Lower airway

Question 1

Discuss DDX of asthma

Answer 1

Infectious

• bronchiolitis
• croup
• pneumonia
• TB
• bronchiolitis obliterans

Anatomical or congenital

• GORD
• CF
• CCF
• Tracheoesophageal fistual
• mediastinal mass
• vascular ring

Acqured

• Foreign body aspiration
• anaphylaxis `

Question 2

Discuss management of moderately ill asthmatic children

Answer 2

Characterised by alert tachypnoeic children who have wheezing throughout expiration, an IE ratio of 1:2 and significant use of accessory muscels. Typically sats will be maintained between 92-95%

Cornerstone is SABA, ipratropium bromide 2-3 doses in the first hour and corticosteroids

Question 3

Discuss management of severe asthma in children

Answer 3

Characterised by a restless or tired child with extreme tachypnoea and tachycardia, audible wheezing I:E ratio greater that 1:2 use of accessory muscles and o2 sats less than 92%

Continous salbutamol neb, Ipratropium, IV steroids
NRB or highflow may be necessary to maintain sats
IV salbutamol 1-20mcg/min
aminophylline 6mg/kg load and than 0.5mg/kg/hr
Magnesium 50-75mg/kg over 20 minutes

Question 4

Discuss bronchiolitis

Answer 4

An acute infectious disease that resutls in inflammation of the small airways in children younger than 2 years of age. More common in children under 12 months of age.
RSV is the most common agent identified in children estimated to cause 70% of cases
Other viral causes includ parainfluenza, human metapneumovirus, influezna, adenoviurs, bocavirus and rhinovirus

Question 5

Discuss risk factors for severe bronchiolitis

Answer 5

• Prematurity (gestational age <36 weeks)
• Low birth weight
• age less than 12 weeks
• chronic pulmonary disease, particularly bronchopulmonary dysplasia
• anatomical defects of the ariways
• Haemodynamically significant congenital heart disaese
• immunodeficiency
• neurological disease

Question 6

Discuss clinical features of bronchiolitis

Answer 6

Typically under 1 year of age
First symptoms are generally a viral prodrom
Followed within a few days by a tight cough often associated with difficulty in feeding

A combination of poor feeding and increased insensible fluid losses often has an impact on an infants hydration status and should be assessed

The worst phase of the illness is generally under day 2-3 with resolution over 7-10 days

Question 7

Discuss risk stratification of bronchiolitis

Answer 7

Mild 
-behaviour normal 
-RR normal 
-Nil to mild WOB 
-O2>92% in RA 
Apnoeic episdoes nil 
Feeding normal 

Moderate
-Some intermittent irritability
-RR increased
-Moderate chest wall retraction, suprasternal retraction, nasal flaring
-O290-92% in RA
may have brief apnoeas
Some difficulty with or minor reduced feeding

Severe
-Increased irritability or drowsiness
-Marked RR increased or decrease
-Marked chest wall retraction, suprasternal retraction, nasal flaring
-O2 <90 in RA - may not be corrected with o2
Increaseingly frequent or prolonged apnoea
Reluctant or unable to feed.

Question 8

Discuss management of bronchiolitis

Answer 8

Hydration
- if less than 50% over 12 hours - NGT hydration

O2 if spo2 <92%
High flow 2l/kg