Paediatric respiratory Flashcards
What are the signs of respiratory distress?
Raised RR
Intercostal and subcostal recessions
Use of accessory muscles
Nasal flaring
Head bobbing
Tracheal tugging
Cyanosis
Abnormal airway noises
What are the respiratory failure red flags?
Drowsiness
Lethargy
Cyanosis
Tachycardia
Laboured breathing
What is croup also known as?
Acute Laryngeotracheobronchitis
What was croup previously caused by and what did it lead to?
Diptheria and lead to epiglottitis
What is the cough in croup due to?
Upper airway infection causing oedema and mucosal inflammation in the larynx
When does croup tend to occur?
6 months-6 years. Peaks at 2-3 years.
At what time of year is croup most common?
Autumn and Spring
Is croup more common in boys or girls?
Boys
What is the cough like in croup?
Barking cough
What is the main causative pathogen of croup?
Parainfluenza virus
Apart from parainfluenza virus, what are the other causes of croup?
Influenza, adenovirus and RSV (Respiratory syncytial virus), enterovirus
What are the main symptoms of mild croup?
Occasional barking cough with no audible stridor, no recession, child eating and drinking as normal
What are the main symptoms of moderate croup?
Frequent barking cough with audible stridor at rest, suprasternal recession, child not agitated
What are the main symptoms of severe croup?
Frequent barking cough, prominent stridor, marked sternal recession, agitated and distressed child potentially with tachycardia.
What is the examination and history for croup?
1-4 days history of non-specific rhinorrhea, fever and barking cough
Worse at night
stridor
decreased bilateral air entry
tachypnoea
costal recession
Hoarse voice
low grade fever
What might you do for diagnosis and rule out DDx for croup?
FBC, CRP U+E
CXR to exclude foreign body
How long can symptoms of croup last?
48 hrs-1 week
What is the management for most children with croup?
Fluid and rest at home
What drug do you give to treat croup?
Single dose of oral dexamethasone 0.15mg (150 mcg/kg)or nebulised budesonide/prednisolone
How do you treat severe croup?
Oral dexamethasone, oxygen, nebulised budesonide/adrenline and adrenaline, intubation and ventilation if needed (in stepwise progression)
What are the complications of croup?
Otitis media
Dehydration due to reduced fluid intake
Superinfection: Pneumonia
What is acute epiglottitis?
Acute upper airway obstruction due to swelling of the epiglottis and surrounding tissue. it is a medical emergency!
What pathogen causes acute epiglottitis?
Haemophilis influenzae B
What sounds will a child with acute epiglottitis be making?
Soft inspiratory stridor with no cough
Muffled voice
How might a child with acute epiglottitis present apart from sounds
Unable to speak or swallow (drooling).
Sitting upright with open mouth to optimise airway. (tripod position) Sore throat in septic looking child
high fever
scared and quiet child
What should you not do if acute epiglottitis is suspected?
Do not examine throat
What will a lateral x ray of the neck show?
Characteristic thumb sign
What drug is given to children with acute epiglottitis?
IV cefuroxime
And steroids (dexamethosone)
What is a common complication of apiglottitis?
Epiglottic abscess
What has reduced the incidence of acute epiglottitis?
Introduction of the HiB vaccine
What might an unvaccinated child presenting with a fever, sore throat and difficulty swallowing that is sitting forward and drooling have?
Epiglottitis
What is whooping cough also known as?
Pertussis
What is whooping cough?
Bacterial URTI
What pathogen causes Whooping cough?
Bordetella Pertussis (highly contagious)- gram negative bacillus
When are vaccinations given against whooping cough?
2,3,4 months, booster at 3 years 4 months
What are the sounds of whooping cough?
Inspiratory whoop (forced inhalation against a closed glottis)
When is the cough in whooping cough worse?
At night
What can the cough in whooping cough causes?
vomiting, cyanosis, epistaxis and subconjunctival haemorrhages, pneumothorax.
How long does the paroxysmal phase of Whooping cough last?
3-6 weeks but can last months
What is the clinical presentation of whooping cough?
Catarrhal phase: lasts 1-2 weeks: coryzal symptoms
Paroxysmal phase: occurs weeo 3-6: characteristic “inspiratory whoop”
Spasmodic coughing episodes
low grade fever
Sore throat
Convalescent phase: downgrade of cough lasting up to 3 months
How do you investigate whooping cough?
Per nasal swab culture
(FBC and antibody test)
What is the treatment for whooping cough lasting less than a month?
Azithromycin 5 days
What is the treatment for whooping cough lasting more than a month?
Azithromycin/Erythromycin 7 days
What are the complications of whooping cough?
Seizures
Pneumonia
Bronchiectasis
Encephalopathy
Otitis media
What is the most common LRTI in children?
Bronchiolitis
What is the most common respiratory illness in children?
Bronchiolitis
What is bronchiolitis?
Viral infection of the bronchioles (inflammation)
What ages are most common for bronchiolitis?
1-9 months- rarely up to two years old (children who are ex-premature with chronic lung disease)
When does bronchiolitis peak?
Winter and Spring
What pathogen mainly causes bronchiolitis?
RSV (very infectious)( Respiratory Syncytial Virus)
What other 2 pathogens can cause bronchiolitis?
parainflueza virus, human metapneumovirus
What are the risk factors for bronchiolitis?
Breastfeeding<2 months
Smoke exposure
Older siblings who attend nursery/school
Chronic lung disease of prematurity
What are the main symptoms of bronchiolitis?
Symptom onset in 2-5 days Coryzal, breathlessness, poor feeding, Fine end inspiratory crackles, high pitched wheeze, cyanosis (on feeding), cough. signs of respiratory distress, tachypnoea, dyspnoea, mild fever, apnoeas
What is the typical course of RSV?
coryzal symptoms and half then get better. Other half have chets sympotms over days1-2, worst symptoms 3-4 and usually last 7-10 days, fully recover in 2-3 weeks.
What are infants who have bronchiolitis more likely to have in childhood?
Viral induced wheeze
What are the abnormal airway noises heard in bronchiolitis?
Wheezing (on expiration), grunting and stridor
What is wheezing?
whistling sound heard on expiration caused by narrowed airways
What is grunting?
exhaling sound with the glottis partially closed to increase positive end-expiratory pressure
What is stridor?
high pitched inspiratory noise caused by obstruction of the upper airway
What 2 investigations can you do for bronchiolitis?
PCR analysis of nasal secretions for RSV
FBC, Urine, Blood gas if severely unwell
CXR- not usually but shows hyperinflation, air trapping and flattened diaphragm
What might you see on a CXR in bronchiolitis?
Hyperinflation
What would suggest urgent hospital admission in bronchiolitis?
Apnoea
Resp rate >70
Central cyanosis
SpO2<92 %
What would suggest non-urgent admission in bronchiolitis?
Resp rate>60
Clinical dehydration
What drug can be used to prevent bronchiolitis?
Palivizumab
What kind of drug is palivizumab?
Monoclonal antibody
Which children may get palivizumab to prevent bronchiolitis?
CF, immunocompromised, congenital heart disease, Downs
What is pneumonia?
Infection of the lower respiratory tract and lung parenchyma which leads to consolidation
What are the characteristic chest sounds of pneumonia?
Bronchial breath sounds, focal coarse crackles, dullness to percussion
What general cause of pneumonia is most common in infants?
Viral
What general cause of pneumonia is more common in older children?
Bacterial
Which pneumonia is more common in winter; viral or bacterial?
Viral
What is the most common bacterial cause of pneumonia?
Streptococcus pneumonia
What bacteria causes pneumonia in pre-vaccinated infants during birth?
Group B strep
If staphylococcus aureus causes pneumonia, what might be seen on the chest x ray?
Pneumoceles and consolidation in multiple lobes
Apart from streptococcus pneumonia, Group B strep and staphylococcus aureus, what can cause paediatric pneumonia?
Group A strep
What is the most common viral cause of paediatric pneumonia?
Respiratory Syncytial virus (RSV)
Apart from RSV, what other viral causes are there of paediatric pneumonia?
Parainfluenza virus and influenza virus
What are the causes of pneumonia in neonates and which is most common (put 1st)
Group B strep
E.coli
Klebsiella
Staph aureus
What is the main cause of pneumonia in infants?
Strep pneumoniae
What are the causes of pneumonia in neonates and which is most common (put 1st)
Strep pneumoniae
Staph aureus
Group A strep
Mycoplasma pnuemoniae
What is the clinical presentation of pneumonia?
Fever
SOB
Lethargy
Signs of respiratory distress
Auscultation signs: dullness to percuss, crackles, decreased breath sounds, bronchial breathing
Wheeze and hyperinflation more typical of viral infection
What 4 investigations should you do for paediatric pneumonia?
CXR, Sputum cultures, blood cultures and ABG
What is the medication management of paediatric pneumonia?
Amoxicillin and a macrolide
Why is a macrolide adding to treatment of paediatric pneumonia?
To cover atypical pneumonia
Give three examples of macrolides
Erythromycin, clarithromycin and azithromycin
What is the medication treatment for paediatric pneumonia when the patient has a penicillin allergy?
Macrolides as monotherapy
What is the medical treatment of neonates with pneumonia?
Broad spectrum IV Abx
What is the medical management of infants with pneumonia?
Amoxicillin/ co-amoxiclav
What is the medical management of over 5s with pneumonia?
Amoxicllin/Erythromycin
What are the complications of pneumonia?
Risk of parapneumonic collapse and empyema
If a patient is getting recurrent LRTIs, what conditions do you want to check for?
Reflux, aspiration, neurological disease, heart disease, asthma, CF, primary ciliary dyskinesia and immune deficiency.
What immunoglobulin do you test to check for immunoglobulin class-switch recombination therapy?
G
What is immunoglobulin class-switch recombination therapy?
Where a patient is unable to convert IgM to IgG and therefore cannot form long term immunity to that bug.
A patient comes in with cough, high fever, tachypnoea, tachycardia, increased work of breathing, lethargy and delirium. What could this be?
Pneumonia
A patient comes in with increased work of breathing, barking cough, hoarse voice, stridor and a low grade fever. What could this be?
Croup
A patient comes in with progressively worsening SOB, signs of respiratory distress, tachypnoea and expiratory wheeze. What could this most likely be?
Acute exacerbation of asthma
A patient comes in with episodic symptoms of dry cough with wheeze and SOB. Has diurnal variability with widespread polyphonic wheeze. What could this most likely be?
Chronic Asthma
A patient comes in with coryzal symptoms, signs of respiratory distress, dyspnoea, tahcypnoea, mild fever and wheeze and crackles on ascultation. What could this most likely be?
Bronchiolitis
An unvaccinated child comes in with a sore throat and stridor, drooling, tripod positioning, high fever and a muffled voice. What could this most likely be?
Epiglottitis
What can asthma be triggered by?
Infection, exercise or cold weather
What is the most chronic condition in children?
Asthma
What is asthma?
Reversible paroxysmal constriction of the airways with inflammatory exudate and followed by airway remodelling
Do people with asthma have an inspiratory wheeze or expiratory wheeze?
Expiratory wheeze
What are the levels of severity of acute asthma?
Moderate, Severe and life threatening
If a patient has peak flow > 50% predicted and normal speech, how severe is the acute episode of asthma?
Moderate
If a patient has a peak flow < 50% predicted and is unable to complete sentences in 1 breath, how severe is the acute episode of asthma?
Severe
What percentage of predicted peak flow rate is considered to be life threatening?
<33%
What RR in a child aged 3 is considered to be severe in asthma?
> 40
What RR in a child aged 7 is considered to be severe in asthma?
> 30
What HR in a child aged 4 is considered to be severe in asthma?
> 140
What HR in a child aged 8 is considered to be severe in asthma?
> 125
What is the aetiology of asthma?
Genetic
Prematurity
Low birth weight
Parental smoking
Viral bronchiolitis in early life
Cold air
Allergen exposure
What are the clinical presentations of asthma?
Episodic wheeze which is infrequent
Dry cough often worse at night
SOB
Wheeze
Reduced peak flow
What type of bronchodilator is salbutamol?
Beta-2 agonist
What type of bronchodilator is ipratropium bromide?
Anti-muscarinic
What bronchodilators can you give in an acute asthma attack?
Salbutamol, ipratropium bromide, IV magnesium sulphate, IV aminophylline
What are the steps for a moderate/severe asthma attack?
- Salbutamol inhaler
- nebuliser with salbutamol/ipratropium bromide
- oral prednisolone
- IV hydrocortisone
- IV magnesium sulphate
- IV salbutamol
- IV aminophylline
What side effects can salbutamol causes?
Tachycardia and Tremor
What are the 4 investigations for asthma?
Spirometry with reversibility testing- highly suggestive of asthma
Direct bronchial challenge test with histamine or methacholine
Fractional exhaled nitric oxide- ENO levels of nitric oxide correlate to inflammation
Peak flow variability- FEV1 is significantly reduced, FVC normal, FEV1:FVC may be <70 % if poorly controlled
What is the first step for the management of all children with asthma?
- short-acting beta 2 agonist inhaler (salbutamol)
What is the second step for the management of children under 5 with asthma?
SABA + trial ICS (belclomethasone)
What is the second step of the management of children with asthma?
ICS- Beclomethasone
What is the third and fourth step in the management of children over 5 with asthma?
- Long-acting beta 2 agonist inhaler (salmeterol)
- Titrate up corticosteroid and consider adding oral leukotriene receptor antagonist ( montelukast) or oral theophylline
Is cystic fibrosis autosomal dominant or recessive?
Recessive
What glands does cystic fibrosis affect?
Mucous glands
What is cystic fibrosis caused by?
A genetic mutation on the cystic fibrosis transmembrane conductions regulatory gene on chromosome 7
What is the most common variant of cystic fibrosis mutations?
Delta-F508
What does the delta-F508 gene code for?
cellular channels particularly chloride channels
What percentage of people are carriers of CF?
1 in 25
What percentage of children have CF?
1 in 2500
What are the three main consequences of CF?
Thick pancreatic and biliary secretions
Low volume thick airway secretions
Congenital bilateral absence of the vas deferens
What is the test at birth that screens for CF?
Newborn bloodspot test
What is often the first sign of CF?
Meconium Ileus
What are the common presentation signs of CF?
Chronic cough, recurrent RTIs, steatorrhoea, failure to thrive, abdominal pain and bloating
What signs might a child show on their hands if they have CF?
clubbing
What are the causes of clubbing in children?
Hereditary, Infective endocarditis, TB, liver cirrhosis, cyanotic heart disease, CF, IBD
What is the gold standard test for diagnosing CF?
Sweat test
How do you test for CF during pregnancy?
Amniocentesis or chronic villous sampling
What common bacteria is often resistant to abx and can cause morbidity and mortality in CF?
Paseudomonas aeruginosa
How do you prevent staphylococcus aureus infection in CF patients?
Prophylactic flucloxacillin
What medical treatment can you give for patients with CF?
Prophylactic flucloxacillin and CREON tablets
What is viral induced wheeze?
Episodic wheeze- a symptom of viral URTI and symptom free between events.
In what age does viral wheeze tend to present?
Before 3 years old
What is the management of viral induced wheeze?
SABA inhaler via spacer max 10 puffs/4 hourly
LTRA and ICS via spacer
Who does respiratory distress syndrome affect?
premature neonates, before the lungs start producing adequate surfactant, common in below 32 week babies.
What is the pathophysiology of respiratory distress syndrome
Inadequate surfactant leads to high surface tension within alveoli leading to atelectasis (lung collapse) as it is more difficult for the alveoli and the lungs to expand leading to inadequate gaseous exchange and hypoxia, hypercapnia and respiratory ditress.
What is the management of respiratory distress syndrome?
Dexamethasone is given to mothers with suspected or confirmed preterm labour to increase production of surfactant and reduce incidence of respiratory distress syndrome
Intubation and ventilation may be needed
Endotracheal surfactant (artificial) delivered into the lungs via an endotracheal tube
CPAP
Supplementary oxygen to maintain sats 91-95%
Short term complications of respiratory distress syndrome?
Pneumothorax
Infection
Apnoea
Intraventricular haemorrhage
Pulmonary Haemorrhage
Necrotising Enterocolitis
Long term complications of respiratory distress syndrome?
Chronic lung disease of prematurity
Retinopathy of prematurity
Neurological, hearing and visual impairment
What is bronchopulmonary dysplasia?
Infants who still require oxygen at a postmenstrual age of 36 weeks are described as having BPD.
What is the pathophysiology of BPD?
The lung damage comes from pressure and volume trauma of artificial ventilation, oxygen toxicity and infection
What is the choice of investigation in BPD?
CXR
What does a CXR show in BPD?
Widespread areas of opacification and sometimes cystic changes, fibrosis and even lung collapse
What is the management of BPD?
Infants are weaned onto CPAP and potentially corticosteroids however there is risk of neurodevelopment with these
What are the major complications of BPD?
Intercurrent infection leading to death or pulmonary hypertension
