Paediatric Respiratory Flashcards
Outline the most common cause of bronchiolitis
- Viral infection
- Specifically, respiratory syncytial virus (RSV)
Bronchiolitis - state the following:
- Pathophysiology
- Most common age
- Presentation (including any red flags)
- Differential diagnosis
- Investigations
- Management
Pathophysiology:
- Inflammation and infection of the bronchioles
(excess mucus production, IgE-mediated type 1 allergic reaction causing inflammation, bronchiolar constriction and oedema)
- Usually caused by viruses, specifically respiratory syncytial virus (RSV)
Most common age:
- Under 1 year (up to 2 years if previously premature and chronic lung disease)
Presentation:
- Coryzal symptoms e.g. snotty nose, sneezing
- Signs of respiratory distress
- Dyspnoea
- Tachypnoea
- Poor feeding
- Mild fever
- Wheeze on auscultation
- Crackles on auscultation
RED FLAG: Signs of respiratory distress
Investigations:
- Pulse oximetry = KEY
- ABG if severely unwell
- Blood and urine culture if child is pyrexic
- Consider chest x-ray
- Consider ELISA (test for RSV)
Management:
Mainly supportive
- Adequate intake (oral, NG tube, IV fluids)
- Controlled O2 if < 92%
- Saline nasal drops / suctioning
- Ventilatory support if required
Describe the following abnormal airway noises
- Wheezing
- Grunting
- Stridor
Wheezing - whistling sound typically during expiration, caused by narrowed airways
Grunting - caused by exhaling with glottis partially closed, to increased positive end-expiratory pressure
Stridor - high pitched inspiratory noise, caused by obstruction of the upper airway (commonly heard in croup)
State signs of respiratory distress in children = IMPORTANT!
Head and neck:
- Head bobbing
- Nasal flaring
- Tracheal tug
- Abnormal airway noises e.g. grunting
Chest:
- Tachypnoea
- Intercostal and subcostal recessions
- Use of accessory muscles
Body:
- Cyanosis
Outline the typical course of respiratory syncytial virus (RSV)
Often causes bronchiolitis
- Starts as an URTI with coryzal symptoms (of which 50% get better spontaneously)
- Other 50% develop chest symptoms in following 2 days
- Symptoms worse on days 3-4, lasting 7-10 days in total
- Most recover by 2-3 weeks
State some reasons for admission in infants with bronchiolitis
Non-modifiable:
- Under 3 months
- Pre-existing condition e.g. pre-maturity, Down’s or cystic fibrosis
Modifiable:
- Tachypnoea > 70
- O2 sats < 92%
- Moderate-severe respiratory distress
- Apnoea (episodes of stopping breathing)
- Clinical dehydration/ significantly less intake of milk (50-75% less)
- Parents not confident in managing at home
State the 3 types of ventilatory support which can be used for children
- High flow humidified oxygen via tight nasal cannula (air and oxygen continuously with pressure to prevent airways collapsing)
- CPAP - similar to previous but can deliver more high pressure / controlled pressure
- Intubation and ventilation
Can use capillary blood gases to monitor in ventilatory support
State some risk factors for bronchiolitis
- Chronic lung disease due to prematurity
- Siblings who attend nursery or school (increased risk of exposure to viruses)
- Smoke exposure (eg. parents’ smoke)
- Being breast fed for less than 2 months
State some differentials for bronchiolitis
- Heart failure – VERY IMPORTANT not to miss this
- Pneumonia
- Asthma / viral induced wheeze
- Bronchitis
- Croup
- Cystic fibrosis
State 2 complications of bronchiolitis (once infection has resolved)
- Persistent cough or wheeze (very common)
- Bronchiolitis obliterans (airways become permanently damaged due to inflammation and fibrosis)
Acute asthma attack - state the following:
- Pathophysiology
- Presentation (including any red flags)
- Investigations
- Management
Pathophysiology:
- Acute worsening of symptoms of asthma
- Usually caused by any of the typical triggers of asthma
Presentation:
- SOB
- Expiratory wheeze (throughout chest)
- Signs of respiratory distress
- Tachypnoea
- Reduced air entry
RED FLAG: silent chest
Investigations - investigate severity:
- PEFR
- O2 sats
- Listen to chest
- Count RR and HR
Management:
Mild: manage in community with regular Salbutamol inhaler in spacer
Moderate-severe - stepwise approach:
- Salbutamol inhaler / nebuliser
- Ipratropium Bromide nebuliser
- Oral Prednisolone / IV Hydrocortisone
- IV Salbutamol
- IV Magnesium
- IV Aminophylline
Chronic (ongoing) asthma - state the following:
- Pathophysiology
- Presentation
- Investigations
Pathophysiology:
- Chronic inflammatory disease with variable reversible airway obstruction
Presentation:
- Intermittent episodes with evidence of triggers
- Dry cough, worse at night (diurnal variability)
- Wheeze
- SOB
- Family history of atopy (asthma, hayfever, eczema)
+ improvement of symptoms with bronchodilators
Investigations:
No single diagnostic test, based on typical history and examination. If doubt, can do following options
- Monitor PEFR twice daily, 2-4 weeks
- FeNO
- Spirometry (if > 5)
- Direct bronchial challenge with histamine
State which factors need to be met for a child to be discharged after an acute asthma attack
- Inhaler technique assessed/taught
- Written asthma management plan given and explained to parents
- SaO2 >94% in air
- GP should review the child 2 days after discharge
- Regular bronchodilator use, 6 puffs every 4 hours
State some differential diagnoses for asthma
- Viral wheeze
- Bronchiolitis
- Inhaled foreign body
- Cardiac failure
- Cystic fibrosis (CF)
- Primary ciliary dyskinesia
State how asthma is managed long term for the following age groups:
Under 5
5-12+ (same as adults)
Under 5:
- SABA e.g. Salbutamol
- Low dose ICS or Montelukast
- Low dose ICS AND Montelukast
- Refer to specialist
5-12+:
- SABA e.g. Salbutamol
- Low dose ICS
- LABA e.g. Salmeterol
- Increase dose ICS
- Consider adding Montelukast or theophylline
- High dose ICS
- Refer to specialist
Outline the impact of inhaled corticosteroids on growth when used in children (as if explaining to a parent)
- Some evidence to show that use of ICS can slightly reduce growth velocity and reduction in final adult height of up to 1cm
- However, this is dose dependent (small dose, less impact)
- The impact of poorly controlled asthma can have a greater impact on growth than ICS
Regular asthma reviews will monitor growth velocity
Pneumonia - state the following:
- Pathophysiology
- Presentation (signs and symptoms, including any red flags)
- Investigations
- Management
Pathophysiology:
- Infection of lung parenchyma
- Leads to inflammation of parenchyma and increased mucus production in airways and alveoli
- Can be caused by: bacterial, virus and atypical bacteria e.g. mycoplasma
Presentation - symptoms:
- Productive cough (yellow green)
- Fever
- SOB / increased work of breathing
- Chest pain
Presentation - signs:
- Tachypnoea
- Tachycardia
- Hypoxia
- Delirium
- Bronchial breath sounds
- Dullness to percussion
- Focal coarse crackles
Investigations:
- Chest x-ray is investigation of choice, although not always required (used if doubt or complicated)
- Consider sputum culture or viral PCR to guide treatment if needed
Management:
- Controlled O2 therapy if < 92%
- Oral antibiotics (commonly Amoxicillin)
- Can add Macrolide e.g. Erythromycin to cover atypical or if penicillin allergy
- Consider IV antibiotics if sepsis or intestinal absorption issues
State differential diagnoses for pneumonia in children
- COVID-19
- Acute bronchitis
- Asthma exacerbation
- Heart failure
- Bronchiectasis
- TB
- Empyema
- PE
- Pneumothorax
- Hypersensitivity pneumonitis
State the most common causes of pneumonia in children (bacterial and viral)
Bacterial:
- Streptococcus pneumonia = most common
- Group strep A
- Group strep B (GBS in vagina after birth)
- Staph aureus
- Haemophilus influenzae
- Mycoplasma pneumonia
Viral:
- Respiratory syncytial virus (RSV) = most common
- Parainfluenza
- Influenza
Suggest some underlying conditions to consider for a child presenting with recurrent chest infections (and the test to check)
- Low WCC (FBC)
- Scarred lungs (chest x-ray)
- Antibody deficiency (serum immunoglobulins)
- Cystic fibrosis (sweat test)
- HIV (HIV testing)
Croup - state the following:
- Pathophysiology
- Most common age
- Presentation (including any red flags)
- Investigations
- Management
Pathophysiology:
- Acute upper respiratory tract infection (also known as acute laryngotracheitis)
- Causes oedema in the larynx
- Generally caused by viruses, mainly parainfluenza virus
Most common age:
- 6 months to 3 years (can be older)
- Peak incidence at 2 years
Presentation:
- Barking cough (clusters of coughing fits)
- Increased work of breathing
- Hoarse voice
- Stridor
- Low grade fever
RED FLAGS: signs of respiratory failure, drowsiness, lethargy
Investigations:
- Not generally needed
- Chest x-ray and lateral neck if suspicion of foreign body ingestion
Management:
- Supportive at home if mild with fluids and rest
- Consider admission if high risk
- Single dose of oral Dexamethasone (allowed 2nd dose 12 hrs later) or Prednisolone
- Further care: oxygen, nebulised Budesonide, nebulised Adrenaline
State differential diagnoses for croup
Anything that causes upper airway obstruction!!
- Inhaled foreign body / noxious substance
- Epiglottitis
- Acute anaphylaxis
- Bacterial tracheitis
- Laryngomalacia
- Peritonsillar abscess (quinsy) / retropharyngeal abscess
- Diphtheria
State the main causes of croup (viral)
- Parainfluenza = most common
- Influenza
- Adenovirus
- Respiratory syncytial virus (RSV)
State the name of the scoring system used to determine the severity of croup, and it’s rough parameters
Westley Croup Score
SCARS
Sats (<92%)
Conscious level
Air entry
Retractions
Stridor
State some factors for when to consider admission for croup
- Previous history of severe airway obstruction
- Very young (< 6 months)
- Immunocompromised
- Inadequate fluid intake
- Poor response to initial treatment
- Uncertain diagnosis
- Significant parental anxiety
Outline the differences between croup and epiglottitis for the following parameters
- Time Course
- Features prior
- Cough
- Feeding
- Mouth
- Fever
- Stridor
- Voice
Time Course:
Croup = days
Epiglottitis = hours
Features prior:
Croup = coryzal
Epiglottitis = none
Cough:
Croup = barking
Epiglottitis = slight if any
Feeding:
Croup = can drink
Epiglottitis = none
Mouth:
Croup = closed
Epiglottitis = open, drooling saliva
Fever
Croup = < 38.5 (no fever)
Epiglottitis = > 38.5 (fever)
Stridor:
Croup = rasping
Epiglottitis = soft
Voice
Croup = hoarse
Epiglottitis = weak / silent
Epiglotittis - state the following:
- Pathophysiology
- Presentation (including any red flags)
- Investigations
- Management
Pathophysiology:
- Acute inflammation and swelling of epiglottis
- Usually caused by infection, specifically Haemophilus influenza B (also streptococcus pneumoniae)
Presentation:
4 D’s!
- Drooling
- Dyspnoea (difficult breathe)
- Dysphagia (painful / difficult swallow)
- Dysphonia (muffled “hot potato” voice)
- Tripod position
- High fever
Investigations:
No examinations!
- Lateral x-ray shows thumbprint sign or can exclude foreign body
Management:
- Keep child as comfortable as possible, no examinations
- Immediate escalation to senior paediatrician and anaesthetist
- Most recover okay, but prepare for intubation or tracheostomy
- Once secure airway, IV antibiotics and Dexamethosone
State a common complication of epiglottitis
Epiglottic abscess
- Treatment similar to epiglottitis
List some differentials for epiglottitis
- Croup
- Inhaled foreign body
- Retropharyngeal abscess
- Tonsillitis
- Peritonsillar Abscess
- Diphtheria
Whooping cough - state the following:
- Pathophysiology
- Presentation (including any red flags)
- Investigations
- Management
Pathophysiology:
- Highly contagious upper respiratory tract infection
- Caused by Bordetella pertussis (gram negative bacteria), which paralyses cilia and promote inflammation
- Under 3 months have yet to be vaccinated (vulnerable)
Presentation:
- Starts with mild coryzal symptoms, low grade fever and mild dry cough
- Then severe coughing fits, getting progressively worse
- After coughing fits, large loud inspiratory ‘whoop’ (apnoea more common if < 3 months)
Investigations:
If 2-3 weeks since onset = Nasal swab PCR for Bordetella pertussis
If > 3 weeks, can use anti-pertussis toxin test for IgG antibodies
Management:
- NOTIFIABLE DISEASE (contact public health)
- Simple supportive care in most cases, admission is severe or respiratory distress
- Can use Macrolide antibiotics e.g. Azithromycin in early stages to reduce further spread
- If close contacts vulnerable, can give prophylactic antibiotics
Cough can last up to 100 days after infection
State a key complications of whooping cough
Bronchiectasis
State some differential diagnoses for whooping cough
- Bronchiolitis / viral respiratory infection
- Pneumonia
- Asthma
- TB
Cystic fibrosis - state the following:
- Pathophysiology
- Ways in which CF can present
- Symptoms of CF
- Investigations
- Management
Pathophysiology:
- Autosomal recessive genetic condition affecting mucus glands
- Defect in the chloride ion transporter (CFTR)
- Affects osmotic gradient for water, leading to thicker mucus and impaired clearance
Ways in which CF can present:
- Newborn spot test
- Meconium ileus
- Recurrent chest infections
- Difficulties gaining weight / failure to thrive
- Pancreatitis
- Male infertility
Symptoms of CF:
- Chronic cough and thick sputum
- Recurrent chest infections
- Steatorrhoea
- Abdominal pain and bloating
Investigations - 3 methods:
- Newborn spot test
- Sweat test (gold standard for diagnosis)
- Genetic testing for CFTR gene
Management:
- Ensure up to date on vaccinations
- Chest physiotherapy and exercise
- Creon tablets and high calorie diet
- Prophylactic Flucloxacillin and treatment of chest infections
- Bronchodilators e.g. Salbutamol
- Nebulised saline
Outline the systems that are affected in cystic fibrosis
- Pancreatic and biliary ducts - leads to lack of digestive enzymes in the digestive tract and reduced ability to break down and absorb nutrients
- Thick airway secretions - reduce airway clearance leading to increased respiratory infections
- Congenital bilateral absence of vas deferens leading to male infertility
State the most common first sign of cystic fibrosis
Meconium ileus
- Thick and stick meconium
- Failure to pass meconium within the first 24 hours of life (in 20% of CF babies)
- Leads to abdominal distension and vomiting
State 2 key organisms that are commonly found in infections in those with cystic fibrosis
- Staph aureus (take long term prophylactic Flucloxacillin)
- Pseudomonas aeruginosa (very difficult to get rid of once infected = significant increase in mortality and morbidity)
State some conditions that those with cystic fibrosis need to be screened for
- Diabetes (pancreatic insufficiency)
- Vitamin D deficiency / osteoporosis
- Liver failure
Viral induced wheeze - state the following:
- Pathophysiology
- Most common age
- Presentation (including any red flags)
- Investigations
- Management
Pathophysiology:
- Describes an acute wheezy illness, caused by a viral infection
- Young children tend to have small airways and a viral illness can cause inflammation and oedema
- This restriction of an already small airway can lead to obstructive flow and a wheeze
- Commonly RSV and rhinovirus
- Some children are more susceptible than others to swelling (hereditary element?)
Most common age:
- Under 3 years (smaller airways)
Presentation:
Similar to asthma!
- Expiratory wheeze = widespread
- Fever (1-2 days prior)
- Cough (1-2 days prior)
- Coryzal (1-2 days prior)
- SOB
- Signs of respiratory distress
Investigations:
- PEFR
Management:
- Same management for acute asthma (child)
State the difference between asthma and acute viral wheeze
- Viral wheeze presents before 3 years old (asthma tends to be later)
- No atopic history
- Occurs in tandem with viral infection
Asthma can also be triggered by viral/bacterial infections, however it’s generally trigger by other things as well e.g. exercise, cold
State differential diagnoses for viral induced wheeze
- Asthma
- Bronchiolitis
- Inhaled foreign body
- Atypical lower respiratory tract infections
- Cystic fibrosis
- GORD
- Structural airway problems
Bronchiectasis - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Dilatation of the airways caused by destruction of bronchial tissue
- Inflammatory response in response to severe infection causes structural damage and scarring, reducing number of cilia within bronchi
- Commonly occurs as a result of cystic fibrosis
- Potentially reversible
Presentation:
- Purulent sputum
- Wheeze
- SOB on exertion
- Haemoptysis
- Chest pain
- History of recurrent chest infections
Investigations:
- HRCT (signet ring sign) = gold standard
- Chest x-ray (bronchial wall thickening or airway dilatation)
- Consider spirometry
- Investigate underlying cause e.g. sweat test or immunoglobulin assay
Management:
- Chest physiotherapy
- Antibiotics to treat chest infections
- Can use bronchodilators
- Regular follow ups
State some differential diagnoses for bronchiectasis
- Asthma
- COPD (e.g. alpha 1 anti-trypsin deficiency)
- Chronic sinusitis
- Pneumonia
- TB / lung cancer
- Interstitial lung disease (ILD)
State some complications of bronchiectasis and general prognosis
- Recurrent chestinfections
- Pneumothorax
- Haemoptysis
- Lung abscess
- Reduced QOL / poor growth and development
Prognosis: dependent on underlying cause
If post-infection, treatment should halt progression
However if more complex like HIV then prognosis based on status of underlying disease
State the different causes of bronchiectasis
- Cystic fibrosis with recurrent chest infections / primary ciliary dyskinesia
- Post infection e.g. strep pneumonia, adenovirus
- Immunodeficiency e.g. HIV, antibody defect
- Post obstructive
- Young & yellow-nail syndromes
List some indications for (chronic) home ventilation
Airway narrowing:
- Obstructive sleep apnoea
- Bronchiectasis
- Bronchiolitis obliterans
- Tracheobronchomalacia
Chest/lung problems:
- Chest wall deformity
- Kyphoscoliosis
- Lung hypoplasia
- ILD
Neuromuscular disorder:
- Spinal cord injury
- Spinal muscular atrophy
- Myasthenia gravis
- Diaphragmatic dysfunction
- Congenital muscular dystrophy
- Brain damage e.g. post infection
Outline the different types of home ventilation
Non-invasive:
- Bi-level positive pressure (BiPAP)
- Continuous positive airway pressure (CPAP)
Invasive:
- Tracheostomy
Obstructive sleep apnoea - state the following:
- Pathophysiology
- Risk factors for developing OSA
- Presentation (including any red flags)
- Investigations
- Management
Pathophysiology:
- Temporary obstruction of nose, throat or upper airway during sleep
- In children, most common cause is enlarged adenoids and/or tonsils
Risk factors for developing OSA:
- Obesity
- Sickle cell disease
- Down syndrome
Presentation:
- Snoring
- Sleep in unusual position (ease breathing)
- Tiredness
- Unhappy or change in behaviour
- Poor growth and weight gain
- Poor school performance / lack of concentration
Investigations:
- Sleep study (records HR, RR and O2 sats whilst sleeping as well as video/sound recording
Management:
- Weight loss if obesity
- Surgery to remove the adenoids and/or tonsils
- Non-invasive ventilation e.g. BiPAP or CPAP
- Nasopharyngeal airway (splint open)
- Nasal steroids or Montelukast to reduce inflammation
State the difference between meconium ileus and meconium aspiration syndrome
Meconium Ileus:
- Failure to pass meconium within the first 12–24 hours of life
- Presents with bilious vomiting and a distended abdomen
Meconium Aspiration Syndrome:
- Presence of meconium in the amniotic fluid
- May lead to respiratory distress in the neonate
Suggest some causes of breathlessness or reduced exercise tolerance in children
- Anaemia
- Congenital heart problems
- Respiratory disease e.g. asthma, pneumonia
- Obesity
- Chronic infections (viral or bacterial)
- Allergies
- Passive exposure to cigarette smoke / other harmful gases
- Genetic conditions e.g. cystic fibrosis, muscular dystrophy
State some causes of pneumothorax in children
Primary (spontaneous) pneumothorax = no underlying lung disease
Secondary pneumothorax = underlying or chronic lung disease
- infection
- foreign body aspiration
- cystic fibrosis
- asthma
- interstitial lung disease
State some risk factors for pneumothorax
- Previous pneumothorax
- Chronic respiratory disease e.g. cystic fibrosis, asthma
- Tall and thin male
- Family history of pneumothorax
- Connective tissue disorders e.g. Marfan’s, Ehlers-Danlos syndrome
- Prematurity / chronic lung disease of prematurity
- Non-invasive ventilation e.g. CPAP
- Use of recreational drugs (older children)
State investigation and management for paediatric pneumothorax (tension, small or large)
Investigation:
- Chest x-ray
- O2 sats
Management:
If tension/unstable = emergency management of 15L O2 non-rebreathe mask and emergency chest drain in anterior 2nd ICS on affected side (above rib)
- If small = conservative and regular observations
- If large = admission and needle aspiration
State some causes of respiratory distress/arrest in children
- Foreign body obstruction
- Upper airway obstruction e.g. epiglottitis, mucus
- Lower airway obstruction e.g. aspiration, constriction
- Decreased respiratory effort / exhaustion e.g. CNS disorder, CNS depression from drugs
- Outline what breath holding spells are, including the 2 main types
- Most common age to be affected
- Involuntary episodes where a child holds their breath
- Usually triggered by something that upsets them
2 main types
1. Cyanotic breath holding spells
- when child is upset, worked up and crying
- can stop breathing, cyanotic and lose consciousness
- regain consciousness after ~1 min
2. Reflex anoxic seizures
- when the child is startled
- vagus nerve sends strong signals to heart to stop it breathing
- can go pale, cyanotic and lose consciousness
- may have seizure like muscle twitching
- regains consciousness and heart restarts in ~30 seconds
Most common age:
- Between 6 months and 18 months
Outline how breath holding spells are managed
Exclude any underlying pathology, especially iron deficiency anaemia (has been linked)
Educate and reassure parents - most children usually grow out of them by 4-5 years old
State some risk factors for someone experiencing severe / life threatening asthma attacks
- Previous near-fatal asthma
- Previous admissions / A&E for asthma
- 3 or more types asthma medication
- Heavily relient on Salbutamol
