Difficulty in Breathing and Respiratory Presentations

Question 1

3 minute toolkit for assessing sick child?

Answer 1

Airway: secretions, stridor, foreign body
Breathing: resp rate, recession/ accessory muscle use, oxygen saturation, auscultation
Circulation: colour (pale mottled?), HR, cap refill, temperature of hands and feet
Disability: pupils, limb tone and movement, AVPU/ GCS
Exposure: check top to toe
ENT: ear nose throat examine
T: temperature
T: tummy

Question 2

Difficulty in breathing in children is most commonly due to a _________ Most severe respiratory illnesses tend to occur in ________ Commonest causes of breathlessness in children are ________________

Answer 2

• In children difficulty in breathing and coughing is a common presentation
• Most commonly due to a viral infection
• Most severe respiratory illnesses tend to occur in first 3 years of life
• Commonest causes of breathlessness in children: asthma, bronchiolitis, pneumonia and croup

Question 3

Explain what asthma is and how it can change the airways?

Answer 3

• Asthma is defined as recurrent but reversible obstruction to the airways in response to substances that are not necessarily noxious
• Asthma is a type 1 hypersensitivity reaction involving eosinophilic inflammation and a TH2 response
• Chronic asthma can cause permanent changes to the airway such as smooth muscle hypertrophy, increased mucus and epithelial damage with subepithelial fibrosis

Question 4

What causes asthma?

Answer 4

• Not fully understood
• Atopic Asthma is part of the atopic triad which includes asthma, hayfever and eczema (people with one of these are more likely to have the others)
• Increased risk of having asthma if family history of asthma
• Asthma exacerbations generally have triggers e.g., pollen, dust, air pollution, cold weather

Question 5

What is viral induced wheeze?

Answer 5

• In babies and toddlers you can get viral induced wheeze which may last for a while after an infection, this is not asthma

Question 6

Symptoms and signs of asthma?

Answer 6

• Tight chest
• Widespread wheeze
• Dry cough
• Diurnal variation in symptoms
• Symptoms associated with triggers

Question 7

Investigations for asthma?

Answer 7

• FEV1 is reduced but FVC is normal, the FEV1/ FVC ratio is reduced
• Should have reversibility on administration of a bronchodilator
• Peak flow testing is done and people may be given a peak flow diary

Question 8

Management of asthma?

Answer 8

• Those with a diagnosis of asthma should be prescribed a SABA for relief of symptoms
• The frequency of use of a SABA is a good measure of asthma severity and control
• If a preventer is needed inhaled ICS has been shown to be the most effective and is first line in adults and most children
• Can add on other preventer therapies which seems to be patient dependent on what is prescribed e.g. Leukotriene receptor antagonists (montelukast), LABAs, Sodium cromoglicate and theophylline (methylxanthines)
• Very unresponsive asthma may be referred for monoclonal antibody treatment
• Under ones are less likely to respond to beta agonists

Question 9

Unders 1s are unlikely to respond to what in asthma?

Answer 9

beta agonists

Question 10

What is croup? What age group gets it and what virus causes it?

Answer 10

• Laryngotracheobronchitis
• A common respiratory disease that typically occurs in children aged 6 months and 3 years
• It is generally caused by a virus, typically parainfluenza
• Clinical features of croup result from inflammation, swelling of upper airway structures (larynx, vocal cords and trachea), and oedema, leading to narrowing of the subglottic region

Question 11

Presentation of croup?

Answer 11

• Can be diagnosed clinically
• Characterised by a sudden onset of a seal-like barking cough, which may be accompanied by voice hoarseness, stridor and/or respiratory distress
• Symptoms are typically worse at night and increase with agitation
• May see typical signs of airway obstruction e.g. intercostal, subcostal, sternal recession or tracheal tug
• Prodromal, non-specific upper respiratory tract symptoms e.g. cough, rhinorrhoea, coryza and fever may have been present between 12 and 72 hours
• Buzzword: steeple sign on XR

Question 12

Management of croup?

Answer 12

• Children with mild croup (no stridor or sternal/ intercostal recession at rest) can be managed at home, symptoms usually resolve within 48 hours but some episodes may last up to 1 week
• Children with moderate, severe or impending respiratory failure should be admitted to hospital (i.e if they have stridor and sternal/ intercostal recession at rest they meet criteria to be admitted to hospital)
• All children with croup should receive a single dose of oral dexamethasone, if too unwell can give it inhaled or IM
• in those classified as severe ie severe resp distress, cyanosis, exhaustion - can give nebulised adrenaline

Question 13

What is bronchiolitis? What age group does it occur in an what is the usual viral cause?

Answer 13

• Lower respiratory illness that involves acute inflammatory injury of the bronchioles usually due to infection with RSV
• Occurs in babies under 18 months old

Question 14

Presentation of bronchiolitis?

Answer 14

NICE guidelines advise it should be considered in children under the age of 2 presenting with:
* Persistent cough and
* Either tachypnoea or chest recession (or both) and
* Either wheeze or crackles on chest auscultation (or both)

Other features – wet cough, fever, poor feeding, very young babies may present solely with apnoea

Question 15

Investigations for bronchiolitis?

Answer 15

• Pulse oximetry
• Viral throat swabs for respiratory viruses
• CXR and bloods are not advised for routine management unless there is evidence of deterioration and worsening respiratory distress

Question 16

Management of bronchiolitis?

Answer 16

• Most infants have mild self limiting illness that can be managed at home
• Mainstay of treatment is supportive
• Anti-pyretics only needed if temperature causing distress to the child
• In secondary care supportive is still mainstay, high flow nasal oxygen or CPAP may be used
• Most children make a full recovery in a week

Question 17

Describe what pneumonia is and common causes in children?

Answer 17

• Pneumonia is defined as a lower respiratory tract infection with new consolidation on X-ray
• Babies and young children are at higher risk as their immune systems are not fully developed
• Strep pneumonia is the most common cause of bacterial pneumonia, Hib is another cause (although there is a vaccine) and RSV is a common viral cause

Question 18

Presentation of pneumonia in children?

Answer 18

• Clinical signs of pneumonia in children are notoriously subtle
• The child will be more unwell and lethargic than with a normal cold
• Temperature will be above 38.5 degrees C
• May be refusing food and drink
• Raised RR and low oxygen saturations

Question 19

Investigations for pneumonia in children?

Answer 19

• CXR – often need to think clinical signs of infection and get a CXR to see if it’s pneumonia
• Sputum culture/ swabs

Question 20

Management for pneumonia in children?

Answer 20

• Any supportive management
• Then amoxicillin in non severe, co-amoxiclav for severe

Question 21

Explain what apnoea is and what it means?

Answer 21

• Apnoea (pause in breathing) is a red flag – child needs admitted to hospital by ambulance – note that apnoea although a sign of serious illness is not always a sign of respiratory illness can also occur in conditions like meningitis

Question 22

Babies who are premature or had a stay on neonatal ward should have ________

Answer 22

lower threshold for admitting

Question 23

Explain recession of ribs in children and what it means?

Answer 23

Recession of ribs happens in children because they have pliable rib cages so when respiratory effort is high there will be indrawing:
* Tracheal tug
* Supraclavicular recession
* Sternal recession
* Intercostal recession
* Subcostal recession
Should note that rib cages become less pliable as get older so in neonates recession is a less serious sign and in older children it is much more serious as suggests very high respiratory effort

Question 24

Explain involvement of accessory muscles in breathing and what it means?

Answer 24

Accessory muscles may also be involved in respiratory effort is high
* Abdominal breathing caused by forced diaphragm movement
* Head bobbing in babies caused by pulling on sternocleiomastoid muscle pulling

Question 25

Explain the importance of measuring oxygen sats in children?

Answer 25

• Obvious cyanosis implies life threatening illness
• Most children can look well but O2 sats be low
• < 94% is significant illness, < 90 is alarming

Question 26

Explain the relevance of auscultation in children?

Answer 26

• Should note that auscultation is less useful in children because small chests mean sounds tend to be transmitted all over and will not be localised
• Also doesn’t tend to give an idea of how ill the child is

Question 27

What is bronchiectasis?

Answer 27

• This is defined as abnormal dilatation of the airways with associated destruction of bronchial tissue
• It has been shown that bronchiectasis is potentially reversible especially in children

Question 28

Causes of bronchiectasis?

Answer 28

• Commonly occurs as a result of CF but there are other pathologies:
• Post infectious – e.g. strep pneumonia, staph A, adenovirus etc.
• Immunodeficiency e.g. agammaglobulinaemia, IgA deficiency, HIV etc.
• Primary ciliary dyskinesia (autosomal recessive genetic defect that causes partial or complete inaction of the cilia)
• Congenital syndromes e.g. youngs syndrome (rare)
• Post obstructive e.g. foreign body aspiration

Question 29

Presentation of bronchiectasis?

Answer 29

• Chronic, productive cough
• Purulent sputum
• Chest pain
• Wheeze
• Short of breath on exertion
• Haemoptysis
• Recurrent or persistent LRTI
• On examination may be normal, potential for clubbing, inspiratory crackles and wheezing

Question 30

Investigations for bronchiectasis?

Answer 30

• Everyone with suspected bronchiectasis should be referred to respiratory consultant
• Sputum culture
• CXR
• Spirometry
• O2 sats
• FBCs
• In secondary care likely to do a CT to confirm bronchiectasis, then need to do investigations to determine the underlying cause

Question 31

Management of bronchiectasis?

Answer 31

• Immunisations: pneumococcal and annual flu vaccine
• Chest physiotherapy
• Manage exacerbations with antibiotics
• Person may need long term low dose prophylactic antibiotics

Question 32

What is epiglottitis and what causes it?

Answer 32

• The epiglottis is a flap of elastic cartilage that sits at the entrance of the larynx that prevents food from entering the larynx and trachea when swallowing
• Epiglottitis is inflammation of the epiglottis usually caused by Haemophilus Influenzae
• Occurs in children – life threatening infection as can cause stridor

Question 33

Presentation of epiglottitis?

Answer 33

• Hot, feverish, drooling child
• Thumb print sign on XR

Question 34

Management of epiglottitis?

Answer 34

• Medical emergency must get ENT and anaesthetist involved
• Incidence is generally decreasing as we are vaccinating children against haemophilus influenzae

Question 35

Explain what CF is and how it arises?

Answer 35

• Genetic condition
• CFTR gene mutation results in dysregulation of epithelial fluid transport
• Causes thicker body secretions as the CFTR transporter usually transports chloride allowing water into secretions
• Most common gene mutation is delta F508
• It is an autosomal recessive condition so need 2 copies of the gene to get the disease
• Multisystem disorder but leading cause of death is lung disease
• Majority of patients have pancreatic insufficiency

Question 36

Describe pancreatic presentation of CF?

Answer 36

• The thick secretions can block the ducts in the pancreas meaning less pancreatic fluid can get out to help break down food
• This results in fat malabsorption, steatorrhoea and a failure to thrive
• Patients can also get diabetes due to damage of the endocrine portion of the pancreas although this tends to present when older whereas exocrine failure can present from early on

Question 37

Describe lung presentation of CF?

Answer 37

• Sputum and chronic cough
• Patients develop bronchiectasis due to recurrent RTIs (as sticky mucus means lungs can’t clear pathogens as well) that don’t get fully better
• Breathlessness
• Can develop nasal polyps
• Eventually develop respiratory failure

Question 38

Why may one with CF be infertile?

Answer 38

in males there is congenital absence of the vas deferens causing infertility

Question 39

How may a neonate with CF present?

Answer 39

• Neonates can present with meconium ileus (meconium is the first stool passed by a new-born and CF can mean the stool is so sticky that it actually causes a bowel obstruction), this presents with bilious vomiting, abdominal distension and no passage of meconium

Question 40

CF change in fingernails?

Answer 40

can cause clubbing

Question 41

Diagnosis of CF?

Answer 41

• CF screening is offered to all new-borns so it is often picked up then although they don’t check for every mutation so could potentially be missed
• In adults and children diagnosis is a combination of clinical presentation, sweat test and genetic tests
• Also, you should offer a test for CF to anyone: under the age of 40 with bronchiectasis or with upper lobe bronchiectasis or with colonization with Staph or infertile or low weight/ failure to thrive

Question 42

Management of CF?

Answer 42

Managed by specialist centre:
- Learn airway clearance techniques
- Nebulised therapy to help with mucociliary clearance
- CF patients should not be managed together due to risk of spread of infection
- Broad spectrum antibiotics are used for infections
- Respiratory failure is treated with oxygen and non-invasive ventilation
- Pancreatic enzyme supplements and vitamin tablets are given to those with pancreatic insufficiency
- CF diabetes usually requires insulin
- Ivacaftor and Lumacaftor are new targeted treatments that involve CFTR modulation, these drugs are very expensive

Question 43

Differences in children BLS and why?

Answer 43

15:2 instead of 30:2 and start with rescue breaths (because children are more likely to have respiratory arrest)
If under 1 year head should stay in neutral not head tilt/ chin lift (because under 1 more anterior larynx so head tilt chin lift actually closes airway)

Question 44

Normal PCO2 in asthma attack?

Answer 44

this indicates life threatening asthma

Question 45

Criteria for admitting a child with bronchiolitis?

Answer 45

apnoeas
marked chest recession or grunting
inadequate oral intake (50-75% of usual or less than 100mls/kg per day)
o2 sats < 90 if under 3 months, or < 92 if over 3 months
resp rate more than 70

Question 46

Oral intake for a baby?

Answer 46

normal for growth and development should be 150mls/kg/ day

if baby is unwell as long as they are maintaining 100mls/kg/day this is okay