general Flashcards
what is laboured breathing
abnormal respiration characterised by evidence of an increased effort to breathe , including the use of accessory muscles of respiration, stridor, grunting, nasal flaring
why is it easier to see inhalation of a foreign object in expiration
during inspiration the diameter of bronchi/bronchioles increases; during expiration the diameter decreases. for this reason, inhaled foreign bodies can cause a one way valve effect allowing air entry during inspiration but trapping it during expiration
in expiration will see:
- greater lung volume of the affected side
- no upward movement of the diaphragm
- movement of the mediastinum to the opposite side (because during respiration pressure in the affected side remains constant while on the other side decreases)
what are the clinical features of inhaled foreign body?
- sudden onset in previously well child
- observed coughing, choking, or gagging while eating or playing
- stridor (partial upper airway obstruction)
- silent chest, paradoxical breathing (complete upper airway obstruction)
- wheeze
- chest wall recessions
- reduced air entry in some or all of the affected side
- hypoxia, tachypnoea, cyanosis
- may be asymptomatic with no clinical signs
how do you manage foreign body aspiration in children?
if upper airway FB:
- encourage cough
- 5 back blows followed by 5 thrusts
- if unconscious give 5 breaths then start CPR
if lower airway FB:
- treatment should be supportive with supplemental O2 and referral to paediatric bronchoscopist
what are the complications of FB aspiration?
- pneumonia
- bronchiectasis if chronic or recurrent infection (FB undetected and chronic)
- tracheitis
- lobar collapse/atelectasis
what is croup?
upper airway disorder common amongst infants and children, with peak incidence in age range 6months - 3yrs. most commonly caused by parainfluenza viruses
typically presents with:
- difficulty in breathing
- inspiratory stridor
- ‘seal-like’ barking cough
- hoarse voice
- low grade pyrexia (up to 38.5C)
- often preceded. by viral upper respiratory tract symptoms e.g. coryza
what are the airway symptoms caused by in croup?
caused by inflammation at the supraglottic and tracheal level causing airway narrowing and turbulent airflow (stridor)
list 3 differentials for croup
- epiglottitis
- bacterial tracheitis
- foreign body aspiration
how is croup managed
keep the child calm
mild:
- respond well to single dose steroid therapy (oral dexamethasone 0.15mg/kg/dose)
moderate/severe:
- biphasic stridor, irritability or reduced conscious lever
- may require nebuliser adrenaline and admission
what questions would you ask in an emergency Hx taking to a parent who’s child is having breathing difficulties?
- name/ age of child
- delivery term? how was the delivery? any complications?
- is the child on any medication?
- any previous breathing difficulties/ episodes like this in the past?
- any allergies?
- are immunisations up-to-date?
- what’s been happening e.g. onset/duration/anything make it worse or better?
- eating? drinking?
- could they possibly swallowed anything?
- any recent coughs/ colds/ symptoms?
if a child was drooling and quiet what particular condition would you be worried about? what is the causative organism and when should they be vaccinated against it?
epiglottitis
heamophilus influenza tube B vaccine at 8weeks, 12weeks and 16weeks as part of 6-in-1 vaccine
a) what is the like diagnosis:
Pcx: 3y/o boy with breathing difficulties, breathing noisily, barking cough, worse at night, still able to eat and drink, distressed/crying, temp of 38.5C, pure of 135bpm, cap refill <2sec, O2 sats of 95% on room air and RR of 40per min?
b) if the child was well, had no fever, and suddenly started breathing with stridor and coughing a lot, possibly with some respiratory distress, what might the cause be?
a) croup
(parainfluenza virus. common in 6months - 3 years)
b) foreign body aspiration
how do you assess the severity of croup?
assess intercostal recession, air entry on auscultation, degree of cyanosis and level of consciousness at rest and if agitated/distressed
what tool would you use to call in ahead to paediatric registrar when admitting child with suspected severe croup?
SBAR
situation:
- who are you?
- what are you doing?
- what would you like to do?
- anything very important to the current situation?
background
- Childs age
- background health
- other relevant background information e.g. social
- Hx of tonights presentation
assessment
- on examination… e.g. distresses/unwell/very unwell etc
- relevant findings/negative findings
- changes in presentation
recommendation
- treatment so far
- need for admission and why
- how the pt will be getting to hospital and timing of this
*other tools = ATMIST (useful in trauma when handing over to ambulance/ED), METHANE (for handing over to a control service e.g. ambulance control), AMPLE (key questions in an emergency history taking situation)
consider some types of unconscious bias present in medicine
- anchoring bias - holding on to the 1st diagnosis; some one has written ‘asthma; in the notes, all further presentations with breathing difficulties are attributed to this
- optimism bias - at the end of the shift - you are desperate to get home - yo convince yourself to think that the child’s croup is probably ‘not that bad’ and it will be OK as long as you give a strong worsening statement
- confirmation bias - we only pay attention to results that confirm our preconception; e.g. the sats are normal, you use this to ‘confirm’ that the pt can have severe croup (disregarding other results)
- over-confidence bias - we are overconfident in our ability to manage a situation (think about the ‘unknown unknowns’)
what is stridor?
- noise made by air being forced through narrowed upper airways
- a symptom not a diagnosis thus further Ix is warranted to identify the underlying cause
- caused by stenosis in the supraglottic, glottic, subglottic or trachea level
what are the causes of stridor (upper airway obstruction)?
acute:
- FB inhalation
- epiglottitis
- croup (laryngotracheobronchitis)
- laryngitis
- anaphylaxis
- neck space abscess
chronic:
- laryngomalacia
- subglottic stenosis after prolonged intubation
- vocal cord paralysis
- subglottic haemangioma
- malignancy
what are the common causes of airway obstruction?
- Infection:
- tonsillitis (usually viral: rhinovirus/ adenovirus, herpes simplex, parainfluenza, EBV, CMV)- croup
- epiglottitis
- diphtheria - Allergy:
- anaphylaxis - Obstruction:
- foreign body
- tumour
- blood
- airway intervention
- saliva
- vomit - Trauma:
- trauma
- inhalation injury e.g. burns
what are the signs of airway obstruction?
- absent breath sounds
- added sound of laboured breathing e.g. stridor (upper airway obstruction), expiratory wheeze (lower airway obstruction), gurgling (fluids such as blood/vomit in airway), stretor (snoring - partial airway obstruction above the larynx)
- paradoxical chest movement (indicates complete airway obstruction)
- use pf accessory muscles (gives indication of increased effort required due to obstruction)
- reduced conciousness (can be sign of airway obstruction occurring secondary to cerebral hypoxia and hypercapnia)
differentiations signs between partial and complete obstruction
partial:
- use of accessory muscles to aid breathing
- tracheal tug
- paradoxical chest movements
- intercostal recession
- tripoding
complete:
- absent breath sounds
- unable to talk
- silent chest
- paradoxical chest movements
describe the mechanisms of chocking
- aero digestive FB causing varying amounts of obstruction in the airway
- problems with ventilation and oxygenation can –> significant morbidity and mortality (hypoxic-ischaemic brain injury)
- the relatively small diameter of paediatric airway means they are more prone to significant airflow obstruction with even small FB’s
- dental development also contributes to risk of FB aspiration as molars typically are not present before age of 2, thus can’t grind food into smaller pieces
- the relative anatomical narrowing of the trachiobronchal tree in children, proximal airway is typically the site of obstruction
- complete obstruction –> collapse of the respiratory structures distal to the obstruction (atelectasis)
- parietal obstruction –> formation of ball-valve obstruction with air trapping –> build up of pressure distal to the obstruction
location:
- upper airway obstruction of FB is rare
- right main broncus is most common
- upper lobe only in bedridden its
- most likely to be junction of right inferior and right middle bronchi/ lower and middle lobe aspiration pneumonia
what are the signs of chocking?
general:
- occurs when eating
- pt clutching neck
severe:
- unable to speak
- rescind by nodding
- unable to breathe
- wheeze
- silent cough
- unconscious
mild:
- speaks and answers
- able to speak, cough and breathe
how do you manage chocking?
adult:
- assess severity
2a. severe airway obstruction (ineffective cough)
- start CPR (2 breaths; 30 chest compressions) if pt unconscious
- if conscious -> 5 back blows and 5 abdominal thrusts
2b. mild airway obstruction (effective cough)
- encourage cough
- continue to check for deterioration to ineffective cough or until obstruction relieved
child:
- assess severity
2a. ineffective cough
- if unconscious -> open airway, 5 breaths, start CPR (5 breaths;15 chest compressions)
- if conscious -> 5 back blows, 5 thrusts (chest for infant and abdominal for child >1year)
2b. effective cough -> continue to check for deterioration to ineffective cough or until obstruction relieved
