8 - Respiratory 1 Flashcards
What is bronchiolitis and what is the epidemiology and aetiology of this?
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
What are some risk factors for developing bronchiolitis?
- *• 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**
How does bronchiolitis present?
- 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
- Wheeze and crackles on auscultation
What are the signs of respiratory distress in children?
How long does bronchiolitis last for?
- 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
What are some differentials for bronchiolitis?
Which infants need to be admitted for hospital treatment with bronchiolitis?
- 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
How is bronchiolitis treated in hospital?
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
What ventilatory support can be given to infants with severe bronchiolitis?
- 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.
How can you tell if ventilatory support is working for children with bronchiolitis?
Capillary Blood Gas
How may bronchiolitis appear on a CXR?
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
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?
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
What are some complications of bronchiolitis?
Higher risk of asthma in later life
What is bronchiolitis obliterans?
- 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.
What is asthma and the epidemiology of this in children?
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
What are some risk factors for asthma?
- 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
What are some triggers for asthma?
- Dust
- Animals
- Cold air
- Exercise
- Smoke
- Food allergens (e.g. peanuts, shellfish or eggs)
- Drugs
How may asthma present in children?
EPISODIC USUALLY WITH DIURNAL PATTERN
- Cough
- Breathlessness
- Widespread wheeze
- Chest tightness
What are some differentials for asthma and what are some presentations that point away from a diagnosis of asthma?
DDx: respiratory tract infections, viral wheeze, foreign body inhalation, bronchiolitis, allergic reactions or anaphylaxis
What questions need to be asked in the history if you are considering asthma as a diagnosis?
- 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
How is asthma diagnosed in children?
(memorise image!!!)
Diagnosis is usually clinical, if under 5 no investigations needed just treat symptoms
- Spirometry with bronchodilator reversibility testing (in children aged over 5 years) is first line
- Fractional exhaled nitric oxide (FeNO)
- Direct bronchial challenge test with histamine or methacholine
- Peak flow variability measured by keeping a diary of peak flow measurements several times a day for 2 to 4 weeks
Spirometry is first line investigation for asthma in over 5’s. What may the result show if asthma is present?
- Obstructive Pattern (FEV1/FVC ratio <70%)
- BDR over 12%
What is an FeNO test and how do you interpret the result?
- FeNO = surrogate marker for eosinophilic inflammation in airways
- Over 20ppb is positive in children
- Over 35ppb is positive in adults
What is challenge testing for asthma?
How can peak flow variability aid a diagnosis of asthma in children and what are the drawbacks with this method?
• Variability over two weeks
– > 20% variability (NICE)
– > 12% variability (ERS)
What are the principles of treatment in asthma?
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
How can you assess current asthma control in children?
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
What self-management should you encourage for patients with asthma?
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
What is the stepwise management for asthma in under 5’s?
- Start a SABA inhaler (e.g. salbutamol) as required
- Add a low dose corticosteroid inhaler or a leukotriene antagonist (i.e. oral montelukast)
- Add the other option from step 2
- Refer to a specialist
What is the stepwise management for asthma in over 5’s?
- SABA inhaler (e.g. salbutamol) as required
- Add a regular low dose ICS
- Add a LABA (e.g. salmeterol). Continue only if patient has a good response.
- Titrate up ICS to a medium dose. Consider adding:
- Oral LTRA (e.g. montelukast)
- Oral theophylline
- Increase the dose of the ICS to a high dose
- Referral to a specialist. They may require daily oral steroids.
How do you explain to parents how to use their child’s inhaler?
ALWAYS CHECK INHALER TECHNIQUE AT REVIEWS
What are features of moderate asthma exacerbation in children?
- 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.
What are features of life-threatening asthma exacerbation in children?
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
What are some differentials for an asthma exacerbation?
- Pneumothorax
- Anaphylaxis
- Inhalation of a foreign body
- Cardiac arrhythmia
How is an acute asthma exacerbation managed in a child?
- 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!
What are some causes of wheezing in children?
- Viral induced wheeze
- Bronchiolitis
- Bronchiolitis obliterans
- Bronchomalacia
- Chronic lung disease of prematurity
- Foreign body inhalation
- Asthma
- CF
What is the order of tests in asthma diagnosis?
Why does viral induced wheeze only tend to affect under 3’s?
- 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
How is viral induced wheeze managed?
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
What is the definition of apnea?
Pause in breathing over 20 seconds and is often followed by bradycardia
Very common in prematurity due to immature breathing centre
Risk of SIDS
What are some differentials for apnoea in children?
- Prematurity
- Low birth weight
- Infection
- Hypothermia
- Congenital heart disease
- Whooping cough
- OSA
- GORD
- Post operative apnoea
- Hypoglycaemia
- Bronchiolitis
- Neonatal sepsis
- Meningitis
How can apnoea be managed in neonates?
- 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
How does respiratory distress occur in children?
- Tachypnea
- Nasal flaring
- Intercostal and subcostal recessions
- Grunting
- Cyanosis
What are some causes of breathlessness in children?
- Infection e.g bronchiolitis, whooping cough, pneumonia
- Asthma
- Anaphylaxis
- Congenital heart disease
- Sepsis
- Foreign body
- Fever
What are some differentials for a cough in children?
(Image important)
- Acute infection
- Cystic Fibrosis
- Post-viral cough
- Asthma
- Allergic rhinitis with post-nasal drip
- GORD
What are some causes of cyanosis in children?
- Congenital Heart Disease (e.g Tet of Fallot)
- Respiratory infection
- Sepsis
- Acute asthma
- Anaphylaxis
What investigations should you be doing for a child with cyanosis?
- Cardiac examination for murmurs
- Pre and post-ductal saturations
- CXR
- FBC
What is the severity grading of croup in general terms?
Admit moderate and severe
What are some causes of stridor in children?
Partial Upper Airway Obstruction heard on inspiration
Acute
- Croup
- Inhaled foreign body
- Anaphylaxis
- Epiglottitis
- Retropharyngeal abscess
Chronic
- Laryngomalacia
- Haemangioma
What questions should you ask a parent when their child has stridor?
Why is it concerning if stridor gets quieter and what should you do with this?
All children with stridor should be made NBM
Airway management essential
What are the steps for asthma treatment in children?
What are risk factors for severe asthma?
