Paediatric Respiratory Flashcards
What are signs of respiratory distress in children?
Raised RR
Use of accessory muscles
Intercostal/subcostal recessions
Nasal flaring
Head bobbing
Tracheal tugging
What are causes of stridor? (mnemonic)
Croup - stridor + barking cough
Acute epiglottitis - stridor, drooling, acutely unwell
Inhaled foreign body - choking
Laryngomalacia
What is the cause of bronchiolitis?
RSV (Respiratory syncytial virus)
How does bronchiolitis present?
Coryzal symptoms - runny nose, watery eyes, sneezing
Dry cough
Mild fever
Wheeze
Dyspnoea
Tachypnoea
When should a child with bronchiolitis be admitted?
Immediate referral (999 Ambulance):
- Severe respiratory distress: RR > 70, deep recessions, head bopping, grunting
- Apnoea
- child looks unwell to HCP
- Oxygen sats <92%
Consider referral:
- RR>60
- difficulty with breastfeeding or inadequate oral fluid intake (50–75% of usual volume, consider referral)
- Clinical dehydration
Under 3 months
Pre-existing health condition
central cyanosis
How is bronchiolitis managed?
Supportive
Supplementary oxygen if required
Which children are at risk of severe bronchiolitis?
Bronchopulmonary dysplasia
Congenital heart disease
Cystic fibrosis
How to differentiate Asthma vs. Viral induced wheeze?
Viral induced wheeze..
Features of viral illness e.g. coryza, fever
Presents prior to 3 years
No atopy history
Only occurs during infections
How is viral induced wheeze managed?
1st line = Salbutamol
What is the stepwise management of Asthma in under 5’s?
- SABA (e.g. Salbutamol)
- Low dose ICS or Montelukast
- Add other option
- Refer to specialist
What is the most common bacterial and viral cause of pneumonia in children?
Strep pneumoniae
RSV
How does pneumonia present?
Productive cough
Fever
Tachypnoea
Tachycardia
Hypotension
How is pneumonia managed in children?
1st line = Amoxicillin
2nd line = Macrolide (Clarithromycin <1month, >1 month Erythromycin 7-10days, Azithromycin 3 days)
2nd line = co-amoxiclav/Co-trimoxazole (if macrolides are contra-indicated; not in pregnant adults ie increased risk of genital malformations or babies <6w)
What is croup? What is the most common causative organism?
Upper respiratory tract infection which causes laryngeal oedema, leading to stridor
Most common = Parainfluenza virus
How does croup present?
Stridor
Barking cough
Low grade fever
Coryza
Increased work of breathing
When should a child with croup be admitted?
Stridor at rest
Recessions
Any significant distress
Tachycardia
How is croup treated?
Single dose oral (0.15mg/kg/hour) Dexamethasone
-which can be repeated if required after 12 hours.
Oxygen if required
What organism causes epiglottitis?
Haemophilus influenza type B
How does epiglottitis present?
Acute onset
Sore throat
Stridor
Tripod position
High fever
Drooling of saliva
What is seen on neck XR in epiglottitis?
Thumb sign
How is epiglottitis managed?
IV Ceftriaxone
Oxygen
What is Laryngomalacia?
Soft larynx
Larynx causes partial airway obstruction
Causes chronic stridor on inhalation
How is Laryngomalacia managed?
Problem usually resolves as the larynx matures and grows
What is whooping cough?
URTI caused by Bordatella pertussis
How does whooping cough present?
Sats with coryza symptoms
Then - Severe coughing fits, worse at night
Inspiratory whoop at end of coughing fit
May be vomiting
May be apnoea attacks
How is whooping cough treated?
Supportive care
In first 21 days - can use oral macrolide
What do infants with bronchopulmonary dysplasia receive to reduce infections?
Monthly injection of Palivizumab
What type of inheritance pattern does cystic fibrosis have?
Autosomal recessive
What are the first signs of CF?
Meconium ileus
Prolonged jaundice
What are features of CF?
Chronic cough
Thick sputum
Recurrent infections
Greasy stools
Finger clubbing
Pancreatic enzyme deficiency
What are common colonisers in CF?
Staph aureus
Pseudomonas
What is the gold standard diagnostic investigation for CF? What does it show?
Sweat test showing increased chloride levels
How is CF managed?
Chest physio
High calorie idet
Pancreatic enzyme supplementation
Prophylactic flucloxacilin
What are complications of CF?
Diabetes
Delayed puberty
Male infertility
Nasal polyps
Why are males with CF often infertile?
Absence of the vas deferens
What is primary ciliary dyskinesia?
Autosomal recessive condition: Kartagener’s syndrome
TRIAD
- Paranasal sinusitis
- Bronchiectasis
- Situs invertus
A three-hour-old baby born at 39+3 weeks in the Special Care Baby Unit is showing mildly increased work of breathing, with subcostal recessions and grunting. Their respiratory rate is 66/min without apnoeas, their heart rate is 147bpm and their axillary temperature is 36.7ºC. They are pink, with normal pre-post ductal saturations and no additional heart sounds. Fontanelles are normal. Their birth weight is normal.
Chest X-ray hyperinflation and a thin fluid line in the right horizontal fissure.
Given the likely diagnosis, what is the most significant risk factor?
A. Breech presentation
B. Caesarean section delivery
C. Fever during vaginal delivery
D. Meconium in liquor
E. Smoking during pregnancy
Delivery by caesarean section is a risk factor for transient tachypnoea of the newborn. This is a mildly raised respiratory rate with increased work of breathing in the hours after labour. Crucially, all other observations are normal - this makes other more serious differentials, such as meconium aspiration or sepsis less likely. Additionally, congenital causes of tachypnoea such as congenital diaphragmatic hernia or heart defects are largely ruled out by X-ray and examination. The most important risk for TTN is caesarean section delivery. Other risk factors include the baby being male, birth asphyxia and gestational diabetes.
What are Xray findings of TTN (transient tachypnoea of newborn)?
Chest x-ray may show hyperinflation of the lungs and fluid in the horizontal fissure.
how does CXR differ in bronchopulmonary dysplasia vs respiratory distress syndrome?
The lungs of babies with respiratory distress syndrome often look like ground glass, and those with BPD often look spongy. Blood tests: This shows how much oxygen is in the bloodstream and helps identify any infection.
You are reviewing a 9-month-old child with suspected bronchiolitis. Which one of the following features should make you consider other possible diagnoses?
A. Fine inspiratory crackles
B. Rhinitis
C. Feeding difficulties
D. Temperature of 39.7ºC
E. Expiratory wheeze
D. Temperature of 39.7ºC
A low-grade fever is typical in bronchiolitis. NICE state the following:
Consider a diagnosis of pneumonia if the child has:
high fever (over 39°C) and/or
persistently focal crackles.
what to ask parents in child with stridor: (mnemonic)
what is bronchopulmonary dysplasia also known as?
Chronic lung disease of prematurity (CLDP)
what are features of bronchopulmonary dysplasia:
-Low oxygen saturations
-Increased work of breathing
-Poor feeding and weight gain
-Crackles and wheezes on chest auscultation
-Increased susceptibility to infection
prevention of bronchopulmonary dysplasia:
- Giving corticosteroids (e.g. betamethasone) to mothers that show signs of premature labour at less than 36 weeks gestation can help speed up the development of the fetal lungs before birth and reduce the risk of CLDP.
Once the neonate is born the risk of CLDP can be reduced by:
- Using CPAP rather than intubation and ventilation when possible/early surfactant
- Using caffeine to stimulate the respiratory effort
- Not over-oxygenating with supplementary oxygen
- postnatal steroids
- diuretics (eg if PDA to reduce loading on heart) /adequate nutrition
management of bronchopulmonary dysplasia:
- Babies may be discharged (mild/moderate cases) from the neonatal unit on a low dose of oxygen to continue at home, for example 0.01 litres per minute via nasal cannula. They are followed up to wean the oxygen level over the first year of life.
- Monthly injections of a monoclonal antibody against the RSV virus causing bronchiolitis called palivizumab. This is very expensive (around £500 per injection) so is reserved for babies meeting certain criteria. (+ flu vaccine)
pathophysiology of respiratory distress syndrome:
Inadequate surfactant leads to high surface tension within alveoli. This leads to atelectasis (lung collapse), as it is more difficult for the alveoli and the lungs to expand. This leads to inadequate gaseous exchange, resulting in hypoxia, hypercapnia (high CO2) and respiratory distress.
management of respiratory distress syndrome:
- Antenatal steroids (i.e. dexamethasone) given to mothers with suspected or confirmed preterm labour increases the production of surfactant and reduces the incidence and severity of respiratory distress syndrome in the baby.
Premature neonates may need:
- Intubation and ventilation to fully assist breathing if the respiratory distress is severe
- Endotracheal surfactant, which is artificial surfactant delivered into the lungs via an endotracheal tube
- Continuous positive airway pressure (CPAP) via a nasal mask to help keep the lungs inflated whilst breathing
- Supplementary oxygen to maintain oxygen saturations between 91 and 95% in preterm neonates
Support with breathing is gradually stepped down as the baby develops and is able to maintain their breathing, until they can support themselves in air.
complications of respiratory distress syndrome (short vs long term)
Short term complications:
-Pneumothorax
-Infection
-Apnoea
-Intraventricular haemorrhage
-Pulmonary haemorrhage
-Necrotising enterocolitis
-Long term complications:
-Chronic lung disease of prematurity
-Retinopathy of prematurity occurs more often and more severely in neonates with RDS
-Neurological, hearing and visual impairment
what are important negative findings & positive findings in epiglottitis:
Negative finding: Absence of cough
Positive findings: Children typically present with a short history of fever, irritability, sore throat, Intensely painful throat preventing child from speaking or swallowing; pooling and drooling of saliva, Child sits immobile, upright with open mouth to optimise airway, muffled voice/cry (stridor), toxic looking child
How does laryngomalacia present?
Laryngomalacia is the most common congenital abnormality of the larynx. It causes excessive collapse and indrawing of the supraglottic airways during inspiration, producing stridor. This is often noticeable within a few hours of birth, so there would be a long standing history of breathing difficulties
Management of acute epiglottitis:
This is an emergency. Senior ENT, anaesthetic and paediatric support is required as soon as possible alongside notifying PICU.
- Do not examine or upset the child in the absence of senior support
- Securing the airway is the first priority. 3. Endotracheal intubation may be necessary.
- Once the airway is secure, take cultures and examine the throat
- Treat with IV antibiotics: cefuroxime
A neonate is born at 36 weeks by elective caesarean section. Shortly after delivery, she develops tachypnoea and looks in distress. There was no meconium staining of the liquor. Chest x-ray shows hyperinflation of the lungs and fluid in the horizontal fissure. What is the most likely diagnosis?
A. Aspiration pneumonia
B. Transient tachypnoea of the newborn (TTN)
C. Cystic fibrosis
D. Bronchopulmonary dysplasia
E. Neonatal respiratory distress syndrome (NRDS)
B. TTN
This is the correct answer. TTN describes tachypnoea shortly after birth, and often resolves within the first day of life with supportive therapy with Oxygen. It is caused by delayed resorption of fluid in the lungs and is strongly associated with caesarean section and prematurity. X-ray signs include hyperinflation, and fluid in the horizontal fissure
Not: D: Bronchopulmonary dysplasia:
Bronchopulmonary dysplasia would present with signs of NRDS such as cyanosis, tachypnoea, grunting, and intercostal recession
Not: E NRDS:
NRDS is caused by deficiency of surfactant, and usually occurs in premature neonates. It presents with respiratory distress (tachypnoea, grunting, nasal flaring, intercostal recession, cyanosis) shortly after birth and becomes more severe over the first few days of life, unlike TTN. On chest X-ray there are ground glass lungs and a bell-shaped thorax
when does
Subglottic stenosis usually happen?
before this normally ex-premature (intubated beforehand)
what virus normally causes croup?
parainfluenza
budenoside inhaler exaples
(Pulmicort, Duoresp)
croup vs bacterial tracheitis vs epiglottitis:
-all 3: fever
Bacterial Tracheitis
-The child presents with symptoms which are intermediary between those of croup and epiglottitis.
-Patients may present with difficulty breathing and shortness of breath combined with a temperature.
epiglottitis: high fever & drooling
What is grunting?
Grunt: forcing air out against closed glottis (giving yourself CPAP; breathing out against resistance, sign of lower respiratory problems but you make the noise from the larynx)
what is laryngomalacia?
Laryngomalacia is a condition affecting infants, where the part of the larynx above the vocal cords (the supraglottic larynx) is structured in a way that allows it to cause partial airway obstruction.
This leads to a chronic stridor on inhalation, when the larynx flops across the airway as the infant breathes in (more obvious when crying, feeding). Stridor is a harsh whistling sound caused by air being forced through an obstruction of the upper airway.
signs of
lactate high causes
ischaemia eg bowel, septic or salbutamol toxicity
signs of salbutamol toxicity:
Shivering/tremor, vomiting and high lactate, hypokalaemia/tachycardia
Asthmatic stairs summary
3 x 10 puffs (10 –> space–> 10 –> space–> 10 —> space, total 30 puffs; either salbutamol inhaler or a nebuliser, atrovent (ipratropium bromide) =only give it nebulised, if puffs; give 2 puffs, cannulate-hydro=water=through vein vs oral prednisolone )
> 5 with asthma/history of asthma–> prednisolone, vs pre-school (not appropriate to give prednisolone eg no history of atopy)
what is per-nasal swab for?
Bordetella pertussis (bacteria)
what is npa (nasopharyngeal aspirate) used for?
general respiratory viruses: RSV, rhinovirus, parainfluenza virus 1,2,3,4, covid, whooping cough etc
what is Throat swab usually for?
it’s a M
C &S
usually for Group A streptococcus (GAS) ie strep throat
bronchiolitis management podium
90% in bronchiolotis =baseline (92% in most other things)
-if <90%–> O2 (most hospitals; high flow humidified o2, 2L per kg, optiflow (little bit of pressure) vs CPAP(specific pressure), worried : I % V (intubation and ventilation)
Feeding; food challenge
-if on o2; NG feeds or CPAP; IV fluids
How is the severity of OSAH or OSAS graded?
The apnoea hypopnoea index (AHI) is the number of apnoeas (stopping breathing) or hypopnoeas (reduced airflow during breathing) recorded during the sleep study per hour of sleep. It is generally expressed as the number of events per hour. Based on the AHI, the severity of OSA is classified as follows:
None/Minimal: AHI < 5 per hour
Mild: AHI ≥ 5, but < 15 per hour
Moderate: AHI ≥ 15, but < 30 per hour
Severe: AHI ≥ 30 per hour
what’s the most common virus causing URTI?
Rhinovirus.
Others include influenza virus, adenovirus, enterovirus and RSV.
3 evidence-based treatment strategies for bronchiolitis:
- Nebulised hypertonic saline may modestly reduce length of stay among infants hospitalised with acute bronchiolitis and improve clinical severity score. Treatment with nebulised hypertonic saline may also reduce the risk of hospitalisation among outpatients and emergency department patients. Humidified oxygen should be used to maintain saturations above 92%.
- Patients with dehydration on presentation, increasing respiratory distress or inability to feed require naso/orogastric or iv fluids.
- Syndrome of Inappropriate ADH secretion has been described in bronchiolitis, and if IV fluids are required, restrict to two thirds of usual maintenance.
There is no evidence that physiotherapy, steroids or theophylline is effective in the management of bronchiolitis.
why is stridor more common in children vs adults:
Children are more likely to present with stridor than adults because their upper airway is shorter and narrower than an adult’s and is, therefore, more likely to get blocked.
croup x-ray finding
a posterior-anterior view will show subglottic narrowing, commonly called the ‘steeple sign’: inverted V shape reminiscent of a church steeple
in contrast, a lateral view in acute epiglottis will show swelling of the epiglottis - the ‘thumb sign’
epiglottitis x-ray finding
in contrast, a lateral view in acute epiglottis will show swelling of the epiglottis - the ‘thumb sign’
An 18-month-old boy attends the emergency department with his father. He has had a dry, hacking cough and fever over the last 2 days. Dad describes that he coughs continuously and makes a high-pitched gasping noise between coughing fits. During the night, he was coughing so hard that he vomited.
Given the likely diagnosis, what long-term complication is this patient at risk of?
A. Pulmonary fibrosis
B. Pneumothorax
C. Recurrent pneumonia
D. Chronic obstructive pulmonary disease (COPD)
E. Bronchiectasis
E. Bronchiectasis
Whooping cough-mediated damage to the bronchi, particularly in childhood, is associated with the development of bronchiectasis later in life.
Not B: Pneumothorax rarely occurs in whooping cough and tends to be secondary to increased intrathoracic pressure during coughing fits. It is not a long-term complication of infection.
3 phases of whooping cough:
- Early catarrhal phase: characterized by flu-like symptoms, dry cough, coryza, conjunctivitis, sore throat and a mild fever. Lasts 1-2 weeks.
- Spasmodic phase: patient develops a dry, hacking cough that occurs in spasms and worsens towards night. Whoop occurs because of sustained periods of expiration with little gap between coughs, meaning the patient has to inspire forcefully when the opportunity arises. The child often vomits, faints or appears cyanosed after coughing fits.
- Convalescent phase: coughing may last for two to three months after infection has cleared.
Investigations for whooping cough:
- PCR of nasopharyngeal swabs or secretions
- Culture of these samples.
- Oral fluid testing for IgG.
- Serology (more than 2 weeks patients can be tested for the anti-pertussis toxin immunoglobulin G. This is tested for in the oral fluid of children aged 5 to 16 and in the blood of those aged over 17)
when would you admit patient with whopping cough?
those less than 6 months old or who have significant respiratory symptoms or complications:
a) Significant breathing difficulty (severe paroxysms, apnoea episodes, cyanosis)
b) Significant complications (e.g. seizures, pneumonia)
at what gestation are pregnant women now offered vaccination for whooping cough?
Pregnant women at 28-32 weeks gestation are now offered vaccination to protect infants under 3 months old via passive transfer of maternal antibodies.
croup (mild, moderate and severe treatment):
- Mild croup
o Hospital admission not required
o Safetynet:
* § Advise to take child to hospital if continuous stridor heard or skin between ribs pulling in with every breath
* § Advise to call an ambulance if child is:
* Very pale, blue, or grey (includes blue lips) for more than a few seconds * Unusually sleepy or is not responding
* Having a lot of trouble breathing
* Upset (agitated or restless) while struggling to breathe and cannot be calmed down quickly
* Unable to talk, are drooling, or having trouble swallowing - Moderate croup
* o Oxygen - Severe croup
* o Oxygen
oNebulised adrenaline( 1in1000(1mg/ml))
o Intubation in minority of cases where respiratory failure occurs
Call for senior support (vs Atrovent nebuliser=nebulised ipratropium bromide)
