Lower Respiratory Tract Obstruction Flashcards
What can intra-thoracic airway be divided into?
- Larger airways
2. smaller airways
What are the larger airway causes of obstruction?
Foreign body aspiration
Tracheomalacia
TB gland obstruction
What are the smaller airway causes of obstruction?
- Bronchiolitis
- Asthma
- Bronchiectasis
- Cystic fibrosis
- Cardiac failure
- Pneumonia with eosinophilia
Who are the typical ‘transient wheezers’?
- small for gestational age and born to mothers that smoked during pregnancy
- the wheezing usually occurs after a viral infection and disappears after 3 years
What organisms causes acute viral bronchiolitis?
- RSV in 75%
- Adenovirus
- metapneumovirus
When does acute viral bronchiolitis usually occur?
In winter
At what ages does acute viral bronchiolitis usually occur?
2-6 months but it can occur in children up to 2 years
What is the pathophysiology of acute viral bronchiolitis?
A mucous plug occurs which causes air trapping and hyperinflation of the lungs
Atelectasis can also occur because the air is able to get into the alveoli but it cannot go out causing collapse
What are the clinical signs of acute viral bronchiolitis?
- Starts as a upper airway infection that later becomes lower airway obstruction
- Coughing
- Wheezing
- Tachypnea
What can we expect on chest X-ray in bronchiolitis?
- Areas of air trapping
On examination what are the signs we can expect in a child with bronchiolitis?
- Barrel chest
- Hoovers sign
- Palpable liver-displaced downwards
- Wheezing
- Widespread crackles
- Decreased cardiac dullness
What organism will cause the most severe form of bronchiolitis?
Adenovirus
What is the management of bronchiolitis?
- Supportive
- oxygen nasal prongs with CPAP if needed to relieve hypoxia
- trial of nebulised salbutamol
- give oral feeds unless severely tachypnea if and distressed
- antibiotics are only indicated if there is possible evidence of secondary bacterial infection
What is bronchiolitis obliterans?
- bronchiolitis caused by organism adenovirus
- much more severe and treatment requires high concentrations of supplemental oxygen, and ventilation
- the children remain symptomatic for months after the acute attack with wheezing, air trapping and widespread crackles
How do we diagnose bronchiolitis obliterans?
On CT-we usually see localized areas of air trapping with decreased perfusion
What is the clinical definition for asthma?
Any child of any age presenting with >3 episodes of wheezing and/or dyspnea that responds to a bronchodilator has asthma until proven otherwise
What age is asthma more common in?
2-5 years
What is the pathophysiology of asthma?
- Smooth muscle spasm
- Inflammation with eosinophilia/lymphocyte infiltration
- Mucus plugging of small airways
How do we diagnose asthma?
- Family hx
- Patients symptoms
- Lung function tests
- Response to bronchodilator
- Allergy testing
What are the signs of allergic rhinitis/atrophy?
- Shiners
- Mouth breathing
- Allergic salute
What are the typical signs of asthma?
- Repeated episodes of tigh chest or wheezing
- Cough especially at night
- Signs better after bronchodilator
- Early morning waking
- Wheeze or cough after physical activity
What are the signs of an asthma attack?
- Anxiety and restlessness
- Tachycardia
- Intense wheezing on auscultation
What is mild intermittent asthma?
- Occurs once a month
- No night symptoms
- Normal lung function tests
- No recent hospital admission
What is persistent asthma?
- Occurs during the day and night
What are the main types of treatment for asthma?
- Long acting inhaled corticosteroids-budesonide
2. Short acting beta 2 agonist-salbutamol
What important considerations do we need to do when it comes to medications?
- The severity of the asthma
- How expensive it is
- Safety of the drugs
- Availability of the drugs
- Patient preference
What is the management of mild/moderate asthma?
- Treat with salbutamol 2-10 puffs vita a spacer and increase with 2 puffs per 2 minutes
- Add prednisone or prednisolone 2mg/kg
- Reassess after an hour
What would be the discharge plan for this patient with mild/moderate asthma?
You give them
- Continue with prednisone for 3-5 days
- Continue b2 agonist 4 hourly as necessary
What is severe asthma?
Children younger than 5:
- SATS 92%
- Tachycardiac >140
- Tachypneac> 40
- Use of accessory muscles
- Lung function tests
Children above 5:
Same as above but
Tachycardia >125, tachypnea>30
What is the management plan for severe asthma?
Start with oxygen mask to increase SATS
1. Start with 10 puffs of salbutamol via space
or nebulised salbutamol 2-5mg
2. Give oral prednisone 2mg/kg
3. OR IV hydrocortisone 4mg/kg
4. If poor response add nebulised ipratropium bromide at 0,25mg
5. Repeat the salbutamol and ipratropium every 20-30 minutes according to response
What do you give if you need to admit the patient?
- Continue nebulised salbutamol for 1 hour
- Add single dose IV salbutamol in 15 ml syringe over 10 minutes
- Single dose IV magnesium sulphate 50% solution
What is acute severe asthma?
Medical emergency
- when the child does not respond to 2 puffs of salbutamol (bronchodilator) given 30 minutes apart
- no response to two nebulisations with beta 2 agonist
What can trigger an acute severe asthma attack?
- Emotional triggers
- Viral infection
- Allergens
- Weather changes
What are the typical clinical finding of acute severe asthma?
- Marked chest hyperinflation
- Use of accessory muscles
- Tachypnea and interference with speech
- Wheezing
5I. Pulsus paradoxus >10mmhg
What are the goals of asthma management?
- freedom from symptoms
- miss school/work as little as possible
- be able to play sports
What are the controllers?
-inhaled corticosteroids and leukotrienes
What would we give if significant airway compression occurs as a result from TB lymph nodes?
Prednisone 2mg/kg per day for 30 days is added to the TB treatment
In children with aspiration penumonia what are the risk factors that pre-dispose them?
- Neurological condition(Cerebral palsy)
- Anatomical abnormalities-
Tracheo-oesophageal fistula
Cleft palate - Premature infants
What do we treat aspiration pneumonia with?
Clindamycin
