The Respiratory System Paediatrics OSCE Revision Elizabeth Evans

Plan  What could come up in the OSCE  Respiratory examination  Respiratory conditions

Key Points  Likely to be one examination from: CV/Resp/GI  May have a station with images or recordings  May have a history  Mostly normal children  Know a little about everything: Vivas are v. short  Easiest way to get marks: Be nice to the child!

What could come up? OSCE: -Normal -CF -Hyperexpanded chest from asthma History: -Asthma -CF -Infection Most respiratory disease in children presents acutely, thus unlikely to appear in the OSCE.

Respiratory Examination  Inspection- increased work of breathing  Hands- cyanosis, clubbing (CF or CHD)  RR and HR – remember changes with age  Face- central cyanosis  Avoid trachea in children – indicate to examiner  Chest shape  Palpation- apex beat and chest expansion  Percussion- do not go straight for this on the chest!  Auscultate

Dyspnoea in a child  Nasal flaring  Subcostal and intercostal recession  Expiratory grunting  Difficulty feeding  Added sounds eg expiratory wheeze

CONDITIONS

Respiratory infections  URTI:common cold sore throat otitis media croup diptheria acute epiglottitis  LRTI:pneumonia bronchiolitis whooping cough

Croup  Viral laryngotracheobronchitis (parainfluenza virus)  6 months – 6 years (peak in 2 nd year)  URTI symptoms (coryza/fever) for 2 days before onset of a characteristic barking cough and stridor (subglottic oedema) lasting around 3 days  Most improve spontaneously within 24h  1 in 10 require hospitalisation: under 12months, severe illness or signs of respiratory failure  Single dose of dexamethasone or nebulised budesonide is beneficial  Nebulised adrenaline provides transient improvement (reduces oedema) and is used in more severe cases to enable time for transfer to ITU

Acute epiglottitis  Life-threatening emergency  Haemophilus influenza type B (Hib immunisation has caused reduction)  1- 6 years  Rapid onset, intensely painful throat, febrile child, unable to swallow and reluctant to speak. Sat upright with open mouth drooling saliva.  Resus room, call ENT and anaesthetist  Do not examine the throat!  Secure airway, then take bloods for culture and commence IV cefuroxime  Rifampicin for household contacts

Diptheria  Cornyebacteria diptheriae  Sore throat, fever, lymphadenopathy and stridor  Hallmark sign= thick grey material on back of throat  Potentially fatal, highly infectious  Eliminated by immunisation programme

Bronchiolitis  Commonest serious respiratory infection of infancy  1-9 months  Viral infection (mainly RSV)  Coryzal symptoms followed by dry cough with increasing SOB  Tachypnoea, hyperinflation, bilateral fine crackles and wheeze  CXR: chest hyperinflation  Supportive management to address hypoxia and maintain hydration (1% require assisted ventilation)

Whooping cough  Bordetella pertussis (highly contagious)  Spread by droplet infection  Characteristic inspiratory whoop (may be absent in infants)  During paroxysms of coughing the child may go blue and vomit  May persist for 3 months  Culture organism from nasal swab  Erythromycin reduces infectivity but does not shorten duration of symptoms

Asthma  Most common chronic respiratory disorder of childhood- 10%  Clinical diagnosis usually based on history and examination  If >5 able to demonstrate diurnal variation in PEFR  Wheeze= whistling noise made by the chest

 History: Nocturnal cough Intermittent symptoms Triggers Exercise tolerance Atopy FH of asthma Parental smoking  Examination Usually normal between attacks In chronic severe asthma: -hyperexpansion -pectus carinatum -Harrison sulcus

Asthma Treatment  Aim- asymptomatic with no exacerbations  Educate child and parents on avoidance of triggers, importance of regular therapy and correct inhaler technique  Stepwise approach: British Guidelines for Asthma Management: Step 1: Inhaled SABA Step 2: Low dose inhaled steroids (if requiring 3xday SABA) Step 3: Add LABA or leukotriene antagonist Step 4: Increase inhaled steroid. Oral Theophylline. Leukotriene antagonist. Step 5: Alternate day oral steroids.

Metered dose inhaler: competent older children Metered dose inhaler plus spacer: useful in all children, highly effective as do not rely on technique. Dry powder inhaler: 5 years +

Cystic Fibrosis  Autosomal recessive disease affecting 1 in 2500  Mutation in CFTR protein resulting in defective chloride channel, increased viscosity of secretions in respiratory tract and pancreas  Consider in any child with recurrent chest infection or failure to thrive  Repeated infections lead to bronchial wall damage and abscesses  Deficiency of pancreatic enzymes results in malabsorption and steatorrhoea  Diagnosis: screening performed as part of Guthrie test. Gold standard diagnostic test is the sweat test. Genetic testing also useful to confirm diagnosis.

CF Examination General: small for age, Creon supplements or insulin around bed Peripheral: finger clubbing Airway: nasal polyps, hyperinflated chest, crackles GI: scar from meconium ileus operation

CF Management  MDT approach  Respiratory: physio, aggressive treatment of lung infections  Nutritional: high calorie diet, vitamin ADEK, Creon (pancreatic enzyme supplements)  Severe lung disease may be considered for lung transplantation

Thank you