Chapter 5 Child with breathing difficulties

Question 1

name four things that will increase the respiratory drive

Answer 1

1) acidosis
2) shock
3) poisoning (salicylates)
4) Anxiety/panic attack

Question 2

Name four things that will decrease the respiratory drive

Answer 2

1) coma
2) convulsions
3) raised ICP
4) poisoning

Question 3

Name three cause of upper airway obstruction

Answer 3

1) Croup
2) Epiglottitis
3) Foreign body

Question 4

Name three causes of lower airway obstruction

Answer 4

1) Tracheitis
2) Asthma/viral wheeze
3) Bronchiolitis

Question 5

Name two disorders that affect the lungs parenchyma and can cause breathing difficulties

Answer 5

1) Pneumonia
2) Pulmonary oedema

Question 6

Name three disorders around the lung that can cause breathing difficulties

Answer 6

1) Pneumothorax
2) Pleural effusion or empyema
3) Rib fracture

Question 7

What disease(s) can cause respiratory muscle weakness?

Answer 7

1) Neuromuscular disorder
2) paralysis/envenomation

Question 8

What disorders below the diaphragm can cause breathing difficulties?

Answer 8

1) Peritonism
2) Abdominal distension

Question 9

Regarding a neonante or very young infant, what is meant by paradoxical inhibition of respitatory drive

Answer 9

Occurs during infection and instead of increase respiratory drive apnoea and hypoventilation can be seen

Question 10

What is the difference in sound and implied area of obstruction for stridor and stertor

Answer 10

Stridor: high pitched usually on inspiration, due to obstruction of larynx or trachea
Stertor: lower pitched inspiratory noise, suggest poor airway position or pharyngeal obstruction

Question 11

Name some features that suggest respiratory difficulties are due to cardiac cause

Answer 11

1) cyanosis not correcting with O2
2) Tachycardia out of proportion to respiratory difficulty
3) Raised JVP
4) Gallop rhythm/murmu
5) Enlarged liver
6) Absent femoral pulses

Question 12

Why is it important to consider a fluid bolus in a child with respiratory distress?

Answer 12

Fluid intake has often ben suboptimal and the child may be dehydrated. Especially important if considering intubation and positive pressure ventilation.

Question 13

Name the airway disease most fitting with these features:
coryzal
barking cough
mild fever
hoarse voice

Answer 13

croup - viral laryngotrachobronchitis

Question 14

Name the airway disease most fitting with these features:
sudden onset, history of choking

Answer 14

foriegn body

Question 15

Name the airway disease most fitting with these features:
drooling, muffled voice, septic appearance, absent cough

Answer 15

epiglottits

Question 16

Name the airway disease most fitting with these features:
harsh cough, chest pain, septic appearance

Answer 16

bacterial tracheitis

Question 17

Neck swelling, crepitus, bruising

Answer 17

traumatic damaged to airway

Question 18

Name the airway disease most fitting with these features:
drooling, septic appearance

Answer 18

retropharyngeal abscess or peritonsillar abscess

Question 19

What is the dose of adrenaline in croup (as per APLS)

Answer 19

400 microg/kg max 5mg adrenaline

Question 20

How long till nebulised adrenaline works and how does it last?

Answer 20

onset 10-30 minutes
lasts 2 hours

Question 21

Does nebulising adrenaline provide a long lasting effect/cure?

Answer 21

no, it’s used to buy time for steroids to work or to set up for intubation

Question 22

If a child fails to respond to nebulised adrenaline, what are the other diagnoses to consider?

Answer 22

bacterial tracheitis
epiglottitis
inhaled foreign body

Question 23

does nebulised adrenaline help with epiglottitis?

Answer 23

Unclear. If it upsets the child, stop immediately

Question 24

How quickly do steroids start to work when given for croup?

Answer 24

Within 30 minutes

Question 25

If the child cannot take oral dexamethsone, and you don’t have a IVC.
What is the dose of budesonide?

Answer 25

2mg nebulised
Cover eyes and wash face after

Question 26

What organisms cause bacterial tracheitis?

Answer 26

Staphylococcus aureus
Haemophilus influenzae B

Question 27

Roughly how many children with bacterial tracheitis need intubation?
What antibiotics do you use?

Answer 27

80%
Ceftriaxone or cefotaxime + flucloxacillin

Question 28

What is the clinical course/features of epiglotitits

Answer 28

Most common aged 2-6 (can occur in infants and adults)
Acute onset with high fevers, lethargy, soft inspiratory stridor, rapidly increasing respiratory difficult over 3-6 hours

Question 29

Name a few feature that distinguish epiglottits from croup or bacterial tracheits

Answer 29

In contrast to croup, epiglottitis has no or minimal cough, child sits immobile with chin slightly raised, mouth open, drooling. Toxic looking, most are septicaemic with high fever. Throat pain prevents talking or swallowing saliva.
In contrast to bacterial tracheitis, epiglottitis has very abrupt onset and deterioration (hours) and little to no cough

Question 30

What is the treatment for diptheria?

Answer 30

1) pencillin
2) steroids
3) antitoxin

Question 31

What treatments may assist with upper airway obstruction of tonsillitis or infectious mononucleosis?

Answer 31

Steroids
Nasopharyngeal airway

Question 32

What is the treatment for a retropharyngeal abscess?

Answer 32

1) IV augmentin
2) surgical drainage

Question 33

What are the signs of life threatening asthma?

Answer 33

Exhaustion
Poor respiratory effort
Silent chest
Hypotension
Depressed LOC/agitation
consider whether this could be anaphylaxis

Question 34

When would you get a chest xray in the setting of asthma?

Answer 34

Severe dyspnoea
Uncertainty about diagnosis
Asymmetry of chest
Signs of severe infection

Question 35

When providing a nebule with > 6L O2 running, how does this affect drug delivery?

Answer 35

More of the drug can be lost from the facemask

Question 36

What is the bolus dose of IV salbutamol?

Answer 36

< 2 years = 5 microg/kg
> 2 years = 15 microg/kg

Question 37

What are the indications for intubation in the setting of respiratory distress?

Answer 37

Increasing exhaustion
Progressive deterioration in
-clinical condition
- SpO2 decreasing/O2 requirement increasing
- pCO2 increasing

Question 38

What is the dose of nebulised ipratroprium?

Answer 38

Age < 6 =250 mcg
Age > 6 = 500 mcg

Every 20 minutes for 3 doses then 125mcg every 6 hours

Question 39

What is the loading dose of hydrocoritsone?

Answer 39

4mg/kg IV

Question 40

What is the treatment for bronchioloitis?

Answer 40

Supportive.
Fluid replacement as oral intake has often been poor (NG or IVF but remember NG partially occludes the airway)
Gentle suction of nasal secretions
O2 or HFPN 1-2L/kg/min

Question 41

What is the antibiotic of choice for pneumonia, ora and IV options?

Answer 41

Oral: amoxycillin 25mg/kg if > 1 month (consider cefotaxime if < 1 month)
IV moderate: benzylpenicillin 60mg/kg
IV severe: cefotaxime 50mg/kg
IV empyema or life threatning: add on lincomycin 15mg/kg

Question 42

A child is dyspnoeic and you suspect myocarditis. On the CEWT chart what observation is most likely to be abnormal?

Answer 42

Marked tachycardia supports myocarditis diagnosis