CXR: bronchial wall thickening or airway dilatation High resolution CT: gold-standard, bronchial wall thickening, diameter of bronchus larger than that of accompanying bronchial artery (signet ring) and visible peripheral bronchi CF: Bilateral upper lobe bronchiectasis Post-TB: unilateral upper lobe bronchiectasis Foreign body inhalation: focal lower lobe bronchiectasis
112
Bronchiectasis investigations
``` Chloride sweat test FBC with leukocyte differential Immunoglobulin panel Specific ab levels to vaccinations, e.g. pneumococcal or Hib If bronchoscopy: ciliary brush biopsy HIV test Microbiology Lung function: spirometry obstructive in severe ```
113
Management of bronchiectasis
Chest physiotherapy Ax Bronchodilators if wheeze present Follow-up
114
Complications of bronchiectasis
``` Recurrent infection Life-threatening haemoptysis Lung abscess Pneumothorax Poor growth and development ```

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