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69 Paediatric respiratory cases

Respiratory history hints

Breathing difficulties Failure to thrive Wheeze/cough/ FH of /atopy Exercise tolerance Poor feeding Episodes of apnoea ENT symptoms

Station 186: Paediatric

PALPATION/PERCUSSION AUSCULTATION Check Appropriate size of stethoscope Chest expansion Listen for breath sounds and added sounds Apex beat If older child, ask them to cough Cervical In a younger child, ask them to blow, then Less commonly examined in an OSCE listen when they breathe in again

Age Respiratory rate <1 30-40 ENT GENERAL INSPECTION 1-5 23-35 Important addition to the respiratory • Well/unwell 5-12 20-25 examination in children • Signs of respiratory >12 15-20 Ears: use otoscope distress (count RR) Nose: look for polyps/obstruction • Nutritional state Throat: Breath odour • Audible noises , • Chest deformity REMEMBER THE NB. leave otoscope and depressor • Clubbing ESSENTIALS CHECKLIST examinations until the end!

Station 187: Stridor Station 188:

Ear, nose and throat High salt losses in sweat Epiglottitis • Nasal polyps • Salty taste to skin • Risk of salt-losing crisis Age Older (2–6 years) Younger (6 months to 4 years) Recurrent chest during very hot weather Sex = > • Cough Poor growth • Require 40% extra type b Para- 1 • Purulent sputum Main agent • energy intake compared Seasons Year-round Late autumn and winter • Chronic Pseudomonas with normal child • Poor weight gain Recurrence Rare Common • • Short stature • Chest deformity • Normal growth is Clinical Sudden severe 1–2 day coryzal prodrome, usually non-toxic • Eventual respiratory achievable with Toxic = sick + If severe hypoxia manifested by failure Portacath pancreatic Drooling restlessness, pulse and RR, cyanosis replacement, and Sitting forward No drooling Finger clubbing aggressive Barking cough/hoarseness • Seen with chronic treatment of Stridor (can be soft) ± sternal recession Stridor (often harsh) + sternal recession lung infection chest infections Progression Rapid Slow Liver disease Gastrointestinal • Obstructive effects Causes of chronic stridor Causes of acute stridor jaundice in • Pancreatic neonatal insufficiency Laryngeal anomalies Croup period (rare) • Poor fat • Biliary stasis absorption (floppy ) Tonsillar abscess (quinsy) may require • Steatorrhoea treatment (fatty stools) with • Distended abdomen Upper airway obstruction Anaphylaxis ursodeoxycholic • Rectal prolapse acid • Meconium ileus equivalent • Eventually liver –can mimic acute appendicitis cirrhosis may develop • Need to take pancreatic Tracheal abnormality Epiglottitis enzymes with meals Expectorant therapy • May develop diabetes to clear sputum • Meconium ileus Vascular ring Inhaled foreign body • Regular chest physiotherapy at birth (15%) • Inhaled or nebulised bronchodilators • Nebulised dornase alfa can help thin Male infertility viscid secretions by breaking down • Congenital absence DNA strands within the mucous of the vas deferens

148 OSCEs at a Glance. By A. Blundell and R. Harrison. Published 2009 Blackwell Publishing. ISBN: 978-1-4051-3057-8 OSCE_4_069.qxd 6/5/09 16:21 Page 149

Station 187: Stridor Presentation Recurrent chest infections (50%) • Please discuss with the examiner the different causes of stridor and FTT despite normal intake (30%) how they can be managed Meconium ileus (10%) Pancreatic insufficiency and malabsorption Discussion points Rectal prolapse (rare) • What is the cause of croup? Some children are not diagnosed until they start school • Discuss the management of a child with croup Ix Imaging CXR • Discuss the management of acute epiglottitis Other Sweat test – high concentrations of sodium and chloride are diagnostic Causes Lung function tests • Acute: epiglottitis; inhaled foreign body; croup; tonsillar abscess; Faecal elastase – low in CF anaphylaxis Mx • Chronic: structural abnormalities, e.g. upper airway (micrognathia, Rx Medical Regular exercise pharyngeal cyst), larynx (vocal cord palsy, floppy larynx) or tracheal Treatment of infections (stenosis, tracheomalacia) Oral, IV or nebulised Consider prophylactic antibiotics Ix Epiglottitis Do not investigate until the airway is secured Mucolytics FBC and blood cultures Inhaled bronchodilators (± steroids) if airway Croup None reversibility on lung function testing Foreign body CXR (radio-opaque object) Good nutritional intake – high calorie diet Bronchoscopy Pancreatic enzyme supplements Chronic Microlaryngoscopy Vitamin supplements Barium swallow Surgery Consideration of heart/lung transplant Mx Croup Supportive Monitoring Monitor for diabetes and liver problems Pulse oximetry ± IV fluids MDT Regular chest physiotherapy Nebulised steroids Specialist nurses, dietician, family unit Oral steroids GP, respiratory paediatrician Steam may improve symptoms Psychosocial counselling Epiglottitis Acute emergency examination of the throat is Education For patient and family contraindicated Intubation and stabilisation Station 189: Chesty child IV antibiotics • Please state the causes of pneumonia in a child and discuss the investigation and treatment Station 188: Cystic fibrosis • Write short notes on including diagnosis, investigation • Please examine the of John, who is 12 and management • Emma has a chronic respiratory problem. Please examine her hands and listen to her lungs at the back Hints and tips: bronchiolitis • Acute respiratory distress Hints and tips • Obstruction of the small airways • Check for a portacath or a Hickman line (chest wall) or other long- • Caused by RSV in about 80% of cases term venous access (percutaneously inserted central catheter (PICC) NB. Not all that wheezes and crackles in winter is bronchiolitis (con- in the arm) – used for repeated courses of antibiotics. Also check the sider heart failure). abdomen for a percutaneous endoscopic gastrostomy (PEG) tube. Ix Nasopharyngeal aspirate for immunofluorescence Discussion points Mx Supportive > • What is the genetic problem in cystic fibrosis (CF)? Humidified O2 – aim for sats 92% • How do patients with CF present? Adequate hydration and nutrition • What tests and monitoring are necessary for suspected CF? • Discuss the management principles for a child with CF Causes of pneumonia and bronchiolitis • Bacterial: , Haemophilus influenzae, Aetiology Staphylococcus, Mycoplasma pneumoniae Cystic fibrosis is an autosomal recessive condition that occurs in one • Viral: respiratory synctial virus (RSV); influenza; parainfluenza; in 2500 (one in 25 are carriers). A mutation with the cystic fibrosis coxsackie; metapneumovirus transmembrane regulator protein (CTFR) on epithelial cells causes a problem with the chloride channel. This leads to viscid secretions that Indications for hospitalisation block bronchioles and exocrine pancreatic ducts. Hypoxaemia; increasing respiratory distress; significant feeding prob- lems; social problems

Paediatric respiratory cases Specialties 149