Paediatric respiratory Flashcards
What is croup?
- acute infective URTI
What is the epidemiology of croup?
- 6 months to 6 years, most common under 3 years
- more prevalent autumn - winter
What is the pathophysiology of croup?
- inflammation and swelling resulting in partial obstruction of the upper airway
- oedema in larynx
What are the most common causes of croup?
- parainfluenza
- influenza
- adenovirus
- respiratory syncytial virus (RSV)
How does croup present?
- increased work of breathing
- barking cough in clusters of coughing episodes
- hoarse voice
- stridor
- low grade fever
How is croup managed?
- supportive: fluids and rest
- oral dexamethasone
- infection control measures: handwashing, off school
What is the order of treatment for croup?
- oral dexamethasone
- oxygen
- nebulised budesonide
- nebulised adrenalin
- intubation and ventilation
What is bronchiolitis?
- chest infection causing inflammation and infection in the bronchioles
- lower resp tract infection
What is the epidemiology of bronchiolitis?
- observed in winter
- mostly between 1-9 months
What causes bronchiolitis?
- Majority attributed to respiratory syncytial virus
What is the presentation of bronchiolitis?
- coryzal symptoms
- resp distress
- wheezing
- tachypnoea
- grunting
What are the signs of respiratory distress?
- raised RR
- accessory muscle breathing
- inter and subcostal recessions
- nasal flaring
- head bobbing
- tracheal tugging
- cyanosis
What is wheezing and what is the cause?
- whistling sound
- narrowed airways
- heard in expiration
What is grunting?
- exhaling with glottis closed
- increases positive end-expiratory pressure
What is stridor?
- high pitched inspiratory noise
- obstruction of upper airway
What resp reasons would cause a child to be admitted?
- 50-75% less than normal milk intake
- RR above 70
- central cyanosis
- O2 sats below 92%
- apnoea
- head bobbing/deep recessions
- unwell to hcp
How can ventilation be assessed in children?
- capillary blood gases
What capillary blood gas results show poor ventilation?
- rising pCO2
- falling pH
- respiratory acidosis
- if also hypoxic: type 2 resp failure
How can ventilatory support be provided?
- high-flow humidified oxygen via a tight nasal cannula
- oxygenates lungs and adds positive end-expiratory pressure to maintain airway
- CPAP
- intubation and ventilation
How is bronchiolitis managed?
- adequate fluid intake
- saline nasal drops
- supplementary oxygen
- ventilatory support
What is palivizumab?
- monoclonal Ab targeting RSV
- given to high risk babies
- ex-premature
- congenital heart disease
Why is aspirin usually avoided in children?
- Reye’s syndrome
What is the pathophysiology of viral induced wheeze?
- children <3 have small airways
- when encountering virus they develop inflammation and oedema
- swelling walls and restricting airflow
How can you tell the difference between viral induced wheeze and asthma?
- presenting before 3 years old
- no atopic history
- only occurring during viral infection
How does viral induced wheeze present?
- evidence of viral illness
- SOB
- signs of resp distress
- expiratory wheeze throughout chest
What is the cause of wheeze?
- narrowing of airways causes laminar flow to become turbulent
Which types of drugs are used to relax airway smooth muscle?
- β-2 agonists
- anti-muscarinics
- theophyllines
Which types of drugs are used to dampen inflammation?
- corticosteroids
- leukotriene receptor antagonists
- biologics
- macrolides
What breaks a breath hold?
raised CO2 detected in CSF
Where does gas exchange begin?
- in the respiratory bronchioles
- terminal bronchioles > resp bronchioles > alveolar ducts > sacs
What is asthma?
- chronic inflammatory condition causing variable (but reversible) airway obstruction
- narrowed airways > obstruction of airflow to lungs
- varies over time
What is the presentation of asthma?
- episodic
- diurnal variability and worse at night
- dry cough, wheeze, shortness of breath
- atopic triad: hayfever, eczema, asthma
- family history
What is the physiology behind asthma?
- smooth muscle contracts on irritation
- chronic inflammation leads to scarring and airway remodelling
What are the causes of asthma?
- environmental: pollen, smoke, dust, mould
- genetics
- hygiene hypothesis
What is the investigation for asthma?
- spirometry: FEV1/FEV <0.7
- reversibility: give salbutamol and see if ratio normal (0.8)
- fractional exhaled nitric oxide
- peak flow variability by diary
What is the management of asthma in children aged 5-11?
- SABA PRN
- +low dose ICS
- +LABA and cont if good response
- titrate up ICS to medium dose
- consider adding LTRA/theophylline
- Inc ICS to high dose
What is the management of asthma for children aged <5?
- SABA PRN
- +low dose ICS/LTRA
- try other
- specialist
What is the management of asthma for children aged >12?
- SABA PRN
- +low dose ICS
- +LABA
- medium dose ICS, consider LTRA/theophylline/LAMA
- high dose ICS + consider oral salbutamol
What is an example of:
1. SABA
2. LABA
3. SAMA
4. LAMA?
- salbutamol
- salmeterol
- ipratropium bromide
- tiotropium bromide
How do leukotriene receptor antagonists work?
- Leukotrienes produced by immune system
- cause inflammation, bronchoconstriction, mucus secretion
- antagonists block effects
What is cystic fibrosis?
- autosomal recessive condition affecting mucus glands
- caused by genetic mutation of CFTR gene on chromosome 7 coding for chloride channels
How is cystic fibrosis diagnosed?
- newborn blood spot testing
- sweat test (GOLD)
- genetic testing for CTFR by amniocentesis or chorionic villous sampling
- faecal elastase
What is the sweat test for cystic fibrosis?
- pilocarpine applied to patch of skin
- electrodes placed either side
- current passed causing sweating and sample sent to lab for chloride conc testing
- > 60mmol/L is diagnostic
What are the symptoms of cystic fibrosis?
- chronic cough
- thick sputum
- recurrent RTIs
- steatorrhoea
- failure to thrive
What are signs of cystic fibrosis?
- low weight or height
- nasal polyps
- clubbing
- crackles and wheeze on auscultation
- abdo distention
Which bacteria commonly affect children with cystic fibrosis and how is it prevented?
- S. aureus
- Pseudomonas aeruginosa
- prophylactic flucloxacillin taken
What is the first sign of cystic fibrosis?
- meconium ileus
- thick and sticky black stool - obstructs bowel
- not passing within 24 hrs of birth > abdo distention and vomiting
What is the pathophysiology of the symptoms behind cystic fibrosis?
- thick pancreatic and biliary secretions: block ducts > lack of digestive enzymes
- low volume, thick airway secretions > reduce clearance leading to bacterial colonisation and infection
- congenital bilateral absence of vas deferens
What is the pathology of cystic fibrosis?
- issues with Cl- channel on apical membrane of epithelial cells
- dec Cl- secretion and inc Na+ absorption leads to reduced water secretion and thickened mucus
What is the management of cystic fibrosis?
- chest physio: clear mucus
- exercise: improve resp function
- high calorie + fat diet: malabsorption
- bronchodilators: salbutamol
What is pneumonia?
- infection of lung tissue and inflammation
- causes inflammation and sputum in airways and alveoli
- community, hospital acquired or aspiration
What are the symptoms of pneumonia?
- wet, productive cough
- high fever
- inc work of breathing
- lethargy and delirium
What chest signs present with pneumonia (of consolidation)?
- harsh bronchial breath sounds
- focal coarse crackles + wheeze
- dullness to percussion
What are signs of pneumonia?
- tachycardia
- tachypnoea
- hypoxia
- hypotension
- confusion
What investigations are done for pneumonia?
- CXR
- sputum cultures and throat swabs
- viral PCR
- blood culture if septic
- capillary BG if unwell
What are the bacterial causes of pneumonia?
- S. pneumoniae
- Group A strep
- S. aureus
- Mycoplasma pneumoniae
Which bacteria cause pneumonia in prevaccinated children?
- Group B strep
- H. influenza
What are viral causes of pneumonia?
- RSV
- parainfluenza virus
- influenza virus
How is pneumonia managed?
- amoxicillin
- add a macrolide e.g. erythromycin
- IV Abx if sepsis
- O2 above 92%
What is the management of children with recurrent admission for LRTI?
- FBC
- CXR
- serum immunoglobulins
- IgG
- sweat test
- HIV test
Which bacteria is epiglottitis typically caused by?
- haemophilus influenza type B
What is epiglottitis?
- inflammation and swelling of the epiglottis
How does epiglottitis present?
- sore throat
- stridor
- drooling
- tripod position
- high fever
- painful swallow
- muffled voice
How is epiglottitis investigated?
- lateral X-ray of neck
- thumb(print) sign
- soft tissue shadow looks like thumb pressed into trachea
- caused by oedematous and swollen epiglottis
How is epiglottitis managed?
- don’t examine and don’t upset
- distress could prompt airway closure
- secure airway
- prepare to intubate at any time
What medical management is there for epiglottitis?
- IV Abx (ceftriaxone)
- steroids (dexamethasone)
What is the prognosis of epiglottitis?
- most recover without intubation
- epiglottic abscess
What is whooping cough?
- URTI
- caused by Bordetella pertussis
What type of bacteria is Bordetella pertussis?
- gram negative coccobacillus
What are the initial symptoms of whooping cough?
- mild coryza symptoms
- low grade fever
- paroxysmal cough
What is paroxysmal cough?
- sudden and recurring fits with cough free periods
How does whooping cough present after a week?
- paroxysmal cough
- severe fits > loud inspiratory whoop
What are the complications of severe coughing fits in whooping cough?
- fainting
- vomiting
- pneumothorax
How do infants present in whooping cough?
- sometimes without whoop
- with apnoea
How is whooping cough diagnosed?
- nasopharyngeal or nasal swab
- PCR testing or bacterial culture
- if >2 weeks then test for anti-pertussis toxin IgG
How is whooping cough managed?
- supportive care
- notify PHE
- macrolide Abx e.g. clarithromycin if presenting within 21 days
What is a key complication of whooping cough?
- bronchiectasis
What is bronchopulmonary dysplasia?
- infants who still require oxygen at an age of 36 weeks
What is the cause of bronchopulmonary dysplasia?
- lung damage
- from pressure and volume trauma of artificial ventilation, oxygen toxicity and infection
What is seen on CXR in bronchopulmonary dysplasia?
- widespread opacification
- cystic changes
- fibrosis
How is bronchopulmonary dysplasia treated?
- weaning onto CPAP
- additional oxygen where needed
- prophylactic palivizumab for bronchiolitis
