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Yeah, and everyone hearing me. Ok. Just a very quick. Yes, on the chat. Thank you. Ok, so hi guys. Uh my uh welcome to uh today's session. Uh My name is Nish. Um I'm one of the co-founders of a lot uh lot uh previously been the head of education for many years. Um It's, it's good to be uh to, to come back and uh teach today. It's been a, been a bit, a bit of, a bit of a while, but uh I do really enjoy teaching and it's good to be back and great to see some of you guys here today. Um So I'm gonna be teaching the second part of pediatrics. The uh first part of pediatrics uh was done uh about a month ago where uh Justin went over key uh card, cardiovascular and gastro gastro presentations. Uh Today, I'm gonna be taking you guys uh mainly through uh respiratory um pathologies in uh pediatric um disease. Uh that, that's one of the most important aspects of pediatrics, uh recognizing um key uh pulmonary presentations. As many parents get really worried when their child is out of breath. So it's really important to be very confident in these presentations. Uh, not just for exams but for clinical practice as well. And so there'll be a loads of SBA S today. Uh, make sure you guys interact with the polls, ask any questions you guys want in the chat. Uh, it'll be super interactive loads of fun, uh, session will probably last around, uh, hour, hour and 15 minutes. Ok. It'll be really quick. Um, we'll do loads of questions, uh really focused teaching that will, er, that's completely mapped to the sort of UK MLA C curriculum. So all, er, important conditions to know for your finals exams and hopefully you guys will have a really good comprehensive um, awareness and knowledge of pediatrics by the end of today. So just some of the key points II want you guys to remember before we go into the SBA S is some important um, bits of clinical anatomy um to remember about why um Children have, are more prone to um airway disease. So first point infants have really small airways. Ok. So if you think about a anything which is small, you know, if you ever, if you have a water pipe, ok, if it's just the smaller the radius, the harder it is for water to go, to go through it. Ok. If you increase the size, the easier it is for water to go out, uh to go, to go through the pipe. Ok. So infants have small airways, so small. Airways means you have a big rise in airway resistance, airway resistance if there's anything that blocks the airway. Ok. So, really important. So, in because naturally infants are smaller, smaller airways, they're more prone to any kind of airway disease. Ok. Any kind of ob obstruction. Ok. Infants are main, mainly nasal breathers. Ok. So any kind of obstruction in the nasal cavity, uh nasal pharynx area that's gonna significantly increase the work of breathing as well. Ok. So this is why, um when you think about um, if you ever see uh gone to pediatrics placements, ok. Uh Really important to always look through their nose if they are, if they are presenting with any kind of respiratory symptoms, check for any nasal stuffiness. Ok. Just doing a quick nasal suction, um can significantly improve a child's work of breathing. Ok. Really, really important um to remember because infants are mainly nasal breathers. If they're blocked in their nose, that's gonna significantly um affect their breathing. Ok. Uh, that's why I always think about tubes and a nasal suction. Ok? I mean another big, not so much for your exams, but when you are in uh in pediatric assessment unit, seeing these babies um acutely short of breath is a crying baby. Is a breathing baby. Ok. Really, really important. Ok. Uh obviously if that it's not nice to see babies crying, ok. But if they're able to produce a straw, um, cry, ok. That, that means that tells you a lot. Ok. That tells you that their airway is patent and they are getting enough oxygen to their vocal cords to be able to generate a strong cry. Ok. That, that actually tells you a lot of physiological information if they're able to produce a strong um cry. Ok. Uh But obviously if, if they are, do think about reasons why they are crying, but in terms of a breathing and airway perspective, it's generally a positive sign. Yeah. So we got our first question. Uh We're gonna co cover loads of different respiratory presentations. Uh But we'll start off with some sort of newborn respiratory presentations. Uh If you can load the Pope, get uh it's been minutes. You go about that. OK. Pull it there. So um I just uh I if you can clo close apo just blocked my screen, sorry. Um But yeah, so most of you have um chosen uh b um So let's go through it. The correct answer here is actually d um mater maternal diabetes. Uh So let, let's go, let's go through it. So, uh question uh questions uh basically uh regarding a newborn presentation of short of uh shortness of breath. So we have a newborn boy who's born with respiratory distress syndrome. We'll talk more about respiratory distress syndrome. Uh He's born uh vaginally uh preterm. OK? And he has got uh many different important clinical signs. OK? And we'll go through some videos of these but in terms of intercostal subcostal recessions, nasal flaring, what do you guys think these are signs of, what if you see these in a child? What are they? What, what does that mean? C cyanosis to keep you if you see all, all of these signs in a child? What do you think? What do you worry about? Very good uh respiratory distress? Ok. So I told you this is respiratory distress syndrome. So this child has got signs of respiratory distress. Ok. But I'll show out we'll go through a couple of videos and make sure you guys are comfortable recognizing these because they're very, very important. They're probably the most important thing you guys should take away from today's session. Um So this guy's got signs of respiratory distress syndrome, uh chest X ray here. Um I wanna describe main abnormality here. What is the, how would you describe the abnormality in on this chest X ray? Uh effusions? No uh angles are good. There's no meniscal angle here. This um so it's just bilateral um haziness, uh opacification increased um interstitial markings. You can describe it that way. Yeah, so just bilateral general haziness across both um airway spaces. Uh It's one of the key general common chest X ray finding ground glass appearance is very good. OK. That's the one that's the key description um for uh res dress. It's a key X ray finding. Uh question is asking what the risk factors for this condition? Ok. So the most important risk factor to remember is prematurity. Ok. And we'll go through why prematurity is a key risk factor. But another one is maternal diabetes. Ok. Um Anyone tell me what is the main cause of respiratory distress syndrome? What is the pathophysiological basis for respiratory distress in newborn? Why are they in respiratory distress in terms of physiology? Very good, lack of lack of surfactant. Ok. So um if there's no surfactant, think about pathophysiology, no surfactant means your alveolar are gonna collapse and that's where you can get the respiratory distress snd drugs cos your lungs can't expand properly cos there's no surface tension, lungs can't expand you, you, you're not gonna ventilate properly. You get these respiratory distress. Ok. Prematurity is a key risk factor because your lungs haven't had the time to produce uh surfactant. Anyone know why maternal diabetes might be a risk factor for respiratory distress. Anyone have anyone give me a pathophysiology, pathophysiological basis for that insulin interferes with production. Yeah. Yeah. Um So essentially with maternal diabetes or you know, just gestational diabetes, I should say um if your mum's got high sugar, that means the baby's gonna have high sugar. Ok? If the baby has high sugar, that means they're gonna have high insulin and insulin. Like uh like you said in the chat, insulin in, in insulin is gonna affect the production of cefa. Ok. Basically, um what, what is the most important um h um substance, a hormone that uh helps in surfactant production. What is one of the key hormones that helps with surfactant production? Do you guys know prostaglandin? What, what do we give? What do we give to improve surfactin production? Steroids? Very good cortisol, very good steroids. Ok. So that we give um we give mum um antenatal corticosteroids because steroids, you know, particularly cortisol helps with surfactant production uh with maternal diabetes when you have high insulin levels in the blood, high, high insulin um a um antagonizes cortisol. So if you have less cortisol, you're gonna have less surfactant production. OK? That's the main physiology. So gestational diabetes leads to high insulin in the baby. High insulin antagonizes cortisol. If you don't have enough cortisol, you're not gonna produce surfactant. You get respiratory distress. Ok. So uh talking about respiratory distress, I've got a couple of videos. OK. So I'm gonna show you some videos of um babies of some of the key signs of respiratory distress. Uh This is a trigger warning. OK. This these are babies who are unwell. Um But if that's gonna affect you in any way, uh just, just look away. Ok? But it's important to just be able to recognize these signs. We'll go through each video. Uh one by one. And you guys just tell me what um clinical signs you can recognize. OK. Uh A lot of you are saying uh recessions good. There are, there is a recession there. I I've got another video to demonstrate recessions. I'll play the video again. There's another important clinical sign I want you guys to pick up but you eyes are right. There is a, a subcostal re recession. There anything any other clinical sign? Very good. You guys got it. Um So yeah, uh you guys are right there is there is clear um subcostal um recessions here. Well, I'll show you another video of that, but the main one I wanted you guys to see is if you look at the nose, you can see the, the nasal flaring here. Um So that's the one I want you to pick up. So nasal flaring. So the opening of the um nostrils basically um that's one of the important signs of uh respiratory distress, ok? But remember I told you Children are mainly nasal breathers, ok? So if they're, if they're nasal flaring, it means that it's, it's a sign that the nasal breathers because because they're primarily breathing through the nose, they're trying to reduce their airway resistance, increase the radius in the nasal cavities. So that's why the nasal flaring, ok. Important sign of um increased work of breathing next video. Uh So this is just to uh help you orientate. This is the baby's uh neck, ok? This is the chin, but that one more time. Very good. You guys, you guys, you guys know your signs very good. So this is uh tracheal tugging again, another sign of increased work of breathing, sign of re respiratory distress. Um So essentially you can see the um trachea being pulled in. Um w when Children are, are in severe respiratory distress, a lot of accessory muscles are working. Um and uh everything's getting pulled in to try and increase the in uh pressure to try and help with the uh work of breathing, ok? And then you can see that that's why the trachea is being pulled in and downwards, ok? Because of the increased work of breathing. I look at this video, say that again, the child is not listening to music, head bobbing. Very good, very good. Uh So again, these are, these are all important signs of work of breathing. Ok. So here you can see the child just bobbing um forward and back. Ok. Um er, again, this is, again, is a sign of increased work of breathing. Er, here in this case, it's because of accessory muscle use. So particularly your sternal er mastoid and uh neck muscles being used to help with breathing because they're contracting uh a and at the same time as their breathing, that's why the head is bobbing forward and back again because they're not able to properly support the weight, weight of the head um fully. So if they, if the neck muscles are contracting the head's gonna move. Ok? X video, as you uh let's start with this one. Say it again. Yeah. So here uh have a look at the, mostly the chest. OK. And see what's happening with the chest. Uh Someone said subcostal recession. So this is more um intercostal uh recessions here. Ok. So if you see in the sternum sternum area, spaces between each um where it's mo mostly above uh sort of at the zip steroid level. So these are mostly intercostal recessions. Ok. Um You could, there is probably some, there is some subcostal recession as well. You can but it's mostly intercostal recessions, I'd say. Yeah. Uh I'll look at this one. Ok. What would you guys say is happening though? Yeah, so these are the, these are definitely um subcostal recession. OK. You can see clearly before below these if you start stone level, this is very clear. Um um subcostal uh recessions, OK? Uh recessions, recessions are a really, really um important um clinical sign to look, look for in respiratory um as a sign of respiratory distress. Ok. Um Again, it's because all your respiratory muscles are working harder, they're contracting, pulling everything in. So you're getting these um recessions. Ok. Really, really important clinical sign to look for. Ok. For these ones, uh these are all um er airway sounds to be looking out for. Ok. So for these ones, don't, don't worry too much about the video, think l listen to the sound and tell me what the clinical sound um is. Ok? Er, and hopefully the audio plays out. Ok. Uh I apologize if it doesn't, uh, come out that well on Zoom, but just have a go and try and tell me what you guys think. Uh, have a listen again. Anyone, anyone have any ideas what's causing the sound? What, what is the, what is the sound? How would you describe the sound? Uh, you can't hear everything. Ok. Uh, so, so I'll try and, oh, sorry about that. Ok. So, er, hopefully the recording might have picked it up. Um, if not, I'm sorry about that. This was, this was a, um, wheeze, um, expiratory. Wheeze. Um, any anyone tell me some common causes of a wheeze in a infant or there are some of the common causes of wheeze. Uh Someone said bronchiolitis really good. Ok. We're gonna talk about bronchiolitis in good detail today. Uh Croup, croup, you can get wheeze, it's mainly worry about another sound with Croup, which we'll talk about viral induced. Wheeze is another one. which again will I'll mention as well. Um, asthma gets. Ok. Um But yeah, yeah, asthma, bronchiolitis, viral induced. Wheeze really the common causes of, uh, wheeze in infants. Um, hopefully this the sound. Uh if, if the sound doesn't play out that well, don't worry about it. Just try and listen to, try and just Google, Google these sounds and make sure you're familiar with what they sound like. I'll just play this. Hopefully it'll play it better. Uh, tr er, nothing. Ok. No worries. Ok. So this was, er, sound of Stridor. Ok. Uh Can you guys list me to some common causes of stridor in infants? Uh, it is a in inspiratory strider croup. Very good. Ok. What I, what is the most common cause of croup in infants? Oh, sorry. What's the most common cause of, um, of, uh Stridor? I should say. Uh most common cause of stridor. It's definitely not epiglottitis, but epiglottitis is one of the most worrying causes of Stridor. Most common cause of Strida in infants. Very good. Someone's got laryngomalacia. Very good. Uh We'll, we'll talk about that as well. Very good, very good. Um So yeah, um we'll talk about many important cause of stridor, laryngomalacia, croup, epiglottitis, um foreign body obstruction as well. Really important cause of um Stridor. Ok. Uh I'll I II won't pay the last one. The last one is uh just showing um grunting sound. So, basically because this child is just so tired. Um And it's basically having no respiratory effort. They're just making those, those kind of sounds. Ok? They're just grunting and this tripod position, essentially, they're sitting forward, uh uh body upright trying to increase the passage of air. That's just a position. Uh If they're in very severe respiratory distress. Um A lot of, a lot of um infants will take up this tripod um position. Ok. Uh Sorry about the sounds. Um Just make sure you just have a, have a look on youtube and make sure you're able to um recognize these different sounds. Ok. So that was a quick run through of some important um er, clinical signs of distress in Children. Ok. So this table is basically just summarizing them and just a key sort of pathophysiological basis for them. So many different signs of increased work of breathing. And we talk about most uh most of these um airway obstruction, different breathing sounds and just remember general signs as, as well. Ok. Crackles hypoxia and your every everything you look in terms of your clinical assessment. Um Make sure you're very, this is probably the most important slides to take out of today. Ok. Make sure you are familiar with every single one of these clinical signs really, really important for exams and, and clinical practice. Ok. So next question, uh if you can leave the Pope, uh we're gonna start talking about different uh pathologies. Now you'll end up there. Ok. Um uh someone's asked me to just quickly go back to the last slide. So I'll just go back um quickly and. Ok, that's fine. Right. So, um Mo mo most of you have put down e and uh well done. That is the correct correct answer here. So can you guys tell me what is uh what is going on here? What is the cause of this patient's um symptoms? So, if you, if you just go through it, so this, we got a two day old girl Uh again, signs of respiratory distress syndrome, uh premature um developed a acute grunting, increased work of breathing, decreased breath sounds, um intercostal recessions, heart sounds louder. So, on the right side, what do, what do you guys think is happening? Very good pneumothorax. Ok. So uh a lot of the stuff in your adult medicine still will apply to your pediatric medicine. Ok. There are many of the the important clinical um knowledge you have of adult um apologies. So if you, if you go through this, so uh again, you've got a um distress syndrome. Why are you due distress? There's no er surfactant in the baby. And so I've made a point about saying this was a very rushed delivery, ok. So even though the mothers received antenatal cortico stories to try and improve surfactant production, it's a very rushed delivery. So it's probably unlikely that it's taken enough an effect to reduce the risk of um respiratory distress syndrome. Um I, we, you guys, I should be familiar now with the signs of respiratory distress. So, grunting, we I told you important uh clinical clinical finding increased work of breathing recessions, um all signs of respiratory distress, but I've made a point about saying there are decreased breath sounds unilaterally, ok? And heart sounds loudest over the right side. Ok. And um these are all pointing towards a uh in the context of respiratory distress syndrome when you're having these unilateral um symptoms. Um and especially your heart sounds like on the right side, we would be very concerned about um a pneumothorax. Ok. Specifically a te 10 tension pneumo tension pneumothorax. Um and it is patients also de desaturating as well. Um So really, really important is that uh patients who have respiratory distress syndrome are at a very high risk of getting pneumothoraces. Ok. Um Just because they are very fragile alveoli because of the lack of surfactant because they're not expanding properly. The alveoli can very easily rupture and air and fluid can easily leak into the pleural cavity and causing pneumothorax. Ok. So patients with uh babies with R DS, very high risk for pneumothoraces management principles for attention pneumothorax supplies same as in adults. Ok? You don't wait for a chest X ray and you go straight for needle decompression. Ok. Um Other options decrease nasal increase, decreased nasal cpap. Um You, you need to manage the pneumothorax. Ok. Echocardiogram. So this isn't a um tamponade. Ok. Even uh this is a uh tension pneumothorax. Ok. And uh that's why you need to manage with the decompression. Uh Another question, er, one is again related to respiratory distress syndrome. You guys are properly gonna understand neonatal respiratory distress. Er We got one more question on this and then I'll er we got a few um teaching slides on it. Uh Someone's asked why do you get pneumothorax secondary to cpap. So you're getting a pneumothorax. Um because of uh because um the, it's not the CPAP necessarily being a risk factor. It's the, um, it's the respiratory to distress syndrome is the risk factor for pneumothoraces. Uh, having, having ventilation on top of that can, does increase the risk of pneumo thoracis as well because it's causing barre trauma. Your alveoli are already very fragile so that can increase the risk of pneumothoraces. Ok. But yeah, but yeah, that a good question. Ok, let's pull it up. Uh Good. Uh Most of you, you guys are on it. Most of you got the correct answer again. Uh Which in this case is e bronchopulmonary dysplasia again. So, uh this question's all um going on some of the complications of um ventilation and prolonged oxygen therapy. So again, we got a child who's had um Respi stress syndrome. You know, he's born preterm low birth weight and told you he has R DS. So he's been on ventilation for uh the first er weeks of his life, but since coming off ventilation, he's remained hypoxic. Ok. And he still has um uh oxygen requirement. Ok. And the chest X rays um showed haziness bilaterally. Um So in this case, so we have a child with uh prematurity, uh respiratory distress syndrome, uh persistent hypoxia haziness on a chest X ray. Um This is one of the key, key complications of er, babies being on oxygen for too long. Ok. Um So this is a condition called bronchopulmonary dysplasia. One of the important respiratory complications of um mechanical ventilation. Ok. And most babies who have respiratory distress syndrome are gonna be on long term ventilation. Um, so with, with bronchopulmonary dysplasia, you're getting inflammation and scarring of the lungs and your lungs aren't gonna develop properly because of it. Ok. So that's why this child has continued to have an oxygen requirement. Uh haziness bilaterally or chest X ray is a common finding. Ok. Um So that, that's why this is the um correct answer. Ok, because you're getting, if you have scarred lungs, they're not gonna work that well. Ok. All all these other uh conditions uh and the, the um B BPD is the clear diagnosis uh based on the history of um ventilation and continued um oxygen requirement. Ok. So quick couple of quick slide on um neonatal spirit distress syndrome. You guys should be aware of a lot of these. Now. So I told you no surfactant, it is gonna lead to hypoxia and hyper hypercapnia because you have, you have impaired gas exchange because of the lack of surface tension, key risk factors. To remember, prematurity and maternal diabetes. We mentioned er typically the signs come on very quickly after birth and I've told you that it's gonna increase the risk of pneumatosis. Ok. Really, really important complication. It can also increase the risk of um PDA patent ductus arteriosis as well. Um clinical features. So all the signs of um respiratory distress, which we've mentioned can, will can happen. Ok. So if you make sure you're familiar with all those signs, it's the most important thing to take away from this session. Generally a clinical diagnosis. But as I showed you in that chest X ray, we've got ground glass opacities or infiltrates with air bronchogram. Ok. So on that chest X ray, there were air bronchogram where you can see visible air filled um uh bronchi, ok. Um And in terms of treatment, uh generally it's gonna be um some form of um ventilation. Ok. So generally it's gonna be CPAP with mechanical ventilation. Um uh With C with CPAP, you have an option called er positive end expiratory pressure or peep. And that's really important in respiratory distress syndrome because the key, the problem in respiratory distress syndrome is that your alveoli are collapsing. When you have CPAP, you can add in a peep, which is that um end expiratory pressure, which basically helps to splint all the alveoli open and stop them from collapsing. Ok. So that's why CPAP is generally the go to form of um ventilation in um neonatal distress syndrome. Uh Some of the key complications I've told you um some of these complications, er bronchopulmonary dysplasia is a really important er respiratory comp long term respiratory complication of um prolonged oxygen therapy. Other ones to be aware of is retinopathy of prematurity. So, because you're giving you giving a lot of oxygen that can cause new blood vessels to be formed over the eyes and uh, it can also blood can also accumulate in the ventricles of the brain as well. Uh, someone else, what's the name of the thing you can add? Um, it's called uh Peep P. Uh, it's an abbreviation for positive and expiratory pressure. Ok. Pe ep, peep. Um, other important answers in management. So they're deficient in surfactant. So you're gonna treat that by giving surfactant. Ok. Really think it important thing is you don't give surfactant um as a injection or intravenously. Ok. Cos er, if you think about it, it needs to be able to reach inside the lungs. Ok. So you're gonna basically, you have to intubate them and then spray the surfactant um using, using an endotracheal tube. OK? And most important uh preventative measure against stress, as I mentioned was the antenatal corticosteroids. Ok. You give it as soon as you, er, expect the mother to be, er, mother's gonna d deliver prematurely. You give it um two doses 48 hours apart. OK. To try and im improve the fetal um surfactin maturation. Oh uh So hopefully you guys are confident on, on respiratory distress syndrome. Uh Let's move on to another condition. OK? I think most of you got this. Yeah, so well done. I, most of you have got, are pretty confident in your answer here. So the correct answer here is c so well done. What do you think is the diagnosis here? What do you think is the diagnosis, what's going on here? Bronchiolitis. Ok. So, um you got a young child, ok, four months old. Um So someone's asked why not? Croup. Ok. One of the biggest giveaways for which, which respiratory presentation we'll think about is the age of the patient. Ok. Um Croup you don't typically get in this age group. Ok. This is a four month old and child. Um, bronchiolitis is much more prevalent in this age group. OK? And A we we got many different chest symptoms. OK. Difficulty feeding, shortness of breath, coryza sharp, a nonproductive cough, um tachypnea, tachycardia, hyperinflated chest and crackles, fine crackles as well. These are all classic clinical features of bronchiolitis. OK? These um various different chesty, chesty symptoms, um chesty cough, um hyperinflated chest crackles uh with signs of respiratory distress. OK. This is bronchiolitis. OK? And like you guys said, most common cause of bronchiolitis is R is R SV OK. Respiratory syncytial virus. It's a very, very common common condition. OK? You get epidemics of this and very common er in this time. OK. Winter time. Bronchitis is a very prevalent um common condition which you guys need to have good awareness of. Uh We've got another question I think on um similar presentation uh just have a go. Mm OK. Most of you have got the answer here, so well done. Uh You guys, you guys are right again. Um So correct answer here is a um so if we go through this again. This is a classic presentation of bronchiolitis. Again, we got a three day history of cough, Coryza wheeze increased respiratory rate, a slight temperature. Um but there's many different negative um findings here. Anyone. Tell me what, what is the thing that makes you think? Oh, I need to refer this patient to pediatric assessment unit or 25. I've already highlighted that. So, yeah, the main, the main red flag symptom here we think about is um the reduced feeding. Ok. So, uh even though I've told you there's many uh negative symptoms including no, not that many signs of respiratory distress. Ok? There is a wheeze and crackles but there's no recessions, no apnea, cytosis. The baby's only if the child's only fielding feeding around half of what they normally do. That's a red flag. Ok? And that needs to be escalated. They need to be admitted um for some supportive um care, need for some investigation, supportive care. Ok. So um we'll talk about, we'll talk about some of the key red flag symptoms and in terms of the other options, the paracetamol is not going to do much that I have a temperature. It's not going to do do, it's not the treatment for bronchiolitis, san Home Safety Netting advice. Uh Nope, they need, they're feeding only half half of what they normally do. They need to be admitted. Uh Well, not necessarily admitted but they need to have some um ob obs observation in er, assessment unit, salbutamol amoxicillin. And can anyone tell me how does salbutamol work in bronchiolitis? Does, does salbutamol work? No. Why does salbutamol not w, not work? Even though, even, even though they're having a wheeze and, you know, if, if they have a wheeze or some kind of um obstructed bronchus, why, why doesn't work in these Children? Why does this salbutamol not work in these young kids? No. Yeah. So uh essentially the salbutamol works by anti, by um antagonizing be two receptors, right? But you need to have the receptors for it to work. OK. So in the, when you're this young, you don't have the smooth muscle receptors that are gonna be acted on by salbutamol. OK? They need to, they need to get much older for these receptors to start to develop. So salbutamol is not gonna work. OK? So no matter how much salbutamol you try and pump in to open the airways, it's not gonna work. OK. So that's all I there's no evidence for the use of uh bronchodilators in um uh b in um bronchiolitis, OK. And amoxicillin as well. There's no, there's no evidence for the use of antibiotics in bronchiolitis as well. So when you think about the febrile febrile child, OK. Um Main thing, it really, really important to be aware of some of the key uh red flag symptoms. Ok. Um So I'm not gonna go through this in detail, but really important, just familiarize, familiarize yourselves with some of these key red flag symptoms. The this is taken from the nice um, traffic nice guidelines, the traffic light um system for um, triaging pediatric patients. Um So these, so the symptoms in red are obviously the ones you worry about most. Ok. And we've talked about some of these ones, uh, difficulty fee feeding, uh to get near a high respiratory rate, grunt thing we've mentioned. We've talked about a lot of these. So generally, if they're, if they're not that unwell, it's mostly just green Smptom, then you can manage them at home with safety netting if they're significantly unwell. So mostly yellow symptoms, then you consider admission, they need some monitoring and treatment in hospital and you want to do a full septic screen as well. Um uh you know, there's many different uh sources of infection in Children. So you need to do a full screen for various sources of infection and seriously unwell Children. So they have a lot of these red flag symptoms or any of these red flag symptoms, they need to be admitted to hospital. And you want, because for suspected sepsis, you do, you want to start intravenous antibiotics as quick as you can? Ok. So in terms of bronchiolitis, so, uh what is bronchiolitis? It's uh infection of the bronchioles. Certainly. It's a, I told you it's an epidemic. It's uh one of the leading causes of hospital admission in young Children. Most common cause RRS V. Uh prematurity is a big risk factor for um bronchiolitis um as well. And it's generally a disease of very young Children. Ok. It generally occurs less than one year. Ok. In most cases, uh in very young um babies. Ok. Clinical features we've talked about. Ok. Generally it's a clinical diagnosis. Uh If you have, if you have a young child with uh with these combination of clinical features, it's bronchiolitis until proven otherwise. But you can do other things like um uh nasal swab to look for R SV. Chest X ray has different findings as well. Uh We'll in terms of the main treatment options. So as I mentioned, there's no evidence for antibiotics, bronchodilators, corticosteroid therapy. Most of bronchiolitis management is supportive. Ok. So you're just supporting the different um vital functions, ok. Managing their temperature. So you can give paracetamol NG tube. So things like nasal suction cause I told you that improves the work of breathing. Um nasal um saline drops, decongestants and oxygen ventilation as they need. Ok. Uh big exam tip. Uh pa pa Palivizumab is a monoclonal antibody which is given for very high risk preterm infants. Ok. So if they're premature or they have, you know, other risk factors like cyanotic heart disease, um cystic fibrosis and things underlying um uh underlying risk factors. They, they uh immunodeficient for whatever reason, then they might be indicated for this um monoclonal antibody called alivium. Ok. Uh but again, it's not completely effective. You need to treat um, many cases of bronchiolitis to, to see one case be prevented. Ok. It's not a, it's not a completely effective um, vaccine. Ok. But it has shown to reduce uh rates of bronchiolitis. So it's, but it's very expensive, you know. Er, and that's why it's very, uh, limited in um, scope. Ok. You can only give it to, um, the patients who need it the most and that, that's why it's only given to high risk preterm infants. Next question. Yeah, bronchiolitis is a clinical diagnosis. Ok? But other things like chest X ray, um nasal PCR pulse oximetry, they all just help with your um uh clinical and judgment as well. Mm. Mhm. Ok. And I'll call it there. So most of you got this right? I'm glad you guys are, are getting most of these right? Because it shows that you guys are able to recognize these key emergencies and you guys are gonna be really safe um safe when you come on to pediatrics and always have uh be thinking about these important emergencies. Um So yeah, character here is uh epiglottis. So another important uh respiratory condition. Ok. Very uh not, not that commonly seen anymore and I will talk about why. So you've got a three year old who's um got uh got a sore throat, just woken up with a sore throat. Ok. So very acute, acute history refused to eat. Ok. So not feeding. Um, paracetamol hasn't helped. Um, has a very high grade, high grade um, fever. Ok. Really important. Ok. So epiglottitis, it, a temperature of 38.7 is high. Ok. So it's a very high high temperature. Um, and this is one of the key signs II told you how, what is the sign called? Patient sitting? Leaning forward, mother's lap, chin, thrust forward as well. Yes. Remember it's the tri tripod sign. Ok. So tripoding very, very good. Um Sometimes uh uh sometimes I've heard doctors call it the uh sniffing, sniffing, sniffing dog sign, ok. Where they're like sitting up with their uh mouth open just trying to get as much air as they possibly can. Ok. So, uh yeah, this is tripoding very, very worrying sign. Ok? If they're tripoding and uh epiglottitis in general is a very worrying condition because it's uh it can, patients can very quickly um deteriorate with it. Ok. It's a very dead, it can be very deadly. Ok? Um Other important signs are hoarse, muffled voice, rhinorrhea, and m mild stridor as well. Ok. So you get a soft stridor with epiglottitis, um hoarse muffled voice. So with epiglottitis, your epiglottis is inflamed and so you're finding it hard to swallow, um, and hard to speak. Ok. So a lot of patients, they'll just be drooling, ok? Because they can't swallow properly. They can't speak properly. So they have this sort of hot potato voice. Um, and their anterior neck is tender to palpation. Ok. So if you're pressing over that epiglottis area, it's gonna be tender as well. Ok. And it's the same question. Ok. Uh, same to vignettes. Uh, sorry, I forgot to change the question question. The question should say, uh, what is the most likely cause of the symptoms? Ok. Um, if you just, uh, read the answer options and let me know what you think is the most likely um cause for this patient's condition. Yeah. Again, don't, don't, don't worry about reading a thing. Just uh just have a look at the options and say what's the um likely cause? How do you differentiate between this and bacterial tracheitis? Very good, good question. So, bacterial tracheitis, generally, it's obviously expecting the trachea. Um it's, it tends to be a much more gradual onset. Ok? You do get very similar symptoms, but the onset is very much more gradual in bacterial tracheitis. And uh you don't get that neck tenderness. Uh The same way you get in epiglottitis as well. Ok. So generally the onset is the key thing that to help you differentiate bacterial tracheitis is quite rare, is very rare as well and it's generally, you have a, some kind of infection history. It's usually caused by uh staph aureus infection as well, uh which you don't have here. Um That, that, that's the vignette was very classical for hypoglottis. Uh Most of you got this right. So, yeah, well, done. So, lack of uh recommended immunizations. Ok. So, uh, what is the organism that causes epiglottitis? Most commonly, most common cause of epiglottitis. A as in, er, if you think wor wor worldwide. Yeah. Yeah. Hib. Ok. Hemo Hemophilus influenza type B. Ok. Um, so we don't, we don't see much epiglottitis now because we have a vaccine a, a against HIB. Um, so in the, in the, uh, especially in um UK and we we western countries, you don't see much epiglottitis as well. Uh A at all. Ok. Um So we have an effective vaccine against Hemophilus. So you don't see that many cases of epiglottitis caused by hip by hip anymore. You, in fact, you actually see a lot more cases of epiglottitis caused by um strep um organisms. But um immunization is the most, a lack of immunization is the most important risk factor to be aware of all these other things are not gonna be associated with eps. So, epiglottitis, really important condition. Um So if your epiglottis is inflamed, you can get rapid edema and swelling and your airway can very quickly, you can lose your airway, airway very, very quickly. Ok. Um It can be a very deadly condition. Um We talked about many of these, many of these symptoms. Ok. So um difficulty speaking, sore throat, they look very unwell, muffled voice, very high fever. Ok. It's like this is, this is a one of the most important clinical diagnoses. You can make, ok? Because the earlier you diagnose it and recognize it. Uh the better outcomes you're gonna have for the baby, ok? Because they need very urgent admission. You need to call, you need to call a pediatrician. You need to call an ent surgeon. You need to call a senior anesthetist, ok? Because they're gonna have very immediate airway admission management. They might need a rapid sequence induction and they need to be intubated very quickly. Ok? Um In terms of general management, they'll need broad spectrum antibiotics to treat it. And if they, if someone is diagnosed with epiglottitis, um close con any close contacts, we're probably gonna need um prophylaxis as well. OK. So a common antibiotic is uh rifampicin. Cool. So that's epiglottitis. Um Let's move on to another condition now. OK. Good. You guys are on this, you guys know your stuff. Um Yeah, yeah, you guys got it all done. So uh mostly you're going for e and that is the correct answer here. So um we go, we're gonna be talking about um Stridor now. So important causes of um Stridor. So, as I mentioned at the start, uh one of the most common cause of Stridor in young infants. OK. Is this condition called uh laryngomalacia? Ok. It's the most common congen airway condition. Ok. So we got a five month old who's presenting with uh some um er abnormal airway sounds. Ok. So he's got his squeaky sound when he cries and it's gone louder. OK. And he's also, um, been spitting up a small amount after feeds. He's got a, he's got a strider and this strider is w, is generally heard when he's lying flat but goes away when he's, um, in the prone position. Ok. Um, so this is, uh, this is very classic for laryngomalacia. OK? II know some people put croup but this, this isn't croup. OK? What the main things I gonna put point away from croup here is the age group. OK? He's a five month old. You don't get croup, generally get croup that this young and this sort of this, the stridor that disappears when he sits upright is also very classic laryngomalacia. OK. So with laryngomalacia, it's a condition where you have uh um Lary where your laryngeal cartilages isn't um developing properly. OK? Um It's, they're very immature and they, and it's lead and you're getting the stridor with it. Ok? Um It's generally, generally, if you have laryngomalacia, you grow out of it. OK? By eight, by around 18 months. Um but it's a generally a benign cause of a Strida. But some patients who have a very severe laryngomalacia can get complications like vocal cord paralysis and things. OK? But generally it's a very, it's a very common condition. Most most kids will grow out of it. This one is a bit more of a um worrying presentation. Have a good OK. This is interesting. You got a bit, a bit, a big split here. Very interesting. Ok, I'll call it that. Um, it's interesting. It's quite a big split tiff. Uh Let me just move this so big split test. So, um we've got a bit of a split between A B and E correct answer here is actually a so uh hope uh some important learning points here. So, uh what do you think is the diagnosis here? Where is the clay diagnosis in? Yes. So this is actually croup. Ok. This is very, this is very clear, severe croup. Ok. So uh it's a older girl compared to what he's had before. Ok. It's an 18 month old girl and he's got very classic symptoms of um croup. Ok. So barking cough is one of the most important uh things to look out for some coris symptoms, runny nose, um low grade fever, ok. Hoarseness of voice as well. And he's, he's got different signs of frus distress. So we've mentioned head bobbing recessions. You guys know these are signs of respiratory distress and she's got a Stridor. OK? And that Stridor is at rest, ok? And it's getting worse when she cries. Ok. So these are, these are all pointing towards a severe presentation of um croup. And uh as I was mentioned, one of the most important management steps in croup is corticosteroids to try and uh reduce the airway inflammation. Um So question asking me the most I thing to the important thing to realize here is the question asking what was the most important appropriate next step? OK. Um So she's already been given one dose of corticosteroids and things and things haven't improved yet. Um Can you guys tell me what is the general approach to a acutely unwell patient? What is our A, what is the approach we use A to B assessments? OK. And the what is the, what is the A airway? Ok. So I, yeah, a lot of you will put e high flow oxygen. OK. But if you think about our A three assessment breathing that comes after airway, OK. So we need to sort the airway problem out and if you sort the airway problem out that could potentially help, that will potentially improve the breathing problem. Ok. So it's an airway problem. Um croup is a, is inflammation of the larynx, bron bronchus and trachea. Ok. So it's an airway problem. So you need to resolve that airway inflammation. So initially, the you need to do something about the airway inflammation. Nebulized adrenaline is what will um help improve the inflammation? Ok. It dexamethasone as well can be given, but she's already been given one dose. It hasn't improved. And she's the key thing is as she's hypoxic as well. What is the advantage of giving nebulizers? Obviously, the adrenaline will help with the inflammation. But what else can you do with the nebulizer? Yeah, you can give oxygen as well. Ok? So if you, if you give a nebulizer, you can also drive, you can drive the medication with oxygen. OK. So with, if you give nebulizer, the adrenaline will help with the inflammation. You can also give oxygen as well, which can help with the saturations. OK. The saturations itself should improve with giving adrenaline. Um But that's why the most appropriate appropriate step here is option A OK. But yeah, it's uh hopefully you guys got some good learning points there. Obviously d is a very inappropriate option. This child needs some intervention. It's a bit early for intubation. Ok. There it's not, you don't need to escalate it that, that far yet. Ok. If they're not improving with uh adrenaline or there's a er, they start to deteriorate, then you would have, you, you would have a low, very low threshold for intubation, but uh it's probably not quite there yet. Ok. So it's oral Dexa first line. Yes. So I've told you that they've already been given one dose corticosteroids. So generally that would be your first line. Ok. But in this case, as they're hypoxic as well and they haven't responded to that first dose. So I would say the most appropriate option is the adrenaline. So let's talk about Croup. Ok. Um, the most common cause parainfluenza parainfluenza virus, it's also known as laryngotracheal bronchitis, ok? Because it's inflammation of the larynx drea and the bronchi. Ok. But mainly it's the larynx which are getting affected. Ok. And again you get tissue edema, swelling, airway, narrowing and severe respiratory distress. Ok. Generally it's, yeah, it's an older age group compared to bronchiolitis. Ok. Um, clinical features we've talked about, ok, barking cough, harsh stridor respiratory distress, key things to look out for. Again, it's a clinical diagnosis. Ok? You don't get with these respiratory presentations in pediatrics. You don't generally, uh, you shouldn't generally, um, delay um, treatment, um, because you, er, because of inter investigations, ok, you generally need to do a, have a clinical diagnosis in mind and, and start um treatment. Ok. Obviously you can do things like chest X ray things to help support your diagnosis. But generally all these presentations are clinical diagnosis. Um, you can do what's called a Wesley Wesley group score to categorize the severity of uh group presentation um in terms of key management steps. So we talked about it, um, minimal handling. So, uh, you don't, don't do things like a throat examination, ok? Because that can just, um, cause spasms and worsen things. Ok. Um, dexamethasone is the mainstay. Ok. So some um, oral um, corticosteroid, if they're not responding, then things like you have a very low threshold for A, for A PQ. So, ok. So a referral to intensive care for oxygen nebulizers, um intubation as well. That croup I've got a few more condition, uh, a few more conditions and we should be wrapping up uh, in the next 1515 minutes, hopefully go color. Ok. So uh most of you gone for a and that is the correct answer. Uh Well done. So, um what do you, what do you guys think is the diagnosis? Um here, what is the cause of this patient's symptoms? Asthma? Very good. Ok. So um you got six year old? Ok. Um So she's over five. Ok. So generally you can't diagnose asthma in anyone under five year old. 55, co uh generally preschool, preschool wheeze is very difficult to uh pin a condition to cos it can be very common and can be associated with various various different viral infections as well. Ok. So she does have a history of viral induced wheeze. And um th this obviously can lead on to ch childhood asthma as well. Um And also she has a history of eczema. Ok. So, uh with as childhood asthma, I generally think about if they have any history of atyp. Ok. So any history of eczema hay fever um cause that's all very strongly um associated with um childhood asthma as well. Um So this is unlikely to be continued viral induced wheeze because she has symptoms between her episodes with viral induced wheeze. Generally, you, you don't expect to see symptoms be between episodes of wheezing or being unwell. Ok. So she has episodes of coughing at night between her wheezy episodes. Um and she's also got um chest, chest signs. So she's got respiratory wheeze and uh she doesn't have any ch uh throats and ears, not uh uh doesn't have any abnormalities as well. So question you asking basically what is the first line investigation for childhood asthma? And correct answer here is spirometry with bronchodilator. Ok. So this is the Gold standard investigation for asthma. And what, what, what, what is the main finding we expect to see on spirometry? What sort of pattern, what pattern of uh what is the pattern of respiratory disease you expect to see? Yeah. Yeah. So expect to see an obstructive pattern. Uh fe low F EV one to F EC. Um so low F EV one to F VC ratio and you expect to see improvement with bronchodilator therapy as well. OK. Um So, so the ASPIR will give uh the gold is the gold standard. OK. Bronchoscopy way too invasive. Initially, chest X ray is not gonna give you uh is not gonna tell you that much. OK. About asthma symptoms, but it's not gonna help you diagnose the asthma per se. If, if the patient have a spiry, you can do a feno test, a fractional exhaled nitric oxide. This is like a second line test. So in asthma because of the acute airway inflammation, um when you breathe out, you can detect levels of nitric oxide because it's a byproduct of inflammation basically. Uh but that's a second line test if they, if spirometry is inconclusive or they can't have spirometry and peak expiratory flow rates. Um is generally a very useful investigation but they generally in a six year old girl, you're not, you're often not gonna get a very good um value for it. OK? It can be very difficult for Children to be able to coordinate doing the peak flow measurement. Um So it's not the first line investigation to do. OK. And it can be very difficult for them to be able to detect the diurnal variation of symptoms using peak flow in this particular um age group. OK. So let's talk about asthma. So diagnosing asthma. So generally, yeah, you can only diagnose if they're over five. OK. You don't tend to diagnose as asthma in pre preschool age first line is spirometry with bronchodilator reversibility. Other things is the feno test and you can also do peak flow. OK? And you're looking for that diurnal variation. So more than 20% variability in symptoms and this is the sort of chronic um childhood asthma management. OK? II don't I, I'm not, I'm not gonna spend too much time on this. Cos I don't think you'll be tested that much on this. Uh This because the BT S and the nice guidelines do slightly differ in the step wise management for childhood asthma. This is the, this is taken from, this is uh I've gone through the BT S guidelines here. Um I don't think your med school is gonna realistically test you that in detail about steps where the management differs between guidelines. So one of the key differences is in nice guidelines, they generally um recommend er LABA for step two. uh because it's a cheaper option uh compared to LTR A, even though LTR A S have been shown to be a bit more effective uh in escalation therapy if they're not responding to an ics. Um but generally in asthma, so you give a SABA as required to all patients. So I give the uh salbutamol as they need. Um you give it as a meter dose inhaler, ok? And ideally, all Children should be using a spacer device to help improve with delivery of medication, um escalation with a pediatric dose um corticosteroid, ok. Generally 200 mcg um inhaled corticosteroid escalate that. So either I A lab or LTR depending on the guidelines and 10, the LTR A is considered a bit more. Um if they're over five, you can try other things, increase the dose of I CS or add in uh more combination therapies if they're not responding to you that you can consider oral steroids. Uh but you're gonna start referring for specialist management at that point as well. So just have a read of us on time. But again, be aware, the guidelines do slightly differ between nice and BT S but just have a general appreciation for the stepwise approach and in terms of acute asthma exacerbations. So this management is generally very similar to your adult management. Ok. It's the same, similar, similar steps you think about, ok, when you think about acute asthma exacerbations, you wanna be able to classify them to if it's a severe attack, a life threatening attack or neo ftal attack. Ok. Um uh in terms of your life threatening symptoms, uh useful pneumonic II tend to remember is chest. Ok. So, c for confusion or synosis, H for hypertension, E for exhaustion. So, if the uh respiratory rate is reduced, silent chest, ok. So if you're auscultating and you can't hear anything, that's another life threatening sign and tachycardia as well. Um Neofetal is uh obviously the main things you're worried about here is raised PCO P AC two. Ok. So if, if your partial pressure of CO2 is increasing, that's always a worrying sign because it means that the respiratory effort is decreasing. Ok. They're becoming so tired that they can't um get rid of the p the carbon dioxide in the blood and that's gonna lead to um problems. Ok? You're gonna get a respiratory acidosis with that and complications from the hypercapnia, um type two respiratory failure and things. And obviously, if they're requiring mechanical ventilation, that's a neo ftal exacerbation with the management. So, if it's a moderate exa moderate exacerbation, you can just manage with a cyber and uh oral oral bread with er more severe attacks. Er, you, er, consider a high flow oxygen therapy, er, give back to back um salbutamol and you give that with a nebulizer as well. Er, depending on the severity you can give, um, intravenous, um, hydrocortisone as well if it's a very severe attack, other additional therapies, which I'm sure you're familiar with and you can give ium bromide magnesium sulfate through ne nebulizer as well. And you have, if they're, if they're in very life threatening, near fatal, even in severe attacks, you have a very low threshold for pi a referral as well. Ok. We got um I think we got three more conditions to cover, I think, and then we'll be done. Uh I if you wanna send the feedback for me in case it should be fine. Yeah, the feedback form has been sent. Thank you a lot. OK. Let's call it up. OK. So we got big splits here. Um You got a big split between BC and uh D. So, uh what do you guys think is the uh so the correct answer is uh C actually um So what are you guys think is the presentation here? What is the cause of this patient's symptoms? I would say very good. OK. So this is a childhood um obstructive um um sleep apnea. Ok. So, um obstructive sleep apnea. So you got loud snoring, restless sleep. Ok. So because of um upper upper airway obstruction, you got loud snoring, difficulty sleeping and uh because of the obstruction, there's episodes of gasping during the night as well. Ok. Frequent bed wetting as well. Uh, so nocturnal, um, enuresis is very commonly associated with OSA as well be, um, um, because of discontinued, um, airway airway obstruction and difficulty breathing. Um, other things are nasal congestion, enlarged tonsils as well and obviously a very high BMI and these all, er, pointing towards the, um, um, um, obstructive picture. Ok. So in, in terms of investigations for OSA, ok, generally, uh, from the history itself should be, should be, should be enough. It's a clinical diagnosis. Uh, um, as most of the other conditions, um, the first line investigation, generally a, a very easy investigation is the overnight pulse oximetry just to check if they're getting hypoxic at night in more complex conditions. So they're very, um, er, they have multiple other things going on multiple co morbidities. They're very young and you can do what's called sleep studies. Ok. So polysomnography. Ok. But that's only done for very specific cases. Ok. They have multiple comorbidities. It, none of the, none of this is just a bog standard, um, obstructive sleep apnea picture. Ok. But generally it's a clinical diagnosis. Overnight pulse proximity is a very easy test that can be done uh, to check if they're getting hypoxic, um, at night. And this question is just asking about the management. Ok. So, um, it's the same, it's same, same, uh, um, clinical vignettes. Um, so don't, you don't, don't need to read it again. It's just asking what is the most appropriate management option. You don't need, don't need to read it again. Just have a go at management. Ok. Is ok. So, um, most of you have gone for c um, unfortunately, that is not the right answer here. Ok. So correct answer here is actually, um, e and this is a bit of a difference from, um, adults. Ok. So this is where the management slightly differ, differs in Children. So in Children who have obstructive sleep apnea, ok. The first two gold standard management is gonna be surgery, ok? You get, if the, um, having these obstructive sleep apnea, um, symptoms and weight loss and lifestyle changes are not gonna do that much. Ok. It's, um, um, uh, and in this 66 year old you can't, you can't advise, it's not the, it's not the gold standard. First time management is to just get them to exercise more and do different lifestyle changes like change their diet and things. Ok? You're gonna do, wanna do something that's gonna improve things much more quickly for them. That's gonna be a sur that's gonna be surgery. Ok. So, adenotonsillectomy, adeno to actin is really um effective in Children because in kids in general, you the same way your tonsils grow up to about, you're eight years old and then regress your, your adenoids also get bigger as you grow up. Ok? They also get bigger the same way as your tonsils. Do they get bigger way quicker than your airway grows. Ok. So that's why your tonsils and your adenoids are very prone to getting hypertrophied. Ok? Because they grow very quickly during your childhood. Um So they're very much prone to getting hypertrophy like in this case. So getting rid of your tonsils and your adenosis can significantly improve the amount of space in your upper airway. Ok. And that can significantly improve um osa osa symptoms. Ok. So that's why adeno tonsillectomy is the first line management of um childhood obstructive sleep apnea, ok. Things like weight loss, lifestyle changes, nasal CPAP. These are all second line things. Nasal CPAP is an option that can be considered. Ok. But the first line of initial management is adenotonsillectomy. So uh obstructive sleep apnea, we talked about it. Main risk factor is obviously gonna be obese, childhood obesity, ok. Obesity obviously uh is starting to increase in childhood age. Um So it's important, it's an important condition to be thinking about even in pediatrics. Um clinical features. So, snoring, choking and sleep um and lack of sleep can lead to daytime symptoms. Ok. So daytime sleepiness, reduced concentrations, so that school academic performance can start to get affected as well and there can also be failure to thrive as well. It's a clinical diagnosis, as I mentioned. But other things like overnight pulse oximetry, sleep studies can also be done. First line management is your surgery. Ok. So remove your adenoids, remove your tonsils and other things like weight loss nasal splints, cpap can also be done as well. But remember in gen generally you're gonna refer them for surgery two more conditions and then we will wrap it up. Ok. Pull it up. Ok. Um, slight split split, uh, between A and B mo mostly you're gone for B which is the correct answer. So, cystic fibrosis, again, very important, another very important respiratory presentation, er, in pediatrics. Ok. Very, very common. Um, and one of the most important um uh genetic conditions to have a good uh knowledge of. So, uh why cystic fibrosis. So there we got a young boy presenting with um difficulty breathing through his nose. So he's got um sinus type sinus type symptoms, uh recurrent episodes of epistaxis, sinus infections and pneumonia as well. Um, evidence of nasal polyps, nasal breathing, digital clubbing, um as well. And um on auscultation, there are diffuse coarse crackles. Ok. Um So someone's correctly asked, wouldn't that have already been picked up on the heel prick test? That's a very good point. And it's an important learning point is that not everyone is picked up. Ok. Most pe most people are picked up in the neonatal screening. Ok. Do a heel prick test. But you can't just assume everyone's been. Everyone who's meant to have been diagnosed with cystic fibrosis has been diagnosed. Ok. He still is any young child, um, or teenager presenting with recurrent episodes of chest infections, sinus in sinus infections, nasal polyps. Uh as well. That's cystic fibrosis until proven otherwise. Ok. Um, there's, there's, there's a chance they've missed the screening. So I've made a little point that, uh, she was, um, a, so there's potential that they've miss, miss it, that, that diagnosis has been missed somewhere it has been documented, uh, at all. Um, so, um, yeah, just always have that clinical suspicion for cystic fibrosis. Ok. Um, digital clubbing as well. One of the, um uh one of the signs of one of the respiratory causes of clubbing is er, cystic fibrosis. Ok. There's obviously other causes we'll talk about um causes of er clubbing um in more detail in our OSK series. Ok. So make sure you come through through our OSK series, important to be aware of some of the important to various causes of clubbing. Um but cystic fibrosis is one of them and diffuse cross crackles as well. That could be a sign of a complication of cystic fibrosis called uh bronchiectasis. Um But course crackles in general, just think about um air airway disease in general. Uh all these other things. So in granulosis with polyangiitis, uh you don't expect to get things like um nasal nasal polyps. It's a very rare, rare condition as well. It's all these other options are much more rare compared to cystic fibrosis. There's presentation of recurrent chest symptoms, sinus infections, clubbing, nasal polyps. There are, there's a cystic fibrosis until proven otherwise. Ok. So cystic fibrosis. So, CF uh autosomal recessive condition. OK. One of one of the most common genetic conditions uh caused by a mutation on chromosome seven. It's a delta F 508 is the most common mutation. Um So, essentially because of the gene defect, you're getting uh impaired sodium chloride transport, which is leading to very thick mucousy, dehydrated um secretions and your ciliary. Um your, your cilia, your mucociliary clearance. Isn't that um functional as well? Ok. So you can't get rid of your mucus in your airways. Ok. But it's a multisystem condition, ok? It doesn't just affect your lungs. So in terms of your pulmonary presentations, you get recurrent chest infections, bronchiectasis are a common complication of it and generally you're, you're having progressive decline in lung function. Ok. So over, over, over many years, if you're doing repeated spirometry, measurements of these patients, their fev one values is going to progressively get worse, worse and worse. Ok. In terms of the common for your exams, remember, in Children, most common causative organism is staph aureus or Hemophilus. But in older age group, you think about pseudomonas, ok. Um Other complications to be aware of gastrointestinal complications. So, uh meconium ili is uh if uh any child is presenting with failure to pass the first stool within sort of 24 hours. Um You do, you're gonna be investigating for cystic fibrosis. Ok. This is a very common association there and they present with bilious vomiting and distension pancreatic insufficiency as well. So, uh uh anyone with pancreatic insufficiency, young age group, you'd think about, uh you investigate for CF as well. So with pancreatic insufficiency, you get scr failure to thrive and also secondary diabetes because of that as well. Ok. Other things, infertility and the sweat can become a bit more salty as well. Ok. Diagnosis in most patients will, will have the neonatal screening. Ok. Through heel prick test, you're testing for a particular protein called um I RT OK, immunoreactive trypsin. But uh we also do the sweat chloride test as a gold standard as well. And you can also have genetic testing. Treatment is very much A MDT management. OK. Very, you're gonna manage um various different things you have. You'll find that there are many respiratory physicians who will just specialize in managing CF OK, because their, their treatment is very, very complex and very, very tailored and focused to each patient, but general of managing lung disease. So the patients need very regular lung function, review chest physio, uh twice a day. OK. Prophylactic antibiotics because they get recurrent infections. Um mucolytic agents can be done as well, other things for complications. So for pancreatic insufficiency uh to replace enzymes, you can give Creon um insulin for any secondary diabetes and other things, there's increasingly use of um C fr modulator drugs. Um and these have been much more commonly prescribed. There used to be a big uh political stance on these drugs. So between pharmaceutical industries, but I think the this these drugs have been more and more prescribed for patients. Uh So these are things like Ivacaftor um Taza and things and they've been shown to significantly er improve outcomes in patients. But obviously in end stage lung disease, most patients are gonna end up needing to have a transplant at some point. OK. OK. This is the last question. Um And yeah, uh Thank you for sticking with me for so long. Uh We've covered it quite a lot. Uh This is the last question. So just push through and uh we'll wrap it up. OK. Let's go through this. Uh Yeah, you guys have been smashing it all night. Uh You guys have got it. So the correct answer here is uh c uh nasopharyngeal swab, well done. Uh What is the diagnosis here? What is the cause of the presentation here? Very good. Uh Pertussis. Uh also known as um whooping cough. Let's put this in charge. So, uh yeah, so you're right. Right. So it's a pertussis infection. Um Why? So we with whooping cough, uh we got this four day history of a very severe cough. Ok. So essentially with whooping cough, we think about these paroxysm infections. Yeah. So these uh paroxysm coughing, uh followed by this inspiratory whoop, whoop sound that they get. Ok. So, yeah, I describe this strange sounding cough. Uh So she's been having this cold Coral symptoms preceding it. And then also the main thing where that probably is a giveaway here is the, uh, vaccination history. Ok. Uh, so she hasn't been vaccinated. So border pertussis is one of the things you get vaccinated against in childhood. She hasn't been vaccinated. So, obviously they had, uh, alarm bells ring for pertussis infection. Also this, uh, vomiting after the cough. Ok. This is known as, um, post of, uh, vomiting. Ok. So essentially they get such violent um coughing, they, they cough so violently that it starts making them sick. Ok. So that's where that's a very another key giveaway as well. Uh Question Ging was the most important um investigation. So essentially you need to do a swab, swab to check for um pertussis infection. Ok. So you do a, you can do a PCR on that and check for the causative organism. So, pertussis, uh like I said, it's caused by B pertussis, a bacterial infection. Uh It's generally caused by uh transmitted but um it's through uh droplet transmission. Ok. So people are coughing at each other. Uh It's part of the uh childhood immunization schedule. Ok. You get it as uh at four months generally in the UK to feature. So you, it generally starts with coral symptoms. Patients get this spasmodic cough, ok. Very violent cough. And that's followed by inspiratory whoop. Ok. And the key thing is that this cough can be, can last for a long time. Ok? Even after the initial, um, um sort of, um coryzal symptoms go away. This cough can persist for a long time. Ok. And like I said, you can get vomiting with that. Um Epistaxis as well and their face can change, start to change color as well because they're just coughing very violently, nasal swabbing culture, like I said, is one of the key investigations. This is a notifiable disease as well. Ok. So remember with any infectious disease uh to uh in your Aussies and um finals exams, uh you need to be aware of some of the key notifiable diseases. So this is a notifiable disease. You need to contact public health. Ok. Key management for ptosis is macrolide antibiotics. Ok? Things like azithromycin, Erythromycin, Azithromycin is the most common one. And obviously, again, with the infectious disease in pediatrics, you need to think about reducing transmission. So Children need to stay off school for at least 48 hours of antibiotic treatment. Ok? Um Yeah, that's pertussis. So key thing. Remember it always think about it in anyone who doesn't have a vaccination history and that's it. Uh Thank you so much for coming today. I hope you guys found it useful. We covered loads of important um respiratory presentations. So I hope you guys got a good conceptual understanding of respiratory distress. It really the most important things to remember are all those different signs of respiratory distress. Ok? Because that's what's gonna help you a lot when you start your pediatric placements. Um And yeah, hope and hopefully you have some appreciation of some of the clinical, important clinical knowledge related to different um pediatric presentations. Uh Thanks so much for coming. Please fill out the feedback form. Let me know if you have any questions. Uh Make sure that you come in for our rest of our finals, easy series. Uh I'll be teaching again. Uh I'll be teaching psychiatry in a few weeks, um, as well. Um, so, yeah, make sure you come in and remember we, we have our OY series as well coming soon as well. So make sure you tune into that. Uh, make sure you do tune into the giveaways if you haven't posted a story yet, make sure you've just post a story. Uh, do your just, uh, take a picture and post it on your stories, share us, uh, on your pages and yeah, uh, we will see you guys soon.