Respiratory upper airway

Question 1

Common cold

Answer 1

assure is self limiting
2-3d Sx, should resolve within 2w
Rest, fluids, healthy diet
Paracetamol/ibuprofen

Question 2

Sore throat (pharyngitis + tonsillitis)

Answer 2

Ix: temp, throat, swabs
Admit: dib, clinical dehydration, abscess, systemic illness, suspected rare cause (Kawasaki)
admit: only if needing IV fluids
Medical Mx: penicillin V 10d (2L clari)
Advice: fluids, salt water gargle, para/ibu
return to school after fever resolved, feeling well and ABx for 24hrs

Question 3

Sore throat in children on specific drugs to watch out for

Answer 3

DMARDs - IC
Carbimazole can causes neutropenia
take FBC in both cases

Question 4

When to offer medical Mx of sore throat in children

Answer 4

After confirming bacterial tonsillitis on RSAT

Question 5

DO NOT prescribe for sore throat

Answer 5

amoxicillin (maculopapular rash if EBV infection)

Question 6

PACES of sore throat

Answer 6

tonsillitis/pharyngitis is an inflammation of the upper airway/back of the mouth
need to take for 10d to totally eradicate organism
Avoid school until 24hr after Abx starting and child feels well
para/ibu, lozenges, gargling, diffllam

Question 7

Scarlet Fever

Answer 7

notify HPT
ABx: pen V qds 10d (2L azithromycin), stay away from school for 24hrs after starting
P/I for analgesia/temp
Should settle in 1w
Rx for 10d to avoid acute glomerulonephritis and rheumatic fever

Question 8

Cx of scarlet fever

Answer 8

Suppurative: otitis media, throat abscess, sinusitis, strep. pneumonia, meningitis, endocarditis, NF, TSS
non-suppurative (autoimmune): rheumatic fever, strep glomerulonephriti

Question 9

Acute otitis media

Answer 9

Ix: temp, otoscopy
Admit: systemic inf., Cx (meningitis/facial nerve palsy), <3m w temp>38C
Advice: 3d-1w, P/I for pain, no evidence for antihistamines/decongestants
?medical management

Question 10

acute otitis media Mx

Answer 10

1. No abx: most cases will self resolve, seek help if no improvement in 3d
2. Back up Abx prescription: abx not needed immediately but if no improvement after 3d then use
3. Immediate abx: seek help if deterioration
   Amox 5-7d (clari2L)
   Abx marginally reduce pain but no effect on hearing loss

Question 11

Recurrent otitis media can lead to

Answer 11

Glue ear (otitis media w/effusion)
Often asymptomatic except for possible reduced hearing
Eardrum dull and retracted. ?visible fluid level
2-7 most common
usually resolves spontaneously
Cx: conductive hearing loss impacting SAL
- offer grommets (benefits do NOT last longer than 12m
IF recurrence after grommet removal reinsert + adenoidectomy

Question 12

Sinusitis in children <10d Sx

Answer 12

Refer: systemic infection, intra/periorbital Sx (cellulitis, displaced eyeball, double vision), intracranial Cx
<10 d Sx: NOT ABx
- explain is usually viral (2% Cx by bacterial infection)
- P/I
- nasal saline/decongestants an option
- seek help in 3wks or if systemically unwell

Question 13

sinusitis in children >10d Sx

Answer 13

consider high dose IN CS 14d if >12yo (mometaosone) unlikely to alter Dx course, may help with Sx but carry SE

consider No or back-up Abx prescription (use after 7d or worsening Sx)
1L: Pen V (if allergic clari), L: co-amox

Question 14

Croup in children Ix

Answer 14

do NOT I examine throat as can worsen dib
Westley score:
- chest wall retraction, stridor, cyanosis, LOC, air entry
max score 17
Mod: 3-5
Sev: 6-11
Impending resp failure: 12
NB. 75% is caused by para-influenza

Question 15

Croup severity

Answer 15

Mild: barking cough but NO stridor or recession at rest
Moderate: barking cough w/stridor and sternal recession at rest, NO agitation/lethargy
Severe: barking cough w/stridor and sternal/IC recession a/w agitation or lethargy
Impeding resp failure: increasing obstruction, recessions, chest wall asynchrony and abdominal breathing, fatigue, pallor/cyanosis. reduced LOC, RR >70
ADMIT ALL WORSE THAN MILD

Question 16

Not admitted for Croup Mx

Answer 16

single stat dose oral dex (0.15mg/kg)

alternative: PO pred, inhaled beclometasone

Question 17

Croup causing recession at rest

Answer 17

PO dex, pred or neb. steroids

Question 18

Severe upper airway obstruction in croup Mx

Answer 18

neb. adrenaline w/oxygen will cause rapid but transient improvement
monitor closely

Question 19

Summary of Croup Mx

Answer 19

stat PO dex (0.15mg/kg) for ALL children
repeat at 12h if necessary
Pred an alternative
Emergency Mx:
- high flow O2
- neb. adrenaline

Question 20

PACES counselling of croup

Answer 20

Dx: infection of airways, common, viral. Will improve over 48hrs and steroids will help reduce inflammation
If worse come back
If blue/pale/red. LOC call ambulance
P/I if distressed
Fluids
Check on child at night when cough is worse

Question 21

Acute epiglottitis

Answer 21

suspected -> URGENT hospital admission and Mx required
ICU (secure airway (if sev. ETT) and give supplemental O2)
Blood culture
IV cefriaxone
consider steroids/adrenaline
recovery 2-3days
Prophylactic rifampicin to household contacts

Question 22

Bronchiolitis in children when to call 999

Answer 22

Apnoea
Seriously unwell
Resp distress (grunting, RR >70)
Central cyanosis
persistent <92% stats OA

Question 23

bronchiolitis consider referral

Answer 23

RR >60
<75% usual fluid intake
clinical dehydration`

Question 24

Ix in bronchiolitis

Answer 24

Clinical Dx
SaO2
Nasopharyngeal aspirate for RSV (ELISA/RT-PCR)
consider CXR

Question 25

Mx bronchiolitis

Answer 25

Humidified o2 supplmentation if sats persistently below 92% CPAP if impending resp failure Upper airway suction if secretions (definitely perform if apnoea) Fluids by NG tube Supportive RSV highly infectious so infection control

Question 26

Recovery from bronchiolitis

Answer 26

mostly within 2wks | RARELY causes lasting damage (bronchiolitis obliterans)

Question 27

Bronchiolitis prevention

Answer 27

palivizumab (mAb) reduces no. admission in high risk preterm infants

Question 28

PACES counselling of bronchiolitis

Answer 28

Dx: viral infection of lungs, affects 1:3 children <1y Should resolve within 2wks P/I, fluids RF: apnoea, distress should prompt visiting dr

Question 29

Viral Episodic Wheeze

Answer 29

Ix: clinical Mx: salbutamol inhaler, encourage stopping smoking

Question 30

Instructions for using inhaler

Answer 30

expiry date shake it insert into end of spacer administer 1 puff into spacer Child breathes slowly and deeply for 5-10 breaths (10 if <2) NB if spacer is whistling means breathing too quickly Clean spacer once per month using soapy water

Question 31

Dosing of salbutamol in VEW

Answer 31

when wheezy/sob give them up to 10 puffs of salbutamol w/spacer every 4hrs

Question 32

Safety net in VEW

Answer 32

If not responding or improving after 10 puffs or if needing it again seek help If they continue to be wheezy 48hrs after discharge come back If experiencing Sx between viral illnesses they are increased risk of asthma

Question 33

If salbutamol ineffective in VEW?

Answer 33

intermittent LTRA, intermittent ICS

Question 34

What is burst therapy

Answer 34

in viral induced wheeze 10 puffs of salbutamol w/spacer Assessed for response to treatment If they can last 4hrs w/o Sx returning they can be d/c Given a weaning regime for salbutamol inhaler w/spacer

Question 35

Summary of VEW

Answer 35

``` Mx is symptomatic 1L: SABA or anticholinergic via spacer 2L: Intermittent LRTA/ICS/both no need for PO pred multiple trigger wheeze: trial of ICS or LRTA for 4-8wks ```

Question 36

PACES counselling of VEW

Answer 36

Dx: narrowing of airways due to viral infection in chest causes sound Mx: inhaled medicine will open the airways, 4hr monitoring and ?d/c, D/c: salbutamol w/spacer: - 10 puffs through spacer max every 4hrs - If no response after 10 seek help - if Sx 48hrs after d/c seek help

Question 37

Whooping Cough Ix

Answer 37

``` Notify HPU Culture NP aspirate PCR NP aspirate Serology useful in later stages FBC Admit: <6mo or acutely unwell Significant breathing difficulties Cx like seizure, pneumonia ISOLATE ```

Question 38

Pharm Mx of whooping cough

Answer 38

If admission NOT needed: Abx if onset of cough is within 21: (macrolide) - <1m = clari - >1m+nonpregnant = azithromycin - pregnant = erythromycin (recommended from 36w to reduce transmission) Co-amox used if macrolides CI (not in pregnany adults or babies <6w)

Question 39

Advice in whooping cough

Answer 39

Rest, fluids, P/I Despite Abx pts are likely to cause non infectious cough that may take weeks to resolve Avoid school until 48hrs after Abx started or 21d after cough onset if no Abx Once acute illness dealt with advise immunisations close contacts should receive macrolide proph.

Question 40

Summary of whooping cough

Answer 40

Ix: culture/PCR for B pertussis, serology Admit: <6m, unwell HPU Oral macrolide if cough <21d Contact prophylaxis avoid school for 48hrs after commencing abx

Question 41

PACES of whooping cough

Answer 41

Dx: cough that may last for a few weeks, will become non-infectious if Abx Rarely seen, imms. concern? Can become reinfected despite prev. infection Abx will treat but cough likely to persist Exclusion until 48hrs after Abx

Question 42

Foreign body inhalation Ix

Answer 42

CXR

Question 43

Foreign body inhalation - conscious

Answer 43

``` coughing external manoeuvres: - back blows x5 - abdo thrusts x5 (not infants) removal of FB: - (1L) rigid/flexible bronchoscopy (rigid bronchoscopy if stridor, asphyxia, object on CXR, Hx of FBI a/w unilateral dec. breath sounds, localising wheeze, obstructive hyper-inflation or atelectasis) done with conscious sedation or GA (2L) - surgery, thoracotomy ```

Question 44

Foreign body inhalation - unconscious

Answer 44

Secure airway immediately unless body can be seen and removed from UA remove FB as you would fot conscious