common resp paeds Flashcards
what is chronic lung disease of prematurity?
bronchopulmonary dysplasia occurring in premature babies
what gestation is chronic lung disease of preemie seen?
typically 28wks
what features are seen in CLDoP?
- Low oxygen sats
- Increased work of breathing
- Poor feeding and weight gain
- Crackles and wheezes on chest auscultation
- Increased susceptibility to infection
how can you prevent lung disease in preemies?
give corticosteroids to mothers showing signs of premature labour <36wks to help with fetal lung development
what management may be used in hospital for CLDoP?
- CPAP rather than intubation and ventilation when possible
- Using caffeine to stimulate the resp effort
- Not over-oxygenating with supplementary oxygen
how do you decide what oxygen babies need for discharge with CLDoP?
need a formal sleep study to access their oxygen sats during sleep supports diagnosis and guides management
- Babies may be discharged from neonatal unit of low dose of oxygen to continue at home
- Babies may need low flow O2 at home may need weaned the oxygen for first yr life
what is given to preemies to protect against bronchiolitis - RSV strain?
- Require protection against RSV to reduce severity of bronchiolitis need monthly injections of monoclonal AB against the virus called palivizumab (very expensive – reserved for babies in certain criteria)
what age does croup usually affect?
acute infective resp disease affecting young children
- Typically affects children 6mths to 2yrs
what is croup?
- URTI causing oedema to larygnx
what can cause croup?
parainfluenza, influenza, adenovirus, RSV
- Can be caused by diphtheria
what does parainfluenza causing croup respond well to?
- Parainfluenza virus: it improves in <48hrs and responds well to treatment in steroids particularly dexamethasone
what can diphtheria cause in relation to URTI?
can cause epiglottis and high mortality, vaccination mean that this is very rare in developed countries
how does croup present?
- Increased work of breathing
- Barking cough – clusters of coughing episodes
- Hoarse voice
- Stridor
- Low grade fever
how do you manage croup?
most needs simple supportive treatment (fluids and rest)
- During attacks it can help to sit the child up
- Measures to be taken to avoid spreading infection eg hand washing and staying off school
- Oral dexamethasone if very effective – 150mcg/kg can be repeated in 12hrs
- Pred can be used as alternative
how is severe croup managed?
Severe croup: oral dexamethasone + oxygen + nebulised budesonide + nebulised adrenaline + intubation/ ventilation
how does pneumonia in paeds present?
cough (wet/ productive), high fever, tachypnoea, tachycardia, increased work of breathing, lethargy, delirium
what signs indicate pneumonia?
derangement in basic observation sepsis secondary to pneumonia
- High RR, high HR
- Hypoxia
- Hypotension
- Fever
- Confusion
- Bronchial breath sounds
- focal coarse crackle
dullness to percuss
what are bronchial sounds?
equally harsh/ loud on inspiration/ expiration consolidation of lung tissue around airway
what are focal coarse crackles?
caused by air passing through sputum similar to using a straw to blow into a drink
what are common causes of pneumonia in paeds?
: strep. Pneumonia (most common), group.A
who is most at risk of group B pnuemonia?
- Group B: occurs in pre-vaccinated infants, often contracted during birth as it often colonises in vagina
how would a staph.a pneumonia present on CXR?
- Staph.a: CXR would show pneumatoceles (air filled cavities) and consolidation in multiple lobes
what is the most common viral cause of pneumonia in paeds?
RSV most common
- Parainfluenza vius, influenza
what investigations are required within pneumonia investigation?
: CXR is investigation of choice for diagnosing pneumonia
- It is not routinely required: can be helpful if complicated
- Sputum cultures/ throat swabs for bacterial cultures/ viral PCR
- Blood cultures
- Capillary blood gas analysis can be helpful
- Blood lactate
how is pneumonia managed?
treated to antibiotics according to local guidelines
- Amoxicillin: first line
- Macrolide – erythromycin. Clarithroymcyin/ azithromycin atypicals
- IV antibiotics: sepsis or intestinal absorption issue
- Oxygen is used as required if <92%
what is bronchiolitis?
: inflammation and infection of bronchioles – small airways of lungs
what usually causes bronchiolitis?
RSV
who is usually affected by bronchiolitis?
- Usually in those <1yr mainly under 6mths
not really seen in those 2+
how does bronchiolitis present if it is caused by RSV?
starts as URTI with coryzal symptoms half get better spontaneously
- Other half develop chest symptoms over first 1-2days
- Symptoms usually worse on day 3-4
- Symptoms last 7-10 days
why do not older kids/ adults get bronchiolitis?
can affect adults but swelling and mucus are proportional to airway size not as big of effect
- Even a small amount of inflammation and mucus in airway has an effect
- Significant effect on infants ability to circulate air to alveoli and back out
- Harsh sounds: wheeze, crackles
what is wheezing and what causes it?
- Wheezing: whistling sound caused by narrowed airways – typically heard during expiration
what is grunting and what causes it?
- Grunting: caused by exhaling with glottis partially closed to increase positive end-expiratory pressure
what is stridor and what causes it?
- Stridor: high pitched inspiratory noise caused by obstruction of upper airway eg croup
how does bronchiolitis generally present?
coryzal symptoms, signs of resp distress, dyspnoea, tachypnoea, poor feeding, mild fever, apnoea’s
what are signs of respiratory distress in paeds?
raised RR
use of accesory msucles
intercostal recessions
subcostal recessions
nasal flaring
head bobbing
tracheal tug
cyanosis
abnormal airway noises
describe tracheal tug?
with each breath - there is a huge dip by jugular notch
what supportive care is given to to infants with bronchiolitis?
- Ensuring adequate intake
saline nasal drops and nasal suctioning
supplementary oxygen
ventilatory support if needed
how do you ensure adequate intake?
orally, NG, IV fluids overfeeding can restrict breathing – need small and frewquent feeds
what do saline nasal drops/ nasal suctioning?
help clear nasal secretions esp prior to feeding
how should supplementary oxygen be given in bronchiolitis?
- Supplementary oxygen – if below 92% want humidified so not going to dry them out
how should ventilatory support be given in bronchiolitis?
- Ventilatory support if required high flow humidified O2, CPAP, intubation + ventilation
how can assess ventilation in paeds?
Assessing ventilation: cap blood gases good in severe resp distress and monitoring children in ventilatory support
- Done in big toe
what would indicate poor ventilation?
- Poor ventilation: rising CO2, falling pH
what is palivizumab?
monoclonal AB that targets RSV
how is palivizumab administered?
- Given to high risk ex-preemie, CHD pts
- Provides passive protection – circulates body until virus is encountered helps activate virus
- Very expensive hence only given to those at biggest risk
what is viral induced wheeze?
wheezy illness caused by viral infection
- Usually RSV or rhinovirus
what causes viral induced wheeze??
- Small amount of inflammation and oedema swells walls of airways and restricts airflow
- Inflammation also triggers smooth muscles of airways to constrict further narrowing of airways
- Has big effect on little people
how can you tell if it asthma or viral induced wheeze?
Not asthma?: asthma does not present < 3yr
- Asthma can be worsened by virus by has other triggers
- Atopic Hx/ eczema asthma
how would viral induced wheeze present?
Presentation: viral illness 2-3 days prior
- SoB
- Signs of resp distress
- Expiratory wheeze throughout chest
what is epiglottitis?
inflammation and swelling of epiglottis typically with HiB
- Epiglottis swells to the point of complete obstruction of airway within hrs of symptoms starting
is epiglottitis an emergency?
life threatening
how is epiglottitis incidence?
- It is rare: due to vaccination programme against haemophilus b
how does epiglottitis present?
- Sore throat and stridor
- Drooling
- Tripod position – sat forward with hands on each knee
- High fever
- Difficulty or painful swallowing
- Muffled voice
- Scared and quiet child
- Septic and unwell appearance
what investigations can be used for epiglottitis?
: if acutely unwell and ?epiglottis – do not perform investigations
- Lateral XR of neck thumb sign or thumb print – soft tissue shadow that looks like thumb pressed into trachea – oedematous and swollen epiglottitis
- XR can help exclude foreign body
how do you manage epiglottitis?
EMERGENCY
1. Do not distress pt – this can cause closure of airway
2. If you see suspected epiglottitis – leave child alone and call senior and anaesthetist
3. Need to maintain airway – do not need intubation initially may need on stand by
4. May need tracheostomy and ICU
5. IV antibiotics – ceftriaxone
6. Steroids – dexamethasone
what is the prognosis of epiglottis?
: most children recover within intubation
- Most that are intubated can be extubated within a few days
- Death can occur if not managed in timely manner
- Risk of epiglottitis abscess
what is laryngomalacia?
condition in infants where part of larynx above vocal cord (supraglottic larynx) is structured in a way that can cause partial airway obstruction
- Leads to chronic stridor on inhalation
- Stridor
how does laryngomalacia present?
: occurs in infants – peak at 6mths
- Inspiratory stridor
- Intermittent and worse on feeding, upset, lying on back, during URTI
- Infants with laryngomalacia does not have associated resp distress
what is laryngomalacia management?
usually gets better as they grow due to larynx maturing and better to support itself
- No interventions and child left to grow
- Tracheostomy may be needed 0 tube through front of neck to trachea bypassing larynx surgery to help improve symptoms
what is whooping cough?
: URTI caused by Bordetella pertussis (gram negative bacteria)
where does whooping cough gets in name from?
- Whooping cough name – coughing fits are so severe child can not take any air in between coughs and makes a loud whopping sound to forcefully suck air in
who is vaccinated against whooping cough?
- Pregnant women are vaccinated against pertussis becomes less effective a few yrs after each dose
- within 6 in 1
how does whooping cough present?
- Mild coryzal symptoms initially – mild dry cough too
- Severe coughing occurs after a week or two may have cough free periods – paroxysmal cough
- Coughing fits are so severe – pt out of breath
- Loud inspiratory whoop
what can hard coughing in whooping cough lead to?
- Hard coughing – fainting, vomiting, pneumothorax, apnoeas
what diagnostic tests can be used in whooping cough?
: nasopharyngeal/ nasal swab with PCR testing or bacterial culture
- When cough has been present for >2weeks can be tested for anti-pertussis toxin iG
what management is needed for whooping cough?
inform PHE
- supportive care
- macrolide antibiotics: azithromycin, erythromycin, clarithromycin
- co-trimoxazole is alternative
- close contacts prophylactic antibiotics if in vulnerable group
what prophylactic antibiotics are give to close contacts for whooping cough
erythromycin
what is the prognosis of whooping cough?
should resolve within 8wks but can last several months
- 100 day cough
what is a key complication of whooping cough?
bronchiectasis
what is primary ciliary dsykinesia?
kartagners syndrome
- Autosomal recessive condition affecting cilia of various cells in body
when is primary ciliary dyskinesia more common?
within consanguinity families
what is the pathophys of primary cilia dsykinesia?
Dysfunction of mobility of cilia leads to build up of mucus in lungs infection
- Similar pres to CF – frequent and chronic chest infections, poor growth and bronchiectasis
apart from effect resp, what else can primary cilia dyskinesia affect?
- Affects cilia in fallopian tubes and tails in flagella of sperm reduced/ absent fertility
what is kartagners triad?
seen in primary cilia dyskinesia
Kartagners triad: paranasal sinusitis, bronchiectasis, situs inversus
- Not all pt will have all three but fairly common
how do you diagnose primary cilia dsykinesia?
recurrent resp tract infections
- Family hx – consanguinity?
- Exam and imaging – CXR to see for situs invertus
- Semen analysis – infertility
- Sample of ciliated epithelium eg nasal brushing or bronchoscopy
how do you manage primary cilila dsykinesia?
Management: daily physio, high calorie diet and prophylactic AB
