Ch 16 - Respiratory diseases Flashcards
URTI can refer to a few conditions, name 3
Common cold (coryza)
Sore throat - pharyngitis/ tonsillitis
Otitis media
Sinusitis (uncommon)
Coryza: causes (3), features (3)
Rhinovirus, coronavirus, RSV
Classical: clear/mucopurulent discharge from nose + nasal blockage, cough, sore throat, fever +/- ear ache (the only bit that has to be there is the runny nose)
Coryza: management (2)
Educate parents that cold is self limiting and ABs of no benefit; esp if
Pharyngitis (sore throat) causes (3)
Viral - adeno/entero/rhino viruses
Bacterial - in older children Group A strep (pyogenes)
Tonsilitis definition + causes(2)
Pharyngitis + tonsillar inflammation, often with purulent exudate
Causes - S. pyogenes, EBV
Tonsilitis: features (3) + management (1)
More marked consitutional disturbance - headache/ abdo pain White tonsilar exudate (bacterial infection) Cervical lymphadenopathy (bacterial infection) Manage with AB: erythromycin/ penicillin (amox is avoided because it causes a rash with EBV)
Acute otitis media (acute middle ear infection): causes (4)
Children particularly prone to middle ear infections because they have short & horizontal eustachian tubes
Causes: viral - RSV, rhinovirus
bacterial - S. pneumoniae, H. influenza, M. catarrhalis
Features of acute otitis media ( 4) + complications (2)
Fever, pain, red bulging tympanic membrane with loss of normal light reflection
Complication - can perforate in which case pus will be visible in external canal; can result in MASTOIDITIS or MENINGITIS
Management of Acute otitis media (1) also neonatal management (1)
Spontaneous resolution; amoxicillin - shorten duration of pain
Neonate - IV Cefotaxine
Glue ear (serious otitis media/ otitis media with effusion): cause (1), features (3)
Cause - recurrent ear infections lead to otitis media + effusion aka glue ear
Features - reduced hearing, eardrum is dull, retracted + fluid level is visible
Glue ear (serious otitis media/ otitis media with effusion): Diagnosis (3)
1st establish reduced hearing: if >4 can show conuctive loss on pure tone audiometry, if
Glue ear (serious otitis media/ otitis media with effusion): management (2)
Grommet insertion
if recurrence grommet insertion + adenoidectomy
Sinusitis: Cause (1), Features (3), Management (3)
Viral infection of paranasal sinuses (occurs with URTIs)
Features - often 2ndary bacterial infection occurs > pain, swelling, tenderness over cheek - from maxillary sinus infection
management - ABs + analgesia + topical decongestants
Give 3 indications for tonsillectomy
Recurrent severe tonsillitis
Sleep apnoea
peritonsilar abscess
NB- remember many children have large tonsils and they shrink spontaneously in late childhood - so large tonsils itself is not an indication
Give 2 indications for adenoidectomy
Recurrent Otitis media + effusion and hearing loss
obstructive sleep apnoea
Acute URT obstruction: causes (5)
Most common - viral laryngotracheobronchitis aka CROUP
Rare causes: epiglottitis, foreign body, allergic laryngeal angiooedema, bacterial trachitis,
Acute URT obstruction: features (4)
Stridor - rasping sound heard on inspiration
Barking cough
SOB
hoarseness due to inflammation of vocal cords
Acute URT obstruction: assessement of severity (2)
assess severity by degree of chest retraction: none, on crying, at rest (severe)
& degree of stridor: none, on crying, at rest/biphasic (severe)
Croup: causes (3), features (6)
Causes: parainfluenza viruses, RSV, influenza virus
Features: age 6 months - 6yrs
Onset over days; fever + coryza > BARKING COUGH, STRIDOR, HOARSENESS.
Symptoms start at night + WORSE at night
Chest recession (mild or severe)
Croup: Scoring (5 categories)
Westley score: cyanosis (5 points), consciousness (5 points), intercostal recession (3 points), air entry (2), stridor (2)
So max 17 points: 6 = severe
Croup: Management (4)
Oral dexamethasone, oral pred
Nebulised steroids e.g. Budesonide
Nebulised adrenaline + O2 via face mask
Tracheal intubation if v. severe
Bacterial trachitis: cause(1), features(3), management (3)
Cause - S. Aureus (much rarer than viral croup)
Features - similar to viral croup but high fever, child looks toxic, loud harsh stridor + copious thick airway secretions
Management: IV Abs + intubation +/- ventilation
Acute epiglottitis: Cause (1), Features (5)
Cause: H. Influenza B (99% reduction since vaccination)
Features: ACUTE onset (over hours), HIGH FEVER, no cough, SOFT INSP STRIDOR, painful throat - preventing speaking, intense epiglottic swelling, septicaemia, toxic looking child
Acute epiglotitis: management (3)
Immidiate intubation (under GA) IV Cefuroxime + blood culture
Laryngomalacia - feature
Recurrent/continuous stridor since birth
Whooping cough: Cause, features
Cause - bordatella pertussis
Features - 1 week of coryza > characterisitic paroxsymal/spasmodic cough followed by insp whoop +/- vomitting
often worse at night
red/blue coloration of child
Whooping cough: Ix (2), management (1)
lymphocytosis
culture from nasal swab
Management - PO erythromycin
Bronchiolitis (
Causes - RSV, adenovirus, rhinovirus, parainfluenza
Features - coryzal symps precede dry cough & increasing SOB
Sharp dry cough
tachypnoea
feeding difficulty,
recession
hyperfinflation of chest (prominent sternum, displacement of liver downwards)
High pitched wheezes - exp > insp
fine end-insp crackles
Bronchiolitis: Diagnosis (2)
PCR analysis of nasal secretions (resp viruses are usually identified via this method)
CxR usually unessecary - shows hyperinflation + focal atelectasis
Bronchiolitis: Management (2), conditions for hospital admission (3)
general - supportive; humidified O2 via nasal cannula, IV fluids, ventilation, paracetamol
Hosp admission if: sats 70
Bronchiolitis: Prevention (1)
IM palivuzimab - anti RSV monoclonal ab
Pneumonia: causative pathogens in: newborn (2), infants + young children (4), Children > 5yrs (3)
NB consider M. TB at all ages
Newborn: pathogens from mums genital tract - GBS main, also gram -ve enterococci
Infants + young children: resp viruses e.g. RSV main, bacterial - S. pneumonia, H. influenza. Bortedella pertussis
Children > 5 - Mycoplasma pneumoniae, S. pneumoniae, Chlamydia pneumoniae
Pneumonia: features (5)
Fever + SOB commonest presentation (often preceded by URTI)
Poor feeding, lethargy
Coarse crackles
Dullness on percussion
Decreased breath sounds, bronchial breathing
tachypnoea - signs of work of breathing e.g. flaring
Pneumonia: Ix (1)
CxR - cannot differentiate between bacterial & viral, with exception of lobar pneumonia which is feature of S. pneumonia
Pneumonia: management (2)
Newborns - broad spectrum IV Ab
Infants - PO amoxicillin
>5 yrs - amoxicillin/ erythromycin
Asthma: 2 categories of wheezing - early transient & recurrent. Describe their characteristics
Early transient wheezing - episodic wheezing due to viral infection - resolves by 5
Persistent recurrent wheeze - recurrent wheeze + evidence of allergy (IgE) to an inhaled allergen - proven by skin prick test or IgE blood test = ATOPIC ASTHMA
Pathophysiology of asthma (7)
Atopy + environemental trigger e.g. URTI, Allergen, smoking, cold air etc. lead to BRONCHIAL INFLAMMATION (oedema + excess mucus+ infiltration of cells e.g. mast cells)
Leads to Bronchial HYPERRESPONSIVENESS (exaggerated response to inhaled stimuli)
Results in airway NARROWING (reversible obstruction - seen as peak flow variability)
Which produes classic symptoms - wheeze, cough, tightness, SOB
Asthma: features (6)
Polyphonic wheeze (lots of small airways rather than 1 large)
Triggers- laughing, cold, exercise, emotion
Positive FH & response to therapy
worse at night + early morning
Prolonged expiration
Harrison sulci - a groove along lower border of thorax - corresponding to costal insertion of diaphragm
Asthma: Ixs (3)
Usually history + examination sufficient
SPT (skin prick)
If uncertainty PEFR - will see morning worse than evening & day to day variability
Asthma: management (5)
Inhaled SABA e.g. salbutamol or Ipratropium Bromide (if v. young)
Add inhaled steroid e.g. beclamethasone, fluticasone
Add LABA e.g. salmeterol if > 5 or Leukotrine receptor antagonist montelukast (oral theophylline is alternative but lots of AEs e.g. headaches insomnia)
Oral prednisolone
Acute asthma: features (5)
Tachypnoea, wheeze, SOB
Cyanosis
Sats
Life threatening features of asthma (5)
Cyanosis
PEFR
Acute asthma: management (initial, 1st line, 2nd line)
ABC, obs, oxygen
1st line: SABA + Pred. Add iprtropium bromide +/- MgSO4 if refractory
2nd line: IV salbutamol + aminophylline if life threatening
Causes of recurrent/ persistent cough (6)
Recurrent resp infections
Post-specific resp infections e.g. RSV, pertussis
asthma
Suppurative lung diseases e.g. CF, Primary ciliary dyskinesia
Recurrent aspiration
foreign body
TB
airway anomalies e.g. tracheo-oesophageal fistula
Primary ciliary dyskinesia aka Kartageners: features (3)
Productive cough, nasal discharge
recurrent ear infections
50% have dextrocardia and situs inversus
Primary ciliary dyskinesia aka Kartageners: management (3)
Daily physio
ABs
ENT follow-up
CF pathophysiology
Genetic mutation in CFTR gene (Cr7) > mutate Cl- channel > Cl- cannot be transported out into exocrine ducts > so Na+ remains static > so water doesnt follow into ducts > thick secretions
CF features (8)
recurrent chest infections ABPA DM cirrhosis + portal HTN pneumothorax sterility in males infancy - meconium ileus, prolonged neonatal jaundice, failure to thrive bronchiectasis sinusitis
CF Ix (2)
Sweat test - Cl- conc in sweat very high
confirmation can be made via gene testing
CF management (5)
MDT approach lung function monitoring physio prophylactic oral ABs pancreatic enzyme replacement high calorie diet 1.5 times normal adult life - regular ursodeoxycholic acid, liver transplant,
What is the cause of sleep related breathing disorders in children?
Adenotonsillar hypertrophy
What predisposes to the risk of sleep related breathing disorders? (4)
Anatomical abnormalities
Hypotonia
Down’s syndrome
cerebral palsy etc.
Features of sleep related breathing disorders (4)
Snoring
apnoea - witnessed pauses in breathing
disturbed sleep
growth failure/obese
Complications of sleep related breathing disorders
daytime sleepiness
LD
lifethreatinging cardiopulmonary events
pulmonary HTN
Ix for sleep related breathing disorders (3)
1st o/n pulse oximetry - quantify severity of desaturations (normal pulse ox does NOT exclude condition) Limited polysomnography (required in more complex cases - provides a lot more info and can distinguish between central and obstructive events) Sometimes need to assess neurological arousal - EEG & submental EMG
Mangement of sleep related breathing disorders (2)
Adenotonsillectomy is curative
CPAP/BiPAP at night if needed
Indications for tracheostomy (5)
Narrow upper airways - laryngeal anomalies (webs, atresia), pierre robin sequence (small jaw and cleft palate), craniofacial anomalies
Lower airway anomalies - severe tracheo-bronchomalacia
Longterm ventilation - muscle weakness, head or spine injury
Wean from ventilation
Airway protection - clearance of secretions & prevention of aspiration
