LRTI

Question 1

What is bronchitis?

Answer 1

inflammation of the lining of the bronchial tubes
- Rare in children
- Viral infection
- Antibiotics not effective
- Confused with asthma

Question 2

What is asthma?

Answer 2

a condition in which a persons airways become inflamed, narrow and swell and produce extra mucus which makes it difficult to breathe

Question 3

Characteristic features of asthma?

Answer 3

1. Common in children
2. Familial
3. Associated with eczema
4. Confused with bronchitis

Question 4

When is asthma diagnosed?

Answer 4

> 3 years and nearly all by the age of 7 years

Question 5

What is the true definition of asthma?

Answer 5

Recurrent and REVERSIBLE bronchospasms

Question 6

Clinical features of asthma?

Answer 6

1. Recurrent cough
2. worse at night

Question 7

Historical points that may suggest that the child’s asthma is triggered by allergens?

Answer 7

1. Seasonal nature: pollen
2. Worse when exposed to a pet: Animal dander
3. Worse when bed is made or carpets/furnisher is dusted: house dust mites
4. Worse in damp house holds: moulds

Question 8

Pathophysiology of asthma?

Answer 8

Trigger > Exacerbations > bronchi mucus, oedema, spasms > Bronchiole obstruction > air trapping OR collapse

Question 9

Classification of asthma?
How it is classified?

Answer 9

Mild, Moderate, and Severe
- classified on frequency and Impact on activity

Question 10

What are acute asthma exacerbations?

Answer 10

episodes of worsening asthma symptoms and lung function
- can be the presenting manifestation of asthma or occur in patients with a known asthma diagnosis in response to a trigger e.g. viral upper respiratory infection, allergen, air pollution etc

Question 11

Treatment of acute exacerbation of asthma?

Answer 11

1. bronchodialators
2. steroids
   - Goal is to stop the spasms and reduce inflammation

Question 12

What bronchodialators are used in asthma?

Answer 12

1. Mild: Salbutamol MDI 2-4 puffs
2. Mod-Severe: Salbutamol nebuliser

Question 13

What steroids are used in asthma?

Answer 13

Oral Prednisolone or IV Dexamethasone

Question 14

If asthma is severe with impending death what do you use to treat?

Answer 14

1. aminophyline
2. magnesium
   Note: aminophyline has a narrow therapeutic window necessitating close monitoring

Question 15

Why is inhaled salbutamol preferred?

Answer 15

because adverse effects—tremor, prolonged tachycardia, and irritability—are less

Question 16

What is the natural progression of an asthma attack?

Answer 16

Cough > Wheezing > Tachpynea > ”silent chest” > Lethargy > Hypocapnia > “Normalizing” of respiratory rate > Respiratory failure > Death

Question 17

Why should you beware of an asthmatic child that looks like they are getting better?

Answer 17

are they getting better or getting tired?

Question 18

What is status asthmaticus?

Answer 18

is an acute exacerbation of asthma that does not respond adequately to therapeutic measures and may require hospitalization

Question 19

Treatment of mild asthma?

Answer 19

Salbutamol rescue Inhaler as needed
- teach guardian to identify triggers

Question 20

Treatment of moderate asthma?

Answer 20

Long acting bronchodilator (e.g., Salmeterol) and rescue inhaler

Question 21

Treatment of severe asthma?

Answer 21

Daily inhaled steroids, long acting bronchodilator, and rescue inhaler
- guardian needs “emergency plan”

Question 22

Management of asthma?

Answer 22

Control allergies
- dust, mold, cockroaches, etc
Note: Oral salbutamol is of little use and should NOT be prescribed for moderate or severe asthmatics

Question 23

What is bronchiolitis?

Answer 23

• ARI primarily in infants (3-6 months)
• Infection and inflammation of the bronchioles.
• Highly contagious (contact)

Question 24

Epidemiology of bronchiolitis?

Answer 24

90% are aged 1–9 months

Question 25

Aetiology of bronchiolitis?

Answer 25

1. RSV is the pathogen in 80% 2. Parainfluenza virus 3. Rhinovirus 4. Adenovirus 5. Influenza virus 6. Human meta­pneumovirus

Question 26

Pathophysiology of bronchiolitis?

Answer 26

1. Epithelial infection 2. Oedema 3. Sloughing of cells into airways 4. Mucus production 5. Obstruction 6. Airway trapping 7. Ciliary function impairment 8. Polymorphonuclear and lymphocyte proliferation

Question 27

Clinical features of bronchiolitis?

Answer 27

1. dry, wheezy cough 2. cyanosis or pallor 3. tachypnea and tachycardia 4. subcostal and intercostal recession 5. hyperinflation of the chest - sternum prominent - liver displaced downward 6. auscultation - fine end-inspiratory crackles - prolonged expiration/wheeze

Question 28

Investigations in bronchiolitis?

Answer 28

1. pulse oximetry 2. Chest X-ray 3. capillary blood gases - are only indicated if respiratory failure is suspected

Question 29

Indication for hospital admission in bronchiolitis?

Answer 29

1. Apnoea (observed or reported) 2. Persistent oxygen saturation of <92% when breathing air 3. Inadequate oral fluid intake (<70% of usual volume) 4. Severe respiratory distress – grunting, marked chest recession, or a respiratory rate over 70 breaths/minute

Question 30

Which infants are most at risk from severe bronchiolitis?

Answer 30

1. Infants born prematurely who develop bronchopulmonary dysplasia 2. those with other underlying lung disease, such as cystic fibrosis 3. or those who have congenital heart disease

Question 31

Management in bronchiolitis?

Answer 31

Supportive 1. Oxygen 2. Monitoring for apnoea 3. Fluids (nasogastric or intravenously) 4. Continuous Positive Airway Pressure

Question 32

Etiology of pneumonia?

Answer 32

1. Viruses are the most common cause in young children beyond the neonatal period 2. bacteria are more common in neonates and older children - In clinical practice, it is difficult to distinguish between viral and bacterial pneumonia and in more than half of cases no causative pathogen is identified.

Question 33

Newborn causes of pneumonia?

Answer 33

1. B streptococcus 2. Gram-negative enterococci and bacilli

Question 34

Infant and young children causes of pneumonia?

Answer 34

1. Viruses (mostly RSV) 2. Bacterial infections - Streptococcus pneumonia - H. influenzae - Staphylococcus aureus  - Bordetella pertussis - Chlamydia trachomatis

Question 35

Causes of pneumonia in children > 5 years?

Answer 35

1. Mycoplasma pneumoniae 2. Streptococcus pneumoniae  3. Chlamydia pneumoniae

Question 36

What can cause pneumonia at all ages?

Answer 36

mycobacterium tuberculosis

Question 37

What reduces the incidence of pneumonia?

Answer 37

Immunization with Hib and pneumococcal vaccines has markedly reduced the incidence of pneumonia from Haemophilus influenzae and invasive Streptococcus pneumoniae

Question 38

Clinical features of pneumonia?

Answer 38

1. Usually preceding URTI 2. Fever, cough and shortness (most common) 3. Lethargy, poor feeding, and appearing ‘unwell’ 4. Pleural irritation (Localized chest, abdominal, or neck pain

Question 39

Physical examination findings of pneumonia?

Answer 39

1. Tachypnoea ± increased work of breathing 2. Raised respiratory rate (most sensitive marker) 3. Signs of consolidation 4. ‘Stony dull’ if effusion or empyema 5. Oxygen saturation may be decreased 6. RR also increased in febrile children

Question 40

What are the signs of consolidation in pneumonia?

Answer 40

1. localized dullness 2. ↓breath sounds 3. bronchial breathing 4. end-inspiratory coarse crackles - Signs of consolidation often absent in young children

Question 41

Investigations in pneumonia?

Answer 41

1. Chest x-ray – only if diagnosis is in doubt. 2. FCB 3. Blood gas 4. CXR 5. Acute phase reactants cannot reliably differentiate viral from bacterial cause

Question 42

What is empyema?

Answer 42

- Pleural effusion associated with pneumonia are initially sterile (para-pneumonic effusion in 1/3 cases) but can become infected (empyema) - When this happens, the fluid becomes increasingly viscous, and fibrin strands form, leading to septations.

Question 43

Indications for admission to hospital in pneumonia?

Answer 43

1. Oxygen saturation <92% 2. Recurrent apnoea 3. Grunting and/or an inability to maintain adequate fluid/feed intake

Question 44

Management of pneumonia?

Answer 44

Supportive care 1. Oxygen 2. Analgesic for pain 3. Fluids to maintain hydration and sodium balance

Question 45

Newborn antibiotic treatment in pneumonia?

Answer 45

Broad-spectrum intravenous antibiotics

Question 46

Older infant antibiotic treatment of pneumonia?

Answer 46

1. Oral amoxicillin 2. Broader-spectrum e.g., co-amoxiclav reserved for complicated/unresponsive pneumonia

Question 47

>5 years of age antibiotic treatment of pneumonia?

Answer 47

Amoxicillin or an oral macrolide e.g. clarithromycin

Question 48

Treatment of empyema?

Answer 48

1. Small parapneumonic effusions resolve with pneumonia treatment 2. Persistent fever after 48 hours of antibiotics suggest infected effusion 3. Drainage required for empyema Regular instillation of a fibrinolytic agent 4. Rarely: Thoracoscopic surgery or thoracotomy and decortication