Breathing difficulty Flashcards
How to distinguish between distress caused by lung disease vs cardiac disease
Cyanosis that is not improved when given O2 is likely to be due to congenital heart disease with right to left shunting
Ddx for a child with breathing difficulties
URTI - viral Pharyngitis/tonsillitis Croup Epiglottitis Tracheitis Peri tonsillar abscess Foreign body Asthma whooping cough Bronchiolitis Pneumonia Chronic lung disease e.g. chronic lung disease of infancy, Cystic fibrosis, Bronchiectasis, aspiration pneumonia Cardiac failure
DDX for child with cough
Pneumonia Asthma URTI Bronchiolitis Croup Whooping cough Inhaled FB
DDX for child with wheeze
Bronchiolitis
Asthma
Heart failure
Inhaled FB
DDX for child with Acute stridor
Croup
Anaphylaxis,
Inhaled FB
Epiglottitis
DDX for child with Chronic stridor
Laryngomalacia
Laryngeal anomalies eg vocal cord palsy
Tracheal abnormality e.g. subglottic stenosis, vascular ring.
Disorders included in URTI
Rhinitis, Tonsillitis Pharyngitis Epiglottitis Laryngitis Sinusitis
Common pathogens infecting nasopharynx
Rhinovirus Parainfluenza RSV Adenovirus Corona Influenza B,C
Common pathogens in oropharynx
GAS, Corynebacterium, EBV, Adenovirus
Common pathogens in larynx and trachea
parainfluenza,
Staph aureus
Common pathogens in bronchi
influenza
Strep pneumonia
H influenza
Hx Q of viral URTI
Hx of sneezing, sore throat, cough, headache, runny or blocked nose, malaise and fever
who get tonsillopharyngitis
Common 5-14yr
Hx of pharyngitis/tonsillitis
Fever
absence cough
difficulty swallowing
foul breath
Examination of pharyngitis/tonsillitis
Tonsillar exudate and swelling
anterior LN - cervical
Modified censor criteria
1 - tonsillar exudate or erythema 1- anterior cervical adenopathy 1 - cough absent 1 - Fever present 1 if age 3-14 0 if age 15-45 -1 if >45yrs Score 4-5 treat with ABx Scor 2-3 preform rapid antigen test if + then ABx. if - then culture. Score 0-1 Symptomatic relief only
ABx for GAS pharyngitis
Phenoxymethyl penicillin BD for 10 days or Roxithromycin if allergic
Mx for pharyngitis/tonsillitis
ABx if indicated
Analgesics
Corticosteroids if severe pain - dexamethasone
Admit if suspected airway obstruction or systemically unwell or signs of cx.
cause of Croup
RSV Parainfluenza Adenovirus Metapneumonvirus Rhino virus
who gets croup
6m to 5yrs
Hx Q for croup
Coryza +/- Seal like barking cough Inspiratory stridor \+/- respiratory distress \+/- fever Worse at night and on 2or3 night
Characteristics of mild croup
Behaviour - normal Stridor - barking cough and stridor only when active or upset RR - normal Accessory muscle use - non or minimal O2 - none required
Characteristics of moderate croup
Behaviour - some/intermittent irritability
Stridor - some stridor at rest
RR - ⇑ + tracheal tug + nasal flaring
Accessory muscle use - moderate chest wall retraction
O2- none required
Characteristics of severe croup
Behaviour - Increasing irritability and or lethargy
Stridor - at rest
RR - Marked⇑or⇓ tracheal tug, nasal flaring
Accessory muscle use - Marked chest wall retraction
O2 - Hypoxia is a late sign of significant Upper airway obstruction
Examination for croup
behaviour
Resp - stridor, effort, rate, O2 stats,
ENT - mininal
Ix for croup
none
Mx of croup
Safety net - ABCD - Check with supervisor - return if concerned minimal handling Steroid - dexamethasone once or 2 doses of prednisolone Observe for half an hour Fluid/ food Discharge once stridor free at rest Severe: Nebuliser adrenalin 1ml+3ml NS Dexamethasone observe for 4hr discharge after stridor at rest and >4hr of post adrenalin. Safety net
What causes epiglottitis
Haemophilus influenza
Strep pneumonia,
Who gets it epiglottitis
Child 1-6yr
Unimmunised or vaccine failure
Hx of epiglottitis
Acute high Fever dysphagia drooling Lethargy Hoarseness Stridor - soft inspiratory stridor and rapidly increasing Resp effort Cough- not prominent or absent
Examination of epiglottis
Acutely ill and anxious child most are septicaemia, toxic and pale looking, Poor peripheral circulation Quiet shallow breathing Head forward Triad position extension of neck
Mx of epiglottis
Minimal handling and stay by the bed
Don’t examine, or X-ray
Resus trolley or transfer to therapy to intubate
ICU care
IV antibiotics - sepsis, IV ceftriaxone
Rifampicin prophylaxis for contacts if no contraindications if HIB.
DDX for child with breathing difficulties high fever Hyperextension of neck Dysphagia Pooling of secretion in throat
Epiglottitis
Retropharyngeal/peritonsillar abscess
DDX for child with breathing difficulties
Toxic appearing child
Markedly tender trachea
Bacterial tracheitis
DDX for infant with breathing difficulties and preexisting stridor
Congenital abnormality eg floppy larynx, haemangioma/subglottic stenosis
Presentation of bacterial tracheitis
Toxic Tender trachea \+/- viral prodrome eg influenza Most commonly Stapy aureus , strep or HiB Croupy cough Sick child High temperature absence of drooling
Tx of bacterial tracheitis
ICU
Maintenance of airway - many require intubation
Maint - O2 and fluid balance
IV antibiotics- flucloxacillin?
Cause of Quinsy (retropharyngeal/peritonsillar abscess)
Polymicrobial - staph aureus and strep pyogenes
Who gets it Quinsy
teenagers and young adults
Presentation of quinsy
Starts as tonsillitis followed by difficulties swallowing with truisms (spasm of jaw = lock jaw) High fever Dysphagia Odynophagia Stridor typical signs of respiratory distress
Examination of quinsy
Pooling of secretion treat
Difficulty moving or unwilling to move their neck
Hyperextension of neck - usually unilateral
Tx of quinsy
Admit to hospital
ABx - procaine penicillin IM or clindamycin
Surgery - aspiration or drainage
Hx of Foreign body in airways
Complete obstruction - coughing, shaking, +/-Vomiting - LOC and Cardiorespiratory arrest. Partial obstruction - Persistent wheeze, cough, fever or dyspnoea - Recurrent or persistent pneumonia - Unilateral wheeze
Examination of foreign body in airways
ABCD Partial - asymmetrical chest movement - tracheal deviation - Chest signs - wheeze or decrease breath sounds May be normal
Mx of foreign body in airway
Complete
- ABCD - remove if you can see it
- send for help
- Prone with head down
- 5 blows to back with open hand to inter scapular area
- turn child face up
- 5 chest thrust (chest compression technique)
- Check mouth - remove if possible
- if not relieve repeat
- still not fixed try Positive pressure ventilation or surgical airway
Partial
- leave in comfortable position and arrange surgery for urgent removal (bronchoscopy)
Features of mild asthma
Normal mental state
Subtle or no ↑ WoB, accessory muscle use or recession
Able to talk normally
Features of moderate asthma
Normal mental state
Some ↑WoB with accessory muscle use/recession
Tachycardia
some limitation to talk
Features of severe of asthma
Agitated/distressed
Moderate/marked ↑WoB with accessory muscle use/recession
Tachycardia
Marked limitation of ability to talk
Features of Critical Asthma
Confused/drowsy Maximal WoB Exhaustion Marked tachycardia Unable to talk Silent chest
Features of Status Asthmaticus
Severe hypoxia, hypercapnia and acidosis
done to hyperinflation and blocks airways due to excess mucous.
Ix for Asthma
Acute - none
Adult - PEFR, Pulse oximetry,
Blood gases (low O2, Low CO2, alkalosis. In severe it can go normal CO2)
CXR (exclude pneumothorax)
Chronic and older then 6 yr
FEV/FVC of less than 70% which does improve with inhaled bronchodilators by more than 15%
Mx of mild Asthma
Salbutamol by MDI/Spacer - give once and review after 20mins,
Good response - discharge on B2-agonist an needed
Poor response - treat as moderate
Oral prednisolone for acute episodes which do not respond to bronchodilator alone - 2mg/kg (max 60mg) initally, only continuing with 1mg/kg daily for1-2 days if regular salbutamol is needed.
Mx of moderate Asthma
O2 if sats are less then 92%
less then 6yr - 6 puffs every 20min for 1 hour.
More then 6 yrs - 12 puff
RV 10-20 min after 3rd dose to decide on timing of next dose.
Oral prednisolone - 2mg/kg (max of 60) initially, then continuing with 1mg/kg daily for 1-2 days if salbutamol is ongoing.
Mx of severe Asthma
O2 if less than 92% Salbutamol 1 dose every 20mins for 1 HR Ipratropium 4 puff if under 6, 8 puffs if over 6yr. Every 20min for 1hr Aminophylline 10mg/kg if deteriorating MgSO4 IV Oral prednisolone Involve senior staff Arrange admission after initial assessment
Mx of Critical Asthma
*Involve senior staff
*O2
*Continuous nebuliser salbutamol - 2x5mg/2.5L nebules
*Nebuliser ipratropium 250mcg 3 times in 1st hour only (20minutely
*Methylprednisolone 1mg/kg IV 6 hrly
*Aminophylline as above
*MgSO4 - as above
*May consider IV Salbutamol
Beware of salbutamol toxicity = tachycardia, tachypnoea, metabolic acidosis. High lactate, might required stopping or reduces therapy if it occurs
Aminophylline, magnesium and salbutamol must be given via separate IV line
ICU for respiratory support
When to discharge pt after asthma attack
- Assess patient for clinical improvement 1hr following initial therapy and discharge if clinical well. if necessary reassess in 30 mins
- Adequate oxygenation - O@ sat less then 92% should not preclude discharge if patient is clinically well and has responded well to treatment.
- Adequate oral intake
- Adequate parental education and ability to administer salbutamol via spacer
- given an action plan
- observe correct inhaler use
- outpatient RV with GP within 48 hrs
Step wise approach to Asthma medication outside of acute attack
SABA
+ ICS
+LABA
+Higher doses and referral
Mx of infrequent episodic asthma
Mx of frequent episodic asthma
Episodes every 2-4 wk
Tx SABA then attack
Use low dose ICS
Mx of persistent asthma
> 3 episodes/wk with cough at night/morning
Tx SABA + LABA + ICS
May need Oral steroids or leukotriene inhibitors
Cause of Whooping cough
Bordetella pertussis
Presentation of whooping cough
Classic - cough and coryza for one week (catarrhal phase) followed by more pronounced cough in spells or paroxysms (paroxysmal phase)
Other - vomiting due to cough, apnoea, cyanosis, sick contact
Immunisation
Sever pneumonia/encephalpathy
Examination finding in whooping cough
Often no signs, appears well between coughs
Fever is uncommon
Ix whooping cough
Not needed as clinical diagnosis
Lymphocytotis
Per nasal swab PCR
Serology IgA- 2 wk after onset
Mx of whooping cough
Admit if 21 days or 14 days from last exposure if unimmunised
Prophylaxis - same as treatment.
Notify
Cx of whooping cough
Pneumonia, cyanosis, apnoea or encephalopathy
Cause of bronchiolitis
Viral RSV - most common Metapneumovirus adenovirus influenza parainfluenza
Who gets it bronchiolitis
less then 2 years old and higher in winter
Risk factors for bronchiolitis
You're infant especially less than 6weeks Ex-prem CHD Chronic Respiratory illness Down’s syndrome Neurological problems Pulmonary hypertension Immunological condition
Hx Q for bronchiolitis
Age - less then2 years \+/- hx of contact with URTI Starts with Coryza/URTI then Cough then Chesty - Wheezy/crackles then Respiratory distress \+/- Decrease feeding - ask about the feeding and urine output hydration \+/- apnoea in infants, changes in colour Determine if fish factors for severe illness Duration of illness FH atopy, eczema, asthma (+exposure to smoking) Full paed hx Sick contacts at child care/home
what to examine for in bronchiolitis
General inspection - colour, apnoea, behaviour, alertness, irritability, increase work of breathing, sough, where
vital obs including oxygen saturation - +/-fever increase HR, RR, BP, CRT peripheral and central, Wt
+/- Coryza
Increased work of breathing (or tiredness)
+/- signs of dehydration
Apnoea
widespread Wheezes and fine crackles
over expansion of chest
Features of mild bronchiolitis
Behaviour - N RR - N Accessory muscle use- Nill or minimal Feeding - N O2 - none >95% Apnoea episodes - none
Features of moderate bronchiolitis
Behaviour - some/intermittent irritability
RR - ↑RR +Tracheal tug +nasal flaring
Accessory muscle use - Moderate chest wall retraction
Feeding - Difficulty or reduced
O2 - Mild hypoxemia corrected by O2 90-93%
Apnoea episodes - may have brief.
Features of severe bronchiolitis
Behaviour - ↑irritability and or lethargy, fatigue
RR - Marked ↑or↓RR +tracheal tug + nasal flaring
Accessory muscle use - Marked chest wall retraction
Feeding - reluctant or unable to feed
O2 - hypoxemia, may not be corrected by O2 (
Ix for bronchiolitis
Not needed NPA CXR - hyperinflation, peribronchial thickening and patchy consolidation and collapse BG U&E - if IV fluids required
Mx of bronchiolitis
Oxygenation
fluid intake
minimal handling
Comfort oral feeds
Mx of mild bronchiolitis
Outpatients
Advice parent to return if any concerns or worsening
Fact sheets
Education on expected course of illness - self limiting, worse by 3-4-5 night, resolve by day 10. cough may last 4 wks.
Smaller more frequent feeds
RV with GP in 24hr or sooner
Mx of moderate bronchiolitis
Admit to paediatric
isolation
O2 vis nasal prongs - aim for 92-93% sats
Continue fluid either oral/NGtube/ IV (2/3 maintenance to prevent SIADH)
Paracetamol
1-2hourly observations
Mx of severe bronchiolitis
same as moderate plus Cardiorespiratory monitoring close nursing supervision O2 and fluids ICU and CPAP or ventilation
Common causes of Pneumonia
Streptococcus pneumoniae Haemophilus influenza Moraxella catarrhalis Viral - most common in children - RSV, influenza Newborns - GBS, E.Coli, Listeria
Prevention of pneumonia
Pneumococcal conjugate (13vPCV)or (23vPPV) high risk. at 2, 4, 6 months (12-18 months ATSI) Pneumococcal polysaccharide (23vPPv) for medically at risk and ATSI). 4,15, 50,65+yrs Haemophilus influenzae type B. 2, 4, 6, 12months Yearly influenza vaccine
Red flags of pneumonia in children
Signs of sepsis Lethargic and unwell Temp >38.5 go off their food Signs of respiratory distress Noisy breathing Cough may be absence Tachycardia especially if higher than fever should make it
Hx of pneumonia in children
Children with short hx of fever, cough, or tachypnoea, nasal flaring, lower chest indrawing or recession, consolidation or effusion, or persistent fever or fever and upper abdominal pain. Grunting common in infants
Signs of pneumonia
↑WoB, pallor, shocked, leaning forward,
Vitals - tachypnoea, tachycardia, hyperpyrexia, reduced O2
Prolonged CRT
Cyanosis
Respiratory distress
↑tactile fremitus and reduced chest expansion
dull precision, crackles, bronchial breath sounds and increase vocal resonance
Mx of children with pneumonia
Pneumonia in children
almost all those 70, intermittent apnoea, not feeding
older children - RR>50, Grunting, signs of dehydration
Both groups - O2 sat 24m penicillin or roxithromycin
Severe - flucloxacillin IV + cefotaxime IV +/- roxithromycin
Cause of Cystic fibrosis
recessive genetic disorder - CFTR gene on Chromosome 7 causes a defect in a cellular membrane chloride channel which leads to excessively thick mucus in many body systems
Presentation of cystic fibrosis
Presentation neonatal screening Weight filtering Diarrhoea Chest infection
ENT - Nasal polyps, Sinusitis
Recurrent chest infections
Cough, purulent sputum, pneumonia, chronic pseudomonas infection, bronchiectasis, chest deformity, eventual respiratory failure
Finger clubbing
Liver disease - Obstructive jaundice in neonatal period (rare), Biliary stasis (may need tx with ursodeoxycholic acid). Eventually liver cirrhosis
Skin - High salt losses in sweat, salty taste to skin, risk of salt-losing crisis during very hot weather.
Development- Poor growth - Require 40% extra energy intake, Poor weight gain, short statue, malabsorption.
GIT
Pancreatic insufficiency, poor fat absorption, steatorrhoea, distended abdomen, rectal prolapse, distal intestinal obstruction syndrome (can mimic acute appendicitis), Diabetes, Meconium ileum at birth (15%).
Male infertility - Congenital absence of the vas deferent.
delayed puberty
Q to ask on Hx of cystic fibrosis
Failure to thrive with ravenous appetite Cough and wheeze Recurrent chest infections and sinusitis Bulky. pale, offensive smelling stools, often difficult to flush away wt loss may indicate CF Delay puberty FmHx cystic fibrosis
Examination for cystic fibrosis
GI - Wasting, short statue, Respiratory distress, submit vascular access devices
Vital
Hands - Clubbing, pallor, Warm and well perfused
Face -
Resp - Chest wall deformity, consolidation, crackles Clubbing,
Abdo - Gastrostomy tube, Hepatosplenomegaly
genital - Delayed puberty
Diagnosis of CF
antenatal - chorionic villus biopsy or amniocentesis
Newborn - newborn blood spot screening
Gene testing - CFTR gene
Sweat test - collected by passing a small electric current across the skin.
Mx of CF
Maintenance - Pancreatic enzymes and Vit ABDECK - Abx prophylaxis - Increase calorie intake - Chest physio - B agonist - Mucolytic trail - Nebuliser dornase alfa - rhGH - Immunisation Tune up - Admit - eg tobramycin - Chest physic with saline daily - Spirometry - Abx - based on colonisation, - Isolation and precaution Acute exacerbation - Abx - Pip-taz (Piperacillin/tazobactam)
Defined bronchiectasis
permanent and abnormal widening of the bronchi due to walls becoming inflamed, thickened and irreversibly damage following obstruction followed by infection
Symptoms of bronchiectasis
Chronic cough that worse on walking Mild disease = yellow or green sputum only after infection advanced disease profuse purulent offensive sputum- green, yellow persistent halitosis (bad breath) recurrent febrile episodes Malaise, wt loss or suboptimal Wt gain Sputum production related to position PmHx - pneumonia, Haemoptysis
Signs of bronchiectasis
GI - cachexia Vitals -fever Hands - Clubbing (severe cases) Face - sinusitis, cyanosis Neck - tracheal midline Resp Commonly affects lower lobe but may have one or more lobes at once I - slight reduction in chest expansion P - normal or decrease vocal femitus P - may be resonant or dull. A - Late inspiratory coarse crackles +/- localised wheeze. bronchial breath sounds.
Ix for bronchiectasis
- Sputum culture = mix of normal flora - bacteria don’t cause it they just grow once it is blocked. Done to exclude TB
Streptococcus pneumoniae, pseudomonas aeruginosa, Haemophilus influenzae (commonest)
Spirometry meter
Diagnosed = CT scan to visulise larger bronchi
CXR - normal or bronchial changes
Cytology - rule out neoplasm
Mx of bronchiectasis
Explanation and preventative advise
Postural drainage eg lie over side of bed with head and thorax down for 10-20 minutes 3 times a day
ABx according to organism - need to eradicate infection to halt progress of disease
Amoxycillin or roxithromycin
Bronchodilators indicated if evidence of bronchospasm.
Complication in a infant with cystic fibrosis
Meconium ileus
Neonatal jaundice - prolonged
Hypoproteinaemia and oedema
Cx in a child with Cystic fibrosis
recurrent lower respiratory tract infection Bronchiectasis - occasionally Poor appetite Rectal prolapse Nasal polyps Sinusitis - rarely with symptoms
Cx in an adolescence with Cystic fibrosis
Bronchiectasis Diabetes mellitus Cirrhosis and portal HTN Distal intestinal obstruction Pneumothorax Haemoptysis Allergic bronchoplumonary aspergillosis Male infertility Arthropathy Psychological problems
MDT member for mx CF
paediatric pulmonlogist Physiotherapist dietician Nurse liaison or practitioner in CF primary care team teacher psychologist
What to educate a parent who smokes around their children
research children who are exposed to passive smoking are at increased risk of croup, SIDS, bronchitis, pneumonia, ear infections, learning difficulties, behavioural difficulties and childhood asthma
Tx for asthma that occurs infrequently or episodic
SABA
Tx for frequent asthma attacks that occur more then once every 6 weeks.
SABA
Inh corticosteroid
If not improving ensure complicance and then increase dose.
Tx for asthma who has a daily symptoms
SABA Inh corticosteroid LABA Increase doses Ref to respiratory specialist
Pathogenesis of Asthma
Acute phase response- Vascular leakage and smooth muscle contraction. 1-2 hrs, Histamine, tryptase, leukotrienes, Platelet activating factor, chemokine and cytokines
Late response - eosinophilic and lymphocytic infiltration of bronchial mucosa. 6hrs post and continue for 24hr. IL5, Eosinophilia, TH2 lymphocytes.
Long term structural changes
- loss of surface epithelium
- Increased basement membrane thickness
- Marked increase in smooth muscle mass
- Marked local inflammatory cell infiltrate,
- Increase vascular permeability
- Remodelling of the airways.
When to ask for help when treating asthmatic
exhaustion, LOC, blood gases showing respiratory alkalosis being replaced by hypoxia, hypercarbia and acidosis .
Common problems is management of CF
Chest infection - mucus plug increase chronic respiratory infection especially by Pseudomonas aeruginosa or Burkholderia cepacia. Lead to rapid deterioration in lung function.
Tx involve regular bronchodilators, antibiotics (oral, nubulised or intravenously which can be delivered at home via indwelling central line). Steroid to suppress lung inflammation. Nebuliser DNase enzymes can help break down mucus in the lung.
Airway clearance
Preventive physiotherapy - exercise, autogenic drainage, positive expiratory pressure, inhalation therapy and postural awareness.
prophylactic immunisation against influenza and pneumococcus is recommended
Bronchodilators, Nebuliser dornase alfa.
Malabsorption - due to pancreatic failure
ectocrine - defect in Vit A, D, E, K. tx with pancreatic enzyme capsules and high calorie diet from infancy
Diabetes melitus - 25%-> impaired glucose tolerance. tx as optimisation of blood glucose is associated with an improvement in lung function
Salt loss - needs monitoring tx with salt tablets
Liver disease - due to sluggish bile flow = biliary disease and rarely cirrhosis - tx Ursodeoxycholic acid.
Pseudo obstruction of bowel mistaken for appendicitis tx pancreatic enzymes or osmotic laxatives.
Sub fertility - Most men have no vas deferens.
Signs of Respiratory distress
Intercostal recession, subcostal retraction, sternal retraction Tachypnoea Cough Noisy breathing (stridor or wheeze) Chest pain Poor feeding Change in colour Poor tone Altered conscious level
Difference between child and adult airways
Anatomy: tongue is larger, soft tissue, short neck, higher larynx, relatively large head, narrowest portion of the airway is at the cricoid ring and smaller airway
Compliance chest wall (decreased efficiency of breathing)
Fewer alveoli in early childhood (V/Q mismatch)
Obligatory nose breathers
Diaphragm is the principal respiratory muscle, it is flatter and has muscle fibres more vulnerable to fatigue
Increased metabolic demands
Immature immune system
Increased frequency of viral illnesses
Investigations for a child with respiratory distress
Pulse oximetry
May be difficult in agitated patient
May be falsely decreased in very anemic patients
Imaging
Chest X Ray: Consider in patients with focal lung findings or respiratory distress of a unknown etiology
Soft tissue radiograph of lateral neck: May identify a retropharyngeal abscess or radiopaque foreign body
Labs
ABG/VBG
Chemistry: calculate anion gap
Urine toxicology and glucose if patient has altered mental status
DDX for respiratory distress
Anaphylaxis FB Retropharyngeal abscess Tracheitis Asthma pneumonia
prevention of asthma
No smoking in pregnancy and passive exposure
Probiotics
Food allergen avoidance
House dust mite avoidance
Breast feeding/hydrolysed formula/normal cow’s milk formula, omega fatty acid
