Level 1 - Respiratory Flashcards
What is asthma?
- Chronic airway inflammation, bronchial hyper-reactivity and reversible airway obstruction
Pathology of asthma?
- mix of genetic predisposition, atopy and environmental triggers that cause:
o Bronchial inflammation
o Infiltration of neutrophils, eosinophils, mast cells, lymphocytes
o Bronchial hypersensitivity
o Airway narrowing
o Thicker, excessive mucous production
o. Reversibility
Epidemiology of asthma?
- Commonest childhood chronic illness
- 15-20% of children
- Males>females
Risk factors for asthma?
- Atopy (40% have FHx)
- Smoking
- Low birth weight/Premature birth
Triggers for asthma exacerbation?
- Allergens (house dust mite, pollen, pets, feathers, fur)
- Exercise
- Viruses
- Cold
- Smoke/Pollution
Symptoms of asthma?
- Cough o Recurrent, dry cough o Worse at night and with exercise (diurnal variation) - Wheeze o Expiratory noise due to airway narrowing o Prolonged expiration o Responds to bronchodilators - Shortness of breath o Limiting exercise, daily life - Stunted growth
Signs of asthma? When is it worse?
Signs (usually normal between exacerbations)
- Barrel-shaped chest
- Accessory muscle use
- Hyperinflated chest
- Harrisons sulcus
What symptoms are there in an acute asthma attack? How is it classified?
- Acute SOB, cough, wheeze, work of breathing
- Severity
o Mild – breathlessness, PEFR >50% of expected
o Severe – cannot complete sentances, RR >25, pulse >130bpm, PEFR <50% of expected
o Life-Threatening – ACHEST3392
DDx of asthma?
Bronchiolitis Pneumonia/TB Inhaled foreign body Croup Cystic Fibrosis
Investigations for children under 5?
- Treat symptoms based on observation and clinical judgement
- Review child regularly
- If still have symptoms at 5 years, carry out objective testing
When to perform investigations for asthma in children 5-16 years?
- Treat immediately if they are acutely unwell
- Perform objective tests for asthma if the equipment is available and testing will not compromise treatment of the acute episode
Give the objective investigations in asthma? Give the positive result values?
o Spirometry FEV1/FVC<70% of predicted o BDR test FEV1 improvement of >12% if positive Diagnosed if both spirometry and BDR positive o FeNO test If uncertain and negative spirometry and BDR 35ppb or more is positive test Refer if negative o PEFR variability 2-4 weeks If normal spirometry OR obstructive spirometry, negative BDR, positive FeNO >20% variability is positive
What happens if child unable to perform objective tests in asthma?
- Treat based on observation and clinical judgement
- Try doing the tests again every 6 to 12 months
What other investigations may be needed to rule out other DDx in asthma?
Chest X-Ray – if exclusion of pneumothorax is needed
Allergy tests – skin prick test
Sputum culture
General measures in asthma management?
Reduce exposure to triggers
Monitor disease
- Symptom and PEFR diary
- After starting or adjusting medicines for asthma, review the response to treatment in 4 to 8 weeks
Educate the family about good inhaler technique
When will you move up asthma ladder in chronic treatment?
3x SABA per week, woken
3 month usually
Step 1 in asthma treatment in children all ages?
- Inhaled short-acting B2 agonist (salbutamol, terbutaline, ipratropium bromide (infants/children))
Step 2 in asthma treatment in children under 5?
Add LTRA
Step 3 in asthma treatment in children under 5?
• Low dose ICS – 8-week trial
- If symptoms resolved then reoccurred within 4 weeks of stopping ICS – restart on low-dose ICS
- If symptoms resolved but reoccurred beyond 4 weeks of stopping ICS, repeat low-dose ICS
Step 4 in asthma treatment in children under 5?
•Refer to respiratory physician
Step 2 in asthma treatment in children aged 5-16?
• Add inhaled paediatric low dose ICS
Step 3 in asthma treatment in children aged 5-16?
• Add on LABA
Review 4-8 weeks
If no response, stop LABA and start LTRA
Step 4 in asthma treatment in children aged 5-16?
• Add LTRA
Step 5 in asthma treatment in children aged 5-16?
• Increase dose of ICS to paediatric moderate dose
Referral to paediatrician
Step 6 in asthma treatment in children aged 5-16?
Increase ICS dose to high dose
Trial of theophylline
Refer to paediatrician
What inhalers should be used in children and what else should be prescribed?
- <5 years, use pMDI and spacer device
• If not tolerated, DPI in 3-5 years or nebuliser - 5-16 years, pMDI and spacer device
Management of mild & severe acute exacerbation in asthma?
Mild - 10 puffs of SABA (given when no oxygen requirement), prednisolone 1-2mg/kg PO 3 days, give 10 puffs of inhalers when needed and space out
Severe
- 1. High flow Oxygen (100%, 15L)
- Salbutamol nebulised
o 10 puffs of SABA if not life-threatening
o 5mg O2-nebulised in 4mL saline (2.5mg if <5 years)
o Continuously then every 30 mins and space out
- Salbutamol nebulised
- Hydrocortisone IV/Prednisolone oral
o Hydrocortisone – 100mg IV
o Prednisolone – 1-2mg/kg to max 40mg (50mg >12 years)
- Hydrocortisone IV/Prednisolone oral
- Ipratropium bromide nebulised
o Can do same time as salbutamol
o 0.25mg in 4mL saline
o Every 20-30 mins for 1st 2 hours then everyW 8 hours if needed
- Ipratropium bromide nebulised
- Magnesium sulphate IV one-off dose
o 40mg/kg over 20 mins (<2g)
- Magnesium sulphate IV one-off dose
- Theophylline (Aminophylline IV)
o 5mg/kg over 20 mins
o Give ondansetron as causes vomiting
- Theophylline (Aminophylline IV)
- Before discharge
o Need PEFR >75%, good inhaler technique
o Wheeze plan
o Inhaled steroids and oral prednisolone (3 days)
Follow-up GP in 1 week and clinic in 4 weeks
What complications dose excessive steroid usage cause children in asthma?
Excessive steroid use
- Impaired growth, adrenal suppression, oral candidiasis
Pathology of bronchiolitis?
- RSV (respiratory syncytial virus) invades the nasopharyngeal epithelium and spreads to the lower airways
- Increased mucus production, desquamation and then bronchial obstruction
- Net effect = pulmonary hyperinflation and bronchiolar atelectasis (one or more areas of your lungs collapse or don’t inflate properly)
Typical time course of bronchiolitis?
- Typically, a 9-day illness
o 3 days prodrome- cold and harsh cough
o 3 days fever + high pitched wheeze + breathless
o 3 days: recovery
Epidemiology of bronchiolitis?
- COMMONEST serious respiratory infection of infancy: 2-3% of all infants are admitted to hospital with the disease each year during winter.
- Usually in infants <2 years old, affects everyone by the age of 2
- 90% are aged 1-9months
Risk factors for bronchiolitis?
o CHD (congenital heart defect) o Chronic lung disease e.g. CF o Prematurity o Immunodeficiency Passive smoking
Causative agents in bronchiolitis?
- RSV (respiratory syncytial virus, single-stranded RNA) - 80%
- Others include parainfluenza, influenza, adenovirus, rhinovirus, metapneumovirus and mycoplasma pneumonia
- Dual infection with RSV + metapneumovirus severe bronchiolitis
Symptoms of bronchiolitis?
- Preceded by coryzal symptoms
- Dry cough respiratory distress (worsening SOB) + wheeze
- Low Fever
- Feeding difficulty
- Episodes of apnoea
- Rarely encephalopathy with seizures due to hyponatraemia
Signs of bronchiolitis?
- Cyanosis or pallor
- Sharp, Dry cough
- Tachypnoea + tachycardia
- Subcostal and intercostal recession
- Chest hyperinflation prominent sternum + liver displaced downwards
- Pauses in breathing or apnoea
- On auscultation:
o Wide spread wheeze
o Prolonged expiration
o Fine end-inspiratory crackles
Investigations in bronchiolitis?
- Vital Signs to measure level of respiratory distress
- Nasal/Throat Swabs
Others: - Capillary blood gas only done in severe infections
Throat swabs - CXR only needed in atypical cases to rule out pneumothorax/lobar collapse
o Will show hyperinflation, widespread consolidation
Management of bronchiolitis?
Most infants treated at home
Hospital when:
- Feeding poorly, lethargy, sats <94%, tachypnoea
Hospital treatment:
- Humidified O2 via high flow nasal cannula
o SpO2 >92%
- If tachypnoea, minimise oral feed - use NGT feeds
- Mechanical ventilation if severe
o CPAP or via high flow nasal cannula - Not routinely given but nebulised salbutamol to ease wheeze
Prevention of bronchiolitis?
Mortality increase in which groups (given preventative measures)?
- Palivizumab (monoclonal antibody to RSV) given monthly by IM injection for 6 months in high risk pre-term infants
Congenital heart, preterm infants, immunodeficiency
What does croup stand for?
Laryngotracheobronchitis
Name the 3 common conditions in tracheal inflammation?
Viral croup
Spasmodic croup
Acute epiglottitis
What is viral croup? Due to what?
URTI
Mucosal inflammation affecting the nose to the LRT
Due to parainfluenza, influenza and RSV in children aged 6 months – 6 years
What is spasmodic/recurrent croup?
Barking cough and hyperreactive upper airways
No respiratory tract symptoms
What is acute epiglottitis?
Life-threatening swelling of the epiglottis and septicaemia due to H. Influenzae type B infection
Now rare due to Hib immunization
Epidemiology of laryngotracheal infections?
- Viral croup= 95% of the laryngotracheal infections
- Most common in autumn
- Peak at 2yrs old, in children aged 6M-6yrs
What is acute epiglottitis most common?
- Acute epiglottitis: most commonly in ages 1 – 6 years, rare due to Hib immunisation
Causative agents in viral croup?
o MOST COMMONLY due to parainfluenza
o Others include Influenza and RSV
Causative agents in acute epiglottitis?
o H. Influenzae type B infection
Symptoms of croup?
Develops in days - Often worse at night o Barking cough o Harsh stridor o Hoarseness preceded by fever & coryzal URTI
Symptoms of acute epiglottitis?
Develops in minutes to hours - Often worse at night o High fever, toxic-looking child o Intensely painful throat Stops swallowing or speaking o Saliva drooling o Respiratory difficulty o Child sitting immobile, upright, with open mouth
Difference between croup and epiglottitis?
Croup
Days, preceding cough, severe, barking cough, can drink, closed mouth, not toxic, <38.5, harsh, rasping stridor
Hoarse, Stridor voice
Acute epiglottitis
Hours, no coryza, absent or slight cough, no feeding, drooling saliva, toxic, >38.5, soft, whispering stridor
Weak or silent voice (reluctant to speak)
Examination in croup/epiglottitis?
- Examination—DO NOT EXAMINE THE THROAT—assess severity:
o Degree of stridor and subcostal recession
o RR
o HR
o LOC (drowsy?), tired, exhausted
o Pulse oximetry
What else should be done in epiglottitis? and severe croup?
- Anaesthetist makes diagnosis by laryngoscopy – cherry-red swollen epiglottis
- Electively intubate before obstruction occurs
Immediate management to croup/epiglottitis?
- LEAVE CHILD ALONE - DO NOT DISTRESS (especially in epiglottitis)
o Differentiate between croup and acute epiglottitis
o Stabilise child, give oxygen and keep airway open
Management of mild viral croup?
o Mild illness can be managed at home
Usually resolves after 48hours
Take paracetamol/ibuprofen PRN
o If there is recession and stridor at rest, then return to hospital
Management of moderate/severe croup?
o Infants <1yr need closer attention o Tx include: Moist or humidified air • Ease breathing Steroids • Oral dexamethasone (0.15mg/kg stat dose) or oral prednisolone (1-2mg/kg stat) or nebulised budesonide (2mg stat dose) Nebulised adrenaline (epinephrine) • Transient relief of Sx (airway obs) My need endotracheal intubation.
Management of acute epiglottitis? Prevention of acute epiglottitis?
o Manage in ICU after endotracheal intubation
o Once procedure completed take blood cultures and start IV Abx
Cefuroxime IV for 7-10 days
o Rifampicin prophylaxis to close contacts
Definition of pneumonia?
- Acute infection of lower respiratory lung parenchyma
When does incidence of pneumonia peak?
during infancy
When is no cause for pneumonia found?
- 50% no cause found
Causative organisms of pneumonia in neonates?
Organisms of the genital tract
Group B Streptococcus
Gram negative enterococci
Causative organisms of pneumonia in Infants&young kids?
RSV most common
Streptococcus pneumoniae, Haemophilus influenzae, Bordetella pertussis, Chlamydia trachomatis
Rare but serious cause S.aureus
Influenza, parainfluenza, adenovirus
Causative organisms of pneumonia in children >5y?
Streptococcus pneumoniae
Mycoplasma pneumoniae (all ages)
Chlamydia pneumoniae
Causative organisms of pneumonia in all ages?
Mycoplasma tuberculosis
Risk factors for pneumonia?
o Congenital lung cyst o Chronic lung disease o Immunodeficiency o CF o Sickle cell disease o Tracheostomy
Symptoms of pneumonia?
o Fever o Shortness of breath o Usually preceded by URTI o Cough o Malaise o Poor feeding
Signs of pneumonia?
o Grunting
o Recessions
o Use of accessory muscles
o Pleural pain
o End-inspiratory course crackles and bronchial breathing
o Dullness on percussion
o Decreased breath sounds and oxygen saturations low
Investigations in pneumonia?
- Chest X-ray
o Consolidation usually lobar – classical Streptococcus pneumoniae in right upper lobe
o Pleural effusion shows blunting of costophrenic angles - Nasopharyngeal aspirate
o To identify viral causes - Bloods
o FBC (increased WCC, neutrophils usually in bacteria), CRP, ESR
o Cultures
Prevention of pneumonia in children:?
o Vaccination against Streptococcal pneumoniae (Pneumococcal) and Hib have decreased incidence
Acute management in primary care for pneumonia?
Analgesia and paracetamol for fever Encourage fluid intake Do not smoke in house Antibiotics • Amoxicillin • Alternatives: Co-amoxiclav, erythromycin, azithromycin, clarithromycin • For 7-14 days
Secondary care of pneumonia?
Admit if O2 sats <92% and signs of respiratory distress Oxygen, analgesia IV fluids IV co-amoxiclav 7-14 days Alt: Clarithromycin
What antibiotics to give in CAP pneumonia in secondary care - neonates?
Neonates - IV benzylpenicillin + gentamicin
What antibiotics to give in CAP pneumonia in secondary care - children?
o Oral Amoxicillin
o Alternatives: clarithromycin (if pen allergic)
What antibiotics to give in CAP pneumonia in secondary care - children severe?
<3 months - IV ceftriaxone, cefotaxime
3 months to 18 years - IV co-amoxiclav/amoxicillin
What antibiotics to give in HAP pneumonia in secondary care - severe?
IV Amoxicillin/Co-amoxiclav
Tazocin (if >5 days in hospital)
Complications of pneumonia?
- Pleural Effusions
- Empyema or lung abscess
- Sepsis
- Bronchiectasis
Definition of pharyngitis?
local imflammation of oropharynx with enlarged and tender lymph nodes
Definition of tonsilitis?
form of pharyngitis where there is intense inflammation of the tonsils, often with purulent exudate
Epidemiology of URTI?
- Highest incidence in children and young adults
- More common in winter
- URTI are 80% of respiratory infections
Causative agents of common cold?
Rhinovirus, coronaviruses and RSV (however RSV usually causes acute bronchiolitis)
Causative agents of pharyngitis?
Adenoviruses, enteroviruses, rhinoviruses, influenza types A and B
In older children, group A B-haemolytic streptococcus
Causative agents of tonsillitis?
Group A B-haemolytic streptococcus
EBV
Causative agents of epiglottitis?
Hib
Symptoms and signs of URTI?
- Fever (+/- febrile convulsions)
- Painful throat
- Exudate present in bacterial tonsillitis
- Earache and nasal discharge
- Difficulty feeding and drinking
Examinations in URTI?
- Clinical examination – pus on tonsils indicates bacterial infection
- Neck – think bacterial infection if tender lymphadenopathy
What is the Centor criteria?
Tonsillar exudate Tender anterior cervical lymphadenopathy or lymphadenitis History of fever (over 38°C) Absence of cough IF 3 OR 4, CONSIDER ANTIBIOTICS
General management of URTI?
- Majority caused by viral infections
- 40% of symptoms resolve within 3 day and 85% within 1 week
- Symptomatic relief
o Paracetamol and ibuprofen
When to give antibiotics and what in URTI? What to avoid in all cases?
o If positive culture or Centor criteria 3 or 4:
Tonsilllar exudate
Tender anterior cervical lymphadenopathy
Fever
Absence of cough
o Prescribe penicillin V (phenoxymethylpenicillin) for 10 days
o Alternatives: erythromycin or clarithromycin for 5 days
AVOID AMOXICILLIN AS CAUSES RASH IN EBV
Complications of URTI?
- Otitis Media
- Sinusitis
- Peritonsillar abscess (quinsy)
- Para-pharyngeal abscess
Definition of cystic fibrosis? (CF)
- Autosomal recessive condition causing a defective CFTR protein on chromosome 7
What is CFTR?
- CFTR is a cAMP dependent chloride channel found in membrane of cells
What pathology does CF lead to?
- Leads to excessively thick mucus in many body systems
o Reduction in airway surface liquid layer and impaired ciliary function
o Chronic endobronchial infection ensues
o Thick meconium is produced
o Pancreatic ducts also become blocked by thick secretions
o Abnormal sweat glands
Epidemiology of CF?
- Incidence of 1 in 2500 live births with a carrier rate of 1 in 25
- Average life expectancy is mid-30s
Symptoms and Signs in CF in infancy?
- Meconium ileus (1 in 10)
- Prolonged neonatal jaundice
- Failure to thrive
- Recurrent chest infections
o Cough, purulent sputum, chest deformity
o Initially S.aureus, H.inflenziae
o Pseudomonas aeruginosa, burkholderia cepacia colonisations - Malabsorption (vit ADEK), steatorrhoea – failure to thrive
Symptoms and Signs in CF in young child?
- Nasal Polyp
- Sinusitis
- Recurrent LRTI
- Bronchiectasis
- Diarrhoea
- Rectal Prolapse
- FTT
Symptoms and Signs in CF in older child?
- Allergic bronchopulmonary aspergillosis
Recurrent LRTI - Diabetes Mellitus
- Cirrhosis/Portal Hypertension
- Intestinal Obstruction
- Pneumothorax
- Sterility in males – congenital absence of vas deferens
Signs of CF?
- Evidence of malnutrition, poor weight gain
- Hyperinflation of the chest
- cough (purulent sputum)
- Coarse inspiratory crackles
- Expiratory wheeze
- Finger clubbing
What testing is available to diagnoses CF?
- Screened for in Guthrie test
- Sweat Test >60mmol/l
o Measuring sodium and chloride concentrations in sweat - Gene Testing
CT head and thorax
General management of CF?
- Requires the MDT approach and reviewed anuallly - tertiary centre
Respiratory management of CF?
- Physiotherapy twice a day to remove secretions
o Parents taught airway clearance at home using percussion and postural drainage
o Older children taught forced expiration technique - Physical exercise beneficial
- Oral flucloxacillin prophylaxis needed
- Nebulised DNAse decreases sputum viscosity
- If pseudomonas infection:
o May need oral/IV broad-spectrum Abx - If respiratory function decreases, offer azithromycin
- regular sputum samples
Other management of CF?
- Increase calorie intake by increasing portion size/high calorie foods (150% of normal)
- Offer oral pancreatic enzyme replacement therapy (Creon)
- Omeprazole helps absorption
- Fat-soluble vitamins (ADEK)
