Difficulty Breathing Flashcards
1
Q
What are the differentials for cough and difficulty breathing?
A
- Congenital heart disease - unlikely
- Acute problems e.g. PE
- Acute pneumonia (LRTI)
- Asthma
- DKA
- Foreign body ingestion/inhalation
- Congenital lung issues more common younger children e.g. CF or immunodeficiencies
- Disability can predispose to respiratory problems like scoliosis causing chest wall deformities (can’t expand/retract lungs)
- Parental smoking
- Tics and functional coughs - anxiety causing asthma like symptoms
2
Q
What questions do you want to ask about cough and difficulty breathing?
A
- Any red flags for serious illness? Can they talk? Cyanosed?
- Can parent describe pattern of cough (colour of sputum)
- Any previous episodes
- Fever
3
Q
How would you initially manage a child with difficulty breathing?
A
- Airway - able to talk?
- RR and SaO2
- Resp and cardio exam
- HR, BP and CRT - continuous monitoring of obs
- Conscious level
- PEWS score
- May need to give high flow O2 (15L if acute asthma attack)
- If wheezing - trial of nebulised salbutamol
4
Q
What are the signs and symptoms of acute severe asthma?
A
- Severe recession; SC/ic/tracheal tug
- Posture sitting forward - tripod position
- Intermittent wheeze
- Hyperexpanded chest; symmetrical expansion (poor if severe)
- Trachea central, cardiac apex normal
- Liver pushed down, palpable liver edge
- Percussion: resonant but equal
- Auscultation: air entry equal, poor air entry indicates increased severity
5
Q
What are the signs and symptoms of severe pneumonia?
A
- Respiratory distress with recession and tracheal tug
- Wet cough +/- grunting
- Expansion may be asymmetrical if severe unilateral pneumonia
- Dullness over consolidation may be present
- Decreased air entry +/- bronchial breathing and crackles
6
Q
What is Harrison’s sulci?
A
Horizontal groove along lower border of ribcage, usually due to chronic asthma/obstructive respiratory disease
7
Q
What investigations would you do for cough and breathlessness?
A
- Sputum (culture it): if you can’t get sputum, then cough swab
- FBC: WBC and anaemia (SOB)
- CRP: infection
- Blood culture (can also get culture of aspirate from trachea)
- U+Es: dehydration
- Blood gas (capillary blood gas): monitors progress/deterioration
- Serum lactate: reflects peripheral circulation in children and can assist in assessment of acutely ill children
- CXR: acute infection and persistent changes (indicate on-going recurrent or atypical infections)
- Test for CF if they haven’t had heel prick test
8
Q
How would CF present?
A
- Steatorrhoea
- Failure to thrive
- Recurrent chest infections
- Acute exacerbation: coughing, excess mucus production, SOB
9
Q
What is the treatment for children with a respiratory infection?
A
- Refer to local antibiotic guidelines for choice of antibiotics
- If unwell and not drinking - IV abx using amoxicillin as treatment for CAP
- Reviewed after looking at CXR with senior colleagues and after 48 hrs to ensure they are responding
10
Q
What further investigations would you do to find the cause of the respiratory infection?
A
- Review CXR and comparison to previous films to look for signs indicating a chronic picture
- Tests of immunity: immunoglobulins and subtypes - multiple previous infections can put them at risk for chronic lung damage and bronchiectasis
- Specific tests for CF
- Discussions with GP/asthma nursing team regarding appointments and possible issues of compliance with medication should be considered because in children with asthma, chronic non-compliance with preventer treatment can lead to recurrent presentations and chronic symptoms. Potential pre-existing lack of compliance may have an effect on the parental engagement in the child’s future care.
11
Q
What investigations would you do for significant LRTIs and bronchiectasis?
A
- CT chest: not definitive information unless a specific structural change present e.g. compliance abnormalities
- Measurement of serum immunoglobulin levels: primary immune deficiencies may present with recurrent respiratory infections leading to supportive lung disease; immunoglobulin subtype levels measurements of responses to vaccinations and lymphocyte numbers/HIV test can also be helpful
- Sweat chloride test: gold standard for diagnosis of CF (for children with evidence of chronic lung changes), genetic tests are also likely to be required.
12
Q
What organs are affected in CF?
A
- Sinuses: sinusitis
- Lungs: thick sticky mucus build-up; bacterial infection and widened airways
- Skin: sweat glands produce salty sweat
- Liver: blocked biliary ducts
- Pancreas: blocked pancreatic ducts
- Intestines: cannot fully absorb nutrients
- Reproductive organs: complications
- Mutation in CFTR gene - autosomal recessive (F508del)
13
Q
How do you diagnose CF?
A
- New born heel prick test at approx day 5: immuno-reactive trypsinogen (IRT) is a pancreatic enzyme precursor of trypsin that is significantly elevated in the blood of neonates with CF
- Genetic mutation analysis of all infants with raised IRT: sweat induced with pilocarpine and electrical stimulation, collected in gauze/filter paper/plastic coil
- Sweat testing
- Faecal elastase to assess pancreatic exocrine function
- Cascade genetic testing to family if CF confirmed
14
Q
What is the pulmonary involvement in CF?
A
- Thick mucus
- Recurrent infections - unusual pathogens e.g. Pseudomonas aeruginosa, Non-Tuberculous Mycobacteria, Burkholderia spp.
- Bronchiectasis
15
Q
What is the pancreatic involvement in CF?
A
- Exocrine insufficiency - fat malabsorption, inadequate absorption vitamins ADEK
- Endocrine insufficiency: CF-related diabetes - uncommon <10yrs, associated with decreased life expectancy, screen annually
- Pancreatitis
