Acute respiratory presentations in children Flashcards
Commonest causes of breathlessness in children
asthma
croup
bronchiolitis
pneumonia
(epiglottitis)
(URTI)
Respiratory examination findings in children
noisy breathing
respiratory rate
work of breathing
accessory muscle use
saturations
heart rate
auscultation
peak flow measurement
Types of noisy breathing
coryza
wheeze
stridor
grunting
What is wheeze in children suggestive of?
asthma
bronchiolitis
lower resp tract foreign body
What does stridor suggest?
significant obstruction of airflow in larynx or extra-thoracic trachea
What causes grunting in children?
glottis closure in expiration to increase end expiratory pressure to keep alveoli open
What signs can be commented on for work of breathing in children?
recession
tracheal tug
supraclavicular recession
sternal recession
intercostal recession
subcostal recession
accessory muscle use - abdominal, head bobbing (pulling on SCM), nasal flaring
Resp examination of child red flags
tachypnoea
signs of resp distress: chest indrawing, tracheal tug, head bobbing
hypoxia
toxic-looking child
rigors
vomiting - inability to drink
Normal sats in children
94-100%
<90% = significant hypoxaemia
Typical auscultation sounds in asthma
wheeze
Typical auscultation sounds in bronchiolitis
bilateral crepitation/fine crackles
wheezy
Typical auscultation sounds in pneumonia
many have completely normal sounds
crackles - unilateral, bilateral
bronchial breathing (usually >3y) = harsh blowing sound above area of consolidation
Define respiratory insufficiency
inability of respiratory system to support oxygenation and/or ventilation
Respiratory insufficiency in children causes
extrathoracic congenital = laryngomalacia, tracheomalacia, subglottic stenosis, subglottic web, craniofacial abnormalities
extrathoracic acquired = infections (croup, bacterial tracheitis), foreign body aspiration, trauma
intrathoracic airway + lung causes = bronchiolitis, pneumonia, asthma, aspiration, vascular rings, tracheomalacia, bronchomalacia, cardiovascular disease, pulmonary oedema, pulmonary embolus
respiratory pump = spinal muscular atrophy, duchenne muscular dystrophy, diaphragmatic hernia, GBS, MG, spinal cord trauma
central control = meningitis, central sleep apnoea, congenital central hypoventilation syndrome, drug overdose, traumatic brain injury
Croup presentation
upper airway viral infection –> inflammation –> airway obstruction
difficulty breathing
characteristic barking cough + hoarse voice (seal episode)
inspiratory +/- expiratory stridor
intercostal/subcostal/sternal recession + tracheal tug
What age is croup unlikely?
<6 months
Croup management
avoid upsetting child
responsive to steroids (PO dexamethasone/prednisolone or NEB budesonide)
adrenaline if severe upper airway obstruction (NEB 5ml 1:1000 adrenaline –> decrease inflammation in 20 mins)
When is bronchiolitis most common?
infants over winter months (september –> april)
Most common cause of bronchiolitis
RSV (respiratory syncytial virus)
Bronchiolitis presentation
mild fever <38
runny nose
shortness of breath
wet-sounding cough
wheezy cough
bilateral crepitations to auscultation
Bronchiolitis treatment
no specific treatment - supportive management
fluids (NGT or IV fluids)
oxygen
Most common causes of pneumonia in children
viral
streptococcus pneumoniae
haemophilus influenzae type b
mycoplasma pneumoniae
Pneumonia presentation in children
often subtle in children <3
appear more unwell + lethargic
fever >38.5
anorexia/vomiting
abdominal pain
cough less reliable symptom than in adults
small chest transmits sounds all over so focal sounds hard to detect
Extrapulmonary symptoms of pneumonia in children
diarrhoea
vomiting
myalgia
abdominal pain
When to CXR in suspected pneumonia in children
respiratory distress
fever >39
rapid deterioration or not response to treatment
complication such as pleural effusion suspected
Criteria for admission of children with pneumonia
O2 <92 on air
grunting or apnoea
significant resp distress
poor feeding
concerns regarding supervision
Pneumonia in children treatment
antibiotics - no reliable way to distinguish between bacterial + viral
What antibiotics are used for pneumonia in children?
amoxicillin
alternatives: co-amoxiclav, cephalosporins, erythromycin, clarithromycin, azithromycin
macrolide added if:
- no response to 1st line
- mycoplasma/chlamydia suspected
- very severe disease
Asthma auscultation findings
hyper-reactive asthmatic airways:
- bronchial constriction –> wheeze
- mucous secretion –> inflamed mucosa –> wheeze
- prolonged expiration (alveolar air trapping)
Clinical signs of life-threatening asthma
exhaustion
hypotension
cyanosis
silent chest
poor respiratory effort
confusion
Asthma acute treatment
beta agonist (salbutamol) using spacer
Which children require supplemental oxygen?
if needed to maintain sats >92
(or 94 in severe heart failure, severe sepsis, asthma or brain injury)
Croup xray sign
steeple sign
narrowing of the airway that appears as a steeple or inverted V on an X-ray of the neck
