6. Respiratory / ENT major Flashcards
What is the most common respiratory disorder in children?
-Asthma (>10%)
-Severe asthma = most common reason for PICU admission
-Many childhood asthmas improve / resolve with age
What is the pathophysiology of asthma?
-Airway hypersensitivity
-Increased airway inflammation / mucosal oedema
-Bronchoconstriction
-Hyper-secretion of mucus
What risk factors are there for developing asthma?
-Personal / FHx of atopy
-Antenatal factors eg maternal smoking, viral infection
-LBW / pre-term birth
-Not breast fed
-Hygiene hypothesis
-Male sex
What features make a diagnosis of asthma more / less likely?
MORE LIKELY
-Cough + wheeze
-Hx of atopy
-Wheeze on auscultation
-Responsive to therapy
LESS LIKELY
-Symptoms with colds only
-Moist / isolated cough
-Normal examination
-Non-responsive to therapy
What tests can be done to confirm an asthma diagnosis?
-PEFR
-Spirometry - FEV1/FVC (usually reduced)
-FeNO (fractional exhaled nitric oxide)
What signs indicate acute severe asthma vs life-threatening asthma?
ACUTE SEVERE
-PEFR 33-50% best / predicted
-HR >140 in 2-5yrs / >125 in >5yrs
-RR >40 in 2-5 yrs / >30 in >5yrs
-Unable to complete sentences in 1 breath / too breathless to talk
LIFE-THREATENING
-PEFR <33% predicted
-Silent chest, cyanosis, hypotension, exhaustion, poor respiratory effort
BOTH
-Sats <92%
How would you manage acute asthma?
-A-E + oxygen
-SALBUMATOL NEBS
–<5 - 2.5mg every 20-30mins back to back
–>5 - 5mg
-IPRATROPIUM BROMIDE NEBS
–250mcg every 5 mins
-PREDNISOLONE PO
–<2 = 10mg, 2-5 = 20mg, >5 = 30-40mg
NO RESPONSE?
-+ MAGNESIUM SULFATE to each neb
-Aminophylline / IV salbutamol (specialist)
-Hydrocortisone IV (50/100mg)
INFECTIVE?
-Amoxicillin
–250mg TDS PO for 5 days
How should asthma be managed in children <12yrs?
- Inhaled SABA
- Regular preventer (ICS / LTRA <5yrs)
–200-400mcg/day - Add Inhaled LABA >5yrs / ICS <5yrs
–Increase ICS (+ stop LABA if no benefit) 400mcg/day - Increase ICS to 800mcg / add theophylline + refer
- Daily oral steroids
How should asthma be managed in children >12yrs?
- Inhaled SABA / ICS
–2-800mcg/day - Add inhaled LABA +/- ICS
–Increasing ICS (+ stop LABA) if limited benefit - Addition of LTRA / theophylline
- Daily oral steroids
What is bronchiolitis and what causes it?
-Acute LRTI usually following a viral URTI
-Small airway obstruction caused by infection
-1 in 3 children will get it in 1st year of life
-80% caused by respiratory syncytial virus, rest caused by adenovirus, influenza
How does bronchiolitis present and what are red flag symptoms potentially requiring admission?
Typically a 9 day illness (peaks day 5-7):
-3 days prodrome with cold + harsh cough
-3 days ill with fever, high-pitched wheeze, fine inspiratory crackles, SOB
-3 days recovering
-Cough can last for up to 2-3 weeks
RED FLAGS
-Disrupted breathing
-Central cyanosis
-No wet nappy for 12h
How should you investigate bronchiolitis?
-None needed in mild cases
-In severe cases:
–Capillary blood gas (respiratory acidosis)
–CXR
–Nasal swab for virus type
-Admit in cases of:
–Dehydration / intake <50% normal
–RR >70 / marked recession
–Apnoeic episodes
–Sats <92
–Exhaustion
How should you manage bronchiolitis?
MILD = minimal distress, feeding ok, o2 fine
-Home with safety netting
MODERATE = increased work of breathing, low o2, poor feeding
-Admit for feeding + support +/- oxygen (40L/min through nasal cannula)
SEVERE = worsening distress, respiratory acidosis, apnoea, dehydration
-HDU/PICU
-CPAP / ventilation + IV fluids
Who is at risk of severe bronchiolitis?
-Infants born at or <35 weeks (up to 6months)
-Chronic lung disease / significant congenital heart disease (up to 2yrs)
-Previous episode of wheeze
-PALIVIZUMAB given as prophylaxis - monthly IM for 6months during winter months
What is croup and what causes it?
-Acute viral laryngo-tracheo-bronchitis (URTI)
-Most cases caused by parainfluenza virus (can be caused by RSV, influenza, adenovirus)
-Peak incidence = 6m-3yrs
How does croup present compared to epiglottis?
CROUP
-Very common, can be mild to severe
-STRIDOR, hoarse voice
-Fever
-Barking cough
-Drooling not seen
EPIGLOTTITIS
-Rapid onset, intensely painful throat, emergency
-Unable to speak or swallow
-Muffled voice
-Soft, inspiratory stridor
-Drooling
How should croup vs epiglottis be managed?
CROUP
-Parental advice eg ibuprofen/paracetamol, increase fluid intake
-Admission required if moderate-severely ill or high risk
-Oral dexamethasone 0.15mg/kg
-Inhaled budesonide nebs 2mg OR IM dexamethasone
-Nebulised adrenaline in severely ill
EPIGLOTTITIS
-Do not distress child - urgent ENT / anaesthetics referral
-Single dose of oral dexamethasone
-IV abx +/- intubation (caused by H. influenza)
What can cause pneumonia in children of different ages?
-1/3 are viral (RSV, parainfluenza, adenovirus, rhinovirus)
-Bacterial causes:
–NEONATES = GBS, E. coli, listeria, chlamydia
–INFANTS = strep pneumonia, H.influenza
–CHILDREN = strep pneumonia, H.influenza, GAS, mycoplasma pneumoniae
How is mild pneumonia managed?
AT HOME
-1st line = amoxicillin
-2nd line = macrolides if no response or if mycoplasma / chlamydia suspected
-Fluids + temp control advice
-Safety net
How is moderate-severe pneumonia managed?
ADMISSION
-Oxygen to maintain sats >93
-IV co-amoxiclav if influenza-associated
-Cefotaxime / cefuroxime
-Fluids
-Close observation
What complications can arise from pneumonia?
-Pleural effusion
-Sepsis
-Bronchiectasis
-Empyema
-Lung abscess
What would indicate a bacterial URTI?
CENTOR CRITERIA
-Purulent exudate on tonsils
-Tender cervical lymphadenopathy
-History of fever
-Absence of cough
If 3 or more of the above present, 40-60% chance GBS is causative organism
How should bacterial sore throat / tonsillitis be managed?
-Phenoxymethylpenicillin (erythromycin if penicillin-allergic) for 7-10 days
-Avoid amoxicillin as may cause a rash if actually caused by EBV
-Treat if 3+ centor criteria or Hx of rheumatic fever, immunodeficiency
When can a tonsillectomy be considered?
-If 5+ recurrent episodes a year, disabling + prevents normal functioning
-If causing obstructive sleep apnoea / stridor / dysphagia
-Quinsy (= unilateral peritonsilar abscess, complication of tonsillitis)
