Cardio + resp Flashcards
Define apnoea
cessation of breathing for 20 seconds or shorter if there is bradycardia, cyanosis, pallor or hypotonia
Give 3 central and 3 obstructive causes of apnoea (in a child)
central: - apnoea of prematurity - head trauma - toxins - seizures - breath holding spells - arrhythmias - congential hydrocephalus obstructive: - adenotonsillar hypertrophy - reflux - foreign body - anatomical obstruction - LRTI or URTI
What is apnoea of prematurity and how is it treated?
decreased responsiveness to hypercapnia due to immaturity of system- treat with caffeine
What are breath holding spells and how are they managed?
When an infant cries and they hold their breath, it can lead them to become pale/ blue and even faint.
They are benign and self limiting and the parent just needs reassurance that theyll grow out of them
Describe the clinical features of a child with asthma
- recurrent symptoms (wheeze, cough, SOB) which occur between exacerbations (differentiates from viral induced wheeze)
- variable symptoms (worse at night, with certain triggers, at different times of year)
- history of atopy (eczema, hay fever, allergy)
- variable PEF
- Age >2 (generally >5)
How is a diagnosis of asthma and decision to treat made in a child?
- high probability based on symptoms: start 6 weeks ICS, good response then diagnose as asthma
- mid probability: spirometry and reversibility, FeNO, blood eosinophils, IgE testing
- too young for spirometry (generally <5yrs): watchful waiting if asymptomatic and monitored treatment if symptomatic
Name 2 long acting beta agonists and 3 corticosteroids used to treat asthma?
LABA: salmeterol (MDI, accuhaler), fometerol (turbohaler)
ICS: beclomethasone (MDI, clickhaler, easibreathe, easihaler), fluticasone (MDI, accuhaler), budesonide (MDI, easihaler, turbohaler)
Name 2 combination inhalers and the drugs that are in them
Seretide (fluticasone + salmeterol)- MDI or accuhaler
Symbicort (budesonide +fometerol)- turbohaler
What is the first line therapy for asthma if >5 and <5yrs
if >5yrs very low dose ICS
if <5yrs can use leukotriene receptor antagonists (monteleukast)
+ SABA for symptom relief
What are the 2nd, 3rd and 4th line therapies for asthma in children
2nd= add LABA if >5 and LRTA if <5yrs 3rd= increase ICS dose, consider adding LTRA. stop LABA if no help, continue if some help 4th= increase ICS again, consider adding 4th agent eg theophyline and refer to specialist 5th= specialist use of oral steroids, monoclonal antibodies etc
Why may a childs asthma be poorly controlled?
- poor inhaler technique
- parental smoking
- unidentified triggers/ lack of avoidance
- poor adherence with steroid therapy
- inadequate dose of ICS
- damp/ mould
- developed allergic rhinitis
- chest infection
- wrong diagnosis
give 5 features of well controlled asthma
- SABA use <3 times per week (<1 inhaler per month)
- no daytime symptoms
- no night time wakening
- no rescue med use
- no attacks
- no limits on physical activity
- normal lung function tests
- minimal side effects
- on lowest possible dose of ICS
Describe the features of a moderate and severe asthma attack
Moderate: sats>92%, able to talk, PEFR >50% best/ predicted. HR <25 (or 140 if <5yrs), RR < 30 (<40 if <5yrs)
Severe: <92%, cant talk, accessory muscle use, PERF 33-50%, HR >125//140 RR>30//40
Describe the features of a life threatening asthma attack
Sats <92% + any of:
- poor resp effort
- exhaustion
- agitation
- altered consciousness
- cyanosis
- silent chest
- PEFR <33% best/ predicted
how is a moderate- severe asthma attack managed initially and what do you do if good and poor response?
Salbutamol 6 puffs via inhaler + pred 1-2mg/kg up to 40mg. Give 8L O2 and consider salbutamol as neb (2.5-5mg)if severe.
If good response (PEFR >75%) after 15 mins, continue spacer as needed but if needs >4hrly manage as poor response. continue pred for 3 days and arrange F/U
Poor response: repeat salbutamol 1-2 times. If still poor, send to hospital if not already and manage as life threatening
How is a life threatening asthma attack managed?
Oxygen Salbutamol neb 2.5-5 mg back to back PO Prednisolone (1-2mg up to 40mg) / IV hydrocortisone (4mg/kg up to 100mg) Ipratropium bromide neb (0.25mg) Consider Theophylline IV Consider anaphylaxis dose adrenaline ITU support
Describe the 7 safe discharge criteria for asthma attacks
- PEFR >75%
- stopped nebs for 24hrs
- inpt asthma nurse r/v
- PEFR meter and written asthma action plan given
- 5 days oral pred given
- GP follow up in 2 working days
- resp clinic follow up within 4 weeks
Describe the pathophysiology of bronchiolitis
- viral infection (respiratory syncytial virus- RSV)- often picked up from a sibling going to nursery
- causes excess mucus production, IgE mediated type 1 allergic reaction (infalmmation), bronchiolar constriction, infiltration of lymphocytes (submucosal odema) in the bronchioles
- this leads to a ball valve effect which causes hyperinflation, increased airway resistance, atelectasis (lung collapse) and a V/Q mismatch
What age does bronchiolitis affect? Give 3 risk factors
- children <2yrs, generally <1 yr
RFs: breast feeding for <2 months, parental smoking, siblings are nursery, chronic lung disease due to prematurity
Describe the clinical features of bronchiolitis
- usually starts off as cold like symptoms for 2-5 days
- Over 6-12 hrs they begin to get wheezy, have feeding difficulty, may have low grade fever
- tachypnoea, grunting, nasal flaring, inter/ subcostal or subclavicular recessions, inspiratory crackles and expiratory wheeze, hyperinflated chest, cyanosis or pallor may be seen on examination
How should bronchiolitis be investigated? and what are cxr signs (4)
- nasopharyngeal aspirate/ throat swabs for RVS rapid testing and viral cultures to confirm diagnosis
- blood and urine sample if pyrexic for sepsis screen
- fbc, crp and cap blood gas to check not in resp failure
- CXR if diagnostic uncertainty or atypical course (findings: hyperinflation, focal atelectasis, air trapping, flattened diaphragm)
How should bronchiolitis be managed in hosp?
- O2 if sats <92%
- NG fluids if reduced oral intake
- CPAP if resp failure
- upper airway suctioning if secretions are causing apnoeas
- no role for abx, steroids or bronchodilators (NICE) but bronchodilators in particular are often given anyway
When can a bronchiolitis baby be discharged? (3)
- clinically stable
- adequate oral fluids
- sats >92% for 4 hrs
give 4 complications of bronchiolitis?
- hypoxia
- dehydration
- fatigue
- resp failure
- persistent cough or wheeze for several weeks
- bronchiolitis obliterates- permanent damage due to inflammation and fibrosis (rare)
How is cystic fibrosis diagnosed?
- one or more characteristic phenotypical features AND
- a history of CF in a sibling
- or +ve newborn screening rest AND increase sweat chloride concentration
- or two CF mutations identified on genotyping
- or demonstration of abnormal nasal epithelial ion transport (nasal potential difference)
What 4 ways does cystic fibrosis tend to present?
- meconium ileus (intestinal obstruction shortly after birth- bilious vomiting, abdo distension, delay meconium)
- intestinal malabsorbtion -> failure to thrive (deficiency in pancreatic enzymes is main cause)
- recurrent chest infections
- newborn screening (heel prick test)
Give 4 common complications of cystic fibrosis, briefly describe their management
- resp infections- aggressive chest physio and abx, prophylactic abx and other prevention measures
- low body weight- give pancreatic enzyme replacement therapy + high calorie diet, NG or PEG feeding
- distal intestinal obstruction syndrome (DIOS)- usually due to insufficiency of pancreatic enzyme replacement, salt deficiency or hot weather. Manage w/ AXR to diagnose, gastrogaffin to treat and dietician r/v and movicol on d/c
- diabetes- as normal
What lifestyle advice should be given to a pt with cystic fibrosis?
- no smoking
- avoid other cf pts
- avoid hot tubs
- clean and dry nebs well
- avoid ppl with colds/ infections
- avoid stables and compossts
- get flu jabs
- NaCl tablets in hot weather and exercise
What are the 3 types of LRTI?
- bronchiolitis
- bronchitis
- pneumonia
- viral induced wheeze
What are the common and atypical causes of LRTIs?
60% bacterial: strep pneumonia, h influenza, staph a, klebsiella pneumonia, e coli
45% viral: influenza virus, RSV, VZV
atypical: mycoplasma pneumonia, legionella pneumophila, chlamydia pneumoniae
Describe the normal resp rates for children of different ages
<60 for 0-5 months
<50 for 6-12 months
<40 for >12 months
<30 for >24 months
give 6 signs of resp distress in children/ babies
- cyanosis
- grunting
- nasal flaring (<12 months)
- tachypnoea
- chest indrawing
- recessions (intercostal, subcostal, supraclavicular)
- seesaw breathing
- tripod positioning
- low sats
- crackles/ wheeze on auscultation
give 4 differentials for LRTI in children
- asthma attack
- inhaled foreign body (usually stridor but may be small and gone lower)
- pneumothorax
- cardiac failure (think congenital defects and check liver size)
- pneumonitis from other causes (smoke, aspiration of reflux, extrinsic allergic alveolitis)
- URTI (no tachypnoea)
How should an LRTI be investigated?
- fbc, crp, cap blood gas
- sputum and blood cultures
- cxr- poor at differentiating viral from bacterial but may pick up pleural effusions, empyemas and diagnosing pneumonia
- tuberculin skin testing if ?TB
- drainage and culture if pleural effusions
What abx are used for pneumonia?
If no recessions- mild- oral amoxicillin +/- erythromycin
If recessions, no cyanosis- moderate- Iv cefuroxime +/- PO erythromycin
If recessions + cyanosis- severe- Iv cefuroxime +/- PO erythromycin and consider others
What causes croup and who gets it?
- laryngotracheobronchitis usually caused by parainfluenza virus, can be caused by RSV, adenovirus, rhinovirus
- common infection affecting 6months- 3 yr olds.
- affects M>F, commonest in autumn and spring
Describe the clinical features of croup?
- 1-4 day history of non specific cold like symptoms
- cough starts and progresses to become barking and hoarse
- symptoms worse at night
- O/E: stridor, chest sounds decreased (severe airflow limitation), tachypnoea and recessions if severe
- concerning features: lethargy/ drowsiness, cyanosis, laboured breathing, tachycardia
Describe the differences between mild, mod and severe croup
mid: ocassional barking cough, no stridor, no recession, eats and plays
mod: frequent cough, stridor, recession, not distressed
severe: cough, prominent stridor, recessions, agitated/ distressed, tachycardia
Give 3 differentials for croup? (stridor)
- epiglottitis
- inhaled foreign body
- acute anyphalxis
- peritonsilar abscess
Describe how epiglottitis is different from croup?
- onset over hrs
- no coryza
- drooling saliva
- marked fever
- soft rather than rasping stridor
- doesn’t eat/ drink
- weak or silent rather than hoarse voice
- it is much rarer due to Hib vaccine
How should croup be investigated?
clinical diagnosis
- can do cxr if ?foreign body
- direct or infirect laryngoscopy not usually performed unless illness is atypical or ? another cause
- pulse oximetry to monitor sats
How should croup be managed?
- single dose oral dexamethasone (0.15mg/kg) or oral pred
- adrenaline neb can provide temporary relief but may distress baby so only if needed
- keep child calm- play specialist, keep with mum, quiet surroundings etc
- oxygen
- ENT/ anaesthetist referral if need airway support
