Respiratory Flashcards
(99 cards)
1
Q
What is Croup?
A
Viral laryngotracheobronchitis.
2
Q
What are the risk factors for croup?
A
- FHx
- LBW / Prematurity
- Autumn / Winter
- M > F
3
Q
What are the causes of croup?
A
- Main cause = Parainfluenza
- Other causes
- RSV
- Rhinovirus
- Influenza
4
Q
What are the signs and symptoms of croup?
A
- Affects 6 months to 6 years → 2 years = peak
- Acute onset of - over days
- Coryzal symptoms
- “Barking cough” - from vocal cord impairment
- Stridor - from inflamed/oedematous airways
- Hoarse voice
5
Q
What are the appropriate investigations for suspected croup?
A
- Clinical
- Obs
- Do NOT examine throat
6
Q
How is croup classified?
A
Westley score
- Mild = 0-2
- Moderate = 3-7
- Severe = 8-11
- Impending respiratory failure = 12-17
7
Q
What is the management of croup?
A
- Mild (Westley 0-2) = Oral Dexamethasone + Discharge
- Moderate (Westley 3-7) = Nebulised Dexamethasone + Admission
- Severe (Westley 8-11) = Nebulised Dexamethasone ± Adrenaline + Admission
- Impending respiratory failure (RR >70 and/or Westley 12-17) = Nebulised Dexamethasone ± Nebulised Adrenaline + O2 Admission ± ITU
8
Q
What are the complications of croup?
A
- Secondary bacterial superinfection
- Pulmonary oedema
- Pneumothorax
9
Q
What counselling should be given to child/parents with a child with croup?
A
- Explain diagnosis -common viral infection of the airways
-
Explain that it gets better over 48 hours and steroids help
- Paracetamol or ibuprofen if distressed
- Advise good fluid intake
- Safety net:
- Advise regularly checking on the child at night - cough is worse
- If it gets worse = come back
- If the child becomes blue or very pale for more than a few seconds, unusually sleepy or unresponsive or serious breathing difficulties call an ambulance
10
Q
What are the causes of bronchiolitis?
A
- RSV (80%)
- Parainfluenza
- Rhinovirus
- Adenovirus
- Influenza
- Human metapneumovirus (rare → PICU care)
- Co-infection = more severe illness
- RSV highly infectious so infection control measures
11
Q
What is the progression of bronchiolitis?
A
Bronchiolitis (0-1yo) → Viral-induced/episodic Wheeze (1-5yo) → Asthma (>5yo)
12
Q
What are the risk factors for bronchiolitis?
A
- Pre-term/BPD
- Passive smoking
- LBW
- Chronic heart disease
- Hypotonia
- Winter
- Protective = BREASTFEEDING
13
Q
What are the complications of bronciolitis?
A
Can cause permanent airway damage - bronchiolitis obliterans
- Rare
14
Q
What are the signs and symptoms of bronchiolitis?
A
- <1 year old → 2-3% of infants are admitted with it
- Coryzal symptoms → progressive to below
- Dry wheezy cough
- SoB
- Grunting
- High RR/HR
- Subcostal/intercostal recessions
- Hyperinflation
- Auscultate – how to differentiate from croup/other ‘-itits’
- Fine, bi-basal, end-inspiratory crackles
- High-pitch expiratory wheeze
- Feeding difficulty → admission
15
Q
What are the appropriate investigations for?
A
- Clinical diagnosis with SpO2 → can do NPA to confirm
- If there is significant respiratory distress + fever = CXR to rule out pneumonia
16
Q
What is the management of bronchiolitis?
A
-
Supportive
- Nasal O2 + NG fluids/feeds ± Nebulised 3% saline → CPAP (if respiratory failure)
- <6m old = no beta receptors in lungs so salbutamol won’t work – would give it if over 1yo
- If high-risk preterm infant (BPD, congenital HD, immunodeficiency) = Palivizumab (monoclonal Ab vs RSV)
- Hospital admission
- <2m = lower threshold as deteriorate quick
- Apnoea / Central cyanosis / Grunting
- SpO2 <92% on room air
- Poor oral fluid intake (≤50% normal in <24hrs)
- Severe respiratory distress (i.e. RR>70)
17
Q
Define Rhinitis.
A
Common cold causing acute and self-limiting inflammation of URT mucosa, involving nose, throat, sinuses or larynx.
18
Q
What is the most common infection in childhood?
A
Rhinitis
19
Q
What are the causes of rhinitis?
A
- Rhinovirus (50%)
- Coronavirus (10%)
- Influenza (5%)
- Parainfluenza (5%)
- Human respiratory syncytial virus (5%)
20
Q
What are the signs and symptoms of rhinitis?
A
- Clear/mucopurulent discharge
- Nasal block
21
Q
What are the appropriate investigations for suspected rhinitis?
A
Clinical diagnosis
22
Q
What is the management of rhinitis?
A
-
Health education
- Self-limiting
- No Abx - virus
- May reduce anxiety and unnecessary visits to doctor
- Cough may last 4 weeks after cold → generally recover after 2 weeks
- Pain = Paracetamol or Ibuprofen
- Potentially Decongestants or Antihistamines
23
Q
What are the complications of rhinitis?
A
- Otitis media
- Acute sinusitis
24
Q
Define Sinusitis.
A
Infection of the maxillary sinuses from viral URTIs which can get a secondary bacterial infection.
- Unlikely to be frontal sinus → don’t develop until after 10 years old
25
What are the signs and symptoms of sinusitis?
* Pain, swelling and tenderness on front of face
* Influenza-like illness
26
What are the appropriate investigations for suspected sinusitits?
Clinical diagnosis
27
What is the management of sinusitis?
* Symptoms lasting \<10 days
* **No antibiotic**
* **Advice** → virus, takes 2-3 weeks to resolve, only 2% get bacterial complication, simple analgesia, nasal saline or nasal decongestants
* Symptoms lasting \>10 days
* **High-dose nasal corticosteroid** for 14 days (if \>12yo; e.g. mometasone)
* May improve symptoms but unlikely to affect duration of illness
* Abx not indicated → can give back up prescription if symptoms don’t get better in 7 days or if symptoms get rapidly worse
* 1st line = phenoxymethylpenicillin (clarithromycin if penicillin-allergic)
* 2nd line: co-amoxiclav
* Refer to hospital if there are symptoms and signs of
* Severe systemic infection
* Intraorbital or periorbital problems
* Intracranial complications / Features of meningitis
28
What are the risk factors for viral-induced wheeze?
* Maternal smoking (ante-/post-natal)
* Prematurity
* FHx of viral-induced wheeze
29
What are the signs and symptoms of asthma?
* **Wheeze** - end-expiratory polyphonic
* **Cough**
* **SoB**
* **Chest tightness**
* *Symptoms worst at night / early morning*
* *Symptoms with non-viral triggers*
* *Personal or FHx of atopy*
* *Positive response to asthma bronchodilator therapy*
* Examination
* **Hyperinflated chest ± accessory muscle use**
* Harrison’s sulci - **depressions at base of thorax** where diaphragm has grown in muscular size
30
What are the appropriate investigations in to suspected asthma in a child under the age of 5?
Clinical diagnosis
31
What are the appropriate investigations in to suspected asthma in a child over the age of 5?
* **Clinical + Picture**
* Spirometry - FEV1/FVC \<70%
* Bronchodilator - 12% pre/post difference
32
What are the signs of a moderate asthma attack in a child?
* PEFR = 50-75%
* Normal speech
33
What are the signs of a severe asthma attack in a child?
* PEFR = 33-50%
* RR
* 2-5 years = \>40
* 5-12 years = \>30
* \>12 years = \>25
* HR
* 2-5 years = \>140
* 5-12 years = \>125
* \>12 years = \>110
* SpO2 = \>92%
* Inability to complete sentences in one breath
* Accessory muscle use
* Inability to feed
34
What are the signs of a life-threatening asthma attack in a child?
* PEFR = \<33%
* SpO2 = \<92%
* PaCO2 = \>4.8kPa
* Altered consciousness
* Exhaustion
* Cardiac arrhythmia
* Hypotension
* Cyanosis
* Poor respiratory effort
* Silent chest
35
What is the management of a moderate asthma attack?
* **No admission** needed
* **Salbutamol** - 4-hourly up to max 4/day
* **Oral prednisolone** - for 3d
* Follow-up in 48hrs
36
What is the management of a severe to life-threatening asthma attack?
* Admit to hospital/A&E
* 1. Burst step
* **O2 therapy** (maintain SpO2 \>92%)
* 3x Salbutamol nebs / 10 inhales on a pump
* 2x **Ipratropium bromide** nebulisers
* 1x oral **Prednisolone** (benefit after 4-6h)
* 2. IV bolus step
* **IV bolus MgSO4** + one of the below
* **IV bolus Salbutamol**
* **IV bolus Aminophylline**
* *Monitor ECG → both can cause arrhythmias*
* 3. IV infusion step – one of the below
* **IV Salbutamol**
* **IV Aminophylline**
* 4. Panic step
* **Intubate and ventilate + Transfer to ICU**
* Once stabilised = **Salbutamol 1-hourly → 2-hourly → 3-hourly → 4-hourly → Home when:**
* Stable on 4-hourly treatment - *further wean at home*
* Peak flow at 75% of best predicted
* SpO2\>94%
* Follow-up within 2 days of discharge
* Patient Education
37
What are the contraindications for beta-agonists (salbutamol)?
* Beta blockers
* NSAIDs
* Adenosine
* ACEi
38
What is the outpatient management of asthma in a child?
* **SABA - Salbutamol PRN** → Step up when using inhaler ≥3x a week
* Can use a spacer if young or difficulty using
* Do not exceed 4-hourly puffs (i.e. 4 puffs a day)
* **Low dose ICS - Becotide** (*Beclomatsone dipropionat*e)
* **Leukotriene Receptor Antagonist - Oral Montelukast**
* Review after 4-8w
* 5-16yo = if fail on review, switch LTRA to LABA
* \<5yo = if fail on review, stop LTRA and refer to specialist
* **Increased ICS dose - Flixotide** (*Fluticasone propionate*)
* Consider reducing dose once asthma controlled
* **Oral steroid - Prednisolone**
* Lowest dose to maintain control
* Managed by specialist
39
How common is acute otitis media?
* Very common - Most children have 1 episode
* Young eustachian tubes are short, horizontal and function poorly → middle ear infection
40
What are the risk factors for acute otitis media?
* 6-12 months
* FHx
* Male
* Cleft palate
* Down's
* *Most children have at least one episode*
41
What are the signs and symptoms acute otitis media without effusion?
* Pain in the ear
* Fever
42
What are the appropriate investigations for suspected acute otitis media without effusion?
* Temperature check
* Otoscopy
* Bright red bulging tympanic membranes
* Loss of normal light reaction
* Perforation
* Pus
43
What is the management of acute otitis media without effusion?
* Advice
* Acute otitis media lasts about **3 days (up to 1 week)**
* Most recover **without Abx**
* Use **regular ibuprofen/paracetamol**
* No evidence for decongestants or antihistamines
* Medical Management / Antibiotic regimen
* **No antibiotic prescription** → seek help if symptoms haven't improved after 3 days or clinical deterioration
* Delayed antibiotic prescription used at this point
* **Immediate antibiotic prescription if systemically unwell, age \<2yo**
* **Amoxicillin** (5 days) → *penicillin allergy = clarithromycin, erythromycin*
44
What is the management of acute otitis media with perforation?
* **Oral Amoxicillin - 5 days**
* Review in 6 weeks to ensure healing
45
What are the signs and symptoms of otitis media with effusion?
* Asymptomatic except for possible **reduced hearing -** *conductive hearing loss*
* Can **interfere with normal speech development** → learning difficulties
46
What are the appropriate investigations for suspected otitis media with effusion?
* **Tympanometry**
* **Audiometry**
* **Otoscopy -** eardrum is dull and retracted, often with a fluid level visible
47
What is the management of otitis media with effusion?
* Co-existent cleft palate, Down’s, hearing loss, structurally abnormal tympanic membrane or cholesteatoma discharge → refer to ENT
* No co-morbidities à active observation for 6-12 weeks
* 1) Two hearing tests (pure tone audiometry) 3 months apart
* 2) If persistent past 6-12 weeks → refer to ENT
* Non-surgical = **Hearing aids, Active monitor for 3m, Auto-inflation**
* Surgical = **Myringotomy and Grommets**
* *Benefits don't last longer than 12 months*
48
What are the complications of acute otitis media?
* Perforation
* Mastoiditis
* Meningitis
* Facial nerve palsies
* Febrile convulsions
49
Describe Mastoiditis.
Chronic otitis media → honeycomb structure behind ear inflamed → Discharge + Swelling behind ear
50
What are the diagnosis for the following otoscopy examinations?
51
What counselling should be given to child/parents with a child with pneumonia?
* **Explain the diagnosis** - chest infection
* Explain **whether admission is needed**
* **Explain treatment** - antibiotics
* **Advise:**
* **Paracetamol** used if distressed
* **Adequate fluid intake**
* **Against parental smoking**
* **Check the child regularly** during the day and night
* **Safety net**
* ↑ RR
* Apnoea
* Cyanosis
* ↑ WOB
* Dehydration
* Fever does not settle 48h+ of AbX
* ↑ Drowsy
52
What are the consequences of Group A Strep tonsillitis?
**Scarlet Fever** → can progress to **Rheumatic fever**
53
What are the signs and symptoms of Scarlet fever?
* **After 2-4 day incubation**
* **Fever**
* **Headache**
* **Vomiting**
* **Myalgia**
* **Rash (12-48 hours later) ± erythroderma**
* Neck + chest → spread to trunk + legs
* Characteristic ‘sandpaper’ texture
* ‘Pastia’s lines’ (rash in prominent skin creases)
* Strawberry tongue
* May progress to Rheumatic Fever with a week latency period
54
What are the appropriate investigations for suspected Scarlet fever?
* Clinical
* *FBC (polymorphonuclear lymphocytosis, eosinophilia)*
* *ELISA*
* *Rapid antigen test*
55
What is the management of Scarlet fever?
* Phenoxymethylpenicillin
* 2nd line = Azithromycin
* Notify PHE
56
What are the causes of pneumonia in children?
* Neonate = Mother’s genital tract commensals = GBS, gram -ve enterococci
* Infants / Young children = RSV, S. pneumoniae, H. influenzae, Bordetella pertussis, C. trachomatis, S. aureus
* \>5yo = M. pneumoniae, S. pneumoniae, Chlamydia pneumoniae
* All ages = Mycobacterium tuberculosis should be considered
57
What are the signs and symptoms of pneumonia?
* Fever
* Cough
* SoB
* Preceding URTI
* Auscultation
* Consolidation - stony dull, bronchial breathing, decreased breath sounds
* Coarse crackles
58
What are the appropriate investigations for suspected pneumonia?
* Basic obs - temperature, O2 saturations, RR, respiratory exam
* Bloods - FBC, U&Es
* Cyanosis and hydration status
* VBG
* CXR
59
What are the appropriate investigations for suspected childhood TB?
* Manteaux test → if -ve = excludes → IGRA test (if -ve, prophylaxis; if +ve, treat)
* Manteaux \>5mm = +ve in immunodeficiency
* Manteaux \>10mm = +ve in at-risk groups (child \<4yo, healthcare workers, IVDU)
* Manteaux \>15mm = +ve in normal population
60
What is the management of childhood TB?
* **RIPE** = 6m Rifampicin, 6m Isoniazid, 2m Pyrazinamide, 2m Ethambutol
* **RiCES** = Rifampicin, Clarithromycin, Ethambutol ± Streptomycin/amikacin
* Prophylaxis = isoniazid
61
What examination findings can distinguish between pneumonia and bronchiolitis?
* Pneumonia = coarse crackles
* Bronchiolitis = fine crackles
62
What is the management of pneumonia?
* Antibiotics
* Child \<2yo with mild LRTI → do not have pneumonia usually = No antibiotics
* 1st line = **Amoxicillin** (7-14 days)
* 2nd line = **Co-amoxiclav + Macrolides** (clarithromycin)
* Alternative = cefaclor
* Macrolides for pen-allergic patients
* In pneumonia associated with influenzae → co-amoxiclav
* **Supplementary O2** - if SpO2 \<92%
63
What are the indications for hospital admission of a child with a respiratory condition?
* SpO2 \<92% on air
* Grunting
* Marked chest recession
* RR \>60/min (severe tachypnoea)
* Cyanosis
* T \>38oC
* Child \<3months
* Low feeding
* Low consciousness
64
What counselling should be given to parents with a child with tonsillitis?
* **Explain** that this is tonsillitis → Centor score the child
* Explain that **importance of taking antibiotics** correctly for 10 days even if symptoms get better in that time
* **Avoid school until 24 hours after starting antibiotics** and the child is feeling well
* Advise on the use of **paracetamol, lozenges, saltwater gargling and Difflam for symptomatic treatment**
65
What are the causes of tonsillitis?
* Bacterial → Group A β-haemolytic streptococcus – *rare under 3yo or ≥45yo, common 3-14yo*
* Viral → EBV
66
What shouldn't be given to patients with EBV?
Amoxicillin → can get generalised maculopapular eruption
67
What are the signs and symptoms of tonsillitis (pharyngitis and laryngitis)?
* Sore throat
* Fever
* Dysphagia/odynophagia
* Hoarseness
* GORD
* Rhinitis
* Lethargy / fatigue
* Post-nasal drip
* Laryngitis - *dysphonia, aphonia*
68
What are the appropriate investigations for suspected tonsillitis?
* **ENT exam + temperature**
* **Rapid strep test**
* **Centor score** - *likelihood of bacterial cause*
* +1 = Exudate/swelling on tonsils
* +1 = Tender/swollen anterior cervical lymph nodes
* +1 = Temperature \>38C
* +1 = Cough absent
* +1 = Age 3-14yo → -1 if age ≥45yo
* **Consider swabs**
69
What is the management of tonsillitis?
* **Medical Management**
* Bacterial tonsillitis confirmed using rapid streptococcal antigen testing = **Phenoxymethylpenicillin**
* 10 days, QDS → prevent sequelae like rheumatic fever
* Avoid amoxicillin = widespread maculopapular rash if due to mono
* Clarithromycin if pen-allergic
* **Advice**
* Adequate fluid intake
* Paracetamol or ibuprofen when necessary
* Saltwater gargling
* Lozenges or anaesthetic sprays (e.g. Difflam)
70
What are the indicators for tonsillitis admission?
* Difficulty breathing
* Clinical dehydration
* Peri-tonsillar abscess or cellulitis
* Marked systemic illness or sepsis
* Suspected rare cause → e.g. *Kawasaki disease, diphtheria*
71
What is Cystic Fibrosis?
* Defective CFTR – cAMP dependent chloride channel due to a mutation on chromosome 7
* \>900 different gene mutations of CFTR → 78% are F508
* *Class 2 mutation = incorrect folding of CFTR protein*
72
What are the signs and symptoms of cystic fibrosis?
* **Meconium ileus**
* **Recurring chest infections**, wheezing, coughing, SoB, damage to the airways (bronchiectasis)
* Growth faltering (difficulty putting on weight)
* ABPA, nasal polyps, sinusitis
* Jaundice (cirrhosis, portal HTN)
* Diarrhoea or constipation
* Diabetes mellitus
* Male sterility (absence of the vas deferens)
* Clubbing of the fingers
73
What are the appropriate investigations for suspected cystic fibrosis?
* Screening at birth = **heel prick test for IRP** / Immunoreactive Trypsinogen (if +ve, further tests are done) →
* **Sweat test** (abnormally high NaCl in sweat) → 60-115mmol/L (10-40mmol/L)
* **Genetic tests**
* CXR → hyperinflation, peri-bronchial shadowing, bronchial wall thickening, ring shadows
74
What is the management of cystic fibrosis?
* **MDT** - all should be specialists in CF
* **Routine specialist reviews**
* Weekly in 1st month
* Every 4w in 1st year
* Every 6-8w when 1-5yo
* Every 2-3m when 5-12yo
* Every 3-6 months from then on
* RESPIRATORY Management:
* Monitoring with **spirometry and symptoms watches**
* **Physiotherapy twice a day** → airway clearance manoeuvres and devices + encourage physical activity
* **Mucolytic therapy**
* 1st line = rhDNase
* *If too young use mannitol dry powder*
* 2nd line = rhDNase + hypertonic saline
* *Orkambi - Lumacaftor with Ivacaftor (potentiators and correctors) → may be effective in prolonging life in F508 mutation*
* **Trikafta -** 3 drug combination → 2 drugs allow F508del-misfolded CFTRs to get to cell surface, the 3rd allows the protein to fold properly
* *Available on NHS but is expensive and not in NICE guidlines*
* **Lung transplant**
* NUTRITIONAL Management:
* **High calorie + high fat diet** (150% of normal) **+ fat-soluble vitamin supplements**
* **Pancreatic enzyme replacement**
* PYCHOLOGICAL Management
* GENERAL TEENAGERS and ADULTS Management:
* **DM therapy** - becoming more common as CF live longer
* Liver problems (i.e. cirrhosis, portal HTN) = **Ursodeoxycholic acid, laxatives → may ultimately require transplantation**
* Sterility → intracytoplasmic sperm injection *(only affects men)*
75
What is the management of infection in CF?
* **Prophylaxis oral antibiotics** (flucloxacillin and azithromycin to reduce exacerbation chance)
* **Rescue packs** → prompt IV Abx with any symptoms or signs of infection
* **Appropriate Abx for sensitivity**
* **Minimise contact with other CF sufferers when infected**
76
What are the common infections in cystic fibrosis?
* **S. aureus**
* **P. aeruginosa**
* Burkholderia cepacia complex
* H. influenzae
* Non-tuberculosis mycobacterium
* Aspergillus fumigatus
* Prophyla
77
What counselling should be given to parents with a child with cystic fibrosis?
* **Explain the diagnosis** - thick secretions
* **Explain it is lifelong**
* Explain that that management requires an **MDT approach**
* Explain that they will be referred to a **specialist cystic fibrosis centre** to discuss the ongoing management
* Offer to **outline the aspects of management**
* Pulmonary – physiotherapy, mucolytics
* Infection – prophylactic antibiotics, monitoring
* Nutrition – enzyme tablets, high-calorie diet, monitor growth
* Psychosocial – provide support for child and carers
* Offer information on **genetic counselling** if considering having more children
* **Support groups** - Cystic Fibrosis Trust
78
Define Acute Epiglottis.
Intense swelling of epiglottis associated with sepsis → Medical Emergency
79
What are the signs and symptoms of acute epiglottis?
* High fever - ‘toxic-looking’ child
* Drooling → child cannot swallow as too sore
* Stridor - soft inspiratory with high RR
* **Tripod sign**
* **Immobile**
* **Upright**
* **Open mouth**
80
What is the management/investigations for acute epiglottis?
* **MEDICAL EMERGENCY**
* Do not lie the child down - immobile and upright stance is optimal
* Do not examine the child’s throat → may precipitate total obstruction
* **Immediate referral to ENT, paediatrics and anaesthetics →** Transfer to ITU/anaesthetics
* Secure airway
* **Blood cultures**
* **Empirical ABx** **± Dexamethasone**
* *Most children recover in 2-3 days*
* *Rifampicin given to close household contacts as prophylaxis*
81
Define Otitis externa.
Inflammation of the outer ear – auricle, external auditory canal and outer surface of eardrum
82
What are the types of otitis externa?
* **Acute diffuse otitis externa** (Swimmer's ear)
* Moderate temperature and lymphadenopathy, diffuse swelling, variable pain and pruritus, moving ear/jaw is painful, impaired hearing
* Bacterial infection common
* **Chronic otitis externa**
* Discharge and itch are common
* Fungal and associated with underlying skin conditions, diabetes, immunosuppression
* **Necrotising otitis externa** = Life-threatening extension into mastoid and temporal bones → urgent ENT referral
* Pain, oedema, exudate, micro abscess, granulation tissue, pseudomonas culture
* Mainly due to P. aeruginosa or S. aureus
* Mainly in elderly
83
What are the risk factors for otitis externa?
* Hot and humid climates
* Swimming
* Older age
* Immunocompromised
* Diabetes
* Wax build-up
* Narrow external canal
* Obstruction of canal
* Insufficient wax - *predispose infection*
84
What are the appropriate investigations for suspected otitis externa?
Swabs and Culture
85
What is the management of acute otitis externa?
* Topical drops of
* **Acetic acid** - only effective for 1 week
* **Antibiotics** - neomycin or clioquinol
* Wicking and removal of debris
* If the above fails → reconsider diagnosis
* If cellulitis or cervical lymphadenopathy → oral antibiotics
86
Define Laryngomalacia.
Congenital abnormality of larynx cartilage predisposing to supraglottic collapse during inspiration.
87
What are the signs and symptoms of laryngomalacia?
* 2-6 weeks old = **Noisy respiration and Inspiratory stridor**
* Worse → supine, when feeding or if agitated
* Not present at birth
* GORD ± feeding difficulties
* Cough/choking
* Normal cry → no abnormality with vocal cords
* Baby otherwise comfortable
88
What are the appropriate investigations for laryngomalacia?
* O2 monitor
* **Flexible laryngoscopy**
89
What is the management of laryngomalacia?
* **Conservative** → close observation and monitoring of growth
* Usually resolve by 18-24 months (70% by 1-year-old)
* May initially worsen with age, max at 6-8 months
* **Endoscopic supraglottoplasty** - if airway compromise or feeding disrupted sufficiently to prevent normal growth
90
What are the complications of laryngomalacia?
* Respiratory distress
* Failure to thrive
* Cyanosis
91
What is chronic lung disease (Bronchopulmonary dysplasia)?
* Lung damage in the newborn / child due to:
* Delay in lung maturation (i.e. premature)
* Pressure and volume trauma from artificial ventilation
* Oxygen toxicity
* Infection
92
What are the appropriate investigations for suspected chronic lung disease (Bronchopulmonary dysplasia)?
Chest X-Ray = widespread opacification
93
What is the management of chronic lung disease (Bronchopulmonary dysplasia)?
* O2 requirements
* Artificial ventilation *(in bad CLD)*
* CPAP or high-flow nasal cannula *(normal CLD)*
* Corticosteroids
* Low-dose for short course
94
What causes Whooping cough?
Bordetella pertussis → gram -ve bacteria
95
What are the risk factors for whooping cough?
Unvaccinated → included in the 6-in-1
96
What are the signs and symptoms of whooping cough?
* 1-week coryzal symptoms followed by
* **Continuous coughing followed by inspiratory whoop**
* Vomiting
* Epistaxis
* Conjunctival haemorrhages
* Child = worst at night, may go red/blue
* Infants = apnoea rather than a whoop
97
What are the appropriate investigations for suspected whooping cough?
* **Culture ± PCR** - *Naso-Pharyngeal Aspirate for Bordetella pertussis*
* Notify HPU
98
What is the management of whooping cough?
* **Antibiotics**
* \<1 month = oral clarithromycin
* \>1 month = oral azithromycin
* *2nd line = co-amoxiclav*
* Advice
* **Rest, fluids, paracetamol or ibuprofen**
* **Educate parents**
* *Disease is likely to cause a protracted non-infectious cough → may take weeks to resolve*
* *Complete any outstanding immunisations*
* *Cose contacts prophylaxis macrolides*
* **Avoid nursery until 48 hours of antibiotics** or **until 21 days after the onset of the cough** if not treated
* Admit
* \<6mo
* Acutely unwell
* Significant breathing difficulty
* Significant complications → e.g. seizures, pneumonia
99
What counselling should be given to parents with a child with whooping cough?
* **Explain the diagnosis** - cough that lasts for a reasonably long time
* **Explain it's uncommon because of the immunisation -** discuss concerns about immunisation with the parent
* **Explain you can have it again**
* **Explain the treatment = antibiotics but cough often persists for a long time**
* **Exclude from school until 48 hours after starting antibiotics**
