Respiratory Flashcards
(101 cards)
1
Q
What is croup
A
subglottal oedema, inflammation and exudate
Barking cough with respiratory distrss due to upper airway obstruction
2
Q
What pathogen causes croup
A
parainfluenza virus
3
Q
Most common age group affected by croup
A
Age 2-5
6 months - 6 years
4
Q
when do you admit a child
A
- moderate to severe symptoms
- RR>60
- <3 months old
- Pre-existing resp condition
- inadequate feeding
- resp distress
- hypoxia
5
Q
What is considered mild croup
A
cough, no stridor at rest
minimal recession
no cyanosis
6
Q
What is considered moderate croup
A
Frequent cough
stridor at rest
sternal recession at rest
7
Q
What is considered severe croup
A
restlessness/agitation cyanosis signs of resp distress Asynchronus chest wall movement - resp failure RR >70 Tachycardia
8
Q
What is the management of mild croup
A
- no hospital admission
- dexamethasone 0/15mg/kg one off ose
Return if stridor or recessions
9
Q
What is the management of moderate/severe croup
A
O2 if severe: 15L then titrate
Dexamethasone 0.15mg/kg
2mg budesonide neb/5mls 1:1000 adrenaline neb
ENT if not maintaining airway
10
Q
what patient info do you give regarding Croup
A
Very common viral infection which results in a barking cough due to inflammation of the voice box. you can get breathing symptoms due to inflammation and mucus in the windpipe. The cough is worse at night and is accompanied by coryzal symptoms. Peaks after 1-3 days then improves however, the cough can last a week
11
Q
What is acute bronchiolitis
A
Commonest LRTI in babies usually under 1 year old
12
Q
What pathogen causes bronchiolitis
A
RSV - respiratory syncytial virus
13
Q
what are the signs and symptoms of bronchiolitis
A
- coryza precedes cough
- Tachypnoea
- apnoea
- fever
- res[iratory distress
- inspiratory crackles
- +/- cyanosis
14
Q
What is the management of bronchiolitis
A
- O2 until sats >92
- Nasogastric feeds
- resp support - CPAP
- Ribavrin if immunocompromised or known heart/lung problem
15
Q
What are the usual pathogens in infant pneumonia
A
Pneumococcus
mycoplasma
haemophillus
16
Q
What is the treatment of pneumonia in children
A
- oral ABC: amoxicillan, co-amoxiclav
- advice on managing fever and dehydration
- identifying deterioration
17
Q
What is whooping cough
A
Bordetella pertussis
18
Q
What are the signs of Whopping cough
A
Apnoea
Whoop: Inspiration against a closed glottis (not always heard)
Worse at night or after feeding
+/- cyanosis or co-infection with bronchiolitis
19
Q
How long do you keep your child off school with whooping cough
A
48hrs after first antibiotics dose
If no Abx, 3 weeks
Incubation period 10-14 days
20
Q
What is cystic fibrosis - doctor
A
deltaF508 mutation: decrease in CFTR on membranes which decreases chloride leading to thick secretions
21
Q
What is cystic fibrosis - patient
A
Cystic fibrosis is a genetic condition whereby secretions such as mucus in our windpipe are too thick which makes the little finger-like projections in our wind pipe that normally remove mucus and pathogen don’t work as well. This results in the windpipe being filled with thick secretions and increases susceptibility to infection. It also has an impact on other organs such as the pancreas
22
Q
What is the genetic inheritence of CF
A
Autosomal recessive
1 in 2000
23
Q
What is the presentation of CF
A
- newborn screening
- Newborn meconium ileus
- Recurrent pneumonia and clubbing
- Failure to trhive
- Steatorrhoea
24
Q
what is steatorrhoea
A
pale, fatty, oily smelly stools
25
What are the investigations for Cf
Sweat test: Cl >60mmol
(<40mmol is normal)
NOT TO BE DONE ON DAY 1 Cl >65
26
What can cause a false positive in the sweat test
```
adrenal insufficiency
hypothyroidism
dehydration
malnutrition
atopic eczema
```
27
What can cause false negatives in the sweat test
oedema
| poor technique
28
What might you see on CXR in someone with CF
- hyperinflation
- increase AP diameter
- bronchial dilatation
- cysts
- linear shadows
- infiltrates
29
What do you see in spirometry of someone with CF
Obstructive pattern
decreased FVC
Increased lung vol
30
Complications of CF
- GI obstruction if creon omitted/inadequate
- Impaired glucose intolerance with age: OGTT yearly >12
- Malabsorption
- Increased energy needs
- pneumonia
- infertility (male)
31
What is the management of CF as an infant
- chest physio TDS
- postural drainage and percussion
- Forced expiration when older
32
What is meconium ileus
Failure to pass stool or vomiting in the first 2 days of life. Will see distended bowel loops through abdo wall.
33
What is the management of meconium ileus
NG drainage, washout enemas, excision of gut containing meconium
34
What is the prognosis of CF
- most survive to adulthood
- median age 50 if born after 2000
- death from pneumonia or cor pulmonale
35
What are the RF for asthma
```
Low birthweight
bottle fed
male
past lung disease
FH
Atopy
Pollution
```
36
What are the differentials of asthma
```
foreign body
pertussis
croup
pneumonia/TB
hyperventilation
Aspiration
CF
```
37
What general advice do we give to parents of an asthmatic
- Annual review: Sx, exacerbations, time off school, inhaler technique
- Advice re smoke exposure
- record height and weight
38
What a red flags/indicators of other pathology in asthma
```
Failure to thrive
Unexplained clinical findings
Symptoms present from birth or perinatal lung problem
Excessive vomiting or posseting
Severe URTI
Persistent wet or productive cough
Family history of unusual chest disease
Nasal polyps
```
39
Step 1 management of asthma
Low dose corticosteroid
| Salbutamol inhaler
40
Step 2 management of asthma
Low dose corticosteroid + LABA or LTRA (>5). LTRA (<5)
| Salbutamol inhaler
41
Step 3 management of asthma
- consider increasing cortico-steroid inhaler
- Add LTRA e.g montelukast or LABA
- If no response to LABA stop
42
Step 4
specialist referral
43
What constitutes a moderate asthma attack
- Sats >92%
- able to talk
- HR <140
- RR <40
- PEF >50% normal
44
What constitutes a severe acute asthma attack
- Sats <92%
- Unable to complete sentences
- HR >140
- RR >40
- accessory muscle usage
- PEF 33-50% normal
45
What constitutes a life threatening acute asthma attack
Sats <92% AND one of;
- Silent chest
- poor respiratory effort
- agitation
- confusion
- cyanosis
- PEF <33% of normal
46
when to lower threshold for admission following an acute asthma attach
- Late afternoon or evening attack
- Recent hospital admission
- Previous severe asthma attack
- Concerns over social circumstances/ability to cope at home
47
Management of acute asthma attack
- Salbutamol via oxygen driven neb
- Ipratropium neb
- oral prednisilone/hydrocortisone
- IV salbutamol
- IV magnesium sulphate
- IV aminophylline
- CALL ANAESTHETIST
48
Management of a mild asthma attack at home
4-6 puffs every 4 hours via spacer
49
What step down protocol should you take with an acute asthma attack
```
10 puffs 2 hourly
10 puffs 4 hourly
6 puffs 4 hourly
4 puffs 6 hourly
Consider discharge
```
50
Prior to discharging a child from an acute asthma attack what should you do
Finish the course of steroids if these were started (typically 3 days total) - tell them to
Provide safety-net information about when to return to hospital or seek help
Provide an individualised written asthma action plan
51
Presentation suggesting chronic asthma
Episodic symptoms with intermittent exacerbations
Diurnal variability: worse at night and early morning
Dry cough with wheeze and shortness of breath
Typical triggers
Atopy
Family history of asthma/atopy
Bilateral widespread “polyphonic” wheeze
Symptoms improve with bronchodilators
52
Typical asthma triggers
```
Dust (house dust mites)
Animals
Cold air
Exercise
Smoke
Food allergens (e.g. peanuts, shellfish or eggs)
```
53
How do you diagnose asthma
- mainly clinical and on history
- Spirometry with reversibility testing (in children aged over 5 years)
- Direct bronchial challenge test with histamine or methacholine
- Fractional exhaled nitric oxide
- Peak flow variability
54
How do you measure peak flow variability
by keeping a diary of peak flow measurements several times a day for 2 to 4 weeks
55
What is an example of long actng beta 2 agonist
salmeterol
56
What are the key consequences of cystic fibrosis
- Thick pancreatic and biliary secretion
- low volume thick airway secretions
- Congenital bilateral absence of the vas deferens
57
What is the result of thick pancreatic and billiary secretions in CF
cause blockage of the ducts, resulting in a lack of digestive enzymes such as pancreatic lipase in the digestive tract
58
What is the result of low volume thick airway secretions in CF
that reduce airway clearance, resulting in bacterial colonisation and susceptibility to airway infections
59
What is the impact of CF on male infertility
Congenital bilateral absence of the vas deferens in males. Patients generally have healthy sperm, but the sperm have no way of getting from the testes to the ejaculate, resulting in male infertility
60
Signs of CF
```
Low weight or height on growth charts
Nasal polyps
Finger clubbing
Crackles and wheezes on auscultation
Abdominal distention
```
61
Examples of common colonisers in CF
```
Staphylococcus aureus ****
Pseudomonas aeruginosa *****
Haemophilus influenza
Klebsiella pneumoniae
Escherichia coli
Burkhodheria cepacia
```
62
Management of CF
- Chest physio and exercise
- Exercise
- high calorie diet
- creon tablet
- prophylactic flucloxacillan
- bronchodilators
- transplants
63
What vaccinations should all CF kids have
Pneumococcal
Influenza
Varicella
64
Prognosis of CF
90% develop pancreatic insufficiency
50% develop cystic fibrosis-related diabetes and require insulin
30% develop liver disease
Most males are infertile due to absent vas deferens
65
How often and what do you monitor in CF patients
- typically every 6 months
- Sputum colonisation
- diabetes screening
- osteoporosis screening
- vitamin D deficiency
- liver failure
66
Is pertussis a notifiable disease
yes
67
How do you diagnosis whooping cough
W/I 2 weeks of symptoms
A nasopharyngeal/nasal swab with PCR testing or bacterial culture
Over 2 weeks of symptoms
- anti-pertussis toxin immunoglobulin G
- oral fluid Age 5-16
Blood: > 17.
68
How long can symptoms of whooping cough last
- usually within 8 weeks
| - complication includes bronchiectasis
69
What is chronic lung disease of prematurity (bronchopulmonary dysplasia)
- occurs in babies <28 weeks
| - suffer respiratory distress syndrome + require O2, intubation and ventilation at birth
70
How do you diagnose chronic lung disease of prematurirty
- CXR changes
| - O2 therapy after 36 weeks gestation
71
What are the key features of chroinc lung disease of prematurity
- Low oxygen saturations
- Increased work of breathing
- Poor feeding and weight gain
- Crackles and wheezes on chest auscultation
- Increased susceptibility to infection
72
How can you prevent chronic lung disease of prematurity
- corticosteroids to women who look like they're going to deliver early
- CPAP instead of intubation
- caffeine to stimulate respiratory drive
- Don't over oxygenate
73
What is the management of chronic lung disease of prematurity
sleep study to assess O2 saturations
can be D/C on low home O2 therapy
Protection against RSV
74
What is epiglottitis
inflammation and swelling of the epiglottis caused by infection, typically with haemophilus influenza type B. The epiglottis can swell to the point of completely obscuring the airway within hours of symptoms developing
MEDICAL EMERGENCY
75
What causes epiglottitis
haemophilus influenzae B
| rare now due to vaccination
76
What is the presentation of epiglottis
```
Patient presenting with a sore throat and stridor
Drooling
Tripod position
High fever
Difficulty or painful swallowing
Muffled voice
Scared and quiet child
Septic and unwell appearance
```
77
how do you investigate suspected epiglottitis
- Do on perform any if patient looks very unwell
- Lateral xray of the neck shows a characteristic “thumb sign” or “thumbprint sign.
- Also rules out foreign body aspiration
78
What is the thumbprint sign
soft tissue shadow that looks like a thumb pressed into the trachea.
Suggests epiglottitis
79
What is the management of epiglottits
- Do NOT distress child
- call senior anaesthetist + paediatrician
- secure airway - not many patients have to be intubated
- IV antibiotics (e.g. ceftriaxone)
- Steroids (i.e. dexamethasone)
80
What is a complication of epiglottits
Epiglottic abscess: collection of pus around the epiglottis
| This also threatens the airway, making it a life threatening emergency
81
What is laryngomalacia
part of the larynx above the vocal cords (the supraglottic larynx) is structured in a way that allows it to cause partial airway obstruction. This leads to a chronic stridor on inhalation, when the larynx flops across the airway as the infant breathes in
82
What is stridor
harsh whistling sound caused by air being forced through an obstruction of the upper airway
83
What is the structural abnormalitiy in laryngomalacia
In the larynx we have two cartilage folds called the aryepiglottic fold which act to constrict the opening of the airway to prevent food and fluid entering the trachea. In laryngomalacia, these folds are shortened and tissue surrounding the supraglottic larynx is softer and has less tone in laryngomalacia, meaning it can flop across the airway
84
WHen do infants with laryngomalacia present
peak incidence 6 months
85
How do infants with laryngomalacia present
Intermittent stridor, worse when feeding, lying back, URTI or when the infant is upset
DON'T usually have respiratory distress
Main complication is with feeding
86
What is the management of laryngomalacia
Resolves as larynx matures
Usually no intervention is required
Very rarely a tracheostomy is required
Very rarely surgery is required
87
What is a viral induced wheeze
Children under 3 have small airways and when they contract a virus such as RSV these small airway become inflamed and oedematous. This causes swelling in the walls of these small airways restricting the amount of airflow in and out.
Inflammation also triggers the smooth muscle in the airway to contract further constricting the airway. This all happens in adults as well but as our airways are much larger the swelling doesn't have an impact.
Air flowing through this narrow space causes a wheeze and the restriction in airflow can cause respiratory distress
88
Risk factors for viral induced wheeze
FH - some genetic element
| increased liklihood of developing asthma in future
89
Typical features of viral induced wheeze compared to asthma
Presenting before 3 years of age
No atopic history
Only occurs during viral infections
NB. asthma can be triggered by viral or bacterial infection
90
What is the presentation of a viral induced wheeze
- Coryzal symptoms, fever, cough 1-2 days prior to wheeze onset
- SOB
- Signs of respiratory distress
- Expiratory wheeze throughout the chest
91
How do you manage a viral induced wheeze
As you would acute asthma
92
Most common pathogens in children with CF
Staph aureus
haemophilus influenza
pseudomonas aeriginosa
93
Long term complications of CF on the lungs
bronchiectasis
pulmonary hypertension
cardioresp failure
94
What are the initial complications of the exocrine pancreas in CF
```
pancreatic insufficiency
steatorrhoea
malabsorption
Vitamin A, D, E + K deficiency
coagulation disorders
failure to thrive
```
95
What are the initial complications of the endocrine pancreas in CF
Islet cell damage
CF related diabetes
Vit D deficiency
reduced bone mineral density
96
Initial GI complications of CF
```
meconium ileus
haemorrhoids
rectal prolapse
GORD
Distal intestinal obstruction syndrome
Cirrhosis
```
97
long term complications of CF on the GI
bowel obstruction
bleeding disorders
adhesions
98
Impact of CF on reproductive system
congenital absence of vas deferens
poor motility
thickened cervical mucus
99
Management of acute asthma
1. bronchodilators
2. Ipratropium
3. steroids
4. IV salbutamol if not responding to inhaled
5. IV aminophyliine
6. IV magnesium
100
Why is salbutamol therapy not indicated in bronchiolitis
No beta adreno 2 receptors at a young age.
101
Common causes of chronic cough
- pertussis
- TB
- asthma
- post-nasal drip
- GORD
- environmental agents - smoke/pets
