Respiratory Flashcards
(80 cards)
1
Q
In what groups is the prevalence of childhood asthma higher?
A
- low birthweight
- family history, male
- bottle fed, pollution, atopy
- past lung disease
2
Q
Diagnosis of asthma in children is done using:
A
spirometry (<70%) and bronchodilator reversibility test (12% FEV1 increase is +)
3
Q
Asthma management in children uses stepwise approach, Go up if using reliever >3xweek and down when completely controlled for x months.
A
3 months
4
Q
What are the steps in paediatric asthma control (on top of a SABA reliever inhaler):
1)
2)
3)
4)
5) daily oral steroid, ICS and refer to specialist
A
1) ICS e.g. beclomethasone or LTRA (not in under 5)
2) ICS+LABA combined e.g. Seretide or ICS + LTRA
3) If no response to LABA, stop LABA and increase ICS dose
- If mild LABA response, continue but increase ICS dose or trial LTRA
4) increase ICS more or consider 4th drug e.g. theophylline and refer to specialist
5
Q
What can LTRAs for asthma in children under 5 cause?
A
-hyperkinesia and behavioural problems
6
Q
How can you treat an asthma exacerbation in an infant?
A
-treat early with rescue prednisolone for 5 days (30-40mg/day if 5yrs+ or 20mg/day if 2-5yrs)
7
Q
What is involved in the general management of paediatric asthma (hollistic)
A
- annual symptom review
- time of school/nursery
- check inhaler/spacer use and adherence
- make a personalised self-management plan
- advice re: smoking risk
- monitor growth charts
8
Q
Treating acute severe asthma:
- sit up, high flow O2, maintain sats 94%+
- give salbulamol 5mg (2.5mg if <5yrs) and __ 250mcg +/- __ all O2 nebulised every __ mins for __ hour
- give __4mg/kg/6hr IV or 2mg/kg __ for 3 days
- consider 1 IV dose of __ 40mg/kg over 20mins as 1st IV therapy if nebuliser response is poor
- consider starting CPAP, discuss with seniors
A
- ipratropium bromide
- magnesium sulphate
- every 20mins for 1 hour
- hydrocortisone, prednisolone
- IV magnesium sulphate
9
Q
What are very worrying signs in acute severe asthma?
A
- confused, tiring, silent chest
- sats <92% after Rx, high CO2
10
Q
Before discharge from acute severe asthma what should you ensure (3+)
A
- stable on 4hrly bronchodilators
- peak flow >75% predicted
- good inhaler technique
- written management plan
- follow up GP in 2days and paeds asthma clinic in 2 months if life-threatening episode
11
Q
Moderate asthma = PEFR – % predicted
Acute Severe = PEFR –% predicated
Near fatal = PEFR –% predicated, sats
A
- moderate = 50-70%
- acute severe= 33-50%, increased RR and HR
- near fatal= <33%resp acidosis/needed mechanical ventilation, <92%sats, silent chest..hypotension..
12
Q
Croup is typically fever and coryza followed by what symptoms and why?
A
- hoarseness (due to infalmm. vocal cords)
- barking cough (due to tracheal oedema & collapse
- difficult breathing, symptoms worse at night
13
Q
Croup causing chest recession at rest can be treated with the first line therapy of ___ which decreases the need for hospitalisation, severity and duration of croup.
A
-oral or nebulised steroids
14
Q
In severe upper airway obstruction from croup, nebulised ___ with oxygen can transiently improve things, watch closely over next few hours as effects wear off.
A
-adrenaline
15
Q
Why are young children prone to AOM?
A
-Eustachian tubes are short, horizontal and function poorly
16
Q
What should every child presenting with a fever have checked?
A
-their tympanic membranes (rule out AOM)
17
Q
What are the findings on otoscopy of a child with AOM?
A
-tympanic membrane is bright red, bulging and loss of the normal light reflection +/- perforation and puss in external canal
18
Q
Name 3 common causative organisms of AOM in children:
A
- RSV, rhinovirus
- pneumococcus, H. influenzae, Moraxella Catarrhalis
19
Q
Most widely used Abx to treat AOM that hasn’t self-resolved, is__
A
Amoxicillin
20
Q
If a child with glue ear is treated once with grommets but these fail, what is the next option.. x with adjuvant ..
A
-reinsert grommets with adjuvant adenoidectomy
21
Q
What age group does bronchiolitis most commonly affect?
A
1-9months (affects children <2yrs)
22
Q
What pathogen causes most cases of bronchiolitis? And this with which virus co-infection may cause a more severe disease?
A
RSV
+human metapneumovirus
23
Q
What are symptoms of bronchiolitis, for what reason are most children admitted?
A
- coryzal symptoms followed by dry cough and increasing breathlessness
- feeding difficulty due to dyspnoea –> admission
24
Q
Name 2 pre-disposing risk factors for the development of bronchiolitis?
A
- premature infants w bronchopulmonary dysplasia
- CF/underying lung disease
- congential heart disease
25
What would you be concerned about in a child with: dry wheezy cough, high-pitched wheeze, tachypnoea, tachycardia... and what would you expect on chest exam? NB: liver may be displaced down
Bronchiolitis
- O/E: subcostal and intercostal recession
- hyperinflation of chest
- fine end-inspiratory crackles
26
-What investigation should be done in suspected bronchiolitis?
Pulse oximetry
27
Name 3 reasons for bronchiolitis admission?
- apnoea
- O2 sats <92% On room air
- inadequate oral fluid intake (dehydration)
- severe resp distress
28
What are signs of respiratory distress in children?
- grunting
- marked chest recession
- resp rate >60breaths/min
29
Outline the basics in bronchiolitis management.
-humidified O2 (conc dependent on O2 sats)
-monitor for apnoea
+/- fluids via IV or NG tube, rarely CPAP
-infection control measures
30
What is the time course of bronchiolitis symptoms, how long can it/cough last? And with which pathogen can permanent damage occur aka bronchiolitis ___.
- illness peaks ~3-5days then resolves
- cough may last 2 weeks+
- ~50% may have recurrent cough and wheeze
- adenovirus can -> bronchiolitis obliterans
31
What test can be used in the diagnosis of bronchiolitis?
Nasopharyngeal aspirate for RSV PCR or rapid antigen test
32
What is Palivizumab used for (albeit rarely due to cost and need for repeated IM injections)?
-prevention of brochiolitis of RSV origin
33
What signs may be present in a child presenting with pneumonia?
NB: always measure RESP RATE
-fever
-malaise, poor feeding
-respiratory distress
(older children: pleural pain, crackles, bronchial breathing)
34
When should you admit a child presenting with pneumonia?
- O2 <92%
| - respiratory distress (tachypnoea, cyanosis, grunting, recessions, use of accessory muscles)..
35
What tests would you consider running in a child with severe pneumonia, name 3
- CXR
- FBC
- Blood & Sputum cultures
- monitor TPR
36
Should children <2yrs with mild symptoms of pneumonia routinely be given Abx? Why?
Viral LRTI is more common so no need, just ensure to safety net and follow up if symptoms persist
37
Which antibiotic is most commonly used to treat pneumonia in children?
Amoxicillin
38
Why is viral episodic wheeze common in some pre-school aged children?
NB: it is not an atopy related condition
-their small airways are more likely to narrow and obstruct due to inflammation and aberrant immune responses to viral infection
39
viral episodic wheeze is triggered by viruses that cause the __.
sufferers often have reduced ___ from birth
- common cold e.g. RSV
| - diameter of the small airways
40
Name 2 risk factors for the development/duration of viral episodic wheeze:
- maternal smoking pre/post partum
- prematurity
- family hx of early viral wheezing
41
viral episodic wheeze is more common in males, it usually resolves ~age__ probably because of the __in airway __
- 5yrs
| - increase in airway size
42
What is the relationship between pre-partum smoking and passive smoking and viral episodic wheeze?
Pre-partum: increases risk of child developing it
| Passive: It is not a trigger but it does prolong symptoms
43
Rarely pneumonia in children associated with a pleural ___ (seen as __ of the costo-__ __ on CXR), this can develop into __ and __ strands may form leading to ___
- effusion (blunting of costo-phrenic angle
- empyema, fibrin strands
- --> septations
44
In paediatric pneumonia with persistent fever at 48hr post Abx (suggest pleural effusion -> empyema --> fibrin strands & septations..) how can they be treated?
- chest drain under US guidance to drain collection
- regularly instil a fibrinolytic agent
- if resistant surgery can be done
45
What 2 atypical signs in an unwell child means you should consider pneumonia as a ddx?
- neck stiffness
| - acute abdo pain
46
What is pharyngitis and the most common type of infective cause in younger vs older children?
=inflammation of pharynx and soft palate w locally enlarged tender LNs
- viral in young vs GABHS (group A beta haemolytic streptococcus) in older child
- NB: tonsillitis is a form of pharyngitis
46
What is pharyngitis and the most common type of infective cause in younger vs older children?
=inflammation of pharynx and soft palate w locally enlarged tender LNs
- viral in young vs GABHS (group A beta haemolytic streptococcus) in older child
- NB: tonsillitis is a form of pharyngitis
47
Name 2 common causes of tonsillitis in children:
- EBV
| - GABHS (group A beta haemolytic streptococcus)
48
For severe pharyngitis/tonsillitis what abx is often prescribed, and if allergic, which? Duration of course __days
- Penicillin V or erythromycin if allergic
| - 10days
49
Why is amoxicillin avoided in the treatment of suspected bacterial tonsillitis in a child?
-is causes is actually due to glandular fever (EBV), amox --> widespread maculopapular rash
50
GABHS infection can -> scarlet fever:
- most commonly affects children age ___
- fever usually precedes the presence of h____ and to____ by 2-3__
- rash is variable but classically described as "_____-like m___ with flushed cheeks and ____ sparing
- tongue is often ___ and may be s____
- age 5-12yrs
- fever precedes headache and tonsillitis by 2-3 days
- rash "sandpaper-like", maculopapular, periorbital sparing
- tongue - white and sore/swollen
51
Tonsillitis by GABHS can --> Scarlet Fever, what are 2 complications of this disease
it requires treatment with which medication to prevent these?
- acute glomerulonephritis, rheumatic fever
| - Penicillin V (erythromycin if allergic)
52
If a child had tonsillitis and presents a few days later with a widespread maculopapular rash, what is the medication that has likely been given?
-Amoxicillin to tonsillitis causes by EBV
53
There are 3 indications for tonsillectomy, name 2:
- recurrent, severe tonsillitis
- a peritonsillar abscess (quinsy)
- OSA (adenoids will be removed too)
54
OSA is one indication for tonsillo-adenectomy, what is the other?
-recurrent otitis media with effusion (glue ear) with hearing loss, where it gives a signif long-term additional benefit
55
Biochemical/Guthrie/Heel Prick Test is done on day ___ of life, babies are screened for what 3 diseases? And then 6 inherited metabolic diseases -name 2?
- day 5
- congenital hypothyroidism
- haemoglobinopathies (SC & thalass)
- cystic fibrosis
- Inherited: phenylketonuria, MCAD, maple syrup urine disease, isovaleric acidaemia, glutaric aciduria type 1, homocystinuria
56
Screening for cystic fibrosis (CF) is done in the Guthrie heel prick.. what does it measure?
-If it is positive, another analysis is done to reduce false-positive rate, this looks at what?
- measures the serum immunoreactive trypsin (raised with pancreatic duct obstruction)
- DNA analysis
57
What is the most common cause of liver abnormality in children with cystic fibrosis?
What other liver pathology do 20% of children develop by mid-teens?
- hepatic steatosis (fatty liver)
| - 20% -> cirrhosis and portal hypertension
58
In cystic fibrosis, rarely what can liver disease arises due to thick tenacious bile with abnormal bile acid concentration?
-progressive biliary fibrosis
59
What is the pattern of inheritance for CF?
| Approx expected life expectancy with the condition?
Autosomal Recessive
(1 in 25 Caucasians are carriers)
-approx 40yrs
60
What protein is defective in CF?
What chromosome is it located on?
Over 900 mutations, what is the most common? Delta ____...
What is the function of it?
- CFTR - CF Transmembrane Conductance Regulator
- Gene on chromosome 7, most common = delta F508
- a cyclic-AMP dependent chloride channel found in membranes of cells
61
CF -> abnormal ion transport across epithelium
| -Give 3 changes causes in the lungs due to CF
- reduced layer of liquid in airway surface
- -> so impaired ciliary function
- retention of mucopurulent secretions
- -> chronic endobronchial infection e.g by Pseud Aerug.
- dysregulated inflammation/immune responses
62
CF -> abnormal ion transport across epithelium
- Give 2 changes causes in the GIT due to CF
- what happens to sweat?
- intestine: thick, vescid meconium so 10-20% have meconium ileus
- pancreatic ducts -> blocked by thick secretions -> panc enzyme deficiency hence malabsorption
- excessive conc of sodium and chloride in sweat
63
After positive heel prick, DNA analysis is done looking for common CF mutations, children with 2 mutations then undergo which test for what?
Sweat test
| -to confirm the diagnosis
64
If routine screening doesn’t pick up a CF child, suggest 2 ways in which they may present later?
- recurrent chest infections
- faltering growth
- malabsorption
65
In CF chronic lung infection -> viscid mucus in small airways what is the result of bronchial wall damage and what features will the child’s cough have?
—> bronchiectasis and abscess formation
| -persistent ‘wet’ cough productive of purulent sputum
66
With established CF respiratory disease what peripheral sign may be seen?
Clubbing
67
90% CF children have pancreatic exocrine insufficiency, name 3 things this results in:
- maldigestion/malabsorption
- untreated -> faltering growth
- frequent large pale greasy stools
- diagnosed with low faecal elastase
68
What is meconium ileus? (~15% CF neonates suffer)
1sx
1rx
-inspissated (thick) meconium —> intestinal obstruction
Sx: vomit, abdo distension, failure to pass meconium in 1st few days
Rx: surgery or gastrografin enema
69
Sweat test: simulate it w low voltage current to skin, collect sweat, what is a positive CF Diagnosis result?
Markedly elevated chloride (more than triple normal eg 60-125 =CF
70
What is the aim of CF therapy? How often are patients reviewed?
- prevent progression of lung disease
- maintain adequate nutrition/growth
- at least annual review
71
Suggest 2 things you may note when examining a child with CFs chest:
- hyperinflation of chest due to air trapping
- coarse inspiratory creps
- +/- exp wheeze
72
What prophylactic abx may a child with CF take? Oral rescue packs will be given for infection but is sx persist what must be given for how long via what?
- flucloxacillin prophylaxis
| - IV abx for 14days via a PIC line
73
What does nebulised DNase / hypertonic saline help with in CF?
-decrease sputum viscosity and increase its clearance
| May decrease no Resp exacerbations
74
What is the one therapeutic option for end-stage CF lung disease
Bilateral sequential lung transplantation
75
How is pancreatic insufficiency treated in CF?
- oral enteric-coated pancreatic replacement therapy taken with all meals
- often also fat-soluble vitamin supplements
76
What 2 virulent infections are concerning for CF children to catch (often between patients) due to causing rapid decline in lung function?
Therefore what is advised?
- -Pseudomonas and Burkholderia Cepacia
| - segregate pts, advise not to socialise with others with CF
77
Acute epiglottitis is..
with life-threatening risk of...
caused by organism...
- swelling of epiglottis and surrounding tissues + sepsis
- risk of respiratory obstruction
- caused by H. Influenza type B (Hib)
78
Suggest 4 features of how acute epiglottitis may present? (NB: children 1-6yrs mostly)
- very acute onset
- high fever, ill, toxic-looking child
- intensely painful throat
- prevents child speaking/swallowing
- so saliva drools down chin
- soft inspiratory stridor, worsens
- child sitting immobile, upright
- child's mouth open (optimises airway)
79
How does the presentation of acute epiglottitis differ from that of croup in a child?
-no/minimal cough
-acute onset
NB: must not examine throat! or lie child down can --> total airway obstruction
