Paediatric - Respiratory Flashcards
AIR SOUNDS
What is a wheeze
Polyphonic expiratory noise originating from lower airways
AIR SOUNDS
What conditions present with a wheeze
VIW Asthma CF Bronchiolitis Pneumonia Foreign body
AIR SOUNDS
What is stridor
high pitched monophonic inspiratory noise
originates from turbulent flow through partially obstructed airway
AIR SOUNDS
what conditions present with stridor
foreign body croup acute epiglottitis laryngomalacia bacterial tracheitis anaphylaxis
BRONCHIOLITIS
What is bronchiolitis
Infection and inflammation of bronchioles
BRONCHIOLITIS
When does bronchiolitis commonly present
Winter
BRONCHIOLITIS
What age is bronchiolitis common in
< 1 year
Peak at 6m
BRONCHIOLITIS
Name 3 causes of bronchiolitis
RSV
Parainfluenza
adenovirus
BRONCHIOLITIS
Name 4 risk factors for bronchiolitis infection
passive smoking prematurity low birth weight Immunocompromised - CF Chronic lung or hear disease Downs syndrome
BRONCHIOLITIS
How does bronchiolitis present - sx
Coryzal symptoms - rhinorrhoea - sneezing - dry cough - mild fever wheeze dyspnoea poor feeding
BRONCHIOLITIS
What are the signs of bronchiolitis
signs of respiratory distress fine end inspiratory crackles - Widespread Hyperinflation wheeze cough cyanosis pallor tachycardia
BRONCHIOLITIS
What are the Ix for bronchiolitis
1st line - Pulse oximetry
2nd line - PCR analysis of nasal secretions
3rd line - CXR
BRONCHIOLITIS
What is the management of bronchiolitis
Feeding support - NG tubes
Supportive
- Humidified O2
- Fluids
BRONCHIOLITIS
What presentations warrant admission for bronchiolitis
< 3m Pre-existing conditions feeding < 50% hx of apnoea signs of resp distress cyanosis Sats < 94%
BRONCHIOLITIS
What is the prevention for bronchiolitis and what group of people are eligible for it
Palivizumab - MAB that targets RSV
Monthly vaccinations for:
- CF
- Premature
- Chronic lung disease
- Immunocompromised
- CHD
PNEUMONIA
Name 4 causes of pneumonia
Bacterial - older children
- Strep pneumonia
- Group B strep
- S.aureus
- Mycoplasma pneumonia
- Pneumococcus
Viruses - < 2 years old
- RSV
- H.Influnzae
- Influenzae
PNEUMONIA
Which pathogen commonly causes pneumonia in neonates
Group B strep
PNEUMONIA
What does S.aureus specifically present with
CXR - Pneumatoceles and consolidation in multiple lobes
Pneumatoceles - round air filled cavities
PNEUMONIA
What does Mycoplasma pneumonia specifically present with
Erythema multiforme - red circular rash
PNEUMONIA
Describe the presentation of pneumonia - symptoms
cough High fever - > 38.5 poor feeding chest recessions lethargy
PNEUMONIA
Describe the presentation of pneumonia - signs
tachycardia tachypnoea Respiratory distress hypoxia Pleuritic chest pain auscultation - bronchial breath sounds - focal end inspiratory crackles Percussion - dullness to percussion
PNEUMONIA
What investigations are used for a patient with suspected pneumonia
Sputum cultures / throat swabs for bacterial culture and PCR
- Establish organisms and guide treatment
Capillary blood gas analysis
- metabolic acidosis
- blood lactate
Blood cultures - Sepsis
CXR
PNEUMONIA
What is the management of pneumonia
Supportive
- O2
- Analgesia
- IV fluids
Antibiotics Neonates - broad spectrum Abx Children 1st line - Oral amoxicillin 2nd line - Erythromycin
PNEUMONIA
What investigation should be performed for a child with pneumonia who gets unwell after a period of improvement
CXR - Check for empyema
PNEUMONIA
What investigations should be performed for a child with recurrent LRTI and what are they looking for
FBC - WCC levels CXR - Structural abnormality Serum IgG - Antibody levels IgG - Test immunoglobulin G to previous vaccines Sweat test - CF
VIW
What is a VIW and what does it increase the risk of
Acute wheezy illness caused by viral infection
Children have a higher risk of asthma development later in life
VIW
What are the risk factors
maternal smoking
prematurity
Family hx of wheezing
VIW
What is the presentation of VIW
Evidence of viral illness - fever - cough - coryzal sx for 1 - 2 days S.O.B Signs of respiratory distress Expiratory wheeze throughout chest
VIW
What is the pathophysiology of VIW
children have small airways
virus - RSV or rhinovirus causes inflammation and oedema reducing airway size
smooth muscle constriction occurs due to swelling
air flow through restricted airways causes a wheeze
restricted ventilation causes resp distress
VIW
Name 3 typical features of VIW that differentiates it from asthma
- presenting before 3 years of age
- no atopic history
- only occurs during viral infections
- no interval sx
- typically resolves by 5 years old
ASTHMA
Name 4 asthma triggers
cold weather strong emotions viruses bacterial infections exercise dust Drugs - NSAIDs / Beta blockers
ASTHMA
What is the definition of asthma
Chronic inflammation of airways that causes episodic exacerbations of bronchoconstriction due to hypersensitivity
ASTHMA
Name 3 risk factors for asthma development
Hx of atopy Allergens - dust / grass / pollen - hayfever family hx smoking exposure obesity pollution URTI
ASTHMA
What is the atopic triad
asthma
allergic rhinitis
eczema
ASTHMA
What is the pathophysiology of asthma
Bronchial inflammation
- oedema
- mucus hypersecretion
Airway hyper-responsiveness
- Mass histamine release
- Hypersensitivity
Reversible airflow limitation
- Airway obstruction due to inflammation
- Bronchospasm and chronic bronchoconstriction
symptoms
ASTHMA
What are the distinguishing features of asthma
diurnal variation
sx have non viral triggers
interval sx between exacerbations
ASTHMA
What are the sx and signs of asthma
sx
- wheeze
- dry cough
- S.O.B
- Disturbed sleep
signs
- exercise tolerance
- bilateral polyphonic wheeze
- typical triggers
ASTHMA
What are the investigations for asthma
- hx and investigations
- skin prick for common allergens
- Serial PEFR if > 5 years old
readings at morning and at night - FeNO > 35ppb
- Spirometry
ASTHMA
What are the spirometry readings for an asthmatic patient
FEV1:FVC < 70%
FEV1 improves by 15% after bronchodilator
ASTHMA - drugs
What is used a preventer therapy
- what is the MOA
- What are the A/E
ICS
Decreases airway inflammation to decrease sx
A/E
- Impaired growth
- adrenal suppression
- altered bone metabolism / osteoporosis
- pepti ulcers
ASTHMA - drugs
What is adrenal suppression due to ICS usage caused by
decreased cortisol
ASTHMA - drugs
What is used as a reliver therapy
Bronchodilators
Anticholinergics - Ipratropium bromide
ASTHMA - drugs
What techniques are used to minimise the adverse effects of ICS
Lowest possible dose
spacer usage
rinsing mouth after medication delivery
ASTHMA
What is the management of asthma in < 5 years old
SABA
SABA + low dose ICS
- If uncontrolled on low dose ICS
SABA + ICS + LTRA
ASTHMA
What is the management of asthma in > 5 years old
SABA
SABA + ICS
- Recheck adherence
- inhaler technique
- elimination of triggers
SABA + ICS + LABA
- good response –> continue
- poor response to LABA (1)
- If no response to LABA (2)
- SABA + Titrate ICS dose + LABA
- Stop LABA and add LTRA
- Refer to specialist
- Oral LTRA OR Oral theophylline
ACUTE ASTHMA
What are the features of moderate acute asthma
peak flow > 50%
normal speech
ACUTE ASTHMA
What are the features of severe asthma
peak flow < 33%
sats < 92%
unable to complete sentences in one breath
signs of resp distress
ACUTE ASTHMA
What are the features of life-threatening asthma
33 / 92 / CHEST
peak flow < 33%
sats < 92%
cyanosis
hypotension
exhaustion and poor effort
silent chest
tachycardia
ACUTE ASTHMA
What are the side effects of salbutamol
tachycardia
hypokalaemia
tremor
ACUTE ASTHMA
What is required when giving IV Salbutamol
cardiac monitoring
ACUTE ASTHMA
What is the management of acute asthma
OSHIT ME
O - High flow O2
S - Nebulised salbutamol
- every 15 mins
- 1 puff every 30-60s up to 10 puffs
H - IV Hydrocortisone / oral prednisolone
I - Ipratropium bromide
T - IV Theophylline
M - IV magnesium sulphate
E - Escalate
ACUTE ASTHMA
When can a patient be discharged following an acute asthma attack
PEFR > 75% constantly
asthma action plan
safety net information
1 week GP follow up
ACUTE ASTHMA
What are 4 common reasons response to asthma management is not occurring
adherence bad disease choice of drugs / devices diagnosis environment
ASTHMA
What is the presentation of chronic asthma
barrel chest
hyperinflation
- increased resonance on percussion
Harrison’s sulci
ASTHMA
What are the adverse effects of oral steroids
HTN Hyperglycaemia Adrenal suppression weight gain poor growth
ASTHMA
What are the adverse effects of Montelukast
nightmares
coryzal sx
diarrhoea
fever
CYSTIC FIBROSIS
What is CF
AR disorder due to mutation in CFTR gene on chromosome 7
CYSTIC FIBROSIS
What is the pathophysiology of CF
Decreased Cl- secretion
Increased Na+ absorption
leads to increased H20 absorption into cells with thickened secretions
Mucous stasis and dehydrated airway surface liquid predisposes to infection
CYSTIC FIBROSIS
What is the carrier rate for CF
1 in 25
CYSTIC FIBROSIS What is the presentation of CF for each of these systems: - Resp - GI - GU
Resp - chronic cough with thick sputum - sinusitis - nasal polyps - bronchiectasis Due to recurrent infection - breathlessness - haemoptysis - recurrent chest infections
GI
- Cholesterol gallstones
- meconium ileus
- steatorrhea
- Pancreatitis
- failure to thrive
GU
- pubertal delay
- Secondary amenorrhoea
- Infertility
CYSTIC FIBROSIS
How does meconium ileus present
abdominal distension
vomiting
meconium is
- thick
- sticky
CYSTIC FIBROSIS
How does CF present in infancy
faltering growth malabsorption steatorrhea prolonged neonatal jaundice recurrent infections - pseudomonas
CYSTIC FIBROSIS
How does CF present in young child
bronchiectasis
rectal prolapse
nasal polyps
sinusitis
CYSTIC FIBROSIS
How does CF present in adolescents
diabetes cirrhosis portal HTN Infertility distal intestinal obstruction
CYSTIC FIBROSIS
What ix are required for CF
1st line - Guthrie card
2nd line - Sweat test
DIAGNOSTIC
3rd line - Genetic testing
other:
- CXR
- Faecal elastase
- Lung function
CYSTIC FIBROSIS
What is the Guthrie screening test looking for
Immunoreactive trypsinogen test
conducted between days 5 - 9
CYSTIC FIBROSIS
What does the sweat test measure
measures chloride ions
> 60 mmol/L - diagnostic
CYSTIC FIBROSIS
What is the general management of CF
Stop smoking
vaccinations
CYSTIC FIBROSIS
What is the management of pulmonary disease in CF
Airway clearance techniques to reduce incidence of infections
chest physiotherapy
mucoactive agents
- dornase alpha
- hypertonic NaCl
amiloride
lung transplant
- FCV < 30%
CYSTIC FIBROSIS
What is the MOA of amiloride
Inhibits Na transport
CYSTIC FIBROSIS
How are infections managed in CF
Prophylactic flucloxacillin
- reduced risk of bacterial infection (s.aureus)
vaccinations
- pneumococcal
- flu
- varicella
CYSTIC FIBROSIS What is the extrapulmonary management of CF - Nutrition - fertility - hepatobiliary
Nutritional assesment - increase portion size - high calorie diet - supplements - PERT CREON tablets help patients with pancreatic insufficiency to digest fats (replace lipase)
testicular sperm extraction
liver transplant
CYSTIC FIBROSIS
What microbial colonisers are common for CF in childhood
staph aureus
Haemophilus influenza
Pseudomonas aeruginosa
CYSTIC FIBROSIS
How is pseudomonas aeruginosa managed
avoid contact with other CF patients
- hard to clear once colonised
- resistant to multiple Abx
Nebulised Abx - Tobramycin
Oral ciprofloxacin
CYSTIC FIBROSIS
What is the main differential for CF?
How does it present
Primary ciliary dyskinesia
Presentations - URTI and LRTI bronchiectasis productive cough nasal discharge chronic ear infections dextrocardia
HYPERSENSITIVITY
What is type 1 hypersensitivity reaction and give an example
Allergic - IgE mediated
bee sting
medications
HYPERSENSITIVITY
What is type 2 hypersensitivity reaction and give an example
Cytotoxic - Antibody mediated
haemolytic reactions
good pastures syndrome
HYPERSENSITIVITY
What is type 3 hypersensitivity reaction and give an example
Immune complex
hypersensitivity pneumonitis
SLE
serum sickness
HYPERSENSITIVITY
What is type 4 hypersensitivity reaction and give an example
Delayed - T cell mediated
SJS
HYPERSENSITIVITY
How does anaphylaxis present
urticaria itching angio-oedema S.O.B wheeze stridor tachycardia collapse
HYPERSENSITIVITY
What is the management of anaphylaxis
ABCDE
IM Adrenaline
repeat after 5 mins
other:
Fluid challenge and O2
Antihistamines
- Chlorphenamine
- Cetirizine
steroids
- IV Hydrocortisone
HYPERSENSITIVITY
What is the follow on management of anaphylaxis
observation for 6 - 12 hours
- Biphasic reactions
education for family
HYPERSENSITIVITY
What investigation can be used to determine if a true anaphylactic attack occurred
Serum mast cell tryptase
- elevated for 12hrs following event
CROUP
What is the other name for croup
Laryngotracheobronchitis
CROUP
When does croup commonly present
autumn and spring
CROUP
What are the causes of croup
Parainfluenza 1 and 3
adenovirus
RSV
CROUP
What is the presentation of croup
Preceeding
- low grade fever
- coryzal sx
At time:
- barking cough - worse at night
- Coughing in clusters
- hoarse voice
- stridor
- breathlessness
- poor feeding
CROUP
What are the investigations for croup
Bedside - O2 stats / HR / RR
CXR
- Steeple sign
Minimal examination required
CROUP
What is contraindicated in a child presenting with croup
Throat examination - leads to laryngospasms
CROUP
what is the management of croup
Acronym - ODA
Self-limiting
Supportive
- fluids
- rest
- oxygen
Oral dexamethasone / prednisolone
- 1 dose –> 150mcg/kg
- Can be repeated 12hrs later
Nebulised adrenaline
- If severe: signs of resp distress
ACUTE EPIGLOTTITIS
What is acute epiglottitis
Life threatening emergency
inflammation and swelling of epiglottis due to infection
common in aged 2 - 7
ACUTE EPIGLOTTITIS
Why is acute epiglottitis rare
Due to child immunisation
suspect in an unvaccinated infant
ACUTE EPIGLOTTITIS
What is the cause of acute epiglottitis
Haemophilius influenza B
ACUTE EPIGLOTTITIS
What is the presentation of acute epiglottitis
4 D'S Dysphagia Drooling - difficulty swallowing Distress Dysphonia
HIGH FEVER
Septic looking child
ACUTE EPIGLOTTITIS
What signs are present in a child with acute epiglottitis
stridor - soft inspiratory tripod position - sitting upright and leaning forward muffled voice septic looking absent cough
ACUTE EPIGLOTTITIS
What investigations are required for a child with acute epiglottitis
Direct visualisation - Laryngoscopy
- Beefy red oedematous epiglottis
X-Ray
- thumb sign
ACUTE EPIGLOTTITIS
What is the management of acute epiglottitis
Keep child calm
do not examine throat
1st line - Secure airway
2nd line - cultures
ACUTE EPIGLOTTITIS
what is the pharmacological management of acute epiglottitis
IV Abx - Ceftriaxine
steroids - Dexamethasona
ACUTE EPIGLOTTITIS
what should be given to unvaccinated close contacts
Rifampicin
ACUTE EPIGLOTTITIS
How do you differentiate croup from acute epiglottitis
AE
- faster onset
- no coryzal sx
- no cough
- can’t drink
- drooling
- toxic appearance
- HIGH FEVER
- Whispering stridor
- fullfed voice
croup
- slow onset
- coryzal sx
- barking cough
- low grade fever
- hoarse voice
- harsh stridor only when upset
BACTERIAL TRACHEITIS
What is bacterial tracheitis and what causes it
uncommon condition similar to severe epiglottitis
occurs 6m to 14 years old
causes
- S.aureus
- strep A
WHOOPING COUGH
what is whooping cough
Pertussis - NOTIFIABLE DISEASE
URTI occurring before babies first vaccinations (<4m)
100 day cough
WHOOPING COUGH
What infection commonly co-exists with whooping cough
Bronchiolitis
WHOOPING COUGH
What causes whooping cough
Pertussius bordatella
Gram -ve cocobacilli
WHOOPING COUGH
How does whooping cough present
1st
- mild coryzal sx
- low grade fever
- dry cough
- conjunctivitis
- nasal discharge
- sore throat
2nd - coughing fits
- Proxysmal cough (3-6wks)
- dry hacking cough
- child can turn blue
- worse at night or feeds
- loud inspiratory woop
Apnoea in infants
WHOOPING COUGH
What can occur due to coughing fits in whooping cough
sunconjunctival haemorrhage syncope of seizures fainting vomiting pneumothorax nose bleed
WHOOPING COUGH
What investigations are required in a child presenting with whooping cough
within 2-3 weeks
Nasopharyngeal swabs
- PCR testing
- bacterial culture
cough > 2 weeks
- Anti-pertussis toxin IgG
- Looked for in oral fluid or blood
WHOOPING COUGH
What is the management of whooping cough
supportive care
Abx - reduce infectivity period and useful if given within first 3 weeks
Infants < 1m –> Azithromycin / Clarithromycin
infants > 1m –> Macrolides / Trimethoprim
Pregnant (20-32wks) –> Erythromycin
WHOOPING COUGH
What prophylaxis is given to close contacts
Erythromycin
