Answers to CME questions

Answers to CME questions

Paediatric Respiratory Reviews 14 (2013) 137–138 Contents lists available at SciVerse ScienceDirect Paediatric Respiratory Reviews Answers to CME q...

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Paediatric Respiratory Reviews 14 (2013) 137–138

Contents lists available at SciVerse ScienceDirect

Paediatric Respiratory Reviews

Answers to CME questions Chronic cough in children 1. ANSWER D: The likely clinical diagnosis is of a protracted bronchitis. Chest radiograph is reasonable to help exclude major pathology. Spirometry will be difficult in a two year old. Bronchoscopy and BAL to assess airways inflammation and mucus production, and HRCT to exclude bronchiectasis should be considered if the child fails to respond to a trial of antibiotics or if there are other symptoms or signs. The increasing recognition of the small lifetime risk of malignancy with CT should not discourage its use, but it should be used appropriately and judiciously. 2. ANSWER B: It has not been possible to demonstrate that GORD is a frequent cause of chronic cough in children, unlike in adults. Diagnosis of GORD remains difficult and diagnosis of aspiration secondary to GORD even more so. The lipid-laden macrophage index is not a sensitive or specific marker. However, there are children in most respiratory clinics with severe suppurative lung disease as a consequence of chronic reflux and aspiration. Although fundoplication may be considered where reflux and aspiration is demonstrable and unmanageable, it should probably not be considered for cough in isolation. 3. ANSWER D: Pertussis remains a common cause of chronic cough, in some studies accounting for up to one third of cases. It is common in adolescents due to waning vaccine-induced immunity and in unvaccinated infants. However it can occur in vaccinated children although symptoms may be less severe. Steroids have been used to treat the cough but have not been shown to be helpful. Macrolides may improve cough a little but are more effective in limiting spread. 4. ANSWER E: Cough is common in asthma and is an early predictor of loss of control. However, it is usually seen in conjunction with wheeze or a history of wheezing or shortness of breath. Intermittent wheeze as an indicator of reversible airways obstruction is the cardinal sign of asthma. Cough in asthma is usually dry. Wheezing responds better to bronchodilators than cough. Atopy increases the likelihood of asthma and cough-variant asthma. If the cough does not respond to an appropriate course of inhaled corticosteroids after a few weeks the diagnosis is unlikely to be cough-variant asthma. 5. ANSWER B: On average, healthy children cough around 11 times in 24 hours. Cough is generated by build-up of pressure against a closed glottis which is then opened. Cough sensitivity is reduced in REM sleep. Even in normal childen, approximately 10% will still be coughing three weeks after an URTI. From knemometry to final adult height: Inhaled corticosteroids and their effect on growth in childhood Answer 1. a. false b. true c. true d. false e. true

1526-0542/$ – see front matter ß 2013 Published by Elsevier Ltd. http://dx.doi.org/10.1016/j.prrv.2013.03.005

Answer Answer Answer Answer

2. a. true b. false c. true d. true e. true 3. a. true b. true c. true d. true e. true 4. a. false b. false c. true d. true e. true 5: a. true, b. false, c. true, d. true, e. false

Asthma medication delivery: Mists and myths Deposition - the target area for ICS is all 23 airway generations True/false - the target area for inhaled bronchodilators is all 23 airway generations true/False - the same target area can be reached with a larger size particle size, using a slower inspiratory flow True/false - the area of particle deposition is the same in health and diseasetrue/False - targeting inhaled drug treatments to distal airways results in a homogeneous lung drug concentration true/False Particles - HFA aerosols always have smaller particles than CFC aerosols True/False - HFA aerosols with ethanol as co-solvent have a lower plume velocity True/false - For effective powder dispersal, a high flow within the dry powder inhaler is needed True/false - Higher inhalation flows through the inhaler lead to increased impaction in upper airways True/false - Extra fine particle size ICS are superior than normal particle size ICS in gaining asthma control True/False Patients - Nominal drug doses for inhalation generally remain the same with increasing age True/false - Crying leads to decreased drug delivery for reasons including high inspiratory flows and poor mask seal True/false - For easily distressed infants, administration during sleep is an alternative

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Answers to CME questions / Paediatric Respiratory Reviews 14 (2013) 137–138

True/false - The optimal inhalation maneuver from valved holding chambers is 5-10 tidal breaths True/false - Adherence can be improved by a patient centered care approach including shared decision making True/false Drugs - Rather than giving back to back nebulization of different medications, Drugs should be combined in a single treatment True/false - When a patient is being given many different medications by aerosol, the order of medication delivery is critically important True/false - Ciclesonide, beclomethasone, and flunisolide HFA pMDIs emit ultrafine particles (MMAD about 2 mm) True/false - Albuterol/salbutamol is more effective when used as larger particles (MMAD about 5-6 mm) and inhaled very slowly True/false

- For intubated children in the ICU, it is important to give albuterol/ salbutamol both by pMDI to increase proximal airway dose and by IV infusion so that drug will reach obstructed airways. True/false Devices - All aerosol devices (nebulizers, pMDI, DPI) can be equally effective when used correctly True/false - In children, using a holding chamber with a mask is equally effective as using one with a mouthpiece True/false - It’s been shown that large plastic (polyethylene) drink bottles can be used as a makeshift holding chamber in an emergency True/false - It is important to inhale very quickly from all DPIs in order to disperse drug True/false - In children under 6 years of age with asthma who are treated in the ED, using a pMDI and holding chamber may decrease time in the ED and the admission rate to hospital True/false