Child Health Respiratory Flashcards
Croup epidemiology
peak incidence at 6 months - 3 years
more common in autumn
Croup sx
stridor which is caused by a combination of laryngeal oedema and secretions
barking cough (worse at night)
fever
coryzal symptoms
Croup causative organism
Parainfluenza viruses account for the majority of cases.
Features of mild croup
Occasional barking cough
No audible stridor at rest
No or mild suprasternal and/or intercostal recession
The child is happy and is prepared to eat, drink, and play
Features of moderate croup
Frequent barking cough
Easily audible stridor at rest
Suprasternal and sternal wall retraction at rest
No or little distress or agitation
The child can be placated and is interested in its surroundings
Features of severe croup
Frequent barking cough
Prominent inspiratory (and occasionally, expiratory) stridor at rest
Marked sternal wall retractions
Significant distress and agitation, or lethargy or restlessness (a sign of hypoxaemia)
Tachycardia occurs with more severe obstructive symptoms and hypoxaemia
CKS suggest admitting any child with moderate or severe croup. Other features which should prompt admission include:
< 6 months of age
known upper airway abnormalities (e.g. Laryngomalacia, Down’s syndrome)
uncertainty about diagnosis
Croup the vast majority of children are diagnosed clinically
true
Croup CXR would show
a posterior-anterior view will show subglottic narrowing, commonly called the ‘steeple sign’
in contrast, a lateral view in acute epiglottis will show swelling of the epiglottis - the ‘thumb sign’
Croup mx
single dose of oral dexamethasone (0.15mg/kg) to all children regardless of severity
prednisolone is an alternative
Emergency treatment -high-flow oxygen, nebulised adrenaline
Bronchiolitis is a condition characterised by acute bronchiolar inflammation causative organism is?
Respiratory syncytial virus (RSV) is the pathogen in 75-80% of cases
other causes: mycoplasma, adenoviruses
Bronchiolitis epidemiology?
most common cause of a serious lower respiratory tract infection in < 1yr olds
higher incidence in winter
Maternal IgG provides protection to newborns against RSV
true
Bronchiolitis is more serious if?
bronchopulmonary dysplasia (e.g. Premature), congenital heart disease or cystic fibrosis
Bronchiolitis sx
coryzal symptoms (including mild fever) precede:
dry cough
increasing breathlessness
wheezing, fine inspiratory crackles (not always present)
feeding difficulties associated with increasing dyspnoea are often the reason for hospital admission
Bronchiolitis NICE recommend immediate referral (usually by 999 ambulance) if they have any of the following:
apnoea (observed or reported)
child looks seriously unwell to a healthcare professional
severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute
central cyanosis
persistent oxygen saturation of less than 92% when breathing air.
Bronchiolitis NICE recommend that clinicians ‘consider’ referring to hospital if any of the following apply:
a respiratory rate of over 60 breaths/minute
difficulty with breastfeeding or inadequate oral fluid intake (50-75% of usual volume ‘taking account of risk factors and using clinical judgement’)
clinical dehydration.
Bronchiolitis ix
immunofluorescence of nasopharyngeal secretions may show RSV
Bronchiolitis mx
Management is largely supportive
humidified oxygen is given via a head box and is typically recommended if the oxygen saturations are persistently < 92%
nasogastric feeding may be needed if children cannot take enough fluid/feed by mouth
suction is sometimes used for excessive upper airway secretions
Whooping cough (pertussis) is an infectious disease caused by
Gram-negative bacterium Bordetella pertussis.
Whooping cough (pertussis)infants are routinely immunised at
2, 3, 4 months and 3-5 years.
Whooping cough (pertussis)immunisation results in lifelong protection
false
neither infection nor immunisation results in lifelong protection - hence adolescents and adults may develop whooping cough despite having had their routine immunisations
Whooping cough (pertussis) sx
Features, 2-3 days of coryza precede onset of:
coughing bouts
inspiratory whoop
infants may have spells of apnoea
persistent coughing may cause subconjunctival haemorrhages or even anoxia leading to syncope & seizures
symptoms may last 10-14 weeks* and tend to be more severe in infants
marked lymphocytosis
Whooping cough (pertussis)Diagnostic criteria
Whooping cough should be suspected if a person has an acute cough that has lasted for 14 days or more without another apparent cause, and has one or more of the following features:
Paroxysmal cough.
Inspiratory whoop.
Post-tussive vomiting.
Undiagnosed apnoeic attacks in young infants.
Whooping cough (pertussis)Diagnosis
PCR and serology
Whooping cough (pertussis)Management
infants under 6 months with suspect pertussis should be admitted
an oral macrolide (e.g. clarithromycin, azithromycin or erythromycin) is indicated if the onset of the cough is within the previous 21 days to eradicate the organism and reduce the spread
Whooping cough (pertussis) in the UK pertussis is a notifiable disease
true
Whooping cough (pertussis) household contacts should be offered antibiotic prophylaxis
true
Whooping cough (pertussis) school exclusion?
48 hours after commencing antibiotics (or 21 days from onset of symptoms if no antibiotics )
Whooping cough (pertussis) complications?
subconjunctival haemorrhage
pneumonia
bronchiectasis
seizures
Snoring in children
Causes
obesity nasal problems: polyps, deviated septum, hypertrophic nasal turbinates recurrent tonsillitis Down's syndrome hypothyroidism
episodic viral wheeze is?
only wheezes when has a viral upper respiratory tract infection (URTI) and is symptom free inbetween episodes
multiple trigger wheeze is
as well as viral URTIs, other factors appear to trigger the wheeze such as exercise, allergens and cigarette smoke
Episodic viral wheeze is not associated with an increased risk of asthma in later life although a proportion of children with multiple trigger wheeze will develop asthma.
true
Episodic viral wheeze mx
treatment is symptomatic only
first-line is treatment with short acting beta 2 agonists (e.g. salbutamol) or anticholinergic via a spacer
next step is intermittent leukotriene receptor antagonist (montelukast), intermittent inhaled corticosteroids, or both
Multiple trigger wheeze mx
trial of either inhaled corticosteroids or a leukotriene receptor antagonist (montelukast), typically for 4-8 weeks
Acute epiglottitis is rare but serious infection caused by
Haemophilus influenzae type B.
Acute epiglottitis sx
rapid onset high temperature, generally unwell stridor drooling of saliva 'tripod' position: the patient finds it easier to breathe if they are leaning forward and extending their neck in a seated position
Acute epiglottitis Diagnosis is made by direct visualisation
true
Acute epiglottitis mx
immediate senior involvement, including those able to provide emergency airway support (e.g. anaesthetics, ENT)
endotracheal intubation may be necessary to protect the airway
if suspected do NOT examine the throat due to the risk of acute airway obstruction
oxygen
intravenous antibiotics
Causes of stridor in children include:
Croup
Acute epiglottitis
Inhaled foreign body
Laryngomalacia
Laryngomalacia Infants typical present at 4 weeks of age with:
stridor
most likely causative agent of a bacterial pneumonia in children
S .pneumoniae
bacterial pneumonia in children mx
Amoxicillin is first-line for all children with pneumonia
Macrolides may be added if there is no response to first line therapy
Macrolides should be used if mycoplasma or chlamydia is suspected
In pneumonia associated with influenza, co-amoxiclav is recommended
Asthma - definitions of what constitutes a low, moderate or high-dose ICS have also changed. In contrast to the BTS guidelines NICE also have different definitions for adults and children. For children:
<= 200 micrograms budesonide or equivalent = paediatric low dose
200 micrograms - 400 micrograms budesonide or equivalent = paediatric moderate dose
> 400 micrograms budesonide or equivalent= paediatric high dose.
Children aged less than 5 years asthma mx
- SABA
- SABA + an 8-week trial of paediatric MODERATE-dose inhaled corticosteroid (ICS)
- SABA + paediatric low-dose ICS + leukotriene receptor antagonist (LTRA)
- refer
Asthma mx Children and young people aged 5 to 16
- SABA
- SABA + paediatric low-dose inhaled corticosteroid (ICS)
- SABA + paediatric low-dose ICS + leukotriene receptor antagonist (LTRA)
- SABA + paediatric low-dose ICS + long-acting beta agonist (LABA)
- SABA + switch ICS/LABA for a maintenance and reliever therapy (MART), that includes a paediatric low-dose ICS
- SABA + paediatric moderate-dose ICS MART
OR consider changing back to a fixed-dose of a moderate-dose ICS and a separate LABA
- SABA + one of the following options:
increase ICS to paediatric high-dose, either as part of a fixed-dose regime or as a MART
a trial of an additional drug (for example theophylline)
seeking advice from a healthcare professional with expertise in asthma
Children between 2 and 5 years of age acute asthma attack severity scale?
Moderate attack
SpO2 > 92%
No clinical features of severe asthma
Severe attack SpO2 < 92% Too breathless to talk or feed Heart rate > 140/min Respiratory rate > 40/min Use of accessory neck muscles
Life-threatening attack SpO2 <92% Silent chest Poor respiratory effort Agitation Altered consciousness Cyanosis
Children greater than 5 years of age acute asthma attack severity scale?
Moderate attack SpO2 > 92% PEF > 50% best or predicted No clinical features of severe asthm
Severe attack SpO2 < 92% PEF 33-50% best or predicted Can't complete sentences in one breath or too breathless to talk or feed Heart rate > 125/min Respiratory rate > 30/min Use of accessory neck muscles
Life-threatening attack SpO2 < 92% PEF < 33% best or predicted Silent chest Poor respiratory effort Altered consciousness Cyanosis
For children with mild to moderate acute asthma:
Bronchodilator therapy
give a beta-2 agonist via a spacer (for a child < 3 years use a close-fitting mask)
give 1 puff every 30-60 seconds up to a maximum of 10 puffs
if symptoms are not controlled repeat beta-2 agonist and refer to hospital
Steroid therapy
should be given to all children with an asthma exacerbation
treatment should be given for 3-5 days
Cystic fibrosis (CF) is an autosomal dominant disorder
false
recessive
Cystic fibrosis (CF) is due to
increased viscosity of secretions (e.g. lungs and pancreas). It is due to a defect in the cystic fibrosis transmembrane conductance regulator gene (CFTR), which codes a cAMP-regulated chloride channel
Organisms which may colonise CF patients
Staphylococcus aureus
Pseudomonas aeruginosa
Burkholderia cepacia*
Aspergillus
Cystic fibrosis: features
neonatal sx
meconium ileus, less commonly prolonged jaundice
Cystic fibrosis
sx
recurrent chest infections (40%)
malabsorption (30%): steatorrhoea, failure to thrive
other features (10%): liver disease
Cystic fibrosis assoc short stature
true
Cystic fibrosis
PMH
diabetes mellitus delayed puberty rectal prolapse (due to bulky stools) nasal polyps male infertility, female subfertility
Cystic fibrosis: diagnosis
Sweat test
patient’s with CF have abnormally high sweat chloride
normal value < 40 mEq/l, CF indicated by > 60 mEq/l
Cystic fibrosis: diagnosis
Causes of false positive sweat test
malnutrition adrenal insufficiency glycogen storage diseases nephrogenic diabetes insipidus hypothyroidism, hypoparathyroidism G6PD ectodermal dysplasia
Cystic fibrosis: diagnosis
Causes of false negative sweat test
skin oedema, often due to hypoalbuminaemia/ hypoproteinaemia secondary to pancreatic exocrine insufficiency.
Cystic fibrosis: management
physio
regular (at least twice daily) chest physiotherapy and postural drainage. Parents are usually taught to do this. Deep breathing exercises are also useful
Cystic fibrosis: management
diet
high calorie diet, including high fat intake
vitamin supplementation
pancreatic enzyme supplements taken with meals
Cystic fibrosis: management patients with CF should try to minimise contact with each other to prevent cross infection with Burkholderia cepacia complex and Pseudomonas aeruginosa
true
Cystic fibrosis: management
CF-specific contraindication to lung transplantation
chronic infection with Burkholderia cepacia
Cystic fibrosis: management
what is used to treat cystic fibrosis patients who are homozygous for the delta F508 mutation
Lumacaftor/Ivacaftor (Orkambi)
