Respiratory Flashcards
(108 cards)
1
Q
Define Apnoea
A
Cessation of respiratory airflow
Note: short breathing pauses of 5-10 seconds are normal and common in preterms
2
Q
Define Apnoea of Prematurity
A
Cessation of breathing for >20 seconds, or <20 seconds with a drop in SpO2 and bradycardia
3
Q
Give 3 causes of Apnoea of Prematurity
A
Immaturity of breathing responses to changes in O2 and CO2
Collapse of airways due to poor tone
Nasal Obstruction (neonates are obligate nasal breathers)
4
Q
Define OSA and give some causes
A
Snoring associated with periods of ineffective breathing
Adenotonsillar Hypertrophy, Obesity, Macroglossia, Micrognathia
5
Q
How might OSA present in a child?
A
Snoring and sleep disturbance
Daytime sleepiness
Enuresis
6
Q
How would you investigate and manage OSA?
A
Ix - Sleep Study, CXR, EEG
Mx - CPAP, ?Weight Loss, ?Adenotonsillectomy
7
Q
What is Expiratory Apnoea Syncope? (AKA Blue Breath Holding Spells)
A
Precipitated by anger/crying
Cannot catch breath (stuck in expiration)
Goes blue, stiff then limp with rapid recovery
8
Q
Name three investigations for Apnoea
A
Lumbar Puncture
CXR
Bloods (U&Es, Glucose, Culture)
9
Q
Define Wheeze
A
High pitched musical respiratory sound usually heard on expiration. Associated with airway narrowing and limitations.
10
Q
Give 5 causes of acute wheeze
A
Viral Episodic Wheeze Bronchiolitis/Bronchitis Bacterial tracheitis Foreign Body Aspiration Anaphylaxis
11
Q
Give two structural and two functional causes of chronic wheeze
A
Structural - Tracheobronchomalacia, Tracheal Web
Functional - Asthma, CF
12
Q
How is a Wheeze managed?
A
Treat underlying cause
Beta Agonists and Steroids
Oxygen
13
Q
Define Stridor
A
Harsh respiratory sound produced by turbulent flow in narrow upper airways, affected by severity of narrowing
14
Q
What three associated symptoms with Stridor or should you ask about as a priority?
A
Fever
Drooling (Secure Airway, ENT referral)
Barking Cough (Dexamethasone, Intubate and Admit)
15
Q
Give 5 causes of Acute Stridor
A
Croup (Laryngotracheobronchitis) Epiglottitis Bacterial Tracheitis Peritonsillar Abscess Anaphylaxis
16
Q
Give two congenital causes and two acquired causes of Chronic Stridor
A
Congenital - Laryngomalacia, Subglottic Stenosis
Acquired - Vocal cord paralysis, Tumours
17
Q
In an Acute Stridor or you should avoid looking at the throat until resus equipment is at hand. How else could you assess severity?
A
Only on crying? At rest? Chest Retraction? Cyanosis? Tachypnoea/Tachycardia?
18
Q
Define Cyanosis
A
Bluish/Purplish discolouration of tissues due to increased concentration of deoxygenated haemoglobin in capillary beds
Mostly appreciated in lips/nail beds/mucous membranes
Can be central or peripheral
19
Q
Give three AIRWAY causes of Cyanosis
A
Choanal Atresia
Laryngomalacia
Pierre Robin Syndrome
20
Q
Give three BREATHING causes of Cyanosis
A
Hypoventilation/Apnoea
Pneumonia
Congenital Diaphragmatic Hernia
21
Q
Give three CIRCULATION causes of Cyanosis
A
Anaemia
Methaemaglobinaemia
Cyanotic CHD
22
Q
State five categories of a cough history
A
Onset (Any preceding symptoms) Duration Nature (Dry or Wet) Triggers Associated Sx
23
Q
Give 3 viral causes of Acute Cough
A
URTI (Cold)
Laryngotracheobronchitis
Bronchiolitis
24
Q
Give 2 bacterial causes of Acute Cough
A
Epiglottitis
Bacterial Pneumonia
25
How would an inhaled foreign body appear on a CXR?
The object may be visible on the CXR
Hyperinflation on affected side due to air trapping
26
Give three Pulmonary causes of a chronic cough
Asthma
Post Infectious
CF
27
Give three Extra - Pulmonary causes of a chronic cough
Post Nasal Drip
Cardiac
GORD
28
Define Protracted Bacterial Bronchitis
Chronic Wet Cough as a diagnosis of exclusion
| Resolves with 2-6 weeks of treatment
29
State the boundaries for Tachypnoea in Neonates/Infants/Children/Adolescents
Neonates - >60
Infants - >50
Child - >40
Adolescent - >30
30
State 5 red flags of a Cough
```
Sudden Onset (choking)
Weight Loss
Night Sweats
Cyanosis
Clubbing
```
31
Define Breathlessness
Laboured or increased work of breathing from increased airway resistance, characterised by nasal flaring, grunting, and usage of accessory muscles
32
Give four differentials for breathlessness in a child
Airway obstruction
DKA
Pneumonia
CHD
33
What would point to a Cardiac cause of breathlessness in a child?
Squatting when fatigued
Poor weight gain
Hepatomegaly
Oedema
34
Asthma is the most common chronic condition in children. State the definition
Reversible and paroxysmal constriction of the airways
| Early features include inflammatory exudate, and late features include airway remodelling
35
Asthma is a multifactorial disease in which susceptible individuals have an exaggerated response to various stimuli. Describe the classical pathophysiology.
Driven by TH2 cells which release cytokines resulting in activation of humoral system
Humoral system causes increased proliferation of mast cells/eosinophils/dendritic cells
Leukotrienes cause cytotoxicity and histamine causes exudate production
36
Give four risk factors for Asthma
Genetic (trend of atopy)
Prematurity
Parental Smoking
Early Viral Bronchiolitis
37
There are various triggers that affect Asthma, what effects do NSAIDs have?
Shunts the arachadonic pathway towards leukotriene production which is cytotoxic
38
How could you describe the pattern of wheezing in asthmatic individuals?
Infrequent - discrete episodes lasting a few days with no interval sx
Frequent - occurring 2 to 6 times weekly
Persistent - occurring most days and may occur at night
39
What is Pre- School Wheeze?
50% have at least one significant wheeze by their 5th Birthday
40
Asthma is normally a clinical diagnosis, what are the two main investigations that could be carried out?
Spirometry - if child is over 6, should be normal in between exacerbations if well controlled
PEFR - if over 5y/o
41
What are Bronchial Provocation Tests?
A test used in uncertain cases to assess airway hyper responsiveness to histamine or metacholine
42
How is the Exhaled Nitric Oxide investigation used?
Produced in bronchial epithelial cells, and it’s production is increased with TH2 driven inflammation
Positive result is >35ppb
Note: Also raised in hay fever
43
What investigations could be done to rule out differentials of Asthma?
```
Oesophageal pH
Bronchoscopy
Chlorine Sweat Test
Nasal Brush Biopsy (exclude PCD)
HRCT
```
44
How would you manage Asthma in children under 5 on a day to day basis?
Treat without investigation
Inhalers via Metered Dose Inhaler with spacer
1) SABA as reliever therapy
2) + 8 week trial of ICS
3) + Leukotriene Antagonist (eg Montelukast - beware of behavioural issues)
45
How would you manage Asthma in children 5-16 on a day to day basis?
1) SABA reliever
2) add low dose ICS
3) SABA + ICS + Leukotriene antagonist
4) Stop Leukotriene, start ICS and LABA and SABA
5) MART regimen (Maintenance and Reliever therapy)
6) Higher steroid dose MART regime
7) Increase ICS/Add Theophylline/Oral Steroids/Biologics
46
What are the contents of a Fostair combined inhaler?
Beclametasone
| Formeterol
47
What are the contents of a Seretide combined inhaler?
Fluticasone and Salmeterol
48
What are the contents of a Symbicort combined inhaler?
Budesonide
| Formeterol
49
Describe the features of Mild/Mod Asthma Exacerbation
```
SpO2>92%
Resp Rate under 30(>5) or (<5)
Minimal accessory muscle use
Full Sentences
Wheeze
```
50
Describe the features of Mod/severe Asthma Exacerbation
```
SpO2<92%
PEFR 33-50% predicted
Resp Rate over 30(>5) or 40 (<5)
Incomplete Sentences
Tachycardia
Accessory Muscles and Wheeze
```
51
Describe the features of Life Threatening Asthma Exacerbation
```
SpO2<92%
PEFR <33% predicted
Silent Chest and Poor Resp Effort
Altered consciousness
Cyanosis
```
52
How is an Asthma Exacerbation managed?
1) If O2<94% give O2
2) Nebulised Salbutamol
3) 3d Oral Prednisolone
4) +/- Ipratropium Bromide
Consider IV Salbutamol or MgSO4 if severe
53
What is involved in an Asthma discharge bundle?
```
SpO2>94% on air
Assessed inhaler technique
Four hourly bronchodilators
Written asthma management plan
GP follow up 2d
```
54
Define Bronchiectasis
Abnormal dilation of airways associated with destruction of bronchial tissue. Secondary to an inflammatory response to infection causing structural damage and dilation
55
What are the 5 broad causes of Bronchiectasis?
```
Post Infectious
Immunodeficiency
Primary Ciliary Dyskinesia
Post Obstructive
Congenital
```
56
Give four immunodeficiencies that could result in Bronchiectasis
Hypogammaglobulinaemia
CVID
IgA/IgG specific
Ataxia Telangiectasia
57
Give three of the most common genetic causes of Bronchiectasis
Kartageners (Sinusitis, Bronchiectasis, Situs Inversus)
Young’s (Sinusitis, Bronchiectasis, Infertility)
Yellow Nail Syndrome (Pleural Effusions, Lymphoedema, Dystrophic Nails)
58
Describe the possible CXR findings of Bronchiectasis
Bronchial Wall Thickening
Airway Dilation
Or normal
59
Describe the HRCT findings of Bronchiectasis
Bronchial Wall Thickening
Visible Peripheral Bronchi
Signet Sign
CF - bilateral upper lobe
Post TB - Unilateral upper lobe
60
What tests could you do to determine the underlying cause of Bronchiectasis?
Chloride Sweat Test
Immunoglobulin panel
Ciliary Brush Biopsy
WCC differential
61
How is Bronchiectasis managed?
```
Chest Physio
Exacerbations managed
Vaccinations
Bronchodilators
Regular Follow Ups
```
62
Define Bronchiolitis
Viral infection of the Bronchioles usually caused by RSV
AKA Viral LRTI
63
Describe the pathophysiology of Bronchiolitis
```
Excess Mucous (Goblet Cell Proliferation)
Inflammation (IgE type 1 allergic response)
Bronchiolar Constriction
```
Ball Valve effect resulting in hyperinflation, airway resistance, atelectasis and VQ mismatch
64
Give three risk factors and one protective factor
Smoke Exposure, Siblings Nursery Attendance, Prematurity
Breast Feeding
65
How does a baby with Bronchiolitis present?
Coryzal symptoms for 2-5 days
Poor feeding
OE - Tachypnoea, Grunting, Recessions, Wheeze, Crackles
66
Give three differentials for Bronchiolitis
Pneumonia
Croup
Heart Failure
67
How would you investigate suspected Bronchiolitis
Lab - Nasopharyngeal Aspirate, if pyrexia then blood and urine culture
Imaging - CXR (if diagnostic uncertainty or atypical course)
68
Describe some red flags of Bronchiolitis
RR>60 or Apnoea
Dehydration
Central Cyanosis
O2 Sats <92%
69
The majority of Brinchiolitis cases are managed supportively at home (resolving in 7-10 days), how are they managed as an inpatient?
Oxygen therapy
Fluids (if required)
?CPAP
Secretions - suction
No role for steroids/dilators/antimicrobial
70
Define Croup (AKA Laryngotracheobronchitis) and give two risk factors
Viral Upper Respiratory Tract (commonly parainfluenza) with a peak incidence at 2 years characterised by Stridor, Hoarse Voice and Barking Cough
Male, Autumn/Spring
71
Describe the typical history of a patient with Croup
1-4 day non specific coryza
Progressing to Barking Cough and Hoarseness
Worse at night and associated with fever
72
Describe the typical examination of a patient with Croup
Stridor?
| Respiratory Distress?
73
What is the severity scoring system for Croup and what are the parameters?
Westly Scoring System
Consciousness, Cyanosis, Stridor, Air Entry, Retractions
Mild - <4
Mod - >4
Severe - >6
74
How do you differentiate between Croup and Epiglottitis?
Epiglottitis:
Soft Stridor
More Acute
Drooling
Not necessarily preceded by coryza
75
When would you consider admission for croup?
Previous history of severe airway obstruction
<6 months old
Immunocompromised
Uncertain Diagnosis
76
What advice would you give parents concerning Croup?
Usually resolves within 48 hours but can last up to a week
Antibiotics not appropriate
Paracetamol/Ibuprofen for pain/fever
Safety net
Can give a single dose of Oral Dexamethasone if Mild
77
If inpatient, how is Croup treated?
Steroids
Nebulised Adrenaline
O2 therapy as required
78
How does Cystic Fibrosis affect the lungs?
Reduces airway surface liquid which normally encourages mucous clearance and serves an immunological function
79
How does a Cystic Fibrosis affect the Pancreas?
Normally occluded in pancreas which causes permanent damage to exocrine pancreas rendering pancreatic insufficiency
Overtime Endocrine pancreas becomes affected (CF related Diabetes)
80
How does CF affect GI Tract?
Bowel Obstruction - Meconium Ileus
Cholestasis - Neonatal Jaundice
Dismal Intestinal Obstruction Syndrome
81
How does CF affect Reproductive Tract?
98% of Men are infertile due to congenital absence of Vas Deferens
Pregnancy associated with deterioration in lung health
82
How does CF present in Neonates?
```
Meconium Ileus (distension, bilious vomit)
Failure to Thrive
Prolonged Jaundice
```
83
How does CF present in Infants?
Failure to thrive
Recurrent Chest Infections
Steatorrhoea (Pancreatic Insufficiency)
84
How does CF present in Childhood and Adolescence?
Nasal Polyps, Sinusitis, Pancreatic Insufficiency, Chronic Lung Disease, Gall Stones
85
What might be seen OE of a child with Cystic Fibrosis?
Clubbing
Nasal Polyps
Chest (Hyperinflated, Crepitations, Portocath)
Abdomen (Faecal Mass, Ileostomy scar)
86
How is CF diagnosed?
Fitting Clinical History and Positive Chloride Sweat Test
Chloride Sweat Test - collected by Pilocarpine Iontophoresis, >60mmol/l is suggestive
87
What should be monitored annually in CF patients?
OGTT
LFTs/Coag/Bone Profile
Faecal Elastase
88
How should Airway Clearance in CF be managed?
Twice daily physiotherapy
Mucolytics (DNAse - decreases viscosity by digesting DNA, Hypertonic Saline)
89
How should Nourishment and Exercise in CF be managed?
Exercise should be encouraged
Creon taken before or with meals containing fats
Fat soluble vitamin supplements
Monitor growth and weight (may require build up milkshakes)
90
How should Infection prevention and management in CF be managed?
Prophylactic Abx until age of 3
Infections treated with 14d Abx (even if asymptomatic)
Clinics are split to avoid patient cross contamination
91
How does CF affect non pancreatic endocrine function?
Delays puberty by around 2 years
| Reduces bone mineral density
92
Whooping Cough is a highly infectious notifiable disease caused by Bordetella Pertussis. What is the vaccine schedule against it?
Given at 2,3, and 4 months
Booster at 3 y 4 m
Immunity wanes after 5-10 years
93
Describe the clinical features of Whooping Cough (the three phases)
Catarrhal Phase (Generalised URTI)
Paroxysmal Phase (2-8 weeks of Paroxysms followed by gasp/apnoea)
Convalescent Phase (may last up to three months, gradually decreasing cough)
94
How is Whooping Cough Investigated?
<2 weeks - Nasopharyngeal Aspirate/Swab
>2 weeks - Anti Pertussis IgG Serology
Lymphocytes is
95
How is Whooping Cough managed?
Antibiotics don’t alter clinical course but do alter infectivity so only give in first three weeks (Azithromycin or Clarithromycin first line)
Paracetamol/Ibuprofen/Fluids
Avoid school for three weeks (or 5 days with Abx)
96
When COVID - 19 occurs severely in a child, what is thought to be the cause?
Cytokine Storm Syndrome
97
Describe the features of Paediatric Inflammatory Multisystem Syndrome
Toxic Shock
Atypical Kawasaki
?Covid
98
Give two Bacterial/Viral/Atypical causes of LRTI (encompasses Bronchitis, Bronchiolitis, Pneumonia)
Bacterial - Strep Pneumoniae, H Influenza
Viral - Influenza A, RSV
Atypical - Mycoplasma, Legionella
99
LRTIs present quite typically with grunting and tachypnoea. What are the parameters for Tachypnoea in Children?
0-5 months >60/min
6-12 months >50/min
>12 months >40/min
100
How should Community Acquired LRTIs be managed in Children?
Mild/Mod - Amoxicillin (+/- PO Erythromycin)
Severe - IV Co- Amoxiclav (may add PO Erythromycin for atypical cover)
101
How should Hospital Acquired LRTIs be managed in Children?
Mild/Mod - Co Amoxiclav
Severe - Piperacillin and Tazobactam
102
Obstructive Sleep Apnoea is a spectrum from snoring - upper airway resistance to apnoea. Give three different aetiologies
Adenotonsillar Hypertrophy
Obesity
Neuromuscular Disease
103
How does OSA present?
Snoring
Mouth Breathing
Witnessed Apnoeic Episodes (strangles/quiet breathing followed by gasp)
Poor concentration at school (day time sleepiness less common)
104
How is OSA investigates?
Overnight Polysomnography
Airway Assessment
CT/MRI (structural causes?)
105
Describe the management options for OSA
Medical - CPAP, Weight Loss
Surgical - Adenotonsillectomy, Tracheostomy
Orthodontic - Mandibular advancement
May just outgrow
106
Apart from the normal presentation and Ix of Pneumothorax, what can be done in a child?
Trans illumination of Chest Wall
107
Name a cause of a long standing brassy cough
Airway Malacia
108
Name a cause of an acute brassy cough
Tracheitis
