Respiratory

Question 1

Give 3 signs of respiratory distress in a child.

Answer 1

1. Tachypnoea, RR 40-60.
2. Subcostal and intercostal recession.
3. Stridor.
4. Tracheal tug.
5. Cyanosis

Question 2

What virus can cause croup?

Answer 2

Parainfluenza virus

Question 3

Describe the epidemiology of croup.

Answer 3

Peak incidence at 6 months - 3 years

More common in autumn

Question 4

What is croup?

Answer 4

Acute laryngotracheobronchitis - trachea, bronchi and larynx are all affected.

Question 5

What are 4 features of croup?

Answer 5

stridor
barking cough (worse at night)
fever
coryzal symptoms

Question 6

Clinical Knowledge Summaries (CKS) suggest using the following criteria to grade the severity of croup.

Answer 6

Mild:
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

Moderate:
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

Severe:
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

Question 7

What are the criteria to admit a child with croup?

Answer 7

CKS suggest admitting any child with moderate or severe croup. Other features which should prompt admission include:
< 6 months of age
Known upper airway abnormalities
Uncertainty about diagnosis

Question 8

What is the mx of croup?

Answer 8

A single dose of oral dexamethasone (0.15mg/kg)

Prednisolone is an alternative

Question 9

What is the emergency tx of croup?

Answer 9

High-flow oxygen

Nebulised adrenaline

Question 10

Give 3 signs of bronchiolitis.

Answer 10

Coryzal symptoms precede:

1. dry cough
2. increasing breathlessness
3. wheezing, fine inspiratory crackles (not always present)
4. feeding difficulties associated with increasing dyspnoea are often the reason for hospital admission

Question 11

What viruses can cause bronchiolitis?

Answer 11

RSV = main causative organism!

Also: rhinovirus, influenza, adenovirus, parainfluenza virus.

Question 12

Describe the epidemiology of bronchiolitis.

Answer 12

< 1yr olds (90% are 1-9 months, with a peak incidence of 3-6 months).
Maternal IgG provides protection to newborns against RSV
Higher incidence in winter

Question 13

Give 5 bacterial organisms that commonly cause pneumonia in children.

Answer 13

1. Group B strep in neonates.
2. S.pneumoniae.
3. H.influenzae.
4. K.pneumoniae.
5. M.pnuemoniae.

Question 14

Give 5 signs of pneumonia in children.

Answer 14

1. Fever.
2. Difficulty in breathing
3. Increased respiratory rate (best clinical sign)
4. Cough.
5. Poor feeding.
6. Lethargy.
7. Localised chest, abdominal and neck pain (feature of pleural irritation and suggests bacterial infection)

Question 15

What investigations might you do in a child who you suspect has pneumonia?

Answer 15

• CXR -> look for consolidation.
• Blood cultures.

It is often difficult to get a sputum sample.

Question 16

Describe the treatment for a child with pneumonia.

Answer 16

1. 1st line- Amoxicillin
2. Macrolides eg Erythromycin may be added if there is no response to first line therapy
3. Macrolides should be used if mycoplasma or chlamydia is suspected
4. Pneumonia associated with influenza- Co-amoxiclav

Question 17

What is the difference between wheeze and stridor?

Answer 17

Wheeze: polyphonic noise heard on expiration.
Stridor: monophonic high pitched noise heard on inspiration.

Question 18

Describe the aetiology of recurrent wheeze.

Answer 18

1. Persistent infantile wheeze.
2. Viral episodic wheeze.
3. Asthma.

Question 19

What is persistent infantile wheeze normally associated with/exacerbated by?

Answer 19

Persistent infantile wheeze tends to affect the small airways. It is associated with parental smoking or post-viral infection.

Question 20

Are inhalers likely to help a child with persistent infantile wheeze?

Answer 20

No. Inhalers are unlikely to help; symptoms will improve as the child gets older.

Question 21

What is viral episodic wheeze normally associated with/exacerbated by?

Answer 21

It normally follows a URTI. The child will have no interval symptoms.

Question 22

Are inhalers likely to help a child with viral episodic wheeze?

Answer 22

Bronchodilators may help but there is no benefit from inhaled steroids.

Symptoms are likely to improve with age.

Question 23

How would you manage an acute exacerbation of asthma in a child?

Answer 23

Pg 292 of sunflower book

Question 24

Inhalers: name 2 ‘preventers’.

Answer 24

ICS act as ‘preventers’ e.g. beclomethasone, budenoside.

Question 25

Inhalers: name 2 'relievers'.

Answer 25

Beta agonists e.g. salbutamol. | Muscarinic antagonists e.g. ipratropium bromide.

Question 26

Give 3 long term risks of systemic steroids.

Answer 26

1. Adrenal suppression. 2. Growth suppression. 3. Osteoporosis.

Question 27

Why might asthma treatment fail in children?

Answer 27

1. Poor adherence. 2. Wrong diagnosis. 3. Environmental factors. 4. Choice of drug. 5. Bad disease.

Question 28

Name 3 URTI.

Answer 28

1. Rhinitis. 2. Otitis media. 3. Pharyngitis. 4. Tonsillitis. 5. Laryngitis.

Question 29

Name 3 LRTI.

Answer 29

1. Bronchitis. 2. Croup. 3. Epiglottitis (bacterial). 4. Tracheitis. 5. Bronchiolitis. 6. Pneumonia.

Question 30

Would you expect a patient with bronchitis or with bronchiolitis to be hypoxic and tachypnoeic? Explain why.

Answer 30

Bronchiolitis. Bronchiolitis affects the respiratory portion of the airway, where gas exchange takes place therefore you may see hypoxia and tachypnoea. Bronchitis affects the conducting portion of the airway and so is unlikely to have these effects.

Question 31

Give 3 signs of bronchitis in children.

Answer 31

1. Chronic cough. 2. Cough worst at night. 3. No fever.

Question 32

Name 4 LRTI that could be caused by RSV.

Answer 32

1. Acute bronchiolitis. 2. Wheezy bronchitis. 3. Asthma exacerbation. 4. Pneumonia. 5. Croup.

Question 33

Why are infants more susceptible to descending infection?

Answer 33

Infants have a poor innate immune response

Question 34

Name a bacteria that causes acute epiglottitis.

Answer 34

H.influenzae B. Acute epiglottitis is a severe acute illness.

Question 35

Give 5 signs of acute epiglottitis.

Answer 35

1. High fever in an ill, toxic-looking child 2. Intensely painful throat 3. Dribbling. 4. Huge inflamed epiglottis that blocks the oesophagus and trachea-> soft inspiratory stridor 5. Sitting immobile, upright, with an open mouth to optimise the airway

Question 36

Name 2 respiratory illnesses that can present with stridor.

Answer 36

1. Croup - often a louder stridor. | 2. Acute epiglottitis - often a quieter stridor due to inflamed epiglottis blocking oesophagus and trachea.

Question 37

Describe the immediate management for acute epiglottitis.

Answer 37

Secure the airway - anaesthetist, ENT surgeon.

Question 38

What is pneumonia?

Answer 38

Inflammation of the lung parenchyma with congestion

Question 39

Describe the diagnostic criteria for pneumonia in children.

Answer 39

- If <3: pyrexial, chest recession and RR>50 = pneumonia. | - If older and the child has a history of breathing difficulties, cough and increased RR = pneumonia.

Question 40

Describe the treatment of pneumonia.

Answer 40

- Amoxicillin is first-line for all children with pneumonia - Macrolides may be added if there is no response to first line therapy - Macrolides should be used if mycoplasma or chlamydia is suspected - In pneumonia associated with influenza, co-amoxiclav is recommended

Question 41

What antibiotics might you use in a child with pneumonia caused by mycoplasma pneumoniae?

Answer 41

Mycoplasma pneumoniae is intracellular and so amoxicillin won't work therefore give macrolides e.g. clindamycin, erythromyocin.

Question 42

What is a unilateral pleural effusion suggestive of?

Answer 42

Infection e.g. parapneumonic or empyema.

Question 43

What is a bilateral pleural effusion suggestive of?

Answer 43

Fluid overload e.g. HF or nephrotic syndrome.

Question 44

What are the moderate, severe and life threatening features of asthma?

Answer 44

``` Moderate: PEFR 50-75% best or predicted Speech normal RR < 25 / min Pulse < 110 bpm ``` ``` Severe: PEFR 33 - 50% best or predicted Can't complete sentences RR > 25/min Pulse > 110 bpm ``` ``` Life-threatening: PEFR < 33% best or predicted Oxygen sats < 92% Silent chest, cyanosis or feeble respiratory effort Bradycardia, dysrhythmia or hypotension Exhaustion, confusion or coma ```

Question 45

List 2 causes of pulmonary hypoplasia.

Answer 45

1. oligohydramnios | 2. congenital diaphragmatic hernia