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Flashcards in Respiratory Deck (118):
1

What pathogen causes most resp infections in childhood?

Viruses

2

Which are the important viruses in resp infections? X6

RSV (respiratory syncytial virus), rhino viruses, parainfluenza, influenza, metapneumovirus and adenoviruses

3

Most important bacterial pathogens in resp infections x5

Streptococcus pneumoniae (pneumococcus), haemophilus influenzae, moraxella catarrhalis, bordetella pertussis (whooping cough), mycoplasma pneumoniae

4

Environmental risk factors for resp infection x3

Parental smoking - especially maternal, poor socio-economic status (overcrowding, large family, damp), poor nutrition

5

Host risk factors for resp infections x4

Underlying lung disease, male gender, haemodynamically significant congenital heart disease, immunodeficiency

6

Underlying lung disease which increase risk for resp infection x3

Bronchopulmonary dysplasia (preterm infants), cystic fibrosis or asthma

7

What is encompassed by URTI? X4

Common cold (coryza), sore throat (pharyngitis including tonsillitis), sinusitis

8

What can URTI cause in infants?

Poor feeding as blocked nose obstructs breathing
Febrile convulsions
Acute exacerbations of asthma

9

Classic features of common cold

Blocked nose and clear/mucopurulent nasal discharge

10

Commonest pathogenic causes of common cold

Viruses - rhinoviruses, corona viruses, RSV

11

Treatment of common cold

Self-limiting and no curative treatment
Fever and pain - treat with paracetamol and ibuprofen

12

What is pharyngitis?

Inflammation of pharynx and soft palate
Local lymph nodes enlarged and tender

13

What usually causes sore throat/pharyngitis? And in older children

Viruses - adenoviruses, enteroviruses and rhinoviruses
In older children group a b-haemolytic streptococcus

14

Common pathogens for tonsillitis?

Group a b-haemolytic strep and EBV

15

How do you tell between viral and bacterial tonsillitis

Clinically you can't!
EBV exudate meant to be more membranous
Bacterial may have more constitutional disturbance (headache, apathy and abdominal pain, white exudate and cervical lymphadenopathy)

16

What is treatment for pharyngitis and tonsillitis - how long?

If severe often antibiotics even though only 1/3 are bacterial
To eradicate organism (b-haem strep) and prevent rheumatic fever need 10days of treatment

17

What antibiotic should be used in pharyngitis/tonsillitis and what should be avoided?

Penicillin and erythromycin (if penicillin allergy) usually used
Avoid amoxicillin because can cause maculopapular rash if due to EBV

18

When is acute otitis media most common?

6-12months

19

Symptoms and signs of acute otitis media?

Pain in ear and fever
Tympanic membrane bright red and bulging - loss of normal light reflection
May be visible pus if perforation of eardrum

20

Pathogens of acute otitis media

Viruses especially RSV and rhinovirus
Bacterial include pneumococcus, h.influenzae and moraxella catarrhalis

21

Serious complications of acute otitis media

Mastoiditis and meningitis

22

Treatment of acute otitis media

Paracetamol or ibuprofen for pain - constant rather than as required - more effective - may be needed for up to a week

23

Significance of antibiotics in acute otitis media

Shown to reduce the duration of pain but not affect risk of hearing loss - if no improvement after 4 days - give 5days of amoxicillin (erytho/clarithro if pen allergic)
Don't wait for 4days if bilateral AOM or perforation in children

24

What can recurrent ear infections lead to?

Otitis media with effusion

25

Symptoms and signs of otitis media with effusion

Children asymptomatic apart from possible decreased hearing
Eardrum is retracted and dull and can often see a fluid level

26

Diagnosis of otitis media with effusion

Flat trace on tympanometry
Conductive hearing loss on pure tone audiometry (if >4) or reduced hearing on distraction hearing test in younger children

27

When is otitis media with effusion common

Age 2-7
Peak incidence 2.5-5

28

Treatment of otitis media with effusion

No evidence for benefit of long term antibiotics, steroids or decongestants
Condition usually resolves spontaneously
If affecting hearing - grommet insertion

29

What surgery can be useful for otitis media with effusion

Adenoidectomy because believed adenoids can harbour organisms contributing to infection spreading up Eustachian tubes
Also hypertrophied adenoids can obstruct and affect function of Eustachian tubes - poor ventilation of Middle ear

30

Another name for otitis media with effusion

Glue ear

31

When does sinusitis occur

Infection of para nasal sinuses with viral URTIs

32

What can occur with sinusitis and symptoms?

Secondary bacterial infection
Pain, swelling and tenderness over cheek from infection of maxillary sinus

33

What sinuses not usually affected in childhood sinusitis

Frontal sinuses because they do not develop until late childhood

34

Treatment for sinusitis

Reassure that >95% are viruses and can take 2.5 weeks to get better
Analgesia, intranasal steroids and decongestants, saline irrigation, warm face packs
but if bacterial suspected then antibiotics

35

Treatment for bacterial sinusitis

But if bacterial suspected (purulent discharge, severe pain, temp >38, worsening after initial being okay) then give antibiotics
Amox 7 days, or phenoxymethylpenicillin 7 days (pen allergic doxy (not children) erythro or clarithro)

36

Growth of tonsils and adenoids in childhood

Large in childhood and then gradually regress
If too large can cause trouble such as obstruction of airways (adenoids) and therefore be indication for removal

37

Number of resp infections in preschool children per year

6-8

38

Most common laryngeal/tracheal infection (acute upper airway obstruction)

Croup - viral laryngotracheobronchitis

39

What are symptoms and signs of acute upper airway obstruction x6

Stridor (rasping sound heard on inspiration)
Hoarseness (inflammation of vocal cords)
Barking cough
Dyspnoea
Tachypnoea (severe)
Tachycardia (severe)

40

How can you assess severity of upper airway obstruction

Degree of chest retraction (none, only on crying, at rest)
Degree of stridor (none, only on crying, at rest or biphasic)

41

What is pathology of croup x3

Mucosal inflammation and increased secretions
Oedema of subglottic area - most dangerous factor as causes critical tracheal narrowing

42

Pathogenic cause of croup

Viruses 95% including metapneumovirus, RSV, influenza
Most common is parainfluenza virus

43

Peak incidence of croup

Occurs from 6months-6 years but peak is in 2nd year of life

44

What season is croup most common

Autumn

45

Typical features of croup x6

Barking cough, harsh stridor and hoarseness
Usually preceded by fever and coryza
Symptoms often start and are worse at night

46

Treatment of croup

Oral Dexamethasone, prednisolone or neb budesonide
one dose - repeat next day if not better

47

Treatment of severe upper airway obstruction

Neb adrenaline - needs careful monitoring because risk of rebound symptoms 2hours after adrenaline when effects wear off

48

What is bacterial tracheitis?

Pseudomembranous croup
Rare but dangerous
Similar to viral croup but high fever, toxic and rapidly progressive obstruction with thick airway secretions

49

What causes bacterial tracheitis?

Staph aureus - treated with IV antibiotics

50

What is epiglottis and incidence?

Life threatening emergency caused by h.influenza type b - now massively reduced due to immunisation in infancy
Swelling of epiglottis and surrounding tissues

51

What complicates epiglottis?

Septicaemia

52

What age group is epiglottis common in?

Children 1-6
But can occur in all ages

53

Differences of presentation between croup and epiglottis

Epiglottis onset over hours without preceding coryza - no cough, can't drink or swallow so drooling saliva. They appear very toxic and ill with high fever. Have soft whispering stridor not harsh and muffled voice rather than hoarse

54

Appearance of child with epiglottis

Sitting upright with open mouth to optimise airway

55

Treatment of epiglottis

Intubated with general anaesthetic (24hours)
Blood for culture
IV antibiotics such as cefuroxime (3-5days)

56

What should be done for contacts of epiglottis patients

As with all serious h.influenzae infections - prophylaxis with rifampicin

57

Presentation of bronchitis in childhood

Cough and fever are main symptoms (not usually wheeze presentation)
Cough may persist for 2 weeks

58

What is whooping cough

Highly contagious infection caused by bordetella pertussis

59

Incidence of whooping cough

Epidemic - occurring every 3-4 years

60

Presentation of whooping cough

1) catarrhal phase - week of coryza
2) paroxysmal phase - spasmodic cough followed by inspiratory whoop (3-6weeks)

61

What can occur as a result of the cough in whooping cough

Often worse at night - may lead to vomiting
May also get epistaxis and subconjunctival haemorrhages if vigorous coughing
Red/blue in face during coughing and mucus flows from nose and mouth

62

Uncommon complications of whooping cough x3

Pneumonia
Convulsions
Bronchiectasis

63

Blood count in whooping cough

Typically lymphocytosis >15 x 10(9)

64

Treatment of whooping cough and its effect

Started within 21days of cough onset
under 1m clarithro
>1m azithro or clarithro

65

Contact treatment with whooping cough

Prophylaxis in close contact and vaccination of any unvaccinated infant contacts
same unless pregnant in which case erythro

66

Most common age for bronchiolitis

90% are 1-9months
Rare after age 1

67

Pathogen in bronchiolitis

RSV in 80%
Also other viruses and mycoplasma pneumoniae

68

Symptoms of bronchiolitis

Coryzal symptoms precede:
Dry cough, increasing dyspnoea and difficulty feeding
Cyanosis, pallor, hyperinflation, SDL

69

Auscultation in bronchiolitis x2

Fine end-inspiratory crackles
High pitched wheeze (exp>insp)

70

Chest X-ray in bronchiolitis

Hyperinflation due to air trapping following small airway obstruction

71

Management of bronchiolitis

Humidified oxygen
Antibiotics, steroids and bronchodilators not shown to reduce severity or duration of illness

72

Prognosis of bronchiolitis

Most recover within 2 weeks
Adenovirus can have permanent damage to airways - bronchiolitis obliterans

73

What is palivizumab?

Monoclonal antibody to RSV given to high risk preterm infants

74

Pathogenic cause of pneumonia

50% cause not found
Can be viral or bacteria (viral more common in younger children and bacterial in older)

75

Most common pathogen in newborn pneumonia

Group b strep

76

Clinical features of pneumonia - most common presentation

Fever and difficulty breathing
Usually preceded by URTI

77

Other symptoms of pneumonia - including indication of bacterial infection

Cough, lethargy, poor feeding
Localised pain may suggest pleural irritation and therefore bacterial infection

78

Signs of pneumonia

SDL - tachypnoea, nasal flaring, chest indrawing

79

Auscultation in pneumonia

End inspiratory resp coarse crackles over affected area
Classical signs of consolidation (dullness on percussion, reduced air entry and bronchial breathing) not usually present

80

Management of pneumonia x4

Oxygen for hypoxia
Analgesia if pain
IV fluids if dehydrated
Antibiotics depending on age

81

Antibiotics in newborn with pneumonia

Broad spectrum - amox

82

Antibiotics in older infants with pneumonia

Oral amoxicillin
Broad spectrum eg co-amoxiclav for complicated or unresponsive
Can add in macrolides (azithro etc) if not responding

83

%of children affected by asthma

15-20

84

Two patterns of wheezing in children- indications of asthma

Transient early wheezing
Persistent and recurrent wheezing

85

What is transient early wheezing?

Virus associated wheeze or episodic viral wheeze
Due to small airways being more likely to narrow and obstruction due to inflammation from viral infection
Hence episodically triggered by viral infections

86

Risk factors for transient early wheezing x5

Decreased lung function from birth due to small airway diameter
Maternal smoking during and or after pregnancy
Preterm
Family hx of atopy not a risk factor
More common in males

87

When does transient early wheezing resolve

Age 5

88

What is persistent and recurrent wheezing

Wheezing due to IgE hypersensitivity - aka asthma

89

3 main pathological features of asthma

Bronchial inflammation, bronchial hyperresponsiveness and airway narrowing

90

What triggers most asthma exacerbations

Rhinovirus infection

91

Signs of long standing asthma x3

Hyperinflation
Generalised polyphonic wheeze
Prolonged expiratory phase

92

Indications of another cause of wheeze (not asthma) x3 and what do they indicate?

Wet cough or sputum production
Finger clubbing
Poor growth
Indicate chronic infection such as cystic fibrosis or bronchiectasis

93

Ladder of treatment of asthma in infant >5

Short acting inhaled bronchodilator
Inhaled steroids ( 3 or more b2 needed per week)
Long acting b2
Increase steroid dose
Oral steroids

94

Other than b2 and steroids for asthma what can be added and when?

Leukotriene receptor antagonist or theophyllines - if no response to LABA

95

Asthma ladder in less than 5 years old

Ipratropium bromide + SABA
Inhaled steroids or oral leukotriene r-antagonist (montelukast, zafirlukast) if inhalers not tolerated
LABA
refer to resp paediatrician

96

What is good for exercise induced asthma

LABA + inhaled steroid

97

Signs of severity in acute asthma attack

If less than 5 - RR > 50 (not as good as HR) or HR >130
If older than 5 RR >30 or HR >120
Accessory muscle use and chest recession
Pulsus paradoxus
Can't talk

98

Signs of life threatening asthma

Cyanosis fatigue, drowsiness and silent chest

99

What is good in treating acute asthma

Ipratropium bromide
Steroids - IV if severe

100

Most common cause of recurrent cough in children

1) URTI - common cold
2) Asthma
3) Wet - cystic fibrosis
4) GORD
5) Parents smoking

101

Chronic wet cough is indicative of...

Chronic lung infection eg. Bronchiectasis due to cystic fibrosis, primary ciliary dyskinesia, immunodeficiency or chronic aspiration

102

What is Kartagener syndrome?

Situs inversus
Dextrocardia
Primary ciliary dyskinesia (recurrent productive cough, purulent nasal discharge, chronic ear infections)

103

Who has chronic aspiration

Children with neurodisability

104

Incidence of cystic fibrosis

1 in 2500 live births
Carrier rate 1 in 25

105

Correlation between genotype and phenotype in CF

Weak for lung disease but stronger for GI disease
Indicates that environmental factors influence lung disease (passive smoking, social deprivation, microbial pathogens)

106

Pathogen usually causing infection in CF

Pseudomonas aeruginosa

107

Incidence of meconium ileus in infants with CF

10-20%

108

Other organ affected in CF

Pancreas - pancreatic enzyme deficiency leads to malabsorption
Also sweat glands - increased sodium and chloride in sweat

109

Presentation of CF if not picked up at heel-prick screening x3

Recurrent chest infections, poor growth and malabsorption

110

Examination (resp) in CF

Hyperinflation (air trapping), coarse inspiratory creps and/or expiratory wheeze
Established disease - clubbing

111

Disease in older CF children

DM due to pancreatic dysfunction

112

Diagnosis of CF

Sweat test
Cl 60-120 (10-40normal)
Stimulated by pilocarpine iontophoresis

113

Drugs in CF

Prophylactic antibiotics - usually flucloxacillin
Nebulised DNAse or hypertonic saline to decrease sputum viscosity
Macrolide antibiotic azithromycin - immunomodulatory not antibiotic action

114

Eventual treatment for CF lung disease

Lung transplant
Fortunately not needed in childhood
Usually 50% 10 year survival rate

115

Diet in CF

High calorie 150% of normal
Fat soluble vitamin supplements

116

Organ problems in older patients with CF

1/3 have evidence of liver disease - hepatomegaly or LFT abnormalities

117

Fertility in CF

Females normal
Males always infertile due to absent vas deferens (have sperm therefore can have kids with ICSI)

118

What is Guthrie test

Heel prick test for CF for all children