Paediatric RESP Flashcards
What is the proper medical name for croup?
Viral laryngotracheobronchitis
At what point of the year is croup most common?
Autumn
What age group is affected by croup?
6m to 3y, peak 2y
What is the main cause of croup?
Parainfluenza
Recall 3 differentials for croup
Laryngomalacia
Acute epiglottitis
Inhaled foreign body
Recall the signs and symptoms of croup
1st = coryzal Sx
2nd = barking cough (from vocal cord impairment) + stridor
What investigations should be done for croup?
Clinical diagnosis
DO NOT EXAMINE THROAT
What additional features differentiate moderate from mild croup?
Stridor
Sternal/ intercostal recession at rest
How should croup be managed?
Westley score determines admission
Admit if RR>60, or complications
DEXAMETHOSONE TO ALL
For mild: discharge
For moderate: admit
For severe: admit and add nebulised adrenaline to dex
For impending respiratory failure: same as severe
What are the parameters of the Westley croup score?
Level of consciousness (5)
Cyanosis (5)
Stridor (2)
Air entry (2)
Retractions (3)
If a CXR is performed in croup, what signs are seen?
PA: subglottic narrowing- “steeple sign”
What is the most likely complication of croup?
Secondary bacterial superinfection
Give 2 symptoms/ signs of inhaled foreign body
Acute onset breathlessness
Focal wheeze
What may be seen on CXR if there is inhalation of a foreign body?
NORMAL: majority of FBs are radiolucent
Increased volume + translucency of affected lung (FB creates a valve- air can only enter)
What is the definitive investigation and management for an inhaled foreign body?
Bronchoscopy
What is the most common cause of acute epiglottitis?
Haemophilus influenza B (bacteria!!!!) hence is quite uncommon as vaccinated against
What are the signs and symptoms of acute epiglottitis?
Medical emergency
No cough as in croup
High-fever (‘toxic-looking’)
Stridor is soft inspiratory with high RR
“Hot potato” speech
DROOLING as child cannot swallow
Immobile, upright + open mouth: ‘tripod sign’
What sign would be seen on a lateral CXR in acute epiglottitis?
Swelling of epiglottis: Thumb sign
How should acute epiglottitis be investigated and managed?
Do not lie child down or examine their throat (may precipitate a total obstruction)
- Immediately refer to ENT, paeds + anaesthetics –> transfer + secure airway
- Once airway is secured, blood culture, empirical Abx (cefuroxime) + dexamethosone
In what age range is bronchiolitis seen?
1-9 months
3-6 month peak
What is the most common cause of bronchiolitis?
RSV in 80%
What are the signs and symptoms of bronchiolitis?
1st URTI sx: cough, rhinorrhoea, low fever
2nd = dry, wheezy cough, SOB, grunting, feeding difficulties
Give 3 key features of bronchiolitis
persistent cough
+
tachypnoea or chest recession (or both) +
wheeze or crackles on auscultation (or both).
What are the examianation findings in bronchiolitis?
To distinguish from croup/ other ‘itis’
Auscultate: fine, bi-basal, end-inspiratory crackles
When should pneumonia be suspected as a differential from bronchiolitis?
high fever (>39°C)
+/or
persistently focal crackles.
What investigations should be done in bronchiolitis?
Cinical dx but can do an NPA to confirm
If there is significant respiratory distress + fever, do a CXR to R/O pneumonia
What prompts immediate referral (999) in bronchiolitis? (5)
Apnoea
Looks seriously unwell to HCP
Severe resp. distress: grunting, marked chest recession, or RR > 70
Central cyanosis
SpO2 <90% RA or <92% if high risk/ <6w
When should referral be considered in bronchiolitis? (4)
RR >60
Clinical dehydration
Poor oral fluid intake (50-75% normal)
SpO2 < 92% on RA
What factors lower threshold for admission with bronchiolitis?
Age <3 months
Ex-preterm
Chronic lung disease
Congenital heart disease
What is the management for patients admitted with bronchiolitis?
Supportive care:
nasal O2/ head box
NG fluids/ feeds
Suction if excess secretions
CPAP if respiratory failure
Over how long is bronchiolitis self-limiting?
3 weeks
Describe the ‘spectrum’ of infant asthma
Bronchiolitis if <1y
Viral-induced wheeze (1-5y)
Asthma (>5)
Describe the wheeze in asthma
End-expiratory polyphonic
When are asthma symptoms worst?
Night/ early morning
What will be seen OE in childhood asthma?
Hyperinflated chest + accessory muscle use
Harrisson’s sulci: depressions at base of thorax where diaphragm has grown in muscular size
How should childhood asthma be diagnosed?
<5y = clinical dx
>5y = spirometry, bronchodilator reversibility, PEFR variability (2w)
What spirometry value is diagnostic of asthma?
FEV1/FVC ratio < 70%
(or below the lower limit of normal if this value is available)
Recall the PEFR range of moderate, severe, and life-threatening asthma
Moderate: 50-75%
Severe: 33-50%
Life-threatening: <33%
Give 4 features of moderate asthma attack
Able to talk in sentences
SpO2 >92%
HR <140 (in 1-5s) or HR <125 (in 5+)
RR <40 (in 1-5s) or RR <30 (in 5+)
Give 5 features of severe asthma attack
Can’t complete sentences in 1 breath
SpO2 <92%
HR >140 (in 1-5s) or HR >125 (in 5+)
RR >40 (in 1-5s) or RR >30 (in 5+)
Accessory muscle use
Give 7 features of life threatening asthma attack
SpO2 <92%
Altered consciousness/ confusion
Exhaustion
Silent chest
Hypotension
Cyanosis
Poor respiratory effort: normal pCO2
When should you admit a child with asthma?
Moderate (not responding to Tx)
Severe
Life-threatening
How should severe-life threatening paediatric asthma be managed in a hospital setting?
High flow O2 if SpO2 <94%
- Burst step
- 3 x salbutamol nebs (5mg), or up to 10 inhales on a pump
- 2 x ipratropium bromide nebs
(SE of too much = shivering, vomiting)
MgSO4 neb: Added to each neb in 1st hour if severe
Prednisolone PO
Involve seniors if burst therapy has failed to work
- IV Bolus step = 1 of the following: MgSO4, salbutamol, aminophylline
- Infusion step
- IV salbutamol/ aminophylline - Panic step
- Intubate + ventillate
How is a mild exacerbation of asthma managed?
Hosp admission not required
High flow O2 if SpO2<94%
SABA via MDI + large vol spacer: 1 puff every 30-60s (up to 10 puffs)
Prednisolone PO
For how long after an acute exacerbation of asthma should prednisolone be taken?
3d (may be longer if severe)
What is ipratropium bromide also known as? How often can this be given?
Atrovent
1m-11y: 250ug every 20-30 mins for first 2h, then every 4-6h
12-17y: 500ug every 4-6h
When can children with exacerbation of asthma be discharged? What follow up is required?
Discharge when stable on 3-4h inhaled bronchodilators PEF +/or FEV1 >75% of best or predicted + SpO2 >94%.
F/U within 48h
Recall 4 contraindicated drugs when taking beta-agonists/ salbutamol
Beta-blockers
NSAIDs
Adenosine
ACE inhibitors
Recall outpatient management of asthma in children >5
- SABA
- SABA + low dose ICS
- SABA + ICS + LTRA
- SABA + ICS + LABA
- SABA + low dose ICS MART
- SABA + mod dose ICS MART / mod ICS + LABA
- Specialist: + increase ICS to paediatric high dose / Theophylline
What common SABA is used?
Salbutamol
(Ventolin, Blue inhaler)
What common low-dose ICS’s are used in >5s?
Beclometasone
Budesonide
What common LTRA is used?
Montelukast
(leukotriene receptor antagonist)
Chewable tablet OD, in evening
What common LABAs are used?
Salmeterol
Formoterol
What common MART is used?
Budesonide with Formoterol
Which 3 features indicate that a child should go straight to SABA + ICS?
Asthma related Sx >,3x/ week
Waking at night due to asthma
Asthma not controlled by SABA alone
What is the most common cause of rhinitis?
Rhinovirus
What is rhinitis more commonly known as?
Common cold
What is the general recovery time for rhinitis?
2 weeks
What are the possible complications of rhinitis?
Otitis media
Acute sinusitis
What is sinusitis?
Infection of the maxillary sinuses from viral URTIs
May lead to a secondary bacterial infection
What are the symptoms of sinusitis?
Facial pain: typically frontal pressure pain which is worse on bending forward
Nasal discharge: thick + purulent, discoloured
Nasal obstruction
How should sinusitis be managed if symptoms lasting <10 days?
No Abx
Advise them that virus will take 2-3w to resolve
Paracetamol/ Ibuprofen for Sx relief
How should sinusitis with symptoms present for >10 days be managed?
High dose nasal corticosteroid for 14 days e.g. Mometasone
may improve Sx but is unlikely to reduce duration of illness
can cause systemic SEs
+/- back up prescription of Abx if Sx get considerably worse- Phenoxymethylpenicillin
When should a pt be admitted to hospital for sinusitis?
Severe systemic infection
Intraorbital/ periorbital problems (eg periorbital cellulitis, diplopia, displaced eyeball)
Intracranial complications e.g. features of meningitis
Why are children particularly vulnerable to otitis media?
Eustacian tubes are short, horizontal + function poorly
What are the 3 most common causative organisms in otitis media?
H influenza
S. pneumoniae
RSV
What investigations should be done in otitis media?
Temperature
Otoscopy
What are 5 signs and symptoms of acute otitis media?
Otalgia +/- Tugging/ rubbing ear
Fever ~ 50% of cases
Hearing loss
Recent viral URTI Sx (e.g. coryza)
Ear discharge if TM perforates
What would be seen on otoscopy in acute otitis media?
Bright red/ yellow bulging tympanic membranes
Loss of normal light reaction
Perforation +/- discharge
Recall 3 indications for admission in acute otitis media
Severe systemic infection
Complications (eg meningitis, mastoiditis, facial nerve palsy)
Children <3 months with a temperature >38
What is the advice for acute otitis media?
Advise usual course of AOM is ~3d (up to 1w)
Advise regular paracetamol/ ibuprofen for pain
Resolves spontaneously in most cases (no abx)
When should abx be given in otitis media?
Delayed prescription if not better after 3d or significant deterioration
Immediate Abx if systemically unwell, age <2y with bilateral AOM
If there is a perforation: PO amoxicillin + review in 6w to ensure healing
If indicated, which antibiotic should be given in AOM?
Amoxicillin 5-7 days
How do antibiotics effect the course/ outcome of AOM?
Marginally reduce duration of pain
NO effect on risk of hearing loss
When should an ENT referral be made following AOE?
Failure to respond to 2 courses Abx
Suspected glue ear
Recurrent unexplained AOM +/- complications
Craniofacial abnormalities e.g. DS
What is another name for otitis media with effusion?
Glue ear
What is glue ear?
Collection of fluid within middle ear space w/o signs of acute inflammation
Common following AOM
What are the signs and symptoms of otitis media with effusion?
Asymptomatic apart from reduced hearing
(Can interfere with normal speech development)
+/- intermittent ear pain
What does otoscopy show in otitis media with effusion?
Eardrum is dull + retracted
Air-fluid level
How should otitis media with effusion be investigated?
Otoscopy
Tympanometry
Audiometry
What is the initial management of otitis media with effusion?
Observe for 6-12w- spontaneous resolution in most
2 hearing tests using PTA 3/12 apart, as well as tympanometry
What management techniques can be used for OME?
Autoinflation (balloon in young, valsalva manoeuvre in older)
Hearing aids (if persistent bilateral + surgery CI)
What is the surgical management for OME?
Myringotomy + insertion of grommets
When should a referral be made to ENT in otitis media with effusion?
If persistent past 6-12w
Immediate referral if DS or cleft palate
What are 4 complications of acute otitis media?
Hearing loss (conductive + temporary).
Tympanic membrane perforation.
Labyrinthitis.
Rarely, mastoiditis, meningitis, intracranial abscess, sinus thrombosis, and facial nerve paralysis.
What is another name for acute diffuse otitis externa?
Swimmer’s ear
What is the cause of chronic otitis externa?
Fungal cause
What is necrotising otitis externa?
Life-threatening extension into mastoid + temporal bones
What demographic of folks are most likely to get necrotising otitis externa?
The elderly
How should otitis externa be investigated?
If indicated: swabs + culture
How should otitis externa be managed?
Topical acetic acid (only effective for 1 week)
If indicated: topical Abx (neomycin/ clioquinol)
Wicking + removal of debris
Recall 2 indications for abx use in otitis externa?
Cellulitis
Cervical lymphadenopathy
What’s the most common causative pathogen in tonsillitis? Give 3 examples from most to least common
Viruses:
Rhinovirus
Coronavirus
Parainfluenza virus
What is tonsilitis?
Form of pharyngitis with inflammation of the tonsils + purulent exudate
What is the most common cause of bacterial tonsilitis?
Group A beta-haemolytic streptococcus
What clinical scoring tools can identify those more likely to has GAS tonsillitis, and benefit from antibiotics?
FeverPAIN
Centor
What is the FeverPAIN criteria?
Fever (during previous 24h)
Purulence (pus on tonsils)
Attend rapidly (within 3 days after onset of Sx)
severely Inflamed tonsils
No cough or coryza (inflammation of mucus membranes in the nose)
What is the Centor criteria?
Tonsillar exudate
Tender anterior cervical lymphadenopathy or lymphadenitis
Hx of fever (>38 degrees)
Absence of cough
(Age 3-14)- not on all criteria
1 = no abx
2/3 = rapid strep test
4/5 = rapid strep test + Abx
When should referral to ENT be made for patients with recurrent tonsillitis?
> ,7 episodes per year for 1 y
,5 per year for 2y
,3 per year for 3 y
+ for whom there is no other explanation for the recurrent Sx
For consideration of tonsillectomy
When should you admit for tonsilitis/ pharyngitis/ laryngitis?
Difficulty breathing
Clinical dehydration
Peri-tonsillar abscess (quinsy) or cellulitis
Suspected rare cause (eg kawasaki/ diptheria)
What is quinsy?
Peritonsillar abscess that typically develops as a complication of bacterial tonsillitis.
Give 4 signs and symptoms of quinsy
Severe throat pain, which lateralises to 1 side
Deviation of the uvula to the unaffected side
Trismus (difficulty opening the mouth)
Reduced neck mobility
What is management of Quinsy?
needle aspiration or incision & drainage + IV Abx
Tonsillectomy considered to prevent recurrence
How would diptheria appear OE of the throat?
‘web’/ pseudomembrane at back of throat
If bacterial tonsilitis is confirmed using rapid strep test, how should it be treated?
Phenoxymethylpenicillin 10 days QDS
What tx should be avoided in tonsilitis?
Amoxicillin in case it’s EBV
This would result in maculopapular rash
For how long should school be avoided in tonsilitis?
Unti 24h after abx have been started (in case of scarlet fever)
What should you advise for self-tx for tonsilitis if no abx indicated?
Paracetamol + Ibuprofen
Adequate fluids
Lozenges
What is the connection between tonsilitis and scarlet fever?
Group A Strep (s pyogenes) infection can progress from tonsilitis to scarlet fever
What 3 initial non-specific symptoms may occur in scarlet fever?
Sore throat.
Fever (typically >38.3°C).
Headache, fatigue, N+V
What are 5 signs and symptoms of scarlet fever?
Blanching rash on trunk, then spreads
Red, generalised, punctate, characteristic sandpaper texture
Pastia’s lines (rash prominent in skin creases)
Strawberry tongue (starts as white, then desquamates)
Cervical lymphadenopathy
Pharyngitis
Forchheimer spots: petechiae on hard + soft palate
What investigation can be used for scarlet fever?
throat swab for culture of Group A streptococcus
When are anti-strepsolysin O antibody titres measured in scarlet fever?
NOT useful in acute infection
May aid in dx of post infectious complications e.g. rheumatic fever, glomerulonephritis
How should scarlet fever be managed?
Phenoxymethylpenicillin 10 days QDS
aka. Penicillin V
Can return to school 24h after commencing abx
Notify HPU
What is the most common complication of scarlet fever?
Otitis media
What can scarlet fever progress to?
Acute Rheumatic fever 1-5w after
Glomerulonephritis ~2w after
Upon which chromosome is the cAMP-dependent Cl channel defect in cystic fibrosis?
Chromosome 7
What is the incidence of cystic fibrosis in terms of number of live births?
1 in 2500
Recall 3 signs and symptoms of cystic fibrosis in children?
Meconium ileus
Recurring chest infections
Clubbing of fingers
When is cystic fibrosis screened for in children?
At birth: heel prick test
If cystic fibrosis screening is positive, what further tests can be done?
Immunoreactive trypsinogen
Sweat test (abnormally high NaCl)
Genetic tests
Recall the timeline of routine reviews in cystic fibrosis?
Weekly in 1st month
Every 4w in 1st year
Every 6-8w when 1-5y
Every 2-3m when 5-12yo
Then every 3-6m
What is the main method of monitoring for cystic fibrosis?
Spirometry
How frequent should physiotherapy be done for respiratory symptoms in CF?
twice a day
What is used for mucolytic therapy in cystic fibrosis?
1st line = rhDNase
2nd line = rhDNase + hypertonic saline
What is rhDNase?
Dornase alfa;
Recombinant human deoxyribonuclease
Name a CFTR modulator used in cystic fibrosis. Which patients is this used in?
Orkambi (lumcaftor + ivacaftor)
Those homozygous for delta FG08 mutation
What is the MOA of Orkambi?
Lumacaftor: “corrector”, increases trafficking of CFTR proteins to the outer cell membrane.
Ivacaftor: “potentiator”, increases opening of the defective channel, allowing chloride to pass through
How should recurrent infection be managed in cystic fibrosis?
Prophylactic abx from dx to 3y-6y: Flucloxacillin
Azithromycin for repeated infections
How should cystic fibrosis patients be nutritionally managed?
High calorie + high fat diet (150% of normal)
Fat-soluble vitamin supplementation
Pancreatic enzyme replacemet with every meal –> CREON
How can liver problems in cystic fibrosis be managed?
Ursodeoxycholic acid to help bile flow
What is laryngomalacia?
Congenital abnormality of larynx predisposing to supraglottic collapse during inspiration
What are the signs and symptoms of laryngomalacia?
Presents in first few weeks of life
High-pitched inspiratory stridor, worse on lying flat or on exertion
Normal cry
Give 5 signs of more severe laryngomalacia
Respiratory distress
Dyspnoea with intercostal / sternal recession
Feeding difficulties or episodes of suffocation/ cyanosis whilst feeding
Poor weight gain
Obstructive sleep apnoea
What investigation can be used for severe laryngomalacia?
flexible endoscopy (laryngoscopy) via the nose or mouth to view the larynx + laryngeal cartilages.
How should laryngomalacia be managed?
Majority (99%) self-resolve within 18-24m: reassure
If airway compromise/ feeding disrupted sufficiently to prevent normal growth: Endoscopic aryepiglottoplasty aka supraglottoplasty
What is a breath holding attack?
When child cries vigorously for <15s + then becomes silent
How should breath holding attack be managed?
Resolve spontaneously
What will be heard on auscultation in pneumonia?
Consolidation + coarse crackles
How should TB be investigated if there is exposure?
Manteaux test: if -ve excludes TB
If +ve –> IGRA test
If -ve –> prophylaxis (isoniazid)
If +ve –> tx
Recall the treatment of TB pneumonia
RIPE;
Rifampicin 6m
Isoniazid 6m
Pyrazinamide 2m
Ethanbutol 2m
How can pneumonia and bronchiolitis be differentiated clinically?
Bronchiolitis = fine crackles on auscultation
Pneumonia = coarse crackles
What is the most common cause of pneumonia in children?
Strep. pneumoniae
When should children with pneumonia be referred to hospital immediately? (6)
Persistent pO2 <92% on RA
Grunting, marked chest recession, or RR >60
Cyanosis (indicated by pale/mottled/ashen/blue skin, lips or tongue).
Auscultation: absent BS + dull percussion note raises possibility of pneumonia complicated by effusion
Child looks seriously unwell, does not wake, or if roused does not stay awake, or does not respond to normal social cues.
Temp >,38°C in a child aged ,<3 months
When should hospital admission be considered in pneumonia?
Temp >,39°C in a child aged 3–6 months.
Tachycardia (>160 bpm in <1y, >150 bpm in 1-2y, >140 bpm in 2-5y).
Inadequate oral fluid intake (50–75% of usual volume).
Pallor of skin, lips or tongue reported by parent or carer.
Abnormal response to social cues.
Waking only with prolonged stimulation.
Decreased activity.
Nasal flaring.
Clinical dehydration (reduced skin turgor +/or a CRT >3s, +/or dry mucous membranes, +/or reduced urine output).
How should pneumonia not requiring admission be managed?
Most can be managed at home
Give Abx as difficult to differentiate bacterial v viral
Paracetamol/ Ibuprofen as antipyretics
Adequate hydration
Seek medical advice if RR increases, dehydration or worsening fever
What is the antibiotic therapy for pneumonia in children?
1st line: Amoxicillin 5 days PO (Clarithromycin if allergic)
2: Add Macrolide e.g. Clarithromycin if is no response/ atypical organism suspected
If a/w influenza, co-amoxiclav
What is the gram status of pertussis?
-ve
What is the course of pertussis?
CATARRHAL phase: coryzal Sx ~1w
PAROXYSMAL phase: rapid, violent, + uncontrolled coughing fits (paroxysms) due to difficulty expelling thick mucus from the tracheo-bronchial tree. 1-6w
CONVALESCENT phase: gradual improvement of cough. 2-3w
Describe the cough in pertussis?
Short expiratory burst followed by an inspiratory gasp
Occur frequently at night/ after feeds
In infants: apnoea rather than a whoop
Give 3 symptoms and signs other than cough in pertussis
Post-tussive vomiting, may be severe enough to cause cyanosis
Subconjunctival haemorrhages
Anoxia leading to syncope + seizures
Is there a fever in pertussis?
Fever ABSENT or minimal
What investigations should be done in pertussis?
Nasal swab/ NPA culture (takes days)
PCR: B.pertussis DNA
Serology: antibodies
How should pertussis be managed?
Notify HPU
Decide whether to admit
<1m: clarithromycin
1y: azithromycin
How do you decide whether to admit in whooping cough?
If <6m or acutely unwell
(apnoea episodes, severe paroxysms, or cyanosis)
What is the other name for paediatric chronic lung disease?
Bronchopulmonary dysplasia
What would the CXR show in chronic lung disease?
Widespread opacification
How should chronic lung disease be managed?
If severe: artificial ventilation/CPAP/ low-flow nasal cannula
Short course low-dose CS
What is glue ear?
Collection of fluid within middle ear space w/o signs of acute inflammation
Common following AOM
What is the most common complication of scarlet fever?
Otitis media
Whilst awaiting admission for pneumonia what is the management?
Controlled supplemental O2 if SpO2 <92%
