Wheeze and coughs

Question 1

Cough

Answer 1

“A forced expulsive manoeuvre, usually against a closed glottis with a characteristic sound”
Chronic = daily cough for over 8 weeks
Recurrent = cough for >2wks more than twice yearly

Question 2

Wheeze

Answer 2

A polyphonic expiratory, high pitched whistling sound due to lower large airway obstruction

Question 3

Causes of Cough without wheeze

Answer 3

URTI - most commonly viral - most common cause (10% of young children) - unrelated to colds and without wheeze
can also be caused by TB or Sinusitis

Question 4

Causes of Wheeze without cough

Answer 4

Viral induced wheeze

Mediastinal mass or cancer

Question 5

Causes of both cough and wheeze

Answer 5

Cystic fibrosis Asthma
Bronchiolitis Pneumonia
Croup GORD

Question 6

Features of asthmatic wheeze (4,4)

Answer 6

Multi-trigger wheeze - Diurnal variation (nocturnal), exertion, cold air, viral illness
Atopy –> Food allergies, eczema, rhinitis and FH

Question 7

Features of a viral wheeze

Answer 7

Viral illness prodrome –> develops into wheeze

If under 1yr may be bronchiolitis, if older viral induced wheeze

Question 8

Risk factors for cough and wheeze

Answer 8

Parental Smoking – biggest single factor - 50% of children <11yrs when both parents smoke
Dampness in home, air pollution, SE status
Allergic responses - house dust mites, pollen, cats or dogs

Question 9

Asthma treatment ladder for children under 5yrs

Answer 9

Step 1 - Inhaled short acting Beta-2 agonists PRN (salbutamol)
Step 2 - Add inhaled steroids 200-400mcg/day
Step 3 - Add leukotriene R antagonist to steroid or visa versa
Step 4 - Refer to resp paediatrician (if <2yrs consider skipping stage 3)

Question 10

Complications of viral respiratory Illness

Answer 10

Tonsilitis - painful to swallow leading to dehydration
Obstructive sleep apnoea
Middle ear infection/effusion
Hearing loss and Glue ear

Question 11

GORD

Answer 11

Commonest in infants and the overweight - occurs after meals and when lying down - sandifer’s syndrome, feeling of ‘globus’ in the throat
Complications –> feeding aversion and strictures

Question 12

Sandifer’s syndrome

Answer 12

A combination of GORD and neurological movement disorder (spasmodic torticolis, dystonia and hypotonia)
Treatment of the reflux generally leads to remission of symptoms

Question 13

Tuberculosis in children

Answer 13

Lymph nodes obstruct airways - cause cough
Night sweats and weight loss —> haemophtysis is unlikely in children
Check travel and family history

Question 14

Cystic fibrosis

Answer 14

Chronic moist cough with phlegm - systemic signs and history
Should now be screen when neonate
Associated with Mec ileus, recurrent chest infections, malabsorption (steatorrhoea, FTT), liver disease. Also: short, DM, delayed puberty, rectal prolapse, nasal polyps, infertility (male) or subfertility (female).

Question 15

Aspirated foreign body

Answer 15

Especially in younger children

Sudden onset cough or wheeze

Question 16

Mediastinal causes of wheeze in children

Answer 16

Usually T cell lymphoma most commonly in teenagers with weight loss

Question 17

Congential causes of cough or wheeze (6)

Answer 17

Tracheobronchomalacia or vascular rings (will give stridor)
Tracheo-oesophageal fistula or Laryngeal clefts (cough after feeding)
Primary ciliary dyskineasia or psychogenic cough

Question 18

Physical examination of wheeze (6)

Answer 18

Finger clubbing or chest wall deformities (pectus excavatum or caraium )
Check air entry – equal?, normal or reduced? Wet or dry crepitations, resonance, Wheeze (general or localised)

Question 19

Signs of respiratory distress (7)

Answer 19

Increased respiratory rate Head bobbing
Recession (subcostal or intercostal) Expiratory grunting
Nasal flaring Tracheal tug
Signs of tiring

Question 20

Facial Signs of allergy

Answer 20

Allergic salute (wiping the nose upwards)
Allergic shiners (dark circles under the eyes due to sinus congestion)
Dennie-Morgan folds (extra suborbital folds due to oedema in atopic dermatitis)

Question 21

Glue Ear

Answer 21

Otitis media with effusion (see ENT deck)

Question 22

ENT exam in children

Answer 22

Big tonsils compared to adults

Mouth breathing – suggest nasal obstruction (polyps, Nasal haematoma, swollen turbinates)

Question 23

Asthma treatment ladder for children 5-12yrs

Answer 23

(Step 1+2 as <5s but steroid 200-800mg)Step 3 - Add long-acting B2 agonist.Step 4 - Steroid to 2000mcg + leukotriene R antagonist, theophylline, consider adding B2 agonist tablet. Step 5 - Add daily steroid tablet - optimise other drugs to minimise steroid tablets

Question 24

Differentials for chronic cough

Answer 24

Asthma or Rhinosinusitis (upper airway cough syndrome)
Protracted bacterial bronchitis or Post-infectious cough
GORD or other (10%)

Question 25

Asthma

Answer 25

Cough with wheeze + chest tightness If cough without wheeze = cough variant asthma --> nocturnal exacerbations, triggered by exercise and cold air Decreased exercise tolerance

Question 26

Rhinosinusitis

Answer 26

Nasal obstruction or congestion - rhinorhoea, sneezing, purulent nasal discharge, post-nasal drip, repetitive throat clearing

Question 27

Protracted bacterial bronchitis

Answer 27

Bronchoalveolar lavage --> check cytology for neutrophilia, culture (Hib - 50%, moraxella catarrhalis - 20%, strep pneumoniae 30% Should response to antimicrobials within ten days

Question 28

Post infectious cough

Answer 28

Transient airway hyper-reactivity and inflammation | Due to: Viruses (RSV and Parainfluenza) or Bacteria (chlamydia pneumonia or pertussis)

Question 29

Management of non-specific cough

Answer 29

Watchful waiting up to 8 weeks | In many cases removing smoking is enough

Question 30

Management of rhinosinusitis

Answer 30

Allergen avoidance Trials of long-acting anti-histamines + Intranasal steroids

Question 31

Management of protracted bacterial bronchitis

Answer 31

Sputum culture before treatment | If pertussis start a macrolide antibiotic early (end in mycin)

Question 32

Management of GORD

Answer 32

May not require empirical treatment - if pH shows reflux start treatment on full dose PPI for 1-2mths (if responds switch to low dose, if not double dose). Otherwise consider prokinetic or H2 antagonists --> consider fundoplication

Question 33

Management of aspirated foreign body

Answer 33

Urgent bronchoscopy

Question 34

Causes of wheeze in under 5s

Answer 34

Typical --> transient early, nonatopic/viral or atopic wheeze. Atypical --> GORD, congenital abnormalities, cystic fibrosis, cardiac disease, Foreign bodies, TB, bronchopulmonary dysplasia, immunodeficiency, primary ciliary diskineasia, Mediastinal mass/Ca

Question 35

Transient early wheeze

Answer 35

Starts in infancy - up to 3yrs Related to reduced pulmonary function up to 16yrs RFs --> prematurity, male, exposure to other children, exposure to tobacco smoke

Question 36

Non-atopic wheeze

Answer 36

recurrent viral infections - normal lung function but with intermittent airway obstruction

Question 37

Persistent atopic wheeze

Answer 37

Discrete attacks with symptom free intervals - worse at night FH of asthma or atopy -- Elevated IgE and blood eosinophilia responds to bronchodilators and corticosteroids -- early form/develops into asthma as airways remodel

Question 38

Asthma phenotypes (5)

Answer 38

Concordant disease - Benign asthma or Early onset asthma Discordant symptoms -- obese non-eosinophilic or early symptomatic Discordant inflammation - Eosinophilic inflammation predominant

Question 39

Obese non-eosinophilic asthma

Answer 39

Late onset, in obese females, high symptom expression compared to eosinophil infiltration

Question 40

Benign asthma

Answer 40

Mixed middle aged patients Well controlled symptoms and inflammation Benign prognosis

Question 41

Early onset asthma

Answer 41

Standard Asthma - concordant levels of symptoms, inflammation and airway dysfunction

Question 42

Early symptomatic asthma

Answer 42

Early onset with atopy in patients with normal BMI | Very high symptom expression compared to the level of inflammation

Question 43

Eosinophilic inflammation predominant asthma

Answer 43

Late onset with a male preponderance - Few daily symptoms but active eosinophilic inflammation

Question 44

Infections in cystic fibrosis

Answer 44

Staph aureus Pseudomonas aeruginosa Burkholderia (pseudomonas) cepacia Aspergillus

Question 45

High white cell count in child with respiratory issue

Answer 45

Neutrophilia- pneumococcus | Lymphocytosis- pertussis