1
Q
What is pneumonia?
A
Infection of the lower respiratory tract and lung parenchyma causes inflammation of the lung tissue & sputum filling the airways and alveoli
2
Q
What are resp distress symptoms
A
tracheal tug
intercostal + diaphragm recession
nasal flaring
RR>60
accessory muscle use
wheeze
stridor
cyanosis
head bobbing
3
Q
What is wheeze
A
obstructed lower airway
Expiratory whistle
asthma
bronchiectasis
CF
bronchiolitis
4
Q
what is stridor
A
obstructed upper airway
high pitched harsh inspiration
croup
epiglottitis
laryngomalacia
foreign body
5
Q
What is order of choice of oxygen supplementation
A
high flow O2
CPAP
intubation
6
Q
How does pneumonia present?
A
- Usually precede an upper respiratory tract infection
- Cough (typically wet and productive)
- Fever
- SOB
- poor feed
- Lethargy
- Increased work of breathing
7
Q
What are the characteristic auscultation chest signs of pneumonia?
A
Bronchial breathing
Focal coarse crackles
Dullness to percussion
8
Q
Is bacterial or viral pneumonia more common in young infants
A
viral pneumonia is more common in young infants
9
Q
What are the signs of pneumonia?
A
Tachypnoea (raised respiratory rate)
Tachycardia (raised heart rate)
Hypoxia (low oxygen)
Hypotension (shock)
Fever
Confusion
10
Q
What is the most common cause of pneumonia in neonates
A
Group B streptococcus (GBS)
Escherichia coli (E. coli)
Listeria
Klebsiella
11
Q
What is the most common bacterial cause of pneumonia in children?
A
Streptococcus pneumoniae (most common)
Haemophilus influenzae
12
Q
what are other causes of pneumonia in children
A
Group A strep (e.g., Streptococcus pyogenes)
Staphylococcus aureus
Mycoplasma pneumoniae (atypical bacteria with extra-pulmonary manifestations, e.g., erythema multiforme)
13
Q
What is the most common cause of pneumonia in CF children?
A
Staphylococcus aureus
Pseudomonas aeruginosa
14
Q
What are the typical XRay findings of pneumonia?
A
upper lobe consolidation
15
Q
What are the viral causes of pneumonia?
A
Respiratory syncytial virus (RSV) (MC)
Parainfluenza virus
Influenza virus
16
Q
What Xray findings would you see for Staphylococcus aureus pneumonia?
A
pneumatocoeles (round air filled cavities) and consolidations in multiple lobes.
17
Q
What are the investigations of pneumonia?
A
Clinical
FBC
WCC
CRP
blood cultures
blood gas
Sputum culture and Gram stain:
CXR - fluid in the lungs (associated with Staph)
18
Q
What is 1st line antibiotic for pneumonia?
A
Amoxicillin
Neonates: Broad spec IV Abx
Infants: Amoxicillin/Co-Amoxiclav
Over 5s: Amoxicillin/Erythromycin
19
Q
What antibiotic is added to cover atypical pneumonia or in case of patient with penicillin allergy?
A
macrolide - erythromycin, clarithromycin or azithromycin
20
Q
Name complications of pneumonia
A
Respiratory failure
Sepsis
Pleural effusion (in 1/3 cases)
Empyema
Lung abscess
Risk of parapneumonic collapse and empyema if so follow up at 4-6 weeks with a fluid sample
21
Q
When should child be admitted for pneumonia
A
<93% O2 stat
22
Q
What is croup
A
Acute laryngotracheobronchitis due to parainfluenxa virus
upper respiratory tract infection causing inflammation in the larynx
23
Q
What is the classic cause of croup
A
parainfluenza virus
24
Q
What is the epidemiology of croup
A
Peak incidence 6 months to 3 years
MC in autumn and winter
more common in male, preterm, and those with underlying resp disease
25
Name 3 causes of croup
*Parainfluenza* - MC
Influenza
Adenovirus
Rhinovirus
26
What did croup used to be commonly caused by and what did it lead to?
Croup caused by diphtheria leads to epiglottitis
27
what is the pathophysiology of croup?
Viral infection --> inflammation of the upper airway with oedema formation and infiltration of inflammatory cells --> narrowing of subglottic airway (inspiratory stridor) and increased work of breathing
28
What is mild croup
Occasional barking cough
No audible stridor at rest
No or mild suprasternal and/or intercostal recession
The child is happy and is prepared to eat, drink, and play
29
what is moderate croup
Frequent barking cough
Easily audible stridor at rest
Suprasternal and sternal wall retraction at rest
No or little distress or agitation
The child can be placated and is interested in its surroundings
30
what is severe croup
* Frequent barking cough
* Prominent inspiratory (and occasionally, expiratory) stridor at rest
* Marked sternal wall retractions
* Significant distress and agitation, or lethargy or restlessness (a sign of hypoxaemia)
* Tachycardia occurs with more severe obstructive symptoms and hypoxaemia
31
When do you admit a child with croup?
moderate or severe croup
< 3 months of age
stridor at rest
known upper airway abnormalities (e.g. Laryngomalacia, Down's syndrome)
32
What are respiratory failure red flag signs?
- Drowsiness
- Lethargy
- Cyanosis
- Tachycardia
- Laboured breathing
33
How does croup present on examination?
- 1-4 days history of non-specific rhinorrhea (thin, nasal discharge), fever and barking
cough
- Worse at night
- Stridor
- Decreased bilateral air entry
- Tachypnoea
- Costal recession
34
How is croup diagnosed?
- clinical dx
- FBC, CRP U+E
- CXR - posterior-anterior angle
35
What are the XRay signs of croup?
posterior-anterior
steeple sign = subglottic narrowing
36
How is croup managed?
- *Single dose oral dexamethasone 0.15mg/kg*
- Paracetamol/Ibuprofen for fever/sore throat
- Admission if moderate/severe and consider if dehydrated
- Nebulised adrenaline for relief of severe symptoms
- Oxygen if required
- Monitor for needed ENT intervention if suspected airway blockage
37
What are complications of croup?
- Bacterial Superinfection: (S. Aureus, pseudomembranous croup, thick green secretions Tx IV fludox)
- Otitis Media
- Dehydration due to reduced fluid intake
38
What is asthma?
chronic reversible airway obstruction characterised by mucus hyper-secretions, airway hyper-responsiveness and inflammation
39
What are causes/RH of asthma?
- FHx atopy
- PHx atopy
- Samter's Triad
- Hygiene hypothesis
- Genetic
- Prematurity
- Low birth weight
- Parental smoking
- Viral bronchiolitis in early life
- Cold air
- allergen eg dust pollution
40
patients with asthma also suffer from other IgE-mediated atopic conditions such as
atopic dermatitis (eczema)
allergic rhinitis (hay fever)
41
How does asthma present clinically?
Persistent recurrent resp distress with wheeze, worse at night and in morning
- Episodic symptoms with intermittent exacerbations
- Dry cough often worse at night
- SOB
- Reduced peak flow
- Expiratory wheeze on auscultation
42
What is harrisons sulci
muscles insertions at diaphragm visible
associated with chronic asthma
43
How is asthma investigated >5 y/o first line
measure the fractional nitric oxide (FeNO)
diagnose asthma if:
FeNO is ≥ 35 ppb
44
How is asthma investigated >5 y/o if the FeNO level is not raised, or if FeNO testing is not available:
measure bronchodilator reversibility (BDR) with spirometry
45
What would spirometry investigation for asthma diagnosis?
diagnose asthma if:
the FEV1 increase is ≥ 12% from the pre-bronchodilator measurement, or
the FEV1 increase is ≥ 10% of the predicted normal FEV1
46
How is asthma investigated >5 y/o if spirometry is not available or it is delayed,
measure peak expiratory flow (PEF) twice daily for 2 weeks
diagnose asthma if:
PEF variability (expressed as amplitude percentage mean) is ≥ 20%
47
how is asthma investiagted if asthma is not confirmed by FeNO, BDR or PEF variability but still suspected on clinical grounds:
perform skin prick testing to house dust mite OR measure total IgE level and blood eosinophil count
48
what is the final line in asthma investigation if asthma is not confirmed by eosinophil, BDR, or PEF varibility
refer to a paediatric specialist for a second opinion, including consideration of a bronchial challenge test
49
How is asthma investigated <5 y/o
treating with inhaled corticosteroids as per the management guidelines with regular review
if they still have symptoms at age 5 then attempt objective tests
50
What would Fractional exhaled nitric oxide (FeNO) show for asthma?
High FeNO levels indicate your airways are inflamed or irritated.
>35ppb
51
What is the first step management plan for asthma for children 5-11
twice-daily paediatric low-dose inhaled corticosteroid (ICS) + short-acting beta2 agonist (SABA) as needed
52
if 5-11y/o asthma remains uncontrolled after 1st step what is next
decide if MART or conventional pathways.
53
what is MART pathway
1. Low-dose MART
2. Moderate-dose MART
3. Specialist referral
54
what is MART
maintenance and reliever therapy (MART)
using an inhaled corticosteroid (ICS)/formoterol (LABA) combination inhaler for daily maintenance therapy and the relief of symptoms as needed
55
what is conventional pathway
if symptoms not controlled on ICS + SABA
conventional pathway:
1. Add oral leukotriene receptor antagonist (e.g. montelukast)
2. twice daily low-dose ICS + LABA combination inhaler
3. twice daily moderate-dose ICS + LABA combination inhaler
4. Specialist referral
56
What is the first step management plan for asthma for children under 5y/o
8 to 12 week trial of twice-daily paediatric low-dose ICS as maintenance therapy + SABA as required
consider stopping ICS and SABA treatment after 8 to 12 weeks if symptoms are resolved
Review the symptoms after a further 3 months
57
what is the management pathway for children >12 and adults for asthma
1. AIR therapy -> as needed
2. Low-dose MART -> more regular
3. Moderate-dose MART
4. Specialist referral if FeNO or eosinophils are raised at this stage
5. Add leukotriene receptor antagonist or LAMA (8-12 week trial and switch if not helping)
6. Specialist referral
58
what is difference between AIR and MART
AIR = taken as needed for symptom relief
MART = daily maintenance therapy and the relief of symptoms as needed
59
How is life threatening asthma classified?
Sp02 <92&
PEFR <33%
silent chest
altered GCS
cyanosis
decreased effort to breathe
poor resp effort
60
How is severe asthma classified?
Sp02 <92&
PEFR 33%-50%
RR>30 (under 5)
RR >40 (over 5)
too breathless to feed talk
HR >140 (under 5s)
HR >125 (over 5s)
use of accessory muscles
audible wheeze
61
How is mild-moderate asthma classified?
Peak flow 50%-75%
Breathless
SpO2 >92%
feeding well
talking in sentences
wheeze
62
what is the management for children with mild to moderate acute asthma
Bronchodilator therapy
give a beta-2 agonist via a spacer (for a child < 3 years use a close-fitting mask)
give 1 puff every 30-60 seconds up to a maximum of 10 puffs
Steroid therapy 3-5 days
63
what is the management for Moderate to severe acute asthma
1. Nebulisers Salbutamol 10 puffs + spacer + PO Pred
+
2. Nebulisers ipratropium bromide +/- MgSO4
+
3. IV aminophylline
+ O2 if SpO2 <94%
64
When can a child be discharged after asthma admission
* stable on their discharge medication (i.e. no nebulisers or oxygen) for 12-24 hours
* inhaler technique checked and recorded
* PEF >75% of best or predicted
discharge can be considered when the child well on 6 puffs 4 hourly of salbutamol.
65
What is benefit of a spacer
increase bioavailable drug by keeping neb in vacuum for longer
prevents thrush
easier to administer
avoid breathing med too fast
66
What is total control for asthma defined
no daytime Sx
no acute attacks
no exercise Sx
no night waking
can consider decrease Tx if with control >3 months
67
What can contribute to poor control of asthma
adherence
bad disease
choice of drugs
environment
68
What type of resp failure is asthma attack
Type 2
hypercapnic
high CO2
69
What is viral-induced wheeze
recurrent viral induced wheeze <5 years old due to lung immaturity
self resolving by 5
Episodic Wheeze - a symptom of viral URTI and symptom free in between events
Multiple trigger Wheeze - URTI and other factors trigger wheeze
70
What are 2 RF for viral-induced wheeze
maternal smoking
prematurity
71
What is airway inflation worse in children than adults?
due to the small diameter of a child’s airway, the slight narrowing leads to a proportionally larger restriction in airflow
(Poiseuille’s law = halving the diameter of the tube decreases flow rate by 16 fold)
72
How does viral-induced wheeze present
Evidence of a viral illness (fever, cough and coryzal symptoms) for 1-2 days preceding the onset of:
- Shortness of breath
- Signs of respiratory distress
- Expiratory wheeze throughout the chest
73
What are the typical features of viral-induced wheeze as opposed to asthma
Presenting before 3 years of age
No atopic history
no diurnal variation
Triggered by viral infection otherwise systemically well
74
How is viral-induced wheeze managed?
treatment is symptomatic only
1. SABA inhaler via spacer maximum of 4 hourly up to 10 puffs
2. leukotriene receptor antagonist and/or ICS
3. escalate
75
What is Bronchiolitis
inflammation and infection in the bronchioles, the small airways of the lungs.
widespread wheeze
76
how is Bronchiolitis different to pneumonia
pneumonia = alveoli
Bronchiolitis = bronchioles
77
What is the epidemiology of Bronchiolitis
under 1 year
MC in under 6 months
Most commonly caused by RSV (Respiratory Syncytial Virus)
78
Risk factors for Bronchiolitis
- CHD (congenital heart disease)
- preterm
- CF
- winter
- immunodeficiency
- smoke exposure
79
What is the course of Bronchiolitis?
Symptom onset in 2-5 days after URTI w coryzal symptoms
~ 9 days of Sx, day 5 is peak
half get better half get chest symptoms following the onset of coryzal symptoms
80
What are signs of respiratory distress
Raised respiratory rate
Use of accessory muscles of breathing, such as the sternocleidomastoid, abdominal and intercostal muscles
Intercostal and subcostal recessions
Nasal flaring
Head bobbing
Tracheal tugging
Cyanosis (due to low oxygen saturation)
Abnormal airway noises
81
What are the clinical features of Bronchiolitis?
- Low grade fever
- Rhinorrhea and nasal congestion
- Cough
- Reduced feeding
- Respiratory distress
- Inspiratory crackles
- decrease wet nappies
82
What are Coryzal symptoms
running or snotty nose, sneezing, mucus in throat and watery eyes.
83
What is wheezing
whistling sound caused by narrowed airways, typically heard during expiration
84
What is grunting?
caused by exhaling with the glottis partially closed to increase positive end-expiratory pressure
85
What is stridor
high pitched inspiratory noise caused by obstruction of the upper airway, for example in croup
86
How is Bronchiolitis investigated
Generally clinical - widespread wheeze
Nasopharyngeal aspirate for RSV culture
FBC, Urine, Blood gas if severely unwell
CXR - not used usually but shows hyperinflation, air trapping and flattened diaphragm
87
How is Bronchiolitis managed?
Supportive management from home
88
What indicates urgent hospital admission for Bronchiolitis
- Apnoea
- Resp Rate > 70
- Central cyanosis
- SpO2 < 90%
- 50-75% fluid dehydration
89
How is bronchiolitis prevented?
IM Palvizumab against bronchiolitis (monthly monoclonal IgG injection)
provides passive immunity
90
Who Palvizumab given to
preterm
CHD
CF w/ lung defect
immunocompromised
91
What indicates hospital admission for Bronchiolitis
- Resp Rate > 60
- 50-75% fluid intake
- clinical dehydration
92
What is the inpatient management for Bronchiolitis
- Oxygen to bring SpO2 up
- Fluids
- CPAP if in respiratory failure
- Suctioning of secretions
- Ribavirin for severe cases
- No evidence for bronchodilatory, antibiotics or steroids in bronchiolitis
93
What is complication of Bronchiolitis
bronchiolitis obliterans
94
What is bronchiolitis obliterans
post transplant or recurrent infection
severe scarring
"popcorn lung"
HRCT = mosaic pattern
FEV1 : FVC 16-20%
95
What is cystic fibrosis?
auto rec ΔF508 on CFTR gene of C7
decrease CFTR expression = more Na and Cl retention affecting mucus glands
96
What is the pathophysiology of cystic fibrosis
lungs = impaired mucociliary clearance
GIT = impaired absorption due to thicker secretions
pancreas = B islet damage + decrease enzyme secretion
liver = biliary stasis
97
How is cystic fibrosis detected
screened for at birth with the Guthrie heel prick (newborn bloodspot tes).
98
What is the Guthrie heel prick
serum immunoreactive trypsin
5-9 days of life
also sickle cell
congential hypothyroid
99
What are symptoms of cystic fibrosis in neonate
failure to pass meconium <48hrs
100
How is meconium ileus treated
Gastrografin
101
What are symptoms of cystic fibrosis in infant
jaundice
failure to thrive
recurrent chest infections
102
What is MC caustive organism of recurrent chest infections in cystic fibrosis
P. aeruginosa in adults
S. aureus in kids
103
How is P. aeruginosa treated
ciprofloxacin
104
What are symptoms of cystic fibrosis in child
bronchiectasis
nasal polyps
sinusitis
105
What are symptoms of cystic fibrosis in older childer
Congenital bilateral absence of vas deferens (infertile) (98% of males)
bronchopulmonary aspergillosis
106
What is meconium ileus
first stool (meconium) is thick and sticky and can cause bowel obstruction
presents as not passing meconium within 24 hours, abdominal distention and vomiting.
107
If cystic fibrosis is not diagnosed at birth how does it usually present?
recurrent lower respiratory tract infections, failure to thrive or pancreatitis.
108
What are the symptoms of cystic fibrosis?
- Chronic cough
- Thick sputum production
- Recurrent respiratory tract infections
- Loose, greasy stools (steatorrhoea) due to a lack of fat digesting lipase enzymes
- Abdominal pain and bloating
- salty secretions
- failure to thrive
109
What are the signs of cystic fibrosis?
Low weight or height on growth charts
Nasal polyps
Finger clubbing
Crackles and wheezes on auscultation
Abdominal distention
110
What are DDx for finger clubbing
Hereditary clubbing
Cyanotic heart disease
Infective endocarditis
Cystic fibrosis
Tuberculosis
Inflammatory bowel disease
Liver cirrhosis
111
What are the three methods of diagnosing cystic fibrosis?
- Newborn blood spot testing (guthrie heel prick)
- The sweat test - more than 60mmol/l Ch (GOLD STANDARD)
- Genetic testing CFTR gene during pregnancy by amniocentesis or chorionic villous sampling, or as a blood test after birth
112
What is the sweat test
Pilocarpine applied to skin
Electrodes are placed
sweat is absorbed on filter paper and tested for chloride concentration
more than 60mmol/l = CF
113
Name two key microbial colonisers of cystic fibrosis?
Staphylococcus aureus and Pseudomonas aeruginosa
Burkhodheria cepacia
114
What long term prophylactic antibiotics do people with csystic fibrosis take?
flucloxacillin
115
how is cystic fibrosis managed?
lungs = chest physio 2x daily (clearence, breathing techniques, mucoactive agents = sinase + lumacaftor + hypertonic saline
panc = CREON + OGTT annually <10 y/o
GI = high cal high fat diet
liver = LFT annual screen
- Bronchodilators inhalers
- Nebulised DNase (dornase alfa) makes secretions less viscous
- Vaccinations including pneumococcal, influenza and varicella
- lung transplant - last line
Fertility treatment
Genetic counselling
116
what are Cf patients monitored for
sputum for colonisation
diabetes
osteoporosis
vitamin D deficiency
liver failure
117
how is pseudomonas managed in CF
long term nebulised antibiotics such as tobramycin. Oral ciprofloxacin is also used.
Cystic fibrosis clinics have separate clinic rooms for children with pseudomonas to minimise the risk of transmission
avoid contact with other children with cystic fibrosis
118
When is lung transplant CI in cystic fibrosis
burkholderia infections
119
What is laryngomalacia
congenital floppy larynx
self resolving
inc risk of GORD --> PPI
120
what is kartagener
primary ciliary dyskinesias
triad of bronchiectasis, sinusitis, and situs inversus
121
How is cystic fibrosis progression monitored
chrispin norman score
122
What is Epiglottitis?
acutely inflamed epiglottis in 6-12y due to HiB
life threatening emergency
123
How does Epiglottitis present?
dysphagia, drooling, and distress
dehydration
Tripod position, sat forward with a hand on each knee
124
how is Epiglottitis diagnosed?
- call ent + anaesthetists
- DO NOT examine airway
- CXR lateral view - Thumb sign --> epiglottis swelling
FBC, laryngoscopy
125
how is Epiglottitis managed?
secure the airway first
- intubation/O2
- Nebulised adrenaline
- IV Abx - Ceftriaxone
126
what Abx is given to Epiglottitis close contacts
Rifampicin
HiB vac
127
what typically causes Epiglottitis
Haemophilus influenzae type b
3a paeds
flashcards
Decks in class (12)
# Cards
-
Paeds Resp127
-
Paeds ENT + Ophthalmology67
-
Paeds Cardio121
-
Paeds GI233
-
Paeds Renal + Urology175
-
Paeds Endo + Repro93
-
Paeds Derm + Infectious Disease + Allergy271
-
Paeds Neuro + Psych (+ dev milestones)144
-
Paeds Haematology + Oncology + Genetics262
-
Paeds MSK134
-
Neonatology104
-
passmed wrong qs47
