Respiratory Disorders Flashcards

Question

What are the different types of otitis externa?

Answer 1

* Localised * Acute * Chronic * Malignant

Answer 2

• **Localised otitis externa:** o Analgesia and local heat application using warm flannel. Often sufficient as folliculitis tends to be mild and self-limiting o Oral antibiotics: rarely indicated * Furunculosis or cellulitis spreading beyond ear canal * Systemic infection, e.g. fever * Diabetes mellitus or immunocompromised o Referral for pus incision and drainage: rarely indicated

Answer 3

• **Acute otitis externa: \<3 months** o Ibuprofen/paracetamol can be used for pain management. If severe pain and \>12yo, then can use codeine with the paracetamol o Antibacterial ear drops: ciprofloxacin and dexamethasoneotic (0.3%/0.1%) 2x day for 7-14 days * Ear needs to be cleaned of wax first and may need a wick to deliver the drops if the ear is too swollen o **Oral flucloxacillin OR clarithromycin (penicillin allergic):** rarely indicated * Cellulitis extending beyond external ear canal * Ear canal occluded by swelling and debris, inhibiting wick insertion * Diabetes or immunocompromised, or high risk of severe infection, e.g. Pseudomonas

Answer 4

• **Chronic otitis externa: \>3 months** o Avoidance of triggers, e.g.swimming, scratching, aggressive cleaning o If **fungal** infection suspected: * **Mild-moderate:** * Clotrimazole 1% solution * Acetic acid 2% spray * Clioquinol and corticosteroid (e.g. Locorten-Vioform) o **Cause evident:** * Allergic dermatitis: topical corticosteroid * Seborrhoeic dermatitis: antifungal/corticosteroid combination o **No cause evident:** 7-day topical preparation containing only corticosteroid and no antibiotic. Consider co-prescribing acetic acid spray.

Answer 5

Urgent admission

Answer 6

Intense swelling of the epiglottis and surrounding tissues associated with septicaemia

Answer 7

Life-threatening emergency due to high risk of respiratory obstruction

Answer 8

Cause: **Haemophilus influenzae type b (Hib)** o The introduction of the Hib vaccine has massively reduced the incidence of acute epiglottis

Answer 9

Pathophysiology o Inflammatory pathways lead to localised oedema of the airway, exponentially increasing airway resistance while narrowing the effective supraglottic aperture o The glottis is usually not inflamed as process affects the supraglottic structures

Answer 10

VERY acute o High fever is a very ill, toxic-looking child o An intensely painful throat that prevents the child from speaking or swallowing; saliva drools down chin o Soft inspiratory stridor and rapidly increasing respiratory difficulty over hours o Child sitting immobile, upright, with an open mouth to optimise the airway (tripod positioning) o Irritability It is important to clinically distinguish between epiglottis and croup as they require different treatment

Answer 11

* Lying the child down, examining the throat with a spatula or performing a lateral neck X-ray should be AVOIDED because it can precipitate total airway obstruction * o Note: on lateral neck X-ray would see markedly enlarged epiglottis (‘thumbprint sign’) but this is not usually done unless capable of securing the airway with proper equipment available during the Xray * If epiglottis is suspected, urgent hospital admission and treatment are required * Laryngoscopy

Answer 12

If acute epiglottitis is suspected, urgent hospital admission to intensive care unit and treatment are required Secure the airway (usually requires **intubation**) and give supplemental oxygen Take a blood culture Start IV 2nd or 3rd generation cephalosporins (e.g. **ceftriaxone**) for 7-10 days In some patients, steroids and adrenaline may be used to reduce inflammation In severe cases, prolonged intubation may be necessary With appropriate treatment, most children will recover completely within 2-3 days Once stable and extubated, give oral co-amoxiclav **Rifampicin** prophylaxis to close contacts

Answer 13

Pharyngitis inflammation of the pharynx and soft palate with variably enlarged and tender local lymph nodes.

Answer 14

Tonsillitis is a form of pharyngitis causing intense inflammation of the tonsils, often with a purulent exudate.

Answer 15

o Usually due to **viral infection**→mainly adenoviruses, enteroviruses and rhinoviruses o In older children, **group A beta-haemolytic streptococcus** is common (strep throat) ▪ Accounts for 15-20% of pharyngitis in children aged 5-15 years ▪ Peaks during winter and early spring ▪ More common in school aged children

Answer 16

May be caused by group A beta-haemolytic streptococci and Epstein–Barr virus (infectious mononucleosis or glandular fever) Group A beta-haemolytic can be cultured from many tonsils but it is uncertain why it causes recurrent tonsillitis in some children but not in others

Answer 17

o Pain on swallowing o Fever o Tonsillar exudate * Particularly seen in Group A beta-haemolytic Streptococci * BUT, in reality, it is difficult to distinguish clinically between bacterial and viral tonsillitis (can also be seen in adenovirus) * However, marked constitutional disturbance (e.g. headache, apathy, abdominal pain, white tonsillar exudate and cervical lymphadenopathy) is more common with bacterial infection o Other symptoms o Headache o Sore throat o Abdominal pain o Nausea and vomiting o Rash (Scarlet fever)

Answer 18

o Throat culture o Rapid streptococcal antigen test – to identify GABHS Should be ordered in children over 3 years old with high probability of GABHS as assessed by at least 3 Centor criteria If RADT negative, follow up with throat culture criteria Score of 4: treat Score of 3: consider treatment Score of 2: rapid test/culture Score of 0-1: very low chance of Strep being cause

Answer 19

* Consider Admission * Antibiotics * Advice

Answer 20

o Difficulty breathing o Clinical dehydration o Peri-tonsillar abscess or cellulitis o Signs of marked systemic illness or sepsis o A suspected rare cause (e.g.Kawasaki disease, diphtheria)

Answer 21

**Antibiotics** * Given if either * Group A Streptococcus has been confirmed: **Immediate** or **back-up** * **FeverPAIN score** (4 or 5) or **Centor score** (3 or 4) * Throat cultures * Rapid antigen testing * Person is experiencing severe symptoms, systemically very unwell, or high risk of complications: **immediate** prescription indicated * **Phenoxymethylpenicillin** * Given for 5 to 10 days * Clarithromycin - If penicillin allergy * Avoid amoxicillin because it may cause a widespread maculopapular rash if the onsillitis is due to infectious mononucleosis

Answer 22

o Adequate fluid intake o Paracetamol or ibuprofen when necessary o Salt water gargling, lozenges or anaesthetic sprays (e.g. Difflam) may provide temporary relief of throat pain o Children can return to school after fever has resolved and they are no longer feeling unwell and/or after taking antibiotics for 24 hours o Patients with recurrent tonsillitis may require referral to ENT for **tonsillectomy.**

Answer 23

Scarlet Fever

Answer 24

Laryngitis is an inflammation of your voice box (larynx) from overuse, irritation or infection.

Answer 25

Laryngitis may be short-lived (acute) or long lasting (chronic). Most cases of laryngitis are temporary and improve after the underlying cause gets better. Causes of acute laryngitis include: * Viral infections similar to those that cause a cold * Vocal strain, caused by yelling or overusing your voice * Bacterial infections, although these are less common

Answer 26

* Hoarseness * Weak voice or voice loss * Tickling sensation and rawness in your throat * Sore throat * Dry throat * Dry cough

Answer 27

Laryngitis that lasts longer than three weeks is known as chronic laryngitis. This type of laryngitis is generally caused by exposure to irritants over time. Chronic laryngitis can cause vocal cord strain and injuries or growths on the vocal cords (polyps or nodules). Chronic laryngitis can be caused by: * Inhaled irritants, such as chemical fumes, allergens or smoke * Acid reflux, also called gastroesophageal reflux disease (GERD) * Chronic sinusitis * Excessive alcohol use * Habitual overuse of your voice (such as in singers or cheerleaders) * Smoking Less common causes of chronic laryngitis include: * Bacterial or fungal infections * Infections with certain parasites

Answer 28

Clinical diagnosis If suspect something serious could refer to ENT Laryngoscopy Biopsy

Answer 29

In terms of airway compromise

Answer 30

* If there is airway compromise: * Secure airway–emergency tracheostomy may be required * If patient doesn’t have diphtheria then can give: * Dexamethasone sodium phosphate: to reduce oedema * **Cefalozin** AND **cefalexin:** administered IV to start and then changed to oral antibiotics * If patient has diphtheria: * Patient needs to be isolated * Benzylpenicillin sodium IV/IM for 14d * Diphtheria antitoxin

Answer 31

* If there is no airway compromise: * Viral: * Analgesia as required: paracetamol * Vocal hygiene: voice rest for 3-7d, increase hydration, humidification, decreased caffeine intake * Mucolytic can be given to help lubricate the vocal folds * Bacterial: * Phenoxymethylpenicillin for 14d * Analgesia as required: paracetamol * Vocal hygiene: voice rest for 3-7d, increase hydration, humidification, decreased caffeine intake * Mucolytic can be given to help lubricate the vocal folds

Answer 32

A highly contagious upper respiratory infection caused by **Bordatella pertussis**

Answer 33

o Pneumonia o Seizures o Bronchiectasis B pertussis infection can cause a primary pertussis pneumonia with subsequent respiratory failure and death

Answer 34

Transmission of disease occurs through direct contact with droplet discharges from respiratory mucous membranes of infected people Highly contagious

Answer 35

o Stage 1: **catarrhal stage** ▪ 1-2 weeks ▪ Rhinorrhoea, sneezing, low-grade fever, mild occasional cough o Stage 2: **paroxysmal stage** ▪ 1-6 weeks ▪ Cough gradually becomes more severe ▪ Bursts of coughing increase in frequency, then remain constant and then gradually decrease in frequency ▪ Most diagnoses are made during this stage o Stage 3: **convalescent stage** ▪ Recovery stage ▪ Cough becomes less paroxysmal and usually disappears over 2-3weeks

Answer 36

* A week of coryza (catarrhal phase) * Followed by the development of a characteristic paroxysmal or spasmodic cough followed by a characteristic inspiratory whoop (paroxysmal phase) * Spasms of cough are often worse at night and may cause vomiting * During the paroxysm, the child goes red or blue in the face and mucus flows from the nose and mouth * Note: the whoop _may not be present_ in infants * Nosebleeds and subconjunctival haemorrhages can occur after vigorous coughing * The paroxysmal phase can last up to 3 months * The symptoms will eventually decrease (convalescent phase) * Note: infants and young children suffering severe spasms of cough or cyanotic attacks should be admitted and isolated from other children

Answer 37

* Organism can be identified from culture of a _perinasal swab_ or nasopharyngeal aspirate * PCR of nasopharyngeal aspirate - more sensitive * Serology * FBC * There is marked lymphocytosis

Answer 38

1. Think about admitting 2. Notify HPU 3. Pharmacological Treatment 4. Advice 5. Think about close contacts

Answer 39

o \< 6 months old or acutely unwell o Significant breathing difficulties (e.g. apnoea, severe paroxysms, cyanosis) o Significant complications (e.g. seizures, pneumonia) ▪ NOTE: inform the hospital about need to isolate

Answer 40

If admission is NOT needed, _prescribe an antibiotic_ if the onset of the cough is _within 21 days_ (MACROLIDE antibiotic is first-line) o \< 1 month = **clarithromycin** o 1+ months/non-pregnant adult = **azithromycin** o Pregnant adult = **erythromycin** ▪ Recommended from 36 weeks gestation to reduce the risk of transmission to the newborn o NOTE: co-trimoxazole can be used if macrolides are contra-indicated or not tolerated (however, this is not allowed in pregnant adults or babies \< 6 weeks old)

Answer 41

o Rest, adequate fluid intake and the use of paracetamol or ibuprofen for symptomatic relief o Inform the parents that, despite antibiotic treatment, the disease is likely to cause a protracted non-infectious cough that may take weeks to resolve o Advise that children should avoid nursery until 48 hours of appropriate antibiotic treatment has been started or until 21 days after the onset of the cough if it was not treated o Once the acute illness has been dealt with, advice parents to complete any outstanding immunisations

Answer 42

Bronchiolitis - winter time

Answer 43

o RESPIRATORY SYNCYTIAL VIRUS is the pathogen in 80% of cases o Others: parainfluenza, rhinovirus, adenovirus, influenza virus, human metapneumovirus, swine flu (H1N1)

Answer 44

90% of patients are 1-9 months o \>1 years = viral induced wheeze

Answer 45

Infants born prematurely who develop bronchopulmonary dysplasia or with underlying lung disease, such as cystic fibrosis, or have congenital heart disease are more at risk from severe bronchiolitis

Answer 46

The virus infects the respiratory epithelial cells of the small airways→necrosis, inflammation, oedema, mucus secretion Cellular destruction + inflammation→obstruction of small airways Re-growth of epithelial cell layer does not occur until ~2w after infection with complete recovery requiring 4-8 weeks

Answer 47

Coryzal symptoms followed by dry cough and increasing breathlessness **Feeding difficulty** associated with increasing dyspnoea **Recurrent apnoea (serious complication)** Peaks day 5, lasts 10-14 days Characteristic finding on examination o Dry wheeze cough o Tachypnoea and tachycardia o Subcostal and intercostal recession o Hyperinflation of the chest ▪ Can cause palpable liver edge * *o Fine end-inspiratory crackles** * *o High-pitched wheeze: expiratory \> inspiratory**

Answer 48

Pulse oximetry – should be performed on all children with suspected bronchiolitis Naso-pharyngeal aspirate: will show the virus CXR or blood gases ONLY recommended if respiratory failure is suspected

Answer 49

o Apnoea o Persistent oxygen saturation of \<92% on air o Severe respiratory distress ▪ Grunting ▪ Marked chest recession ▪ RR \> 70 breaths/min

Answer 50

o Respiratoryrate\>60/min o Difficulty with breastfeeding or inadequate oral fluid intake (50 75% of usual volume) o Clinical dehydration

Answer 51

Consider admission * **Humidified oxygen -** If saturation is persistently **\< 92%** * **Fluids -** * By nasogastric/orogastric tube if they cannot take enough fluid by mouth * Give IV fluids if cannot tolerate nasogastric or orogastric fluids or have impending respiratory failure * **CPAP -** If impending respiratory failure → if still hypoxic → Heated, humidified, high flow nasal cannula oxygen (HHFNCO) * **Upper airway suction** * Do not perform routinely * Perform if upper airway secretions are causing respiratory distress or feeding difficulties

Answer 52

o RSV is highly infectious, so infection control measures are needed to prevent cross-infection o Most infants will recover within **2 weeks** o RARELY, the illness may cause permanent damage to the airways (bronchiolitis obliterans)

Answer 53

o **Infection control measures** are required in the ward the patient is placed as RSV is highly infectious o **Palivizumab** (monoclonal antibody against RSV) reduces the number of hospital admissions in high-risk preterm infants

Answer 54

LARYNGOTRACHEOBRONCHITIS

Answer 55

It is a common respiratory disease of the childhood Viral croup accounts for over 95% of laryngotracheal infections Viral causes o PARAINFLUENZA viruses are the most common cause o Rhinovirus o RSV o Influenza

Answer 56

Typically occurs from 6 months to 6 years of age, but peak incidence is _2nd yr of life_ Most common in autumn

Answer 57

The symptoms result from upper airway obstruction due to generalised inflammation and oedema of the airways The narrowed subglottic region is responsible for the seal-like barky cough, stridor (due to increased airflow turbulence), and sternal/intercostal indrawing If obstruction worsens, can lead to respiratory failure→leading to asynchronous chest and abdominal wall motion, fatigue, hypoxia and hypercarbia

Answer 58

• Typical features are coryza and fever followed by: HSBC o _Hoarseness_ – due to inflammation of the vocal cords o **A barking cough, like a sea lion** – due to tracheal oedema and collapse o Harsh stridor o Variable degree of difficulty breathing with chest retraction ▪ The degree of subcostal, intercostal and sternal recession is a more useful indicator of severity of upper airways obstruction than the RR o Symptoms often start, and are worse at night o Agitation can cause worsening of symptoms – so important to ensure comfort when examining • If upper airway obstruction is mild, then the stridor and chest recession will disappear when the child is at rest so can be managed at home o Decision to manage at _home or hospital depends on illness severity_, age of child (**\<12 months low threshold for admission**), time of day, ease of access to hospital, and _parental understanding and confidence about the disorder_

Answer 59

Croup is largely a clinical diagnosis – history and exam

Answer 60

* CATEGORISE severity * Consider admission * For all severitiies * Mid croup * Moderate * Severe

Answer 61

Impending respiratory failure - * increasing upper airway obstruction * sternal/intercostal recession * asynchronous chest wall and abdominal movement * fatigue * pallor/cyanosis * reduced consciousness * respiratory rate \> 70 breaths per minute

Answer 62

o **Oral dexamethasone** (0.15 mg/kg) If oral medication not possible: * Inhaled beclomethasone (2mg) * IM dexamethasone (0.6 mg/kg) If returns with mild stridor but otherwise well – can repeat dexamethasone

Answer 63

o Hospital admission not required o ADVICE * Croup normally resolves after 48 hours ▪ Paracetamol or ibuprofen can be used if the child has a fever and is distressed ▪ Advise good fluid intake ▪ Advise parents to check the child regularly during the night o **Safety net**: * Advise to take child to hospital if continuous stridor heard or skin between ribs pulling in with every breath * Advise to call an ambulance if child is: * Very pale, blue, or grey (includes blue lips) for more than a few seconds * Unusually sleepy or is not responding * Having a lot of trouble breathing * Upset (agitated or restless) while struggling to breathe and cannot be calmed down quickly * Unable to talk, are drooling, or having trouble swallowing

Answer 64

While awaiting admission o Give controlled supplementary oxygen if severe/impending respiratory failure o Give dose of oral dexamethasone→if too unwell, give inhaled beclomethasone (2mg nebulised as single dose) or IM dexamethasone (0.6mg/kg single dose) • SEVERE upper airways obstruction: o **Nebulised adrenaline with oxygen by face mask** **(1 in 1000 (1 mg/ml))** ▪ Causes rapid but transient improvement o Children should be closely monitored for 2-3hrs

Answer 65

14% children in the UK - most common chronic respiratory disorder in childhood

Answer 66

* Incidence increasing worldwide over the last 40 yrs → has now plateaud * Important cause of school absence, restricted activity and anxiety for the child and family * 20 deaths/yr in the UK

Answer 67

o Viral episodic wheeze: wheeze only in response to viral infections o Multiple trigger wheeze: wheeze in response to multiple triggers and is morelikely to develop into asthma over time o Asthma

Answer 68

* Asthma should be suspected in any child with wheezing on more than one occasion, especially if there are interval symptoms. * More common in those with personal or family history of atopy * Ask about wheeze, but wheeze presence is confirmed on auscultation to distinguish it from transmitted upper respiratory noises which are often loud and easy to hear in child. * On auscultation, an asthmatic wheeze is a polyphonic noise coming from the airways [occurs due to presence of many airways of different sizes vibrating from abnormal narrowing] * Examination of chest is usually normal between attacks * Long-standing asthma may cause hyperinflation of the chest and generalised polyphonic expiratory wheeze with a prolonged expiratory phase * Onset of the disease in early childhood can result in Harrison sulci * Check for evidence of eczema and allergic rhinitis

Answer 69

• If \< 5 years old: diagnosis is clinical (hx, ex, response to tx) o Treat symptoms based on clinical observation o Review child regularly o If symptoms present even at age 5, carry out objective tests Can do a skin prick test

Answer 70

* If \> 5 years old * Offer lung function tests (spirometry) * **FEV1/FVC\<70%** of expected or below lower limit of normal is a positive result for obstructive airway disease * Involves measurement of FEV1 (best of 3) * Consider bronchodilator reversibility test if FEV1/FVC \<70% * Improvement in **FEV1 of \>12% after beta2-agonist** is considered positive * Consider FeNo testing (fractional exhaled nitrix oxide) if diagnostic uncertainty and normal spirometry OR obstructive spirometry with negative bronchodilator reversibility test * This tests for airway inflammation * A level **\> 35 ppb** is considered a positive test * Consider peak expiratory flow variability, if diagnostic uncertainty after initial assessment and a FeNo test (normal spirometry OR obstructive spirometry, negative BDR and FeNo \>35ppb) * For 2-4 weeks * **\>20% variability** in diurnal peak flow measurements is positive * Less sensitive to changes in airway calibre than spirometry but is portable and hence helpful for serial measurements * Poorly controlled asthma leads to inc peak flow variability, inc diurnal variation and day-to-day variation * Evidence of atopy→Skin prick testing for common allergens may be performed – helps identify triggers and demonstrate atopy * Positive skin o Blood eosinophilia \> 4% o Raised allergen specific IgE o These tests are NOT part of asthma diagnostic tests but may be done after formal asthma diagnosis has been made

Answer 71

o Assess patient's baseline asthma status (can be done using Asthma Control Questionnaire or a lung function test (e.g. spirometry)) o Provide self-management education and a personalised asthma action plan (available from Asthma UK) o Ensure child is up to date with routine immunisations o Provide information about sources of support (Asthma UK) o Advise about trigger avoidance (specific allergens, smoke, beta-blockers, NSAIDs) ▪ NOTE: parents should be advised to stop smoking o Assess for the presence of anxiety and depression o Ensure that the patient has their own peak flow meter o Explain how to use inhalers with spacer o Arrange follow up 6 weeks after diagnosis to check symptoms

Answer 72

o Confirmadherencetomedication o Reviewinhalertechnique o Reviewiftreatmentneedstobechanged o Askaboutoccupationalasthmaandtriggers

Answer 73

* Maternal smoking during or after pregnancy * Prematurity * Male sex * FH of allergy

Answer 74

**Important**: do not diagnose these patients with asthma as many preschool children will grow out of their illness by the age of 6 and a diagnosis of asthma can affect a person’s future employment e.g. airline pilots, commercial drivers, armed forces, police will require normal pulmonary function tests Management settings most commonly home or hospital. * 1st line: **salbutamol** * **Burst Therapy** is often used for viral-induced wheeze * The child is given 10 puffs of salbutamol using a high-volume space. Give a puff every 30-60s * They are then assessed for a response to treatment * Repeat every 10-20 minutes * If they can last 4 hours without the symptoms reappearing, they can be discharged * They will be given a **salbutamol weaning regime** for the salbutamol inhaler with a spacer. * Use inhaler as required at home in further episodes of VIW * Escalate treatment as per ‘Acute asthma’ section * If mild intermittent wheeze and respiratory symptoms that only occur with viral URTI, consider not giving maintenance treatment but planning a review in an agreed time interval. * Encourage parents who are smokers to stop * **Follow-up** required **within 48h of presentation** if not admitted to hospital, or **2 working days of discharge**.

Answer 75

Children require hospital admission if, after high- dose inhaled bronchodilator therapy, they: o Have not responded adequately clinically i.e. persisting breathlessness, tachypnoea o Are becoming exhausted o Still have a marked reduction in their predicted peak flow rate or FEV1 (\<50%) o Have a reduced oxygen saturation (\<92% on air)

Respiratory Disorders Flashcards

(116 cards)