Respiratory

Question 1

Most common cause of bronchiolitis

Answer 1

RSV

Question 2

When is bronchiolitis most common?

Answer 2

Very common in winter in children under 6 months - 1 year.

Question 3

Presentation of Bronchiolitis

Answer 3

Coryzal symptoms - running or snotty nose, sneezing, mucous in throat and watery eyes
Signs of respiratory distress
Dyspnoea
Tachypnoea
Poor feeding
Mild fever (39 degrees)
Apnoeas (episodes where the child stops breathing)
Wheeze and crackles on auscultation

Question 3

Signs of respiratory distress

Answer 3

Raised respiratory rate
Use of accessory muscles - sternocleidomastoid, abdominal and intercostal muscles
Intercostal and subcostal recessions
Nasal flaring
Head bobbing
Tracheal tugging
Cyanosis
Abnormal airway noises

Question 4

Abnormal airway noises

Answer 4

Wheezing - whistling sound caused by narrowed airways, heard on expiration
Grunting - caused by exhaling with partially closed glottis
Stridor - high pitched inspiratory noise caused by upper airway obstruction

Question 5

Typical RSV course

Answer 5

Bronchiolitis usually starts as an upper respiratory tract infection with coryza symptoms. Symptoms usually worse on day 3 or 4 and usually last 7-10 days. Most patients usually recover within 2-3 weeks.

Question 5

Reasons for admission in children with bronchiolitis

Answer 5

Aged under 3 months or any pre-existing conditions such as prematurity, down’s or CF
50-75% or less of their normal intake of milk
Clinical dehydration
Resp rate >70
Oxygen saturations <92%
Moderate to severe respiratory distress - such as deep recessions or head bobbing
Apnoeas

Question 6

Management of bronchiolitis

Answer 6

Only supportive.

Ensure adequate intake
Saline nasal drops and nasal suctioning
Supplementary oxygen
Ventilatory support if required

Question 7

Differentiating viral induced wheeze vs asthma

Answer 7

Typical features of viral induced wheeze:
- Presents before 3 years of age
- No atopic history
- Only occurs during viral infections

Question 8

Presentation of viral induced wheeze

Answer 8

SOB
Signs of respiratory distress: nasal flaring, tracheal tug, use of accessory muscles (sternocleidomastoid, abdominal and intercostal muscles), intercostal and subcostal recessions, head bobbing.
Expiratory wheeze throughout the chest

Question 9

Management of viral induced wheeze

Answer 9

Same as acute asthma in children

Question 10

Presentation of acute asthma

Answer 10

Progressively worsening of SOB
Signs of respiratory distress
Tachypnoea
Expiratory wheeze
‘Silent chest’ - life threatening

Question 11

Severity classification of asthma in children

Answer 11

Question 12

Management of acute asthma/viral induced wheeze

Answer 12

Supplementary oxygen
Bronchodilators (salbutamol, ipatropium bromide and magnesium sulphate)
Steroids e.g. pred (orally) or hydrocortisone (IV)
Antibiotics if bacterial cause is suspected e.g. amoxicillin or erythromycin

Question 13

Management of acute asthma/viral induced wheeze

Answer 13

Supplementary oxygen
Bronchodilators (salbutamol, ipatropium bromide and magnesium sulphate)
Steroids e.g. pred (orally) or hydrocortisone (IV)
Antibiotics if bacterial cause is suspected e.g. amoxicillin or erythromycin

Question 14

Stepping up bronchodilators

Answer 14

Salbutamol
Ipatropium bromide
Magnesium sulphate IV
IV aminphylline

Question 15

How to manage mild cases of acute asthma

Answer 15

Salbutamol inhaler via space 4-6 puffs every 4 hours

Question 16

Moderate to severe cases of acute asthma

Answer 16

Salbutamol inhalers via a spacer device: starting with 10 puffs every 2 hours
Nebulisers with salbutamol / ipratropium bromide
Oral prednisone (e.g. 1mg per kg of body weight once a day for 3 days)
IV hydrocortisone
IV magnesium sulphate
IV salbutamol
IV aminophylline

Question 17

Review chronic asthma management ladder in children

Answer 17

Yes Ma’am

Question 18

Presentation of pneumonia

Answer 18

Cough - wet and productive
High fever >38.5
Tachypnoea
Tachycardia
Increased work of breathing
Lethargy
Delirium

Question 19

Characteristic chest signs of pneumonia

Answer 19

Bronchial breath sounds - harsh breathing sounds that are equally loud on inspiration and expiration
Focal coarse crackles
Dullness to percussion

Question 20

Causes of pneumonia

Answer 20

Strep pneumonia is most common
Group A strep
Grou B strep
Staph aureus
H. influenza
Mycoplasma pneumonia

Viral : RSV, parainfluenza and influenza

Question 21

Investigations of pneumonia

Answer 21

Sputum cultures and throat swabs for bacterial cultures and viral PCR.
All patients with sepsis - blood cultures, capillary b blood gas analysis

Question 22

Management of pneumonia

Answer 22

Amox is first line + macrolide (erythromycin, Clari) to cover atypical pneumonia

Macrolide used as mono therapy if pen allergic

IV antibiotics can be used in sepsis or a problem with intestinal absorption

Oxygen to maintain saturations above 92%

Question 23

Management of pneumonia

Answer 23

Amox is first line + macrolide (erythromycin, Clari) to cover atypical pneumonia Macrolide used as mono therapy if pen allergic IV antibiotics can be used in sepsis or a problem with intestinal absorption Oxygen to maintain saturations above 92%

Question 24

How do you test for CF?

Answer 24

Sweat test

Question 25

Recurrent lower respiratory tract infections

Answer 25

Test for aspiration, neurological disease (MS), heart disease, asthma, CF, Immune deficiency FBC - to check WCC levels Chest x-ray - check for structural abnormalities Sweat test - CF HIV test - especially if mum status unknown or positive

Question 26

What is croup?

Answer 26

URTI commonly caused by parainfluenza

Question 27

Presentation of croup

Answer 27

Stridor Barking cough Increased work of breathing Hoarse voice Low grade fever

Question 28

Management of croup

Answer 28

Usually supportive - fluids and rest at home Usually very responsive to dexamethasone 150mcg/kg 12 hourly

Question 29

Management of severe croup

Answer 29

1. Oral dexamethasone 2. Oxygen 3. Nebulised budesonide 4. Nebulised adrenaline 5. Intubation and ventilation

Question 30

Cause of epiglottitis

Answer 30

Haemophilus influenza type B

Question 31

Presentation of epiglottitis

Answer 31

Sore throat and stridor Drooling Tripod position - sat forward with hand on each knee High fever Difficulty or painful swallowing Scared and quiet child Septic and unwell appearance

Question 32

Investigation of epiglottitis

Answer 32

Lateral x-ray of neck showers thumb sign or thumbprint sign - oedematous and swollen epiglottitis Neck x-rays also useful for ruling out foreign body

Question 33

Management of epiglottitis

Answer 33

Call for senior help - senior paediatrician and anaesthetist Once airway secure: IV antibiotics e.g. ceftriaxone Steroids e.g. dexamethasone

Question 34

What is whooping cough?

Answer 34

URTI caused by bordetella pertussis

Question 35

Presentation of pertussis

Answer 35

Coryzal sytom - low grade fever and midl dry cough Patients present with paroxysmal cough or coughing fits. They are severe and keeping building until patient is out of breath. In severe cases, can cause pneumothorax.

Question 36

Diagnosis of pertussis

Answer 36

Nasopharyngeal or nasal swab with PCR testing Whooping cough should be suspected if a person has an acute cough that has lasted for 14 days or more without another apparent cause, and has one or more of the following features: Paroxysmal cough. Inspiratory whoop. Post-tussive vomiting. Undiagnosed apnoeic attacks in young infants.

Question 37

Management of pertussis

Answer 37

Notify public health England Infants under 6 months - admit Oral macrolide in early stages Close contacts given prophylactic antibiotics Symptoms usually resolve within 8 weeks

Question 38

Key complication of whopping cough

Answer 38

Bronchiectasis Subconjunctival haemorrhage Seizures Pneumonia

Question 39

Pathophysiology of cystic fibrosis

Answer 39

Autosomal recessive caused by genetic mutation of Cystic fibrosis transmembrane conductance regulatory gene on chromosome 7. Delta F508 mutation coding for chloride channels

Question 40

Consequences of cystic fibrosis

Answer 40

Thickened pancreatic and biliary secretions - causing lack of pancreatic lipase in the digestive tract Low volume thick airway secretions - resulting in bacterial colonisation to airway infections Congenital bilateral absence of the vas deferent - male infertility

Question 41

Presentation of cystic fibrosis

Answer 41

Screened at birth in the newborn bloodsport test (Guthrie test) Meconium ileus often first sign of CF. Recurrent lower respiratory tract infections, failure to thrive or pancreatitis

Question 42

Symptoms and signs of CF

Answer 42

Chronic cough Thick sputum production Recurrent respiratory tract infection Loose, greasy stools (steatorrhoea) due to a lack of fact disgusting lipase enzymes Abdominal pain and bloating Poor weight and height gain Finger clubbing Crackles and wheezes on auscultation

Question 43

Diagnosis of CF

Answer 43

New born screening (Guthrie test) Sweat test Genetic testing for CFTR gene

Question 44

How does the sweat test work?

Answer 44

Pilocarpine applied to skin and electrode are placed on either side of the patch and a small current is passed between the electrodes. This causes the skin to sweat and the sweat is absorbed with the lab issued gauze or filter paper and sent to the lab for testing for the chloride concentration. Diagnostic for CF is >30mmol/L

Question 45

Common microbial colonisers in CF

Answer 45

Staphylococcus aureus and pseudomonas Patients with CF have to take long term prophylaxis flucloxacillin to prevent staph infections.