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Y4 Paediatrics SA > 8 - Respiratory 1 > Flashcards

8 - Respiratory 1 Flashcards

1
Q

What is bronchiolitis and what is the epidemiology and aetiology of this?

A

Most common lower respiratory tract infection in those under 1

3% of patients needs hospital admission

Usually due to RSV virus (RNA) and happens in winter months. Can also be due to adenovirus and parainfluenza virus

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2
Q

What are some risk factors for developing bronchiolitis?

A
  • *• Age less than 3 months**
  • *• Prematurity** (particularly under 32 weeks)
  • *• Low birth weight**
  • *• Male sex**
  • *• Low socioeconomic group**
  • *• Parental smoking**
  • *• Chronic lung disease/airway anomalies**
  • *• Congenital heart disease**
  • *• Neuromuscular disorders**
  • *• Immunodeficiency**
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3
Q

How does bronchiolitis present?

A
  • Coryzal symptoms. of a viral URTI e.g running or snotty nose, sneezing, mucus in throat and watery eyes
  • Signs of respiratory distress
  • Dyspnoea
  • Tachypnoea
  • Poor feeding
  • Mild fever (under 39ºC)
  • Apnoeas
  • cough
  • Wheeze and crackles on auscultation
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4
Q

What are the signs of respiratory distress in children?

A
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5
Q

How long does bronchiolitis last for?

A
  • Starts as URTI with coryzal symptoms. From this point around half get better spontaneously. The other half develop chest symptoms over the first 1-2 days following the onset of coryzal symptoms
  • Symptoms at their worst on day 3 or 4
  • Symptoms usually last 7 to 10 days and most fully recover within 2 – 3 weeks
  • More likely to have viral induced wheeze during childhood
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6
Q

What are some differentials for bronchiolitis?

A
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7
Q

Which infants need to be admitted for hospital treatment with bronchiolitis?

A
  • Aged under 3 months or any pre-existing condition such as prematurity, Downs syndrome or CF
  • 50 – 75% or less of their normal intake of milk
  • Clinical dehydration
  • Respiratory rate above 70
  • Oxygen saturations below 92%
  • Moderate to severe respiratory distress
  • Apnoeas
  • Parents not confident in their ability to manage at home
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8
Q

How is bronchiolitis treated in hospital?

A

SUPPORTIVE CARE and MONITOR VITALS

  • Ensuring adequate intake. e.g orally, NG tube or IV fluids. Avoid overfeeding as can restrict breathing
  • Antipyretics
  • Saline nasal drops and nasal suctioning can help clear nasal secretion
  • Supplementary oxygen if the oxygen saturations remain below 92%
  • Ventilatory support if required
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9
Q

What ventilatory support can be given to infants with severe bronchiolitis?

A
  1. High-flow humidified oxygen via tight nasal cannula. It adds “positive end-expiratory pressure” (PEEP) to maintain the airway at the end of expiration

2. Continuous positive airway pressure (CPAP). This involves using a sealed nasal cannula that performs in a similar way to Airvo or Optiflow, but can deliver much higher and more controlled pressures.

3. Intubation and ventilation. This involves inserting an endotracheal tube into the trachea to fully control ventilation.

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10
Q

How can you tell if ventilatory support is working for children with bronchiolitis?

A

Capillary Blood Gas

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11
Q

How may bronchiolitis appear on a CXR?

A

Bilateral peri-hilar infiltrates with some hyperinflation due to air-trapping

Diagnosis is clinical, only do PCR, CBG and CXR if severe. Also check pulse oximetry

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12
Q

Nebulised saline, inhalers and steroids are not recommended for treatment of bronchiolitis unless the child has a history of wheeze, atopy or asthma. These children may also be given Palivizumab, what is this?

A

Monoclonal antibody that targets RSV

A monthly injection is given as prevention to high risk babies, such as ex-premature and those with congenital heart disease

Not a true vaccine as it does not stimulate the infant’s immune system. It provides passive protection

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13
Q

What are some complications of bronchiolitis?

A

Higher risk of asthma in later life

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14
Q

What is bronchiolitis obliterans?

A
  • Permanent obstruction of the bronchioles due to chronic inflammation which leads to scar tissue formation
  • Usually due to adenovirus
  • Dry cough, wheeze, SOB
  • Most commonly seen in lung or bone marrow transplant patients. Chest X-rays can often appear normal so diagnosis is often made using a CT scan or lung biopsy.
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15
Q

What is asthma and the epidemiology of this in children?

A

Chronic inflammatory airway disease leading to variable airway obstruction that is reversible

Smooth muscle in the airways is hypersensitive, and responds to stimuli by constricting and causing airflow obstruction

1 in 11 children

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16
Q

What are some risk factors for asthma?

A
  • Viral bronchiolitis
  • Family history of asthma
  • History of atopy (allergy/eczema)
  • Exposure to tobacco smoke
  • Exposure to pollution and obesity
  • Smoking in household
  • Low birth weight
  • Prematurity
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17
Q

What are some triggers for asthma?

A
  • Dust
  • Animals
  • Cold air
  • Exercise
  • Smoke
  • Food allergens (e.g. peanuts, shellfish or eggs)
  • Drugs
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18
Q

How may asthma present in children?

A

EPISODIC USUALLY WITH DIURNAL PATTERN

  • Cough
  • Breathlessness
  • Widespread wheeze
  • Chest tightness
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19
Q

What are some differentials for asthma and what are some presentations that point away from a diagnosis of asthma?

A

DDx: respiratory tract infections, viral wheeze, foreign body inhalation, bronchiolitis, allergic reactions or anaphylaxis

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20
Q

What questions need to be asked in the history if you are considering asthma as a diagnosis?

A
  • Frequency of symptoms
  • Severity of symptoms (how many days of school missed? Can the child do PE at school? Can they play with their friends without getting symptoms? Night time symptoms?)
  • Previous treatments tried
  • Any hospital attendances
  • Presence of food allergies
  • Triggers for symptoms
  • Disease history: Viral infections, eczema, hay fever
  • Family history of atopy
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21
Q

How is asthma diagnosed in children?

(memorise image!!!)

A

Diagnosis is usually clinical, if under 5 no investigations needed just treat symptoms

listen to chest for expiratory polyphonic wheeze
expiratory polyphonic wheeze
Fractional exhaled nitric oxide (FeNO > 50 ) / ** eosiniphil count **

If not confirmed by these tests then measure ** bronchodilator reversibility (BDR) with spirometry ** Diagnose asthma if the FEV1 increase is 12%

If above cannot be done then Peak flow variability* measured by keeping a diary of peak flow measurements several times a day for 2 to 4 weeks

** in children under 5 ** treat with inhaled corticosteroids and review the child on a regular basis. If they still have symptoms when they reach 5 years, attempt objective tests

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22
Q

To summarise what is the order of of investigations for asthma in children over 5

A
  1. FeNO and eosinophil
  2. bronchodilator reversibility (BDR) with spirometry.
  3. measure peak expiratory flow
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23
Q

Spirometry in over 5’s. What may the result show if asthma is present?

A
  • Obstructive Pattern (FEV1/FVC ratio <70%)
  • FEV1 increase over 12%
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24
Q

What is an FeNO test and how do you interpret the result?

A
  • FeNO = surrogate marker for eosinophilic inflammation in airways
  • Over 35 ppb is positive in children
  • Over 50 ppb is positive in adults
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25
Q

What is challenge testing for asthma?

A

assesses how sensitive your lungs are through several tests

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26
Q

How can peak flow variability aid a diagnosis of asthma in children and what are the drawbacks with this method?

A

• Variability over two weeks

– > 20% variability (NICE)

– > 12% variability (ERS)

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27
Q

What are the principles of treatment in asthma?

A

GOAL IS GOOD SYMPTOM CONTROL

  • Assess current control and future risk
  • Supported self-management / patient education / empowerment
  • Other factors / psychosocial issues
  • Review medications regularly with asthma nurse
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28
Q

How can you assess current asthma control in children?

A

Poor control:

  • Daytime symptoms 3 or more times a week
  • Nighttime symptoms 1 or more times a week
  • Limitations of activity e.g exercise and school attendance
  • Using SABA more than 2 times a week
  • Exacerbation in the last 12 months
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29
Q

What self-management should you encourage for patients with asthma?

A

Patient education

– Inhaler technique

– Adherence

– Triggers / avoidance (encourage parents to stop smoking)

Written asthma action plan

– Target control

– Treatment

– How to escalate care

– Contact details

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30
Q

What is the stepwise management for asthma in under 5’s?

A
  1. Consider an 8 to12 week trial of BD low dose (ICS) as maintenance therapy with a [SABA] for reliever therapy
  2. If still uncontrolled then , consider a leukotriene receptor antagonist (LTRA - montelukast) in addition to the ICS. Give the LTRA for a trial period of 8 to 12 week
  3. Consider stopping ICS and SABA treatment after 8 to 12 weeks if symptoms are resolved. Review the symptoms after a further 3 months.
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31
Q

If symptoms do not resolve during the trial period for asthma management , take the following sequential steps:

A

check inhaler technique and adherence

check whether there is an environmental source of their symptoms (for example mould in the home, cold housing, smokers or indoor air pollution)

review whether an alternative diagnosis is likely.

32
Q

What is the stepwise management for asthma in over 5’s (5-11)?

A
  1. Offer a twice-daily paediatric low-dose inhaled corticosteroid (ICS), and (SABA) (NO SABA WITHOUT ICS)
  2. step up low dose MART
  3. Consider adding a leukotriene receptor antagonist (LTRA) for a trial period of 8 to 12 weeks
  4. LTRA -> Montelukast (Singulair), Zafirlukast (Accolate), and Pranlukast.
33
Q

What age are children treated with the adult guidelines for asthma?

A
  1. Offer low-dose MART ( A form of combined ICS plus formoterol treatment in which a single inhaler containing ICS and formoterol (LABA) is used for daily maintenance therapy and the relief of symptoms as needed) this combitation reduces the risk of attacks and in once inhaler
    People using MART dont need SABA
  2. moderate dose MART
  3. consider adding leukotriene receptor antagonist (LTRA) (montelukast) or a long-acting muscarinic receptor antagonist (LAMA - tiotropium, ) used in addition to moderate-dose MART. Give the medicine for a trial period of 8 to 12 weeks
34
Q

What parts of the asthma management are associated with poor morbidity?

A
  • Excessive SABA use - use without an ICS gives a high chance of asthma attacks
  • LABA use without using ICS in combination
  • ALWAYS REVIEW AFTER 6 WEEKS
35
Q

What are some side effects of montelukast and steroids to warn parents about?

A

Steroids

  • oral thrush
  • Height
  • Adrenalsuppression

Montelukast

  • Sleep disturbance
  • Aggressivebehaviour
36
Q

If a parent asks you if ICS can slow the growth of their child, what should your response be?

A
  • There is evidence that inhaled steroids can slightly reduce growth velocity and can cause a small reduction in final adult height of up to 1cm when used long term (for more than 12 months). This effect was dose-dependent, meaning it was less of a problem with smaller doses
  • State they control asthma and prevent attacks which could lead to higher doses of oral steroids being given. Poorly controlled asthma can lead to a more significant impact on growth and development
  • The child will also have regular asthma reviews to ensure they are growing well and on the minimal dose required to effectively control symptoms
37
Q

How do you explain to parents how to use their child’s inhaler?

A

ALWAYS CHECK INHALER TECHNIQUE AT REVIEWS

38
Q

How often should spacers be cleaned?

A
  • Once a month
  • Avoid scrubbing and allow to air dry as otherwise can create static which will interact with mist and stop medication being inhaled
39
Q

got to acute asthma

A
40
Q

How will an acute asthma exacerbation present in a child?

A
  • Expiratory wheeze on auscultation heard throughout the chest
  • ALWAYS WORRY WHEN CHEST IS SILENT
  • Progressively worsening shortness of breath
  • Signs of respiratory distress
  • Fast respiratory rate
  • Reduced air entry
41
Q

What are features of moderate asthma exacerbation in children?

A
  • Able to talk in sentences;
  • (SpO2) ≥ 92%;
  • Peak flow ≥ 50% best or predicted
  • Heart rate ≤ 140/minute in children aged 1–5 years; heart rate ≤ 125/minute in children aged over 5 years
  • Respiratory rate ≤ 40/minute in children aged 1–5 years; respiratory rate ≤ 30/minute in children aged over 5 years.
42
Q

What are features of severe acute asthma?

A
  • Can’t complete sentences in one breath or too breathless to talk or feed
  • SpO2
  • Peak flow 33–50% best or predicted;
  • Heart rate > 140/minute in children aged 1–5 years; heart rate > 125/minute in children aged over 5 years;
  • Respiratory rate > 40/minute in children aged 1–5 years; respiratory rate > 30/minute in children aged over 5 years.
43
Q

What are features of life-threatening asthma exacerbation in children?

A

Any one of the following in a child with severe asthma:

  • SpO2
  • Peak flow
  • Silent chest
  • Cyanosis
  • Poor respiratory effort
  • Hypotension
  • Exhaustion
  • Confusion
  • Normal or high pCO2
44
Q

What are some differentials for an asthma exacerbation?

A
  • Pneumothorax
  • Anaphylaxis
  • Inhalation of a foreign body
  • Cardiac arrhythmia
45
Q

How is an acute asthma exacerbation managed in a child?

A
  • High flow oxygen if life threatening or sats <92%
  • Nebulised salbutamol, only spacer if mild/moderate
  • Add nebulised ipratropium bromide (anti-muscarinic)
  • Oral (prednisolone) or IV (hydrocortisone) steroids for 3 days
  • If O2 saturations <92% add magnesium sulphate
  • PICU Referral
  • If severe or life-threatening acute asthma not responsive to inhaled therapy, add aminophylline

ALWAYS BE CONSIDERING ICU INPUT!

46
Q

What is a step-down regime for salbutamol?

A

10 puffs 2 hourly then 10 puffs 4 hourly then 6 puffs 4 hourly then 4 puffs 6 hourly.

47
Q

What may need to be monitored whilst on high doses of salbutamol?

A
  • Serum potassium as may be raised
  • Tremor
  • Heart rate as causes tachycardia
48
Q

What criteria needs to be fulfilled before a discharge can take place after an acute asthma exacerbation?

A
  • Bronchodilators are taken as inhaler device with spacer at intervals of 4-hourly or more (e.g. 6 puffs salbutamol via spacer every 4 hours)
  • SaO2 >94% in air and PEF >75% expected
  • Inhaler technique assessed/taught
  • Written asthma management plan given and explained to parents
  • GP should review the child 2 days after discharge
49
Q

What are some causes of wheezing in children?

A
  • Viral induced wheeze
  • Bronchiolitis
  • Bronchiolitis obliterans
  • Bronchomalacia
  • Chronic lung disease of prematurity
  • Foreign body inhalation
  • Asthma
  • CF
50
Q

What is the order of tests in asthma diagnosis?

A
51
Q

Why does viral induced wheeze only tend to affect under 3’s?

A
  • They have small airways that develop a small amount of inflammation and oedema in the presence of a virus
  • This swelling and constriction of the airway caused by a virus has little noticeable effect on the larger airways of an older child or adult, however due to the small diameter of a child’s airway, the slight narrowing leads to a proportionally larger restriction in airflow
  • These children have a higher risk of asthma later in life
52
Q

How can you tell the difference between viral induced wheeze and asthma?

A

Generally, typical features of viral-induced wheeze (as opposed to asthma) are:

  • Presenting before 3 years of age
  • No atopic history
  • Only occurs during viral infections
53
Q

How is viral induced wheeze managed?

A

SAME AS ASTHMA

Symptomatic treatment with SABA (5 mg to all children aged over 5 years, and 2.5 mg to children aged 2–5 years)

Consider regular preventer therapy (ICS) if frequent symptoms

Oral steroids if severe exacerbation requiring oxygen or frequent inhalers in hospital

54
Q

What is the definition of apnea?

A

Pause in breathing over 20 seconds and is often followed by bradycardia

Very common in prematurity due to immature breathing centre

Risk of SIDS

55
Q

What are some differentials for apnoea in children?

A
  • Prematurity
  • Low birth weight
  • Infection
  • Hypothermia
  • Congenital heart disease
  • Whooping cough
  • OSA
  • GORD
  • Post operative apnoea
  • Hypoglycaemia
  • Bronchiolitis
  • Neonatal sepsis
  • Meningitis
56
Q

How can apnoea be managed in neonates?

A
  • Monitor with alarms
  • Gentle stimulation
  • Nasal CPAP
  • Oxygen
  • Caffeine citrate twice a day for babies <30 weeks

Most babies will outgrow by 36 weeks gestation

57
Q

How does respiratory distress occur in children?

A
  • Tachypnea
  • Nasal flaring
  • Intercostal and subcostal recessions
  • Grunting
  • Cyanosis
58
Q

What are some causes of breathlessness in children?

A
  • Infection e.g bronchiolitis, whooping cough, pneumonia
  • Asthma
  • Anaphylaxis
  • Congenital heart disease
  • Sepsis
  • Foreign body
  • Fever
59
Q

What is one important blood test to do during paediatric sepsis?

A

Clotting!!

Risk of DIC

60
Q

What are some differentials for a cough in children?

(Image important)

A
  • Acute infection
  • Cystic Fibrosis
  • Post-viral cough
  • Asthma
  • Allergic rhinitis with post-nasal drip
  • GORD
61
Q

What are some causes of cyanosis in children?

A
  • Congenital Heart Disease (e.g Tet of Fallot)
  • Respiratory infection
  • Sepsis
  • Acute asthma
  • Anaphylaxis
62
Q

What investigations should you be doing for a child with cyanosis?

A
  • Cardiac examination for murmurs
  • Pre and post-ductal saturations
  • CXR
  • FBC
63
Q

What is the severity grading of croup in general terms?

A

Admit moderate and severe

64
Q

What are some causes of stridor in children?

A

Partial Upper Airway Obstruction heard on inspiration

Acute

  • Croup
  • Inhaled foreign body
  • Anaphylaxis
  • Epiglottitis
  • Retropharyngeal abscess

Chronic

  • Laryngomalacia - a birth defect that causes the tissue in the voice box to be floppy, which can lead to noisy breathing in babies and children.
  • Haemangioma
65
Q

What age group is stridor more common?

A

Younger children with smaller airways

66
Q

What questions should you ask a parent when their child has stridor?

A
67
Q

What investigations should you do for a child with croup?

A

Never approach without airway support e.g ENT

  • Pulse oximetry
  • ABG
  • Lateral and AP cervical spine
  • Bronchoscopy if foreign body
  • Temperature
68
Q

Why is it concerning if stridor gets quieter and what should you do with this?

A

All children with stridor should be made NBM

Airway management essential

69
Q

What are the steps for asthma treatment in children?

A
70
Q

If a child under 5 starts on a new asthma treatment, how should they be reviewed?

A
  • Symptom diary
  • Follow up in 6-8 weeks

Spirometry and Peak flow are not accurate in under 5s so do not use!!!!!

71
Q

What are risk factors for severe asthma?

A
72
Q
A
73
Q
A
74
Q
A
75
Q

more than how many ribs shows an expanded lung

A

9

Y4 Paediatrics SA (31 decks)

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