Paediatric Respiratory Flashcards
What is acute epiglottitis?
rare
serious infection caused by haemophilus influenzae type B.
treat quick or airway obstruction.
used to be childhood in uk but now more common in adults because of immunisation programme.
decreased since HiB vaccine
features of acute epiglottitis?
rapid onset
high temp, generally unwell
stridor
drooling of saliva
“tripod” position : pt finds it easier breathing if learning forward and extending neck in seated position
how would you diagnose acute epiglottitis?
direct visualisation by senior airway staff.
x-ray poss? esp if concerned about foreign body:
- lateral vein in acute epiglottitis will show swelling of epiglottis - the thumb sign
a posterior-anterior view in croup will show subglottic narrowing - steeple sign
how would you manage acute epiglottitis?
oxygen
iv abx
senior involvement - emergency airway support - anesthetics, ent
ENDOTRACHEAL INTUBATION might needed to protect airway.
if suspected dont examine throat due to risk of acute airway obstruction.
only done by senior staff that can intubate if needed.
what is the epiglottis?
The epiglottis is a flap of cartilage located in the throat that prevents food and liquid from entering the lungs while swallowing
What is croup?
URTI in infants+toddlers.
characteristed by stridor caused by combo of laryngeal oedema and secretions.
PARAINFLUENZA VIRUSES account for most cases.
epidemiology of croup
peak incidence at 6mnths-3yrs
autumn more common
features of croup
cough - barking seal like. worse at night
stridor - dont examine throat due to risk of airway obstruction
fever
coryzal sx
increased work of breathing eg retraction
when would you consider admitting a child with croup?
moderate or severe croup
under 3 months
known upper airway abnormalities like downs or laryngomalacia
uncertainty of diagnosis - differentials are: acute epiglottitis, bacterial tracheitis, peritonsillar abscess and foreign body inhalation)
how would you investigate croup?
clinically mostly
if cxr:
posterior anterior view would show subglottic narrowing - steeple sign
in acute epiglottitis an anterior view would show the thumb sign - swelling of epiglottitis
how would you manage croup?
single dose of oral dexamethasone - 0.15mg/kg to all kids regardless of severity
prednisolone alternative if dex not available
grading the severity of croup
mild
moderate
severe
mild:
ocassional barking cough
no audible stridor at rest
no/mild suprasternal and/or intercostal recession
happy child - eat drink play
moderate:
frequent barking cough
easily audible stridor at rest (indication for admission)
-suprasternal and sternal wall retraction at rest
-no/little distress or agitation
- child can be placated and is interested in surroundings
severe:
frequent barking cough
prominent inspiratory/poss expiratory strioder @ rest
marked sternal wall retrctions
tachycardia with more seveere obstructive sx and hypoxeia
signficant distress and agitation, or lethargy or restlessness (sign of hypoxaemia)
how can wheezes be divided?
episodic viral: only when pt has URTI and is sx free inbetween episodes
multiple trigger wheeze: aswell as URTI other factors trigger it like exercise, allergens , cigarette smoke
is episodic viral wheeze associated with an increase risk of asthma in later life?
NO !!!
but a proportion that have multiple trigger wheeze will develop asthma
how would you managed episodic viral wheeze?
encourage parents to stop smoking
symptomatic tx
1st like: salbutamol - short acting beta 2 agonist . or anticholinergic via a spacer.
next step:
intermittent leukotreine receptor antagonist (montelukast) , intermittent inhaled corticosteroids (beclamethasone), or boht
little role for oral pred in kids that dont need hospitalising.
how would you treat multiple trigger wheeze?
tell parents stop smoking
trial either inhaled corticosteroids (beclamethasone) or leukotreine receptor antagonist - montelukast
for 4-8 weeks.
What is pneumonia?
any inflammatory condition affecting alveoli of the lungs, usually secondary to bacterial infection but can be viral/fungal too.
causes of pneumonia
bacterial - MC
viral
Fungal - eg pneumocystic jiroveci
what is the most common cause of pneumonia?
tell me a little about it
streptococcus pneumonia - pneumococcus - bacteria
80% pts
high fever
rapid onset
herpes labialis
vaccine for pneumococcus available
tell me all bacterial causes of pneumonia
streptococcus pneumoniae
haemophilus influenzae - copd pts
staphylococcus aureus - pt following influenze infection
mycoplasma pneumoniae - atypical. dry cough and atypical chest signs/xray : autoimmune haemolytic anemia, erythema multiforme could be seen
legionella pneumophilia - atypical pneumonia.
hyponatremia and lymphopenia common.
classic secondary to infected AC unit.
klebsiella pneumonia - alcholics
tell me the fungal cause of pneumonia
pneumocystis jiroveci -
hiv pts
dry cough
exercise-induced desaturations
absence of chest signs
what is idiopathic interstitial pneumonia
non-infective cause of pneumonia
eg’s:
cryptogenic organising pneumonia - form of bronchiolitis : comp of : RA or amiodarone therapy.
SYMPTOMS OF PNEUMONIA
COUGH
SPUTUM (purulent - rust coloured/bloodstained)
DYSPNOEA
CHEST PAIN : POSS PLEURITIC
FEVER
malaise
SIGNS OF PNEUMONIA
SIGNS OF SYSTEMIC INFLAMMATORY RESPONSE: fever tachycardia
reduced oxygen saturations - below 95% or below 88% in COPD pts
tachypnoea
auscultation:
reduced breath sounds
bronchial breathing
crepitations/crackles
dullness on percussion (fluid)
community vs hospital acquired pneumonia
difference
why is that even important?
most within community - CAP
within hospital 48hrs or more after admission: HAP.
causative organisms diff and therefore 1st line abx is different.
investigating pneumonia
cxr : consolidation (opacity on xray film in area of infection) - possibly effusion too
bloods:
fbc - neutrophilia in bacterial infection
u+e : check for dehydration - U for urea in curb 65
other changes in atypical pneumonia
CRP: raised in response to infection
blood cultures
sputum sample: causative organism after culture
ABG: if ox sats are low or if pt has pre-existing resp disease : COPD
check legionella antibodies - in intermediate/high risk pts
what is the scoring system to risk stratify pneumonia patients? (primary care)
CRB 65
IN PRIMARY CARE ITS CRB-65 because u cant get serum urea result
C - confusion - AMTS (abbreviated mental test score) - less than or equal to 8/10
U
R - RR 30 or more /min
B- bp - systolic less than or equal to 90 and/or diastolic less than or equal to 60 mmHg
65 - AGE EQUAL TO OR MORE THAN 65
interpreting crb 65 score (primary care)
home based care if crb65 is 0 - oral abx - amoxicillin 1st line
1-2: intermediate risk - 1-10% mortality
3/4 : high risk - 10% + mortaility
hospital assessment for all other pts - particularly if score 2 or more
if crp is less than 20 mg/L : no abx
if 20-100 - delayed abx prescription
if over 100 - abx
CURB 65 - hospital
c - confusion - amts - <=8/10
u - urea>7 mmol/L
r - rr >=30/min
b - bp <= 90/60
65 - age>=65
home based care if : 0/1 - low risk - <3% mortality
hospital-based care - 2+ - intermediate risk - 3-15% mortality
intensive care assessment if 3+ - high risk - 15%+ mortality risk
risk factors of pneumonia
under 5 or over 65
smoking
ivdu
recent viral RTI
chronic resp disease: CF, COPD
immunosuppression: cytotoxic drug therapy , HIV
pt risk of aspiration : parkinsons , oesophageal obstruction
non resp co-mordity: DM, CV disease
pathophysiology of pneumonia
pathogen enters lower resp tract.
starts inflammatory cascade.
neutrophils migrated to infected alveoli.
release cytokines - active immune response. induce fever.
accumulation of lfuid and pus in alveoli.
impairs gas exchange
= leads to hypoxic state = characteristic of pneuomonia.
management of pneumonia
low severity CAP:
- amoxicillin - 1st line
if allergy: macrolide (erythromcycin) /tetracycline
5 day course of abx.
moderate/high severity CAP:
- 7-10 day course
- beta-lactamase penicillin : coamoxiclav, ceftriaxone/piperacillin with tazobactam and a macrolide.
what is the discharge criteria for pneumonia pt ?
you cant if in the last 24 hrs they have 2 or more of:
- temp higher than 37.5
- rr 24 breaths per min or more
HR over 100 bpm
systolic bp: 90 or less
ox sats 90 % O/A
abnormal mental status
inability to eat without assistane
what do doctors tell pts about symptoms clearing up?
1 wk - fever resolved
4wk - chest pain/sputum reduced
6wk - cough and breathless reduced
3mths - most sx resolves - fatigue poss
6mth- normal
when should you repeat CXR in pneumonia pts?
why?
cxr at 6 weeks after clinical resolution.
make sure consolidation resolved.
no underlying secondary abnormality - eg lung tumour.
what is the most likely causative agent in bacterial pneumonia in children?
s.pneumoniae
treatment of pneumonia in kids
amox - 1st line
macrolides (erythromcyin) added if no response to above.
macrolides : if mycoplasma or chlamydia suspected
in pneumonia with influenza: co-amoxiclav
What is Mycoplasma Pneumoniae?
cause of atypical pneumonia affecting younger pts.
epidemics of it usually occur every 4 yrs.
associated with erythema multiforme + cold autoimmune haemolytic anaemia.
may not respond to penicillin’s or cephalosporins because it lacks peptidoglycan cell wall.
features of mycoplasma pneumoniae
disease typically prolonged and gradual onset
flu-like sx classically precede dry cough
bilateral consolidation on x-ray
complications might occur as below
investigations of mycoplasma pneumoniae
diagnosis generally by mycoplasma serology
positive cold agglutination test = peripheral blood smear may show rbc agglutination
Management of mycoplasma pneumoniae
doxycycline
or
macrolide (erythromcyin/clarithromycin)
difference between legionella pneumonia and mycoplasma pneumonia
legionella : lymphopenia
mycoplasma: haemolytic anaemia/ITP
legionella: hyponatremia
mycoplasma: erythema multiforme. encephalitis/GBS. peri/myocarditis.
legionella: diagnosis - urinary antigen
mycoplasma pneumonia: diagnosis - serology
similarities of legionella and mycoplasma pneumoniae
atypical pneumonia
flu-like sx
dry cough
deranged lfts
treat with macrolide - erythromycin
what is aspiration pneumonia?
pneumonia caused by foreign materials gaining entry into bronchial tree - usually oral/gastric contents : food and saliva.
depending on acidity of aspirate, a chemical pneumonitis can happen - and bacterial pathogens adding to the inflammation.
how can aspiration pneumonia happen?
incompetent swallowing mechanism like in stroke,MS, intoxication.
or iatrogen causes: intubation.
risk factors of aspiration pneumonia
poor dental hygiene
swallowing difficulties
prolonged hospitalisation or surgical procedures
impaired consciousness
impaired mucociliary clearance