LRTI Flashcards
How do you manage LRTI
Make Dx
Assess patient - oxygenation, hydration, nutrition
Decide whether to treat
What is LRTI
>48 hours Fever >38.5 SOB Cough Grunting Reduced or bronchial breath sounds
What makes bacterial cause of LRTI unlikely
Wheeze
What are common agents in LRTI
H influenza Pneumococcus Mycoplasma Chlamydia S.Aureus
When do you call it pneumonia
Signs are focal Crepitations Consolidation on CXR in adults High fever / cough / SOB etc Otherwise = LRTI but can call it this as pneumonia causes anxiety
What is 1st line treatment in acute LRTI and when do you treat
Amoxicillin Macrolide 2nd line Look for scarlet fever rash IV only if vomiting Treat if oxygenation, nutrition and hydration is okay
How do you diagnose LRTI
What is not routine
HISTORY
CXR and inflammatory markers NOT routine
Only do CXR / bloods if suspect empyema / sepsis
What are signs of respiratory distress
Increased RR >70 Increased HR >160 Grunting Nasal flaring Recession - sternal, intercostal, subcostal Use of accessory muscles - SCM, abdominal and intercostal Cyanosis Sweating Tracheal tug Head bobing Wheeze Stridor As get exhausted - go into type 2 resp failure and develop cyanosis
What is bronchitis
Self limiting infection of bronchi
What age group is bronchitis common in
2-3 years
What does bronchitis present with
Loose rattly cough - can continue for week
Post vomit / glut
May have cold like symptoms, wheeze, sore throat
Chest free of creps / crackles
What causes bronchitis
RSV - common in winter
Adenovirus
Switch of mucociliary clearance so repeated infection
Bacteria can also cause on top
How do you Rx bronchitis
Supportive
Full septic screen / LP if <3 months + fever
What are red flag symptoms (suggest bronchiectasis)
<6 months or >5 Worry in babies especially <1 months as should have mother IgG -full septic screen / LP if fever FTT Disrupt QOL SOB at rest Co-morbidities
What is bronchiolitis
LRTI of infants common in <1 year
Most common 3-9 months as <3 months should be protected
Can occur up to 2 years particularly if pre-mature / chronic resp disease
33% get bronchiolitis
3% admitted
What causes bronchiolitis
RSV most common (RNA) virus
Paraflu III
Often FH of URTI
When is bronchiolitis common
Winter months
Never recurrent like viral wheeze
What are the symptoms of bronchiolitis
Coryza prodrome - discharge / snuffly Persistent cough - can last week Signs of resp distress Dyspnoea Tachypnoea Chest recession Wheeze/ crackles in chest due to small airways filled with mucous \+- fever (30%) Poor feeding due to SOB Increased respiratory effort - refer to 2 care
How may an infant <6 week present
Apnoea only
When do you admit to 2 care
<3 months Pre-mature / Pre-existing lung disease Apnoea Persistent low sats Inadequate oral intake Dehydration Lethargy Persistent resp distress CYanosis Social issues
Who are at risk of more severe
Chronic lung - CF Congenital heart <3 months Premature Bronchpulmonary dysplasia Immunedeficient Neuromuscular - may not see respiratory signs Parenteral smoke
What is the typical history of bronchiolitis
Getting worse 5 days
Worse 3-5
Stabilise and recovery over 2 weeks
Think is oxygen, hydration, nutrition okay?
How do you Dx bronchiolitis
NPA
02 sats show severity
No routine blood / gas / CXR
When would you do blood / gas / CXR / sputum culture
ABG if looks very unwell to see C02 levels / or if on ventilation
If focal signs to exclude pneumonia / pneumothorax
How do you treat bronchiolitis
Max observation, minimal intervention If sats >92% and feeding >50% = safety net Admit Isolation and PPE 02 if sats <92% (humidified) Fluids May need NG tube if not feeding Rarely CPAP Intubation if resp failure Consider suction if significant secretion
Bronchodilators do not work as b2 receptors immature in <2
If you send home what do you safety net with
If increased respiratory effort
Decreased fluid intake
Exhausted
Dry nappy
When do you discharge
Adequate oral intak
Sats okay for 4 hours
When would you consider pneumonia
Bronchiolitis
If high fever
Persistent focal signs - crackles, decreased breath sound, bronchial breathing
Older child
What is important to remember with pneumonia
Look for rash of scarlet fever
When would you consider viral induced wheeze
Persistent wheeze No crackles Recurrent episodic wheeze Don't fit LRTI Prev HX
What causes viral induced wheeze
RSV = common
Passiv smoke worsens
Rare in
How do you treat viral induced wheeze
Mild = none SABA (10 puffs MDI) or anti-cholinergic Inhaled steroid - bexamethasone / LTRA Oral pred if admitted Send home with SABA and reduce amount
What do you do for recurrent viral induced wheeze
Give a preventer - ICS / LTRA
Is it asthma
Could be
Rare in <5
Have to wait and see as no test
Who gets RSV monoclonal Ab
Immunocompromised
Repet bronchiolitis
Premature
Lung or heart abnormality
What causes Whooping cough
Bordetella pertussis - gram -ve
Inc 10-14 days
Routinely immunised - no life long protection
Particuly vulnerable as newborn so pregnant women immunised
What are the symptoms of whooping cough
Whooping cough - inspiratory whoop episodes during coughing fit
Followed by fainting / vomit after
Mild respiratory prodrome 2-3 days prior
Central cyanosis
Apnoea - can present with this rather than cough
Petechia from cough / subconjunctival haemorrhage
Marked lymphocytosis
Chest clear
What are complications of whooping cough
Pneumothorax Bronchiectasis Anoxic seizure Pneumonia Encepahlopathy - seizure
How do you Dx whooping cough
Nasal swab - culture / PCR if symptoms <2 weeks
Serology of blood if >2
How do you Rx whooping cough
Oral macrolide if within 21 days for 3 weeks
Ax prophylaxis to household contacts
Exclude from school 48 hours after Ax or if <21 days from symptom onset
Vaccine to newborn and pregnant women
When do you admit
<6 months
Apnoea
Complications
Resp difficulty
Do you report to public health
Yes
CF
See respiratory
How does chronic lung disease present
Hyper-inflated lung
Surgical emphysema
Pectus carnatum (out)
Pectus excavatum (in)
If patients presenting with recurrent LRTI what should you think
Underlying lung condition e.g. CF
Underlying immune
What should you asses for
Reflux Aspiration Neurological disease Heart disease Asthma CF Primary ciliary diskinesia Immune deficiency
What tests
FBC for WBC CXR for structural Serum Ig to look for low levels Sweat test HIV
Causes of clubbing in children
CF Bronchiectasis Cyanotic heart disease IE TB IBD Liver cirrhosis
What is primary ciliary dyskinesia
AR condition
Affects cilia of tracts
Also known as Kartamenger
What is the triad
Sinusitis
Bronchiectasis - build up of mucous, chronic infection
Infertiltiy - affects epithelium of Fallopian tube
Situs inverts - all organs on different side not just the heart
How do you Dx
FH
Examination
CXR to show situs invertus
Sample of ciliated epithelium for analysis
How do you Rx
Similar to CF and bronchiectasis
Physio
High calorie diet
Ax
