Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

We'll just give people a couple more minutes if you could just let me know in the chart if you can see the slides. Ok, and hear me. Ok. That would be great. Right. We'll get started just because it is seven and I know a lot of you are still on Christmas holidays, so you probably don't want to spend too long. Um, so, hi, my name is Chrissy. I'm an F one. I'm currently working in the trend today. We're gonna be looking over some pediatric respiratory conditions, some of the key ones for the UK MLA exam. Um, I'll have some questions going sort of throughout. Um, it'd be great if you could interact, just answer in the chat with your answers. I've got a couple of polls as well. Um, just make it a bit more interactive and there'll be a chance for questions at the end. I've also put my email address at the end of the presentation as well and I'm more than happy for you to message me any questions you have and I'll either answer them best I can or find someone that can answer for me. Ok? So just, um, a quick look at what we're gonna cover. Um I plan to try and get through quite a lot. So it will be a bit of a whistle stop tour. Hopefully giving you a bit more of that high yield revision that you've probably joined this call for. Um, my advice would be to sort of make notes as you go along, but don't stress too much because the slides will be uploaded. You'll be able to watch the recording back so you can look back at anything you're not sure about. Um I'll try and signpost you to anywhere um for some good sort of advice along the way if I can. Um So I've just included this picture. It's just a very quick look at without going into too much detail. Um, a pediatric upper airway anatomy, um especially in babies and sort of your infants. It's just keeping in the back of your mind when we're talking about all of these conditions, some of the things that make a pediatric airway different to an adult airway. Um So thinking about how sort of, especially relative to their size, the tongue is much larger, um They have these narrow nostrils as well, which when we're speaking about breathing can make quite a big difference. So first, um we're gonna look at bronchiolitis. Um So one of the most important things I'll cover it in detail with this condition and then with the others won't go into it. Um Is thinking about sort of your, your features that you want to ascertain when you take a history. Um, so obviously you have your pediatric history taken, which if you want a session on at another point, let me know and I can look at including that as well. Um, but really what we're talking about here is that focused history taking. Um, so you're wanting to ascertain sort of any symptoms that happened beforehand? Any coral symptoms? Have they had a runny nose? Have they had a bit of a cough or is this something that's newly come on today? Um, and before today, they were not unwell. Um, you're also wanting to look for those signs of respiratory distress and we'll go into those a bit more later. Um, obviously this is very similar all of these so far to adults as well with the dyspnea and tea as well. Um, but more specific to pediatrics, um, is the poor feeding. That's a good sign for you. Um, as a clinician of how unwell a child is, is how is their feeding? And the best person to ask is the parent or carer. Um, are they taking less bottles than normal? Do they normally breastfeed? And they've not been latching well, um, but normally they're fine and have no trouble. Are they a toddler that's normally going around grabbing food constantly and always eating and now they've got no appetite. Um, these are some of the things that you want to ascertain. Ok. So the first poll, um, which I hope will work. I'll start this. Now, we're looking at what is the most common cause of bronchiolitis. So if you just submit your answers to that, take you a minute. Ok. So we have a couple more seconds. Yeah. Ok. Perfect. So we've had 95% of you have said R SV. And that would be correct. Um If you said any of the others, they are all causes, but the most common cause is R SV. So, um, just worth being aware of that for your exam, but it could also be caused by any of the others as well. Um And now is when I need you to sort of message in the chat if you can. Um, what are some signs of respiratory distress that we might be looking for? Um, either in an infant, a baby child, adolescent, I'll give you two minutes if you type in. Perfect. Yeah. Nasal flaring, grunting, head bobbing. Yep. Perfect. Yeah. Retraction. Wheeze. Yeah. Shallow rapid breathing, abdominal breathing. Yes. Perfect. Yeah. Great. Perfect. So I've split these into sort of going from the more mild ones to the more severe. That's not to say that you wouldn't be worried. Um, if you saw any of the things that you've suggested. So starting with sort of your more mild ones, you might have a bit of abdominal breathing. Um The reason why these first ones are mild is because it could just be the normal way of sort of overcoming some difficulty. For example, if you were to go outside and run down to the end of your road, you might be doing so you might be working harder to breathe. But it doesn't mean that you're actually in any kind of real distress or, or real danger of losing your airway, you're just working a bit harder to overcome the issue. Um That's been caused. Um Tracheal tug, it's worth knowing that the older the baby or um that's the more serious that is as a sign. So in very, very little babies or um very young babies, I should say neonates, some tral tug can be more of a mild sign. Um Nasal flaring and intercostal recession are sort of your moderate signs and then your more severe is the head bobbing and grunting. Um I wouldn't worry too much about being able to sort of classify them cos realistically at this stage. Um Even when you're first working, you're more wanting to say, is this a patient that could be in respiratory distress or not? Um So just to be aware of those. OK. So here um is just a slide I've put together that will um help you to think about breathing in infants. So this is actually how it's taught in APL S. Um So don't worry about memorizing it or anything like that cos it's not on the UK MLA content. But it can help with understanding things a bit better, which in turn might help with the UK MLA. Um So in APL S, we divide respiratory distress into effort, efficacy and effect. Where effort is the rate and work that the child is doing. Efficacy is the oxygenation and CO2 removal, cyanosis effect is for example, tachycardia poor perfusion. There might be mottling of the skin, reduced G CS, et cetera. I think maybe not everyone thinks, I think this is uh the best way to think about breathing in babies. And you're asking yourself three things, are they working hard or not? Is it this effective or not? And what is the systemic effect of the effort? So we'll put that into an example. So you may have baby one who's got some intercostal recession, you think they're working a bit hard to breathe, it looks like it might be a bit difficult for them, but it's effective. They're maintaining their saturations really well. And the baby is alert throughout uh no apnea episodes. But you could have baby two again, has some intercostal recession that's working quite hard, but it's not effective. And this baby has poor saturations and a reduced G CS. The difference in these is they have the same effort that they're putting in, but it's the efficacy and effect that's different. Um So it's remembering to look at all of these things. So in this scenario, chances are that actually baby two is in such severe distress that they're so worn out, they've not got the effort that they can put in. So actually all that they can manage is working a bit harder with some intercostal recession. Right. So, the important thing, when would you admit someone to hospital or child to hospital? Um, so there's all sorts of exact numbers you can look at, um, with, as with anything, sort of having an idea of rough numbers is great for exams, but in practice, a lot of it is done based on clinical judgment. Um if there's episodes of apneas, then absolutely admit them, ballpark figures, oxygen saturations less than 90 if the baby or child is over six weeks. Um or if they are under six weeks, then you're looking at less than 92% or if they have any underlying health conditions in terms of oral intake, that's also really important. You're looking to around 50 to 70% of normal intake. Um If you think about sort of when you're unwell, you might not feel like eating as much. But normally, unless you're very, very unwell, you're still able to have some water. You think about a baby, they're getting all of their nutrition sort of from their, either their formula or their breast milk. So they've not got that water intake as well. So we do become very worried very quickly if they are not getting their oral intake and again, moderate respiratory distress. Um So based on those symptoms, we looked at a few slides ago, but if you are somewhere like in a GP and you're not really sure it is always better to err on the side of caution. So some management for bronchiolitis, um, the main things is think about sort of similar in adult medicine. Your A to e approach your treating as you find things A to e will tell you sort of what you're trying to do. You might see that they need oxygen. So you give oxygen, um nasogastric fluids can be used if they don't have good um, intake, um or a gastric um, tubes can be used. This would sort of be found in the neonatal unit mostly. Um, it's when babies aren't able to suck properly. Um IV fluids may be required. Um You can use high flow or noninvasive ventilation if you think some uh baby is at risk of respiratory failure. Um, an upper airway suction in, you'll use this in apneas as you're not sure you can't be sure you need to make sure the airway is clear if they're in distress or their feeding is impeded by upper airway secretions. So, in the comments now, so we've got a baby with, um, we think this is bronchiolitis. When might we consider um, pneumonia as differential? What might suggest that this is pneumonia and not a bronchiolitis? Just give you a couple of minutes. I'll take that these people either. Oh, yeah. Fever. Perfect. So two things really high fever. Yeah, duration as well. That's very true. Um Actually you might be suspecting it. It would probably be on your differential um list, but high fever definitely. And the other one that I've put down is persistently focal crackles. So is quite hard with babies and young Children. But if you're able to listen and you can hear that it's very much localized to one area, you might be thinking that there's some consolidation there and that's what is causing that. So for the next one, again, if you can answer in the chart, that would be great. What would make you think about viral induced? Wheeze. So if you got any answers, anything you can think of when we speak about viral induced wheeze, yeah, vary. Wheeze sound after a recent viral illness. Wheeze over Strida. Perfect. So one thing um so this top point, persistent wheeze without crackles, I've put that there as a bit of a warning. I've seen this written in some textbooks. Um just don't fall into the trap of this is the only thing that is sort of makes the difference um because some bronchi babies may sound wheezy and vice versa. So just be a bit aware of that. Yeah, I've also seen older infant over one great. Um So the main difference is the pathophysiology. So you're looking at bronchiolitis is a slow prodrome over days. Um The viral induced wheeze as you've correctly said is usually above 12 months old, usually a shorter illness. Um, and the work that they're putting in to their breathing is out of keep with the rest of their illness. Um, and you've got that prolonged expiratory phase with the wheeze. Um, and they have a bronchospasm which is not something you can necessarily see or ascertain from the history, but you get that impression. Um, so the idea of the work they're putting in is out of keeping with the rest of their illnesses, they might have something that to another child is quite mild. They might have had just a little bit of a viral infection, a bit of a cold, but actually, they're really struggling with their breathing. You wouldn't expect a child to be wheezing just because they've got a bit of a cold. Um, between nine and 24 months of age, there's a mix of pathology. Um, almost all, under nine months will be bronchiolitis and almost all above 24 months will be viral induced. Wheeze. But in the middle there is a real mix. And again, um, illnesses don't, um, read textbooks. So that's not always the case, but that's pretty much how it follows. And especially with your SBA questions for exams, sort of those age ranges can really help you to find what the correct answer might be moves us on to our next sort of point, which is multi trigger. Wheeze. You might have heard of this. As early onset asthma. Um, multi trigger, wheeze is kind of the preferred terminology now, but you'll probably hear a bit of both. Um, it doesn't matter too much. We are trying to move towards multi trigger. Wheeze though. Um, the most important feature is there are interval symptoms and they'll wheeze more than just when they have a cold. So they'll wheeze at night, they'll wheeze cos, the house is a bit dusty. They'll wheeze cos they went to a friend's house that had a dog and they might have a bit of an allergy. Um If it's someone with viral wheeze, so recurrent viral wheezes, they'll get their cold, they'll look unwell and then they'll get better. Um Whereas your multi trigger wheeze, they don't have this pattern of sort of getting unwell and then getting better. They sort of have these on and off phases of wheezing. Um And then just a note there at the bottom, multi trigger wheeze are more likely to develop asthma as they grow up. Um viral induced wheeze, they tend to grow out of it by age five. But again, just be careful, there'll always be some crossover that you will always have some that don't follow the rule. So here is just a bit of a memory tool. It's not that sort of straightforward, but a bit of a memory tool for viral induced wheeze. This is kind of how um the illness will go. So you encounter a virus Yeah, a bit of inflammation and edema, the airway walls will swell, the smooth muscle will then constrict and then that airflow through a narrowed airway is what causes the wheeze that causes the restricted ventilation and then that causes the respiratory distress. So now we're gonna move on and we're gonna look at acute asthma. Um Does anyone know? And again, put any ideas in the chart, um, how we classify asthma or some of the things we might be looking at when we're classifying acute asthma? Yeah, great. These are all all correct. Two things that we'll be looking at ability, complete sentence, great triggers. Perfect. So acute asthma, we're looking at moderate severe life threatening. Again, different trusts, different places, different experts may have a mild, they may have moderate, they may have severe most now will use moderate, severe and life threatening. Um You again have all these numbers that you could memorize if you want to. But as long as you can roughly know where something fits in. So the the sort of the crude test in the easiest way is if you're talking to a child and they're able to speak back to you, they've got normal speech, you'd probably say they've got moderate asthma, they're able to complete the sentence and they're OK. If they're needing to take a breath, mid sentence, then we'd likely classify this as severe, especially when coupled with sort of an increased respiratory rate or their saturations have dropped life threatening. The most important one is that silent chest. That's a scary, scary sign. That is, um sort of, you immediately need to get as many people in to help you as possible. That's something you don't ever want to be seeing. Ok. So key management of acute asthma and I put in brackets or viral induced wheeze follows kind of similar thing. Um So you're looking at your four steps of supplementary oxygen again, back to this whole a to e idea sort of treat as you find they're struggling with their saturations, give them some oxygen bronchodilators. We've spoken about the airways sort of constricting. So we want to try and open those up, make it a bit easier for them to breathe and then very similar to in adults. Um We're looking at steroids next. So, oral prednisoLONE, IV, hydrocortisone, um IV steroids is something you'd be definitely looking at a senior to um ad advice on whether that's something that needs to be started antibiotics um depending on the cause. Um And then bronchodilators again the same way as in adults, which you probably know, um they're stepped up as they're required as well. So I think I've got another pole for you. Let me OK. So this one is looking at, when can we think about discharging a patient who was admitted with acute asthma? Ok. So we have a bit of a mix of answers there. That's OK. It's either something you know and have come across or you don't. So what we say or the guidance is um when on no more than six puffs, four hourly of salbutamol. And that may seem like quite a lot. Um But actually your sort of most important things when discharging a patient is sort of remembering that from acute asthma, it can take a while to recover. Um So actually, six plus four hourly of salbutamol is not a lot compared to when they were having back to back nebulized salbutamol, maybe IV steroids, um et cetera, et cetera. And actually, while same as with an adult, while a child is in hospital, they are more susceptible to hospital acquired infections as well and further complications when you are looking to discharge someone, um you need to make sure your safety net, always safety net. Most important thing. What should the parent or carer be looking out for? When should they bring them back? What should make them phone an ambulance? What should make them go to the GP? Um What should they do if they get home and they don't know sort of what's going on? Um et cetera, individualized asthma plans. Um It the way sort of asthma is going now, everyone should be having individualized asthma plans. These should start from even in adults with GPS, um producing asthma plans as well at annual reviews, but also these should be reviewed with every acute admission as well to check that they're still relevant if any changes have been made, um, encourage parents to stick it on their fridge, make sure they've got a copy on their phone. Um, if the child's at school, make sure that the school have a copy. So they know what to do if um, they think that the child is having an asthma attack. And then most importantly, when you're the one discharging a patient, are you happy that the parent or carer understand enough about the child's asthma when to get help and how they'll manage at home to be happy to discharge them home if you're not, and you're not sure, you're not sure the parent understands the severity. You're not sure they're gonna be able to safely administer this salbutamol yet or they need a bit more asthma inhaler training. Keep the patient in just so that note as well. Some of you may come across on placement or when you're working or maybe even some things you read reducing regimes. So Children that were admitted with an acute asthma attack used to be discharged on a reducing regime. So on their last day of admission, they might be might have been on six puffs four hourly of the salbutamol, their reducing regime will tell the parent that they're on day one. They should now be on four puffs four hourly and you'll do that for two days and then you'll do two puffs four hourly and so on and so forth we are moving away from this um and actually trying to encourage limited salbutamol use um and trying to encourage regular assessment of a child instead. Um and with that comes more sort of education for the patient if the child is old enough, but the parent um just to answer the question in the chat, yeah, it should always be spaces in pediatrics and actually even in adults now, um they are trying to push for spaces to be u um used more as even in the best inhaler technique, a spacer is just more effective. So when looking at chronic asthma instead, um the most sort of important things are things you've already pointed out about asthma. It might be episodic. Um You're seeing these intermittent exacerbations, sort of, it's happening at night. It's happening when they have hay fever in the summer. You've seen the typical triggers of the pet fur and dust, that should say history of other atopic conditions. Is that be that in the family or in the individual themselves? Have they sort of got the eczema asthma hay fever triad. Um They have this bilateral widespread wheeze. Um it's not sort of located in one area, you can hear it throughout the chest often, you don't even need to listen to the chest, you can just hear them from the end of the bed wheezing away. Um, symptoms will improve with bronchodilators uh with some Children that takes longer to find sort of the level that they need. But in general, asthma improves with bronchodilators. We know that works well. It's just finding sort of the best regime for each patient. So we'll move on looking at croup. So what you need to remember here is this is an upper respiratory tract infection and it's causing edema in the larynx. Um and this is typical in your six month to two year old Children. Um for your exams, be aware of parainfluenza as the cause recruit. There are as with everything multiple causes, but that is the one that they'll ask about a lot. Um, it usually responds well to dexamethasone treatment. Usually only need a single dose and they're better and there are some of your other causes there. Um, in the chat again, um, if you could put any ideas you have about how does croup classically present, what might a child present with that's making you think of this as the diagnosis. There we go. Spot on barking cough. So, presentation is this barking cough. Um, we're actually finding now a lot of parents are very aware of croup as a diagnosis. A lot of them will come in and they know exactly it's a barking cough. Um I think my child has croup. They may have a hoarse voice, stridor a bit of a low grade fever, increased work of breathing. But obviously, that's not very specific to this. You see that a lot, most cases can be managed at home with fluids and rest. Um, these cases again, important to speak with the parent or carer, safety net advice. When do they need to come in? What are they looking out for? And as well as a bit of reassurance, um, it's very scary for a parent or carer who thinks their child may be sort of struggling to breathe and they're hearing this cough and they're distressed because they're not sleeping. Um, so they need a bit of reassurance of sort of that the child is ok. Here's what you can do if XYZ happens, here's when I'd want you to bring them into hospital, here's when you need to get more help. Um So as I've mentioned, oral dexamethasone, a single dose, usually, um, it can be repeated, but normally that is very, very effective. You'll find, um, some of you may see in GP practice, some GP practices do give this others, they will phone across to the local sort of pediatric department or pediatric A&E and essentially the child will sit with their parent in the kind of waiting area or a quiet room, um, be given their dexamethasone and they'll just sit and wait or they'll sit and play with toys and then once we see that they've improved and they're ok, then they'll go home. Um, that's very trust dependent, that might even be sort of GP dependent on what people are comfortable with doing. Um, but often there is that option if we need to. So now this one, I want you to remember as the emergency, you always want to be thinking about epiglottitis. You want to remember this one, because it's a life threatening emergency within a very short amount of time. Um, there can be so much swelling that the airway is completely obscured. Um, and you could be in sort of, um, big trouble trying to help this child. Um, in general, sort of be suspicious in Children who haven't been vaccinated. Um, cases are now reduced and this is due to the vaccination programs in Children. Um, in any child that's presenting with fever, sore throat, difficulty swallowing and sort of sitting forward. Drooling is kind of the pediatric equivalent of the tripoding position. They're sort of leaning forward, they're really trying to catch their breath but they're drooling because that airway is closing. Um, you really want to think about Piloti. Ok. Does anyone know what this is showing what this is or any ideas you have around it? Yes. So, all correct, basically. So it's sometimes known as the thumb sign, the thumb or the thumb print sign. Um, and that's a soft tissue shadow and that's caused by that edema and swollen Piloti. Um, in practice though, you're probably not gonna see this. Um, cos again in the chat, in practice, how would you go about investigating and managing epiglottitis just again, one or two words or whatever, you know, already. Yeah. Perfect. Um, here we go, Emily, that's essentially ideal. Don't examine them. Um, very, very calmly get, yeah, someone with those senior airway skills anesthetics, ent surgeons as well do not try and examine them. Remember that in Children and, um, especially the younger they are any kind of examination is distressing. So, when you're thinking, oh, I'm just gonna ask them to open their mouth or I'm just gonna put my stethoscope on them for a lot of Children that's distressing and that sort of distress could be enough to prompt that airway to close. Um Some general advice is have them sit on a parent or carer lap, you can get the high flow oxygen just somewhere near their face, don't try and put it on their face just somewhere sort of near them. Um And again, spelling mistake, sorry that they calmly contact ent and anesthetics. Um And start to think more about the logistic things. How are you gonna transfer to theater um while keeping them calm? Um What does that look like if the child's happy playing with toys, you don't try and take those toys away, those toys are coming with you and they can be dealt with later. Um And then one of the most important sequelae to be aware of is apnea and that is what causes babies to die. So, so, so important to not try and examine these Children. Um and just get help even if you got help, senior anesthetist came, ent came and they said it, it isn't this, it's not epoc fine. You, that's better than if you've gone. Oh, I'm not sure. But I think it could be this. You spent time examining the child's now upset and crying and their airway starts closing. Ok. Ok. So, whooping cough, um, again, upper respiratory, um, normally starts with mild cries or symptoms. You're kind of seeing a bit of a trend now, a fever. Um, but the more severe coughing episodes will start after a week and sometimes even longer. Um, and you normally have this loud inspiratory sort of whooping noise. Um, that's present when coughing ends. Um, quite often these coughing bouts are severe and will continue until the child is completely out of breath. And that's why you get that inspiratory noise as well. Cos they're really having to try and catch their breath after it's also possible and not massively uncommon for, um, Children to cough so hard that they either faint, um, or develop a pneumothorax as well. Again, to be aware of and important for the UK MLA cos one of the things they want you to know about is notifiable diseases. Um This is one of those. Um, again, there's a note there about antibiotics. I wouldn't worry too much about it, but you could just be aware that, um, as with a lot of notifiable diseases, prophylactic antibiotics can be given um, to close contacts, especially if they're vulnerable um, and also to warn parents mostly that this is sometimes known as the 100 day cough. Um, often you're expecting symptoms to resolve in around eight weeks, but there is the potential for a longer duration and that can be completely normal. Ok. So we're moving on now to one of our last topics. We're gonna look at cystic fibrosis. So I'm gonna put a pole up now. So we're gonna look at cystic fibrosis. So, what is the most common ct fr gene mutation in cystic fibrosis? Um Just answer off the top of your head. Try not to look it up if you don't know, just give it your best. Great. OK. So we've got a few mix but most saying the delta F 508, which is a class two mutation. Um 88% of the mutations are class two. And this, these class two ones, probably the most important one to be aware of is where um the protein, the CT FR protein does get created, but it is mis it misfolds. Um And this stops it from being able to move up to the um cell surface. So important to know autosomal recessive, um You're sort of looking at one of these mutations, probably be aware of the most common one. Don't worry too much about the others because that would be very mean of them to ask. Um sort of key things to think about is the thick pancreatic um biliary secretions, low volume, thick airway secretions and the congenital absence of the vas deferens are important to know about sometimes the symptoms of a chronic cough. You may have the thick sputum production, recurrent infections, ster arteria, um abdo pain and bloating. Um You do also, it sounds like a bit of a textbook thing but you do get parents that say that when they kiss their baby, they taste salty. Um and you will also see faltering growth as well, then signs then is low weight or height on growth charts. So when you're plotting those growth charts important to look at, they also get nasal polyps, finger clubbing, crackles and wheeze and some abdominal distention. So diagnosis often picked up with a newborn blood spot test, sweat test is the gold standard for um diagnosis. There can be genetic testing for the CT FR gene during pregnancy with amniocentesis or CVS. Um and just a bit of a bonus question, just list any, you know, in the chart. Um of what is, what else is screened for on the newborn blood spot test. I'll just give it a couple of seconds for a few more. Ok. Yeah. So a lot of you get in the most important ones and pull great with day five as well. So ideally day five after birth, day eight at the absolute latest, um don't stress about memorizing all of these. Um No, some of the main ones, sickle cell CF and the hyperthyroidism. PKU, probably the most important ones, those first few. And then if you could just recognize the names of the other ones, you'd be doing great important with. Um, CF, is thinking about infections. You've, you probably know one from studying medicine, but two from watching anything on TV, involving CF patients, um, that we're talking a lot about these colonizers. Um, the key ones that you should be aware of are staph aureus and pseudomonas. Um Pseudomonas being that one that is very, very difficult to get rid of, it often becomes resistant to multiple antibiotics. Um, and those patients unfortunately do have a crea an increased morbidity and mortality just because we really struggle um, to treat them. So your general CF management, um chest physio several times a day, you'll find that both patients, patients, parents and carers become absolute experts. They're dealing with this from very, very young age. They know what they're doing. They often know way more than we do. And actually, when these patients become admitted into hospital for an infection or something else, actually, they will be the ones telling you no, I need to do this or no. My child needs to do this. Um, high calorie diets. Uh Creon be just be aware of it. Don't worry too much. Um Prophylactic antibiotics can be used bronchodilators. Again, we're just thinking about um, sort of what's happening with the airway, what's, what's causing these symptoms and how we can treat individual symptoms the same with these sort of nebulizers as well. The vaccination program is very, very important because we want to try and um limit the amount of infections being picked up. Um and then monitoring and screening. Um so diabetes, osteoporosis, bit D deficiency and liver failure. Um and then just a little bit about complications. So, 90% M CF patients will have pancreatic insufficiency, 50% will have CF related diabetes and need insulin. 30% liver disease. And then the absent vas deference causes infertility. Ok. So we're gonna finish on an S VA um rather than me read it out, I'll give you a minute to read it, then I'll put up the poll with the answers and we'll go through if anyone's feeling brave as well, it would be great if you could put maybe a couple of your reasonings for an answer or why you've excluded something um in the chart as well, just skip a few more seconds for any lost answers. Ok? So we had a range of answers. I think 75% of you got the correct answer so well done. But also this is one of those tricky ones that shows you that sort of SBA S are what you need to practice because within the stem, there are things that point you to probably each one of these diagnoses as well. Um So just to pick up on what's in the chart, so I will not appropriate needs dexamethasone. Yeah. Uh cough and cries or symptoms and failure to respond to a SABA is croup correct? So that wouldn't improve with inhaled foreign body after salbutamol. That is also correct. So that does lead to that. So then if we break it down, um the lack of wheeze. So it's being careful with these SBA S and it's quite sneaky. Just the wording, um, noisy breathing doesn't mean wheeze necessarily. Um And the little improvement makes the sort of viral induced wheeze unlikely. So I just remember in that viral induced wheeze, asthma likely to improve with salbutamol. Um We sort of, we'll come back to group, um It's unlikely asthma again, very similar to viral induced wheeze that lack of wheezing, lack of symptom reversal. And again, just remembering with pediatrics, um asthma, this is the first presentation we're not likely to slap a diagnosis of asthma on it at this stage. Um, inhaled foreign body, be aware of sort of what was said in the chart is absolutely correct. And was something that I thought of with this question as well. Um Again, this is more a sort of a UK MLA thing, um med school exam thing to be aware of. It's overnight. No mention of playing with toys is one of those ones that you can rule out on those grounds. Um, epiglottitis, interestingly, no one went for, but um it should be a main differential as well. However, the thing that's pointing you away from that is that symptom onset, um, symptoms, sort of developing over a few hours with no preceding symptoms would be more titi. So then that takes us to our answer. So likely that this is a bit of a secondary infection. We spoke about the child being a bit unwell beforehand. That inflammation of the upper airways leads to that partial obstruction. That's what causes that noisy breathing. So that's the upper airway sound, that difficulty in breathing cries or symptoms, the barking cough. So that's all I have for today. Um Make sure you fill out the feedback form because that means that you'll get a certificate and that also gives me a chance to sort of adjust for future sessions. My email address is there, it will be on the slides that are given to you, but equally, um you can take a picture, email me any questions you have at any point. I'll try and get back to you sort of as quickly as I can. Um, just for your information as well. All of these slides are sent through a pediatric consultant as well. So he does review them. So if there's any questions I can't answer, I can ask him for you. Um, and make sure you join other mind the bleep sessions and I'll see you at the next one. Thank you for attending and Happy New Year, everyone.