Flashcards in Respiratory ||| Deck (103):
What symptoms do disorders of the upper respiratory tract present with (5)?
2. Sore throat
What symptoms do disorders of the lower respiratory tract present with (3)?
3. Respiratory distress
What are features of moderate respiratory distress (6)?
3. Nasal flaring
4. Use of accessory muscles
5. Head retraction
6. Inability to feed
What are features of severe respiratory distress (4)?
2. Tiring because of increased work of breathing
3. Reduced conscious level
4. O2 saturation <92% despite O2 therapy
Which groups of patients are particularly susceptible to respiratory failure (5)?
1. ex-preterm infants with bronchopulmonary dysplasia
2. those with haemodynamically significant congenital heart disease
3. those with disorders causing muscle weakness
4. CF patients
5. those with immunodeficiency
What are the different types of URTI (4)?
1. Common cold (coryza)
2. Sore throat (pharyngitis, including tonsilitis)
3. Acute otitis media
What are the features of the common cold (coryza) (2)?
1. Clear or mucopurulent nasal discharge
2. Nasal blockage
What are the most common pathogens causing coryza (3)?
Viruses - rhinoviruses, coronaviruses and respiratory syncytial virus (RSV)
What is the management of coryza (2)?
1. Health education to parents that colds are self-limiting to ease anxiety
2. Paracetemol or ibrupofen for pain
What is pharyngitis? What are the most common causative organisms?
The pharynx and soft palate are inflamed and local lymph nodes are enlarged and tender
Viruses - adenovirus, enterovirus and rhinovirus
Bacteria - Group A beta-haemolytic streptococcus is common in older children
What is tonsilitis? What are the most common causative organisms (2)?
A form of pharyngitis where there is intense inflammation of the tonsils, often with purulent exudate
Group A beta-haemolytic streptococci and Epstein-Barr virus
What features are more characteristic of a bacterial cause of tonsitlitis (5)?
3. Abdominal pain
4. White tonsillar exudate
5. Cervical lymphaedenopathy
What is the management of severe pharyngitis and tonsilitis (2)?
1. Abx is often prescribed for severe pharyngitis and tonsilitis (penicillin V or erythromycin in penicillin allergy), even though only 1/3 are caused by bacteria
In very severe cases:
2. children may require hospital admission for iv fluid administration and analgesia if they are unable to swallow solids or liquids
What are they symptoms of tonsillitis (11)?
1. sore throat
2. difficulty swallowing
3. hoarse or no voice
11. white pus-filled spots on tonsils
What is the course of tonsillitis?
Symptoms usually go away after 3-4 days
What is the management of mild-moderate tonsillitis (4)?
2. Drink plenty of fluids
3. Paracetemol or ibruprofen
4. Gargle with warm salty water
What are the complications of tonsillitis (3)?
1. Quinsy - abscess formation between tonsils and wall of throat
2. Otits media
3. Rheumatic fever
What criteria is used to aid in the diagnosis of Group A beta-haemolytic streptococcus as a cause of tonsillitis (4)?
Centor criteria: The presence of 3 or 4 of the following clinical signs:
1. tonsillar exudate
2. tender anterior cervical lymph nodes
3. absence of cough
4. history of fever
What age range are throat infections most common among?
What is acute otitis media?
The presence of inflammation in the middle ear associated with an effusion and accompanied by the rapid onset of symptoms and signs of an ear infection
What age range is acute otitis media common in?
Why are infants and young children prone to acute otitis media?
Their Eustachian tubes are short, horizontal and function poorly
What are the symptoms of acute otitis media (8)?
What are the signs of acute otitis media (2)?
1. Pain in ear
In younger children there may be:
3. pulling/rubbing of ear
5. poor feeding
6. restlessness at night
1. Tympanic membrane is bright red and bulging with loss of normal light reflection.
2. Occasionally there is acute perforation of the eardrum with pus visible in the external canal.
What are the causative organisms of acute otitis media?
2. H. influenxae
3. Moraxella catarrhalis.
What are the complications of acute otitis media (4)?
1. Perforation of tympanic membrane
2. Hearing loss
What is the natural course and management of acute otitis media (2)?
It is usually self-limiting within a few days
1. Pain treated with regular analgesic
2. Antibiotics (5 day amoxicillin) may be necessary for those:
-systemically unwell >4 days and not improving
-with symptoms for
What is a complication of recurrent ear infections and what is a consequence of it?
How is it managed (1)?
Glue ear = otitis media with effusions. Can lead to:
1. conductive hearing loss
2. interfere with normal speech development
3. result in learning difficulties in school.
Managed by insertion of grommets
What is sinusitis?
What is the management?
Infection of the paranasal sinuses that can occur with viral URTIs. Sometimes there is 2o bacterial infection with pain, swelling and tenderness over the cheek from infection of the maxillary sinus.
Management for acute sinusitis:
What is stridor?
What are the causes of acute stridor?
A harsh, musical sound due to partial obstruction of the lower portion of the upper airway including the upper trachea and the larynx.
1. Viral laryngotracheobronchitis (croup)
3. Bacterial tracheitis
4. Laryngeal or oesophageal foreign body
5. Allergic laryngeal angioedema (seen in anaphylaxis and recurrent croup)
6. Inhalation of smoke and hot fumes in fires
What clinical characteristics would you use to assess the severity of upper airways obstruction (2)?
1. Characteristics of the stridor
-Only on crying
2. Degree of chest retraction
-Only on crying
What are the signs of severe upper airways obstruction (4)?
What are the signs of an impending complete airway obstruction (4)?
1. Increased respiratory rate
3. Increased heart rate
1. Central cyanosis
3. Reduced level of consciousness
4. Hypoxaemia (by pulse oximetry)
What is croup? What is it usually caused by (4)?
Also known as laryngotracheobronchitis is a type of respiratory infection usually caused by a virus.
1. Parainfluenza viruses are the most common cause
What age does croup commonly occur at?
Age 6 months to 6 years, but peak incidence is 2nd year of life
What are the symptoms of croup (7)?
3. Hoarseness due to inflammation of vocal cords
4. Barking cough due to tracheal oedema and collapse
5. Harsh stridor
6. Variable degree of difficulty breathing with chest retraction
7. symptoms often start and are worse at night
What is the management of croup according to severity?
If upper airway obstruction is mild:
1. The stridor and chest recession disappear when child is at rest, and child can be managed at home.
Chest recession at rest:
1. Oral dexamethasone, prednisolone or nebulised budesonide are first-line
In severe upper airways obstruction:
1. Nebulised adrenaline with oxygen by face mask provides rapid but transient improvement so they must be observed closely for 2-3 hours.
What is acute epiglottitis? What is it caused by?
Intense swelling of the epiglottis and surrounding tissues associated with septicaemia.
It is a life-threatening emergency due to high risk of respiratory obstruction.
Caused by H. influenza type b (Hib)
What age range is epiglottitis most common at?
Aged 1-6 but can affect all age groups
How do you distinguish between croup and epiglottitis (9)?
-Croup comes on over days
-Epiglottitis comes on over hours
2. Preceding coryza in croup, not in epiglottis
3. Barking cough in croup but absent in epiglottis
4. Able to drink with croup, not with epiglottitis
5. Drooling of saliva present with epiglottitis, not croup
6. Fever <38.5 with croup, and >38.5 with epiglottis
7. Child looks more ill and toxic with epiglottis
8. Harsh stridor with croup, soft stridor with epiglottis
9. Hoarse voice in croup, reluctances to speak with epiglottitis
What is the onset and typical features of epiglottitis (8)?
1. Very acute onset with:
2. high fever
3. Very ill and toxic-looking child
4. intensely painful throat that prevents child from speaking or swallowing
5. saliva drools down chin
6. Soft inspiratory stridor and rapidly increasing respiratory difficulty over hours
7. child sitting immobile, upright, with an open mouth to optimise the airway. Tripoding
8. Absent or minimal cough
Management of epiglottitis (6)?
1. Urgent hospital admission and treatment required
2. A senior anaesthetist, paediatrician and ENT surgeon should be called ASAP to theatre/ICU.
3. Child should be intubated under GA.
4. Rarely, this is impossible and urgent tracheostomy is life-saving.
5. Once airway is secured, blood should be taken for culture and
6. iv Abx started
What is bacterial tracheitis?
Rare but dangerous condition where child has:
1. high fever
2. appears very ill
3. has rapidly progressive airway obstruction with copious thick airway secretions.
Usually caused by Staph. aureas
What should you check for if a child with acute stridor presents with atypical features (without apparent infection) or a poor response to treatment (2)?
Think anaphylaxis or inhaled foreign body
What is an acute wheeze and is its cause (3)?
A continuous, coarse, whistling sound occurring during breathing, originating from turbulent flow of air through constricted bronchioles.
It is due to a partial obstruction of the intrathoracic airways. This is from:
1. mucosal inflammation and swelling as in bronchiolitis
2. bronchoconstriction as in asthma
3. mechanical obstruction
What is bronchiolitis and its course?
What is its cause?
Inflammation of the bronchioles
It is the most common serious disease of the lower respiratory tract during the first year of life. Most infants recover by 2 weeks.
Most common cause: RSV
Other causes: parainfluenza virus, rhinovirus, adenovirus, influenza virus and human metapneumovirus.
What are the symptoms of bronchiolitis (4)?
1. Coryzal symptoms precede:
2. a dry cough and
3. increasing breathlessness.
4. Feeding difficulty
What are the signs of bronchiolitis (7)?
1. Dry wheezy cough
4. Subcostal and intercostal recession
5. Hyperinflation of the chest
6. Fine end-inspiratory crackles
7. High-pitched wheezes - Expiratory>inspiratory
What are the risk factors for bronchiolitis (4)?
1. Infants born premature
2. Those who develop bronchopulmonary dysplasia
3. Those with underlying lung disease such as CF
4. Those with congenital heart disease
What are the investigations for bronchiolitis (3)?
What indications prompt hospital admission (4)?
1. Pulse oximetry should be done on all children with suspected bronchiolitis
2. Chest X-ray or 3. blood gases indicated if respiratory failure is suspected
Hospital admission if any of the following are present:
2. persistent O2 sat of <90% on air
3. inadequate oral fluid intake
4. severe respiratory distress (grunting, marked chest recession or a RR >70 breaths/min)
What is the management of bronchiolitis (3)?
1. humidified O2 delivered via nasal cannula or using a headbox
2. fluid may need to be given by nasogastric tube or iv
3. assisted ventilation in the form of non-invasive respiratory support with continuous positive airway pressure (CPAP)
What are the more common causes of upper airway obstruction (4)?
1. Foreign body
What is a consequence of fever in children?
What are the treatment options?
What are the indications for treatment of fever in a child?
-simple: isolated, generalised tonic-clonic seizures
-complex: focal onset/focal features/ duration >15 mins/recurs within 24 hours or same febrile illness/incomplete recovery after 1 hour
Fever can be treated with paracetemol or ibuprofen
Treatment does not prevent febrile convulsions, so should not be used for this purpose. Treat if the child is distressed with the fever.
What are the 3 types of wheeze?
1. Viral episodic wheeze - only in response to viral infection
2. Multiple trigger wheeze - in response to multiple triggers
What is the link between multiple trigger wheeze and asthma?
Multiple trigger wheeze is a frequent wheeze triggered by many stimuli. this group benefit from asthma preventer therapy and a significant proportion go on to have asthma.
What are the key clinical features that indicate asthma (6)?
1. Wheezing on more than one occasion
2. Symptoms worse at night and in the early morning
3. Symptoms that have non-viral triggers
4. Interval symptoms i.e. symptoms between acute exacerbations
5. Personal or family history of an atopic disease
6. Positive response to asthma therapy
What is found on chest examination in short and long term (6) asthma?
Short-term: Normal examination
1. May be hyperinflation of chest
2. generalized polyphonic expiratory wheeze
3. prolonged expiratory phase.
In asthma complicated with chronic infection such as CF or bronchiectasis:
4. a wet cough/sputum production
5. finger clubbing
6. Poor growth can be found
What investigations can be done in the diagnosis of asthma (2)?
Diagnosis is usually from history and examination alone but if there is uncertainty:
1. Peak expiratory flow rate (PEFR) or spirometry (FEV1) can be done. Poorly controlled asthma leads to increased variability in peak flow with both diurnal variability and day-day variability.
2. Response to bronchodilator - can show improvement in peak flow rate or in FEV1 after bronchodilator inhalation. Following treatment, this reversibility often reduces or disappears completely
What drugs are used as short-acting beta2-agonists (2)?
How long are they effective for?
Salbutamol or terbutaline
What is the mechanism of action for beta-2 agonists?
They bind beta 2 receptors and cause smooth muscle relaxation leading to bronchodilation
What drugs are used as long-acting beta2-agonists (2)?
How long are they effective for?
Salmeterol or formoterol
What drug is used as an anticholinergic bronchodilator and when is it used?
Given to young infants when other bronchodilators are ineffective or in the treatment of severe acute asthma.
How does an anticholinergic bronchodilator work?
It blocks muscarinic acetylcholine receptors so promotes the degradation of cyclicGMP leading to decreased levels of intracellular Ca2+ and therefore decreased contractility of smooth muscle in the lung, inhibiting bronchoconstriction and mucus secretion.
What drugs are used as preventer therapy for asthma?
How do inhaled corticosteroids work?
They decrease airway inflammation, resulting in decreased symptoms, asthma exacerbations and bronchial hyperactivity
What are the systemic side effects of high dose corticosteroids (3)?
1. impaired growth
2. adrenal suppression
3. altered bone metabolism
What add-on therapy is used after SABA and LABA are used (2)?
1. Leukotriene receptor antagonist - montelukast (works by blocking the action of leukotriene in the lungs, reducing bronchoconstriction and inflammation)
2. Xanthine - slow-release oral theophylline (inhibits leukotriene synthesis)
What factors indicate complete control of asthma (5)?
In the previous 6 months:
1. absence of daytime or night time symptoms
2. no limit on activities including exercise
3. no need for reliever use
4. normal lung function
5. no exacerbations (need for hospitalisation or oral steroids)
What criteria need to be noted with regards to an acute asthma attack (3)?
1. duration of symptoms
2. treatment already given
3. course of previous attacks
What criteria determine whether a child is hospitalised after an acute asthma attack (4)?
If after high dose inhaled bronchodilator therapy they:
1. have not responded adequately clinically i.e. there is still breathlessness or tachypnoea
2. are becoming exhausted
3. still have a marked reduction in their predicted (or usual best) peak flow rate or FEV1 (<50%)
4. have a reduced oxygen saturation (<92% in air)
What is the management of acute asthma (6)?
1. Assess severity
2. O2 if sats are <92%
3. SABA via a spacer, or nebuliser if severe/life-threatening
4. 3-7 days of oral prednisolone
5. Nebulized ipratropium in severe asthma
6. Magnesium sulhate, aminophylline or salbutamol intravenously can help in severe/life-threatening asthma.
What are the indications of moderate acute asthma (4)?
1. able to talk
2. O2 sats >92%
3. RR <40/min for 2-5 years old, <30/min for 5-12 years old, <25/min for 12-18 years old
4. HR <140beats/min for 2-5 years old, <125beats/min for 5-12 years old, <110 beats/min for 12-18 years old
What are the indications of severe acute asthma (5)?
1. Too breathless to talk
2. O2 sats <92% for <12 year olds
3. Peak flow 33-50% of best
4. RR >40/min for 2-5 years old, >30/min for 5-12 years old, >25/min for 12-18 years old
5. HR >140beats/min for 2-5 years old, >125beats/min for 5-12 years old, >110 beats/min for 12-18 years old
What are the indications of life-threatening asthma (8)?
1. Silent chest, cyanosis
2. Poor respiratory effort
4. Arrythmia, hypotension
5. Altered consciousness
6. Agitation, confusion
7. Peak flow <33% of best
8. O2 sats <92% (all ages)
Which types of pneumonia cause wheezing?
Atypical pneumonia caused by Mycoplasma, chlamydia or adenovirus
How does inhalation of a foreign body present?
Abrupt onset of cough followed by a wheeze in a previously well child
What signs indicate anaphylaxis (4)?
1. Acute urticarial
2. facial swelling
4. previous reaction to an allergen
What pathophysiology does a dry cough with a prolonged expiratory phase suggest?
There is narrowing of the small-sized to moderate-sized airways
What pathophysiology does a barking cough suggest?
Tracheal inflammation, narrowing or collapse
What pathophysiology does a moist cough suggest?
There is increased mucus secretion or infection in the lower airway
What is whooping cough (pertussis)?
How does it present?
A highly contagious respiratory bacterial infection caused by Bordetella pertussis.
1. In the first week, it is the catarrhal phase: coryza
2. the paroxysmal phase where they develop a characteristic paroxysmal or spasmodic cough followed by a characteristic inspiratory whoop. During a paroxysm, the child goes red or blue in the face and mucus flows from the nose and mouth. The paroxysm phase lasts up to 3 months
How is pertussis diagnosed and managed?
Diagnosis: culture of organism on perinasal swab, marked lymphocytosis on blood film
Management: macrolide Abx decrease symptoms only if started during the catarrhal phase
How can gastro-oesophageal reflux cause cough and wheeze?
By causing aspiration of feeds
What age does the incidence of pneumonia peak?
In infancy and old age
What pathogens cause pneumonia? and what age range do they usually affect?
Infants and young children (5)
Children over 5 (3)
All ages (1)
Viruses and bacteria, in 50% of cases, no causative pathogen is identified.
Newborn - organisms from the mothers genital tract:
1. group B streptococcus
2. Gram -ve enterococci and bacilli
Infants and young children
1. RSV most common
2. Strep pneumoniae
3. H. influenzae
4. Bordetella pertussis
5. Chlamydia trachomatis. An infrequent but serious cause is Staph aureus.
Children over 5
1. Mycoplasma pneumoniae
2. Strep pneumoniae
3. chlamydia pneumoniae
1. mycobacterium tuberculosis
What are the clinical features of pneumonia?
3. rapid breathing
-all preceded by a URTI
2. poor feeding
3. unwell child
What symptoms are suggestive of a bacterial cause of pneumonia (2)?
1. localised chest
2. abdominal or neck pain, indicative of pleural irritation
What signs on examination are suggestive of pneumonia (5)?
What signs commonly found in adults are absent in children (3)?
1. Tachypnoea = most sensitive clinical sign
2. Nasal flaring
3. Chest indrawing
4. May be end-inspiratory course crackles over affected area
5. Decreased O2 sats
Classic signs of consolidation are usually ABSENT in children
1. Dullness on percussion
2. Decreased breath sounds
3. Bonchial breathing over affected areas
What investigation is used to confirm the diagnosis of pneumonia?
What are the indications for admission to hospital in children with pneumonia (4)?
1. O2 sat <92%
2. recurrent apnoea
4. inability to maintain adequate fluid/feed intake
What supportive care is given to manage pneumonia (3)?
1. Oxygen for hypoxia
2. analgesia for pain
3. iv fluids to correct dehydration and maintain adequate hydration and sodium balance
In the treatment of pneumonia, what Abx are used for:
2. Older infants
3. Complicated/unresponsive pneumonia
4. children over 5
Newborn: broad-spectrum iv abx
Older infants: oral amoxicillin
Complicated/unresponsive pneumonia: broad spectrum abx such as co-amoxiclav
Children over 5: amoxicillim or an oral macrolide
What is a complication of pneumonia?
Atelectasis (Lobar collapse)
What is the genetic aetiology of cystic fibrosis?
Autosomal recessive - defect of gene for CFTR on chromosome 7
What is the average life expectancy of someone with CF?
What is the pathophysiology of CF (5)?
1. Defective protein called CFTR which is a chloride channel on membrane of cells. In the airways, abnormal ion transport across epithelial cells leads to a reduction in the airway surface liquid layer and consequent impaired ciliary function and retention of mucopurulent secretions. This leads to frequent infections.
2. Defective CFTR also causes dysregulation of inflammation and defence against infection.
3. In the intestines, thick viscid meconium is produced, leading to meconium ileus in some infants.
4. The pancreatic ducts also become blocked by thick secretions leading to pancreatic enzyme deficiency and malabsorption
5. Abnormal function of sweat glands result in excessive concentrations of sodium and chloride in sweat
What are the clinical features of CF in:
1. newborns (2)
2. infancy (5)
3. young child (4)
4. older child and adolescent (6)
1. Diagnosed through screening
2. Meconium ileus
1. prolonged neonatal jaundice
2. growth faltering
3. recurrent chest infections
2. rectal prolapse
3. nasal polyp
Older child and adolescent
1. allergic bronchopulmonary aspergillosis
3. cirrhosis and portal hypertension
4. distal intestinal obstruction (meconium ileus equivalent)
5. pneumothorax or recurrent haemoptysis
6. sterility in males
What chronic bacterial infections do CF usually get?
1. initially (2)
2. subsequently (2)
1. Staph. aureus, Haemophilus influenzae
2. Pseudomonas aeruginosa or burkholderia
What signs do chronic infection of the lungs in CF patients lead to (4)?
Bronchiectasis, abscess formation
1. persistent wet cough
2. hyperinflation of chest
3. coarse inspiratory crepitations
4. expiratory wheeze
How is CF diagnosed?
Sweat test - elevated levels of chloride
What is the management of the respiratory component of CF (7)?
1. Monitoring symptoms in young children, regular spirometry for older children
2. Physiotherapy at least twice a day to clear airway secretions
3. Continuous prophylactic Abx (usually flucoxacillin)
4. Additional rescue oral Abx for any respiratory symptoms
5. Regular nebulized hypertonic saline
6. iv Abx for more severe CF
7. Bilateral sequential lung transplantation for end-stage CF lung disease
What is the management of the nutritional component of CF (3)?
1. regular assessment of dietary status
2. oral enteric-coated pancreatic replacement therapy with all meals and snacks
3. high calorie diet
What are the symptoms of TB (3)?
What are the signs of TB (2)?
1. Persistent productive cough
2. Night sweats
3. Lack of appetite and weight loss
Marked hilar or paratracheal lymphadenopathy
What investigations should be done to diagnose TB (3)?
Chest X-ray and tuberculin skin test or tuberculosis blood tests