8 - Respiratory 1

Question 1

What is bronchiolitis and what is the epidemiology and aetiology of this?

Answer 1

Most common lower respiratory tract infection in those under 1

3% of patients needs hospital admission

Usually due to RSV virus (RNA) and happens in winter months. Can also be due to adenovirus and parainfluenza virus

Question 2

What are some risk factors for developing bronchiolitis?

Answer 2

• *• Age less than 3 months**
• *• Prematurity** (particularly under 32 weeks)
• *• Low birth weight**
• *• Male sex**
• *• Low socioeconomic group**
• *• Parental smoking**
• *• Chronic lung disease/airway anomalies**
• *• Congenital heart disease**
• *• Neuromuscular disorders**
• *• Immunodeficiency**

Question 3

How does bronchiolitis present?

Answer 3

• Coryzal symptoms. of a viral URTI e.g running or snotty nose, sneezing, mucus in throat and watery eyes
• Signs of respiratory distress
• Dyspnoea
• Tachypnoea
• Poor feeding
• Mild fever (under 39ºC)
• Apnoeas
• cough
• Wheeze and crackles on auscultation

Question 4

What are the signs of respiratory distress in children?

Answer 4

Question 5

How long does bronchiolitis last for?

Answer 5

• Starts as URTI with coryzal symptoms. From this point around half get better spontaneously. The other half develop chest symptoms over the first 1-2 days following the onset of coryzal symptoms
• Symptoms at their worst on day 3 or 4
• Symptoms usually last 7 to 10 days and most fully recover within 2 – 3 weeks
• More likely to have viral induced wheeze during childhood

Question 6

What are some differentials for bronchiolitis?

Answer 6

Question 7

Which infants need to be admitted for hospital treatment with bronchiolitis?

Answer 7

• Aged under 3 months or any pre-existing condition such as prematurity, Downs syndrome or CF
• 50 – 75% or less of their normal intake of milk
• Clinical dehydration
• Respiratory rate above 70
• Oxygen saturations below 92%
• Moderate to severe respiratory distress
• Apnoeas
• Parents not confident in their ability to manage at home

Question 8

How is bronchiolitis treated in hospital?

Answer 8

SUPPORTIVE CARE and MONITOR VITALS

• Ensuring adequate intake. e.g orally, NG tube or IV fluids. Avoid overfeeding as can restrict breathing
• Antipyretics
• Saline nasal drops and nasal suctioning can help clear nasal secretion
• Supplementary oxygen if the oxygen saturations remain below 92%
• Ventilatory support if required

Question 9

What ventilatory support can be given to infants with severe bronchiolitis?

Answer 9

only give if oxygen stats are less than 90% on air despite resp effort to breathe
1. High-flow humidified oxygen via tight nasal cannula. It adds “positive end-expiratory pressure” (PEEP) to maintain the airway at the end of expiration

2. Continuous positive airway pressure (CPAP). This involves using a sealed nasal cannula that performs in a similar way to Airvo or Optiflow, but can deliver much higher and more controlled pressures.

3. Intubation and ventilation. This involves inserting an endotracheal tube into the trachea to fully control ventilation.

Question 10

How can you tell if ventilatory support is working for children with bronchiolitis?

Answer 10

Capillary Blood Gas

Question 11

How may bronchiolitis appear on a CXR?

Answer 11

Bilateral peri-hilar infiltrates with some hyperinflation due to air-trapping

Diagnosis is clinical, only do PCR, CBG and CXR if severe. Also check pulse oximetry

Question 12

Nebulised saline, inhalers and steroids are not recommended for treatment of bronchiolitis unless the child has a history of wheeze, atopy or asthma. These children may also be given Palivizumab, what is this?

Answer 12

Monoclonal antibody that targets RSV

A monthly injection is given as prevention to high risk babies, such as ex-premature and those with congenital heart disease

Not a true vaccine as it does not stimulate the infant’s immune system. It provides passive protection

Question 13

What are some complications of bronchiolitis?

Answer 13

Higher risk of asthma in later life

Question 14

What is bronchiolitis obliterans?

Answer 14

• Permanent obstruction of the bronchioles due to chronic inflammation which leads to scar tissue formation
• Usually due to adenovirus
• Dry cough, wheeze, SOB
• Most commonly seen in lung or bone marrow transplant patients. Chest X-rays can often appear normal so diagnosis is often made using a CT scan or lung biopsy.

Question 15

What is asthma and the epidemiology of this in children?

Answer 15

Chronic inflammatory airway disease leading to variable airway obstruction that is reversible

Smooth muscle in the airways is hypersensitive, and responds to stimuli by constricting and causing airflow obstruction

1 in 11 children

Question 16

What are some risk factors for asthma?

Answer 16

• Viral bronchiolitis
• Family history of asthma
• History of atopy (allergy/eczema)
• Exposure to tobacco smoke
• Exposure to pollution and obesity
• Smoking in household
• Low birth weight
• Prematurity

Question 17

What are some triggers for asthma?

Answer 17

• Dust
• Animals
• Cold air
• Exercise
• Smoke
• Food allergens (e.g. peanuts, shellfish or eggs)
• Drugs

Question 18

How may asthma present in children?

Answer 18

EPISODIC USUALLY WITH DIURNAL PATTERN

• Cough
• Breathlessness
• Widespread wheeze
• Chest tightness

Question 19

What are some differentials for asthma and what are some presentations that point away from a diagnosis of asthma?

Answer 19

DDx: respiratory tract infections, viral wheeze, foreign body inhalation, bronchiolitis, allergic reactions or anaphylaxis

Question 20

What questions need to be asked in the history if you are considering asthma as a diagnosis?

Answer 20

• Frequency of symptoms
• Severity of symptoms (how many days of school missed? Can the child do PE at school? Can they play with their friends without getting symptoms? Night time symptoms?)
• Previous treatments tried
• Any hospital attendances
• Presence of food allergies
• Triggers for symptoms
• Disease history: Viral infections, eczema, hay fever
• Family history of atopy

Question 21

How is asthma diagnosed in children?

(memorise image!!!)

Answer 21

Diagnosis is usually clinical, if under 5 no investigations needed just treat symptoms

listen to chest for expiratory polyphonic wheeze
expiratory polyphonic wheeze

Fractional exhaled nitric oxide (FeNO > 35 ) / ** eosiniphil count **

spirometery reversibility is 12%

peak flow increase by 20%

if below 5 just treat with corticosteroids and then diagnose when they are older

Question 22

To summarise what is the order of of investigations for asthma in children over 5

Answer 22

1. FeNO and eosinophil
2. bronchodilator reversibility (BDR) with spirometry.
3. measure peak expiratory flow

Question 23

Spirometry in over 5’s. What may the result show if asthma is present?

Answer 23

• Obstructive Pattern (FEV1/FVC ratio <70%)
• FEV1 increase over 12%

Question 24

What is an FeNO test and how do you interpret the result?

Answer 24

• FeNO = surrogate marker for eosinophilic inflammation in airways
• Over 35 ppb is positive in children
• Over 50 ppb is positive in adults

Question 25

What is challenge testing for asthma?

Answer 25

assesses how sensitive your lungs are through several tests

Question 26

How can peak flow variability aid a diagnosis of asthma in children and what are the drawbacks with this method?

Answer 26

• Variability over two weeks – \> 20% variability (NICE) – \> 12% variability (ERS)

Question 27

What are the principles of treatment in asthma?

Answer 27

GOAL IS GOOD SYMPTOM CONTROL * Assess current control and future risk * Supported self-management / patient education / empowerment * Other factors / psychosocial issues * Review medications regularly with asthma nurse

Question 28

How can you assess current asthma control in children?

Answer 28

**Poor control:** * Daytime symptoms 3 or more times a week * Nighttime symptoms 1 or more times a week * **Limitations of activity e.g exercise and school attendance** * Using SABA more than 2 times a week * Exacerbation in the last 12 months

Question 29

What self-management should you encourage for patients with asthma?

Answer 29

**_Patient education_** – Inhaler technique – Adherence – Triggers / avoidance (encourage parents to stop smoking) **_Written asthma action plan_** – Target control – Treatment – How to escalate care – Contact details

Question 30

What is the stepwise management for asthma in under 5's?

Answer 30

1. Consider an 8 to12 week trial of BD low dose (ICS) as maintenance therapy with a [SABA] for reliever therapy 2. If still uncontrolled then , consider a leukotriene receptor antagonist (LTRA - montelukast) in addition to the ICS. Give the LTRA for a trial period of 8 to 12 week 3. Consider stopping ICS and SABA treatment after 8 to 12 weeks if symptoms are resolved. Review the symptoms after a further 3 months.

Question 31

If symptoms do not resolve during the trial period for asthma management , take the following sequential steps:

Answer 31

check inhaler technique and adherence check whether there is an environmental source of their symptoms (for example mould in the home, cold housing, smokers or indoor air pollution) review whether an alternative diagnosis is likely.

Question 32

What is the stepwise management for asthma in over 5's (5-11)?

Answer 32

1. Offer a twice-daily paediatric low-dose inhaled corticosteroid (ICS), and (SABA) (NO SABA WITHOUT ICS) 2. low dose MART 3. moderate dose MART 4. Consider adding a leukotriene receptor antagonist (LTRA) for a trial period of 8 to 12 weeks- Montelukast (Singulair), Zafirlukast (Accolate), and Pranlukast.

Question 33

What age are children treated with the adult guidelines for asthma?

Answer 33

1. Offer low-dose MART ( A form of combined ICS plus formoterol treatment in which a single inhaler containing ICS and formoterol (LABA) is used for daily maintenance therapy and the relief of symptoms as needed) this combitation reduces the risk of attacks and in once inhaler People using MART dont need SABA 2. moderate dose MART 3. consider adding leukotriene receptor antagonist (LTRA) (montelukast) or a long-acting muscarinic receptor antagonist (LAMA - tiotropium, ) used in addition to moderate-dose MART. Give the medicine for a trial period of 8 to 12 weeks

Question 34

What parts of the asthma management are associated with poor morbidity?

Answer 34

* Excessive SABA use - use without an ICS gives a high chance of asthma attacks * LABA use without using ICS in combination * ALWAYS REVIEW AFTER 6 WEEKS

Question 35

What are some side effects of montelukast and steroids to warn parents about?

Answer 35

**Steroids** * oral thrush * Height * Adrenalsuppression **Montelukast** * Sleep disturbance * Aggressivebehaviour

Question 36

If a parent asks you if ICS can slow the growth of their child, what should your response be?

Answer 36

* There is evidence that inhaled steroids can slightly reduce growth velocity and can cause a small reduction in final adult height of up to 1cm when used long term (for more than 12 months). This effect was ***dose-dependent***, meaning it was less of a problem with smaller doses * State they control asthma and prevent attacks which could lead to higher doses of oral steroids being given. Poorly controlled asthma can lead to a more significant impact on growth and development * The child will also have regular asthma reviews to ensure they are growing well and on the minimal dose required to effectively control symptoms

Question 37

How do you explain to parents how to use their child's inhaler?

Answer 37

ALWAYS CHECK INHALER TECHNIQUE AT REVIEWS

Question 38

How often should spacers be cleaned?

Answer 38

* Once a month * Avoid scrubbing and allow to air dry as otherwise can create static which will interact with mist and stop medication being inhaled

Question 39

got to acute asthma

Question 40

How will an acute asthma exacerbation present in a child?

Answer 40

* ***Expiratory wheeze*** on auscultation heard **throughout the chest** * **ALWAYS WORRY WHEN CHEST IS SILENT** * Progressively worsening shortness of breath * Signs of respiratory distress * Fast respiratory rate * Reduced air entry

Question 41

What are features of moderate asthma exacerbation in children?

Answer 41

* Able to talk in sentences; * (SpO₂) ≥ 92%; * Peak flow ≥ 50% best or predicted * Heart rate ≤ 140/minute in children aged 1–5 years; heart rate ≤ 125/minute in children aged over 5 years * Respiratory rate ≤ 40/minute in children aged 1–5 years; respiratory rate ≤ 30/minute in children aged over 5 years.

Question 42

What are features of severe acute asthma?

Answer 42

* Can’t complete sentences in one breath or too breathless to talk or feed * SpO₂ * Peak flow 33–50% best or predicted; * Heart rate \> 140/minute in children aged 1–5 years; heart rate \> 125/minute in children aged over 5 years; * Respiratory rate \> 40/minute in children aged 1–5 years; respiratory rate \> 30/minute in children aged over 5 years.

Question 43

What are features of life-threatening asthma exacerbation in children?

Answer 43

Any one of the following in a child with severe asthma: * SpO₂ * Peak flow * Silent chest * Cyanosis * Poor respiratory effort * Hypotension * Exhaustion * Confusion * Normal or high pCO₂

Question 44

What are some differentials for an asthma exacerbation?

Answer 44

* Pneumothorax * Anaphylaxis * Inhalation of a foreign body * Cardiac arrhythmia

Question 45

How is an acute asthma exacerbation managed in a child?

Answer 45

* ***High flow oxygen*** if life threatening or sats \<92% * ***Nebulised salbutamol,*** only spacer if mild/moderate * Add ***nebulised ipratropium bromide*** (anti-muscarinic) * ***Oral*** (prednisolone) ***or IV*** (hydrocortisone) ***steroids*** for 3 days * If O2 saturations \<92% add ***magnesium sulphate*** * ***PICU Referral*** * If severe or life-threatening acute asthma not responsive to inhaled therapy, add ***aminophylline*** ALWAYS BE CONSIDERING ICU INPUT!

Question 46

What is a step-down regime for salbutamol?

Answer 46

**10 puffs 2 hourly** then **10 puffs 4 hourly** then **6 puffs 4 hourly** then **4 puffs 6 hourly***.*

Question 47

What may need to be monitored whilst on high doses of salbutamol?

Answer 47

* Serum potassium as may be raised * Tremor * Heart rate as causes tachycardia

Question 48

What criteria needs to be fulfilled before a discharge can take place after an acute asthma exacerbation?

Answer 48

* Bronchodilators are taken as inhaler device with spacer at intervals of 4-hourly or more (e.g. **6 puffs salbutamol via spacer every 4 hours**) * **SaO2 \>94% in air** and **PEF \>75% expected** * **Inhaler technique assessed**/taught * Written **asthma management plan given** and explained to parents * GP should review the child **2 days after discharge**

Question 49

What are some causes of wheezing in children?

Answer 49

* Viral induced wheeze * Bronchiolitis * Bronchiolitis obliterans * Bronchomalacia * Chronic lung disease of prematurity * Foreign body inhalation * Asthma * CF

Question 50

What is the order of tests in asthma diagnosis?

Answer 50

not correct

Question 51

Why does viral induced wheeze only tend to affect under 3's?

Answer 51

* They have small airways that develop a small amount of ***inflammation*** and ***oedema*** in the presence of a virus * This ***swelling*** and ***constriction*** of the airway caused by a virus has little noticeable effect on the larger airways of an older child or adult, however due to the small diameter of a child’s airway, the slight narrowing leads to a proportionally larger restriction in airflow * These children have a higher risk of asthma later in life

Question 52

How can you tell the difference between viral induced wheeze and asthma?

Answer 52

Generally, typical features of viral-induced wheeze (as opposed to asthma) are: * Presenting before 3 years of age * No atopic history * Only occurs during viral infections

Question 53

How is viral induced wheeze managed?

Answer 53

**SAME AS ASTHMA** ## Footnote Symptomatic treatment with SABA (5 mg to all children aged over 5 years, and 2.5 mg to children aged 2–5 years) Consider regular preventer therapy (ICS) if frequent symptoms Oral steroids if severe exacerbation requiring oxygen or frequent inhalers in hospital

Question 54

What is the definition of apnea?

Answer 54

Pause in breathing over 20 seconds and is often followed by bradycardia Very common in prematurity due to immature breathing centre Risk of SIDS

Question 55

What are some differentials for apnoea in children?

Answer 55

* **Prematurity** * Low birth weight * Infection * Hypothermia * Congenital heart disease * Whooping cough * OSA * GORD * Post operative apnoea * Hypoglycaemia * Bronchiolitis * Neonatal sepsis * Meningitis

Question 56

How can apnoea be managed in neonates?

Answer 56

* Monitor with alarms * Gentle stimulation * Nasal CPAP * Oxygen * Caffeine citrate twice a day for babies \<30 weeks Most babies will outgrow by 36 weeks gestation

Question 57

How does respiratory distress occur in children?

Answer 57

* Tachypnea * Nasal flaring * Intercostal and subcostal recessions * Grunting * Cyanosis

Question 58

What are some causes of breathlessness in children?

Answer 58

* Infection e.g bronchiolitis, whooping cough, pneumonia * Asthma * Anaphylaxis * Congenital heart disease * Sepsis * Foreign body * Fever

Question 59

What is one important blood test to do during paediatric sepsis?

Answer 59

Clotting!! Risk of DIC

Question 60

What are some differentials for a cough in children? (Image important)

Answer 60

* Acute infection * Cystic Fibrosis * Post-viral cough * Asthma * Allergic rhinitis with post-nasal drip * GORD

Question 61

What are some causes of cyanosis in children?

Answer 61

* Congenital Heart Disease (e.g Tet of Fallot) * Respiratory infection * Sepsis * Acute asthma * Anaphylaxis

Question 62

What investigations should you be doing for a child with cyanosis?

Answer 62

* Cardiac examination for murmurs * Pre and post-ductal saturations * CXR * FBC

Question 63

What is the severity grading of croup in general terms?

Answer 63

Admit moderate and severe

Question 64

What are some causes of stridor in children?

Answer 64

Partial Upper Airway Obstruction heard on inspiration **_Acute_** * Croup * Inhaled foreign body * Anaphylaxis * Epiglottitis * Retropharyngeal abscess **_Chronic_** * Laryngomalacia - a birth defect that causes the tissue in the voice box to be floppy, which can lead to noisy breathing in babies and children. * Haemangioma

Question 65

What age group is stridor more common?

Answer 65

Younger children with smaller airways

Question 66

What questions should you ask a parent when their child has stridor?

Answer 66

Question 67

What investigations should you do for a child with croup?

Answer 67

Never approach without airway support e.g ENT * Pulse oximetry * ABG * Lateral and AP cervical spine * Bronchoscopy if foreign body * Temperature

Question 68

Why is it concerning if stridor gets quieter and what should you do with this?

Answer 68

All children with stridor should be made NBM Airway management essential

Question 69

What are the steps for asthma treatment in children?

Answer 69

Question 70

If a child under 5 starts on a new asthma treatment, how should they be reviewed?

Answer 70

* Symptom diary * Follow up in 6-8 weeks Spirometry and Peak flow are not accurate in under 5s so do not use!!!!!

Question 71

What are risk factors for severe asthma?

Answer 71

Question 72

Answer 72

Question 73

Answer 73

Question 74

Answer 74

Question 75

more than how many ribs shows an expanded lung

Answer 75

9