Paediatric Respiratory Flashcards
What is croup?
Laryngotracheobronchitis - an upper respiratory tract infection causing oedema and inflammation of the larynx.
What is the most common cause of croup?
Parainfluenza virus type 1 and 3
Other causes include influenza, adenovirus and respiratory syncytial virus
How does croup present?
Seal-like barking cough
Hoarse voice
Stridor
Respiratory distress
How is croup diagnosed?
Clinical diagnosis
May do chest x ray to exclude foreign objects
X-ray will show steeple sign (narrowed trachea)
How is croup treated
Single dose oral dexamethasone as soon as diagnosis made (0.15mg/kg/dose)
Other options if oral intake not possible- nebulised budesonide, IM dexamethasone
Can also give nebulised adrenaline if severe
Oxygen if resp distress
Complications of croup
Otitis media, dehydration, superinfection (e.g. pneumonia)
What is acute epiglottitis
Inflammation and oedema of the airway leading to narrowing of the supraglottic aperture- can lead to complete airway obstruction
What age group are typically affected by croup?
6 months to 3 years
What time of year is croup common?
Late autumn winter
What age group are commonly affected by epiglottitis
Ages 1 -6
What is the most common cause of epiglottitis
Haemophilus influenza type B
How does epiglottitis present?
Acutely ill child
Fever
Can’t speak or swallow
Drooling
Tripoding position (hands on knees)
Hoarse voice - hot potato voice
How should epiglottitis me diagnosed?
Do not examine! - can cause complete airway obstruction
Usually treatment is commenced immediately
May X ray to rule out foreign body - shows thumb sign
Treatment of epiglottitis
O2
Nebulised adrenaline
IV antibiotics - ceftriaxone
May need to intubate or tracheotomy
What is bronchiolitits
Viral infection of the bronchioles
What is the most common cause of bronchiolitis?
Respiratory syncytial virus
Who is commonly affected by bronchiolitis
Children under 2
When is bronchiolitis most common?
Winter and spring
Risk factors for bronchiolitis
Breastfeeding < 2 months
Smoke exposure
Older sibling in nursery or school
Chronic lung disease of prematurity
Presentation of bronchiolitis
May have coryzal prodrome
Low grade fever
Cough
Tachypnoea
Wheeze
Poor feeding
Signs of resp distress- nasal flaring, tracheal tug, head bobbing, grunting
Diagnosis of bronchiolitits
Investigations aren’t common
Pulse oximetry
May test nasopharyngeal secretions
Wouldn’t usually X-ray but if did it may show hyperinflation, air trapping and flattened diaphragm
What are some signs of respiratory distress in paediatrics?
Tachypnoea
Use of accessory muscles to breath (sternocleidomastoid, abdominal and intercostal muscles)
Intercostal and subcostal recessions
Nasal flaring
Head bobbing
Tracheal tug
Cyanosis
Abnormal airway noises
Which children with bronchiolitis should be admitted?
- aged under 3 months with a pre-existing condition such as prematurity, Down’s syndrome, cystic fibrosis
- 50-70% of their usual milk intake
- clinical dehydration
- resp rate above 70
- oxygen saturations less than 92%
- apnoeas and other signs of severe respiratory distress (deep recessions, head bobbing)
Management of bronchiolitis?
Ensure fluid intake- may need NG tube or IV fluids
Supplementary oxygen - humidified nasal cannula or head box
Saline nasal drops and nasal suctioning
Ventilatory support if required
What ventilatory support may be given to infants with bronchiolitis?
High flow humidified oxygen (adds PEEP- positive end-expiratory pressure)
CPAP
Intubation and ventilation
Signs of poor ventilation on capillary blood gas
Rising CO2
Falling pH
What may be given to prevent bronchiolitis in certain infants?
Palivisumab vaccination
What is palivisumab
It is a monoclonal antibody to RSV which is given as a monthly injection to prevent against bronchiolitis
Which infants may be given palivisumab?
Infants born before 29 weeks
Premature infants who have Chronic lung disease of prematurity and had a >21% oxygen requirement at least 28 days after birth
Infants with congenital heart diseases
Infants with neuromuscular and pulmonary diseases
Infants who are severely immunocompromised during RSV season
What is a potential severe complication of bronchiolitis
Bronchiolitis obliterans - permanent damage to the airways
What is viral induced wheeze
An acute wheezy illness triggered by viral infection
Why do children get viral induced wheeze?
Because they have smaller airways so the inflammation and oedema caused by viral illness can cause a large restriction in airflow
Who is most commonly affected by viral induced wheeze?
Children under the age of 6 - usually under 3
What are the two types of viral induced wheeze
Episodic viral wheeze and multi-trigger wheeze
Describe episodic viral wheeze
Wheezing that occurs just when there is clinical evidence of a upper respiratory tract infection- there will be absence of symptoms between these periods
Describe multi-trigger wheeze
Discrete exacerbations of wheezing but also symptoms of wheezing in between episodes which my be associated with triggers such as allergens, emotions and activity
What can be used to predict the development of asthma in viral induced wheeze?
The asthma predicative index
Explain the asthma predictive index
Children under 3 who have had 4 or more episodes of wheeze in ten past year are more likely to have asthma after 5 years if they have one major or two minor factors.
Major- parents with asthma, eczema, sensitivities to air allergens (RAST or skin prick test)
Minor- food allergies, more than 5% blood eosinophils, wheezing apart from colds
Acute treatment of viral induced wheeze
Same as asthma:
- salbutamol
- ipatropium bromide if severe
- oral steroids
Long term treatment of viral induced wheeze
- salbutamol in exacerbations
- if multi-trigger consider inhaled corticosteroids if >4 episodes a year.
- If no response to corticosteroids can try LTRA
What is asthma
A chronic respiratory disorder characterised by paroxysmal constriction of the airways
RF for asthma
Personal or family history of atopy
Low birth weight and prematurity
maternal smoking during pregnancy
Parental smoking
Viral bronciolitis in early life
pollution
Triggers for asthma
Cold air, UPTI, allergens, chemical irritants, activities, emotional upsets, parental smoking
How does asthma present
Episodic wheeze that is often worse at night
Dry cough
Shortness of breath
How is asthma diagnosed in over 5s?
1- spirometry and bronchodilator reversibility test (>12% improvement= +ve)
If positive = asthma
If negative:
1- FeNO -> fraction of exhaled nitric oxide test (>35 = +ve)
2- peak flow variability (>20%= +ve)
IF both positive= asthma
Results of spirometry in asthma
FEV1 reduced
FVC normal
FEV1/FVC - <70%
Reversibility of at least 12 % improvement with bronchodilator
Management of asthma in over 5s
Step 1: salbutamol (SABA)
Step 2: add inhaled corticosteroids (budesonide)
Step 3: add LTRA (SABA+ ICS + LTRA)
Step 3: swap LTRA for LABA (SABA + ICS + LABA)
Step 4: SABA + MART (low dose)
step 5: SABA + MART (medium dose)
Management of acute asthma attack
1.Give high flow oxygen
2. Salbutamol inhalers with spacer- 10 puffs ever 2 Horus
3. Nebulised salbutamol
4. Nebulised ipatropium bromide
5. Oral prednisolone
6. IV hydrocortisone
7. IV magnesium sulphate
8. IV salbutamol
9. IV aminophylline
Signs of moderate asthma exacerbation
Peak flow >50% of predicted
SpO2 >92%
Able to talk in sentences
HR <140 (2-5) and <125 (>5 years)
RR <40 (3-5) and <30 (>5)
Signs of acute severe asthma exacerbation
Peak flow < 50% of predicted
SPO2< 92%
Unable to complete sentences
Resp rate >40 (3-5), >30 (>5)
HR >140 (1-5), >125 (>5)
Signs of life threatening asthma exacerbation
Peak flow <33%
SpO2 <92%
Silent chest
Cyanosis
Hypotension
Poor resp effor
Confusion
Exhaustion
What is whooping cough caused by?
Bordatella perstussis ( a gram negative bacteria)
How does whooping cough present?
A mild coryzal prodrome with low grade fever and mild dry cough
Paroxysmal phase- a period of 1-6 weeks of rapid violent coughing fits
Coughing may be severe enough to make the child faint, vomit or even develop a pneumothorax
There will be a large, loud inspiratory whoop sound after coughing ends to inhale oxygen
Infants may have apnoeas instead
Diagnosis of whooping cough
Nasopharyngeal or nasal swab for PCR testing or bacterial culture
-Can confirm within 2-3 weeks of onset of symptoms
If longer than 2 weeks then testing for anti-pertussis toxin immunoglobulin G can be done- tested in oral fluid between 4-16 and blood >17
Management of whooping cough
Notifiable disease- tell public health England
Supportive care
Admission if acutely unwell, under the age of 6, or presenting with apnoeas and cyanosis
Macrolide antibiotic (e.g azithromycin, erythromycin) may be used if early stages (first 21 days)
Prophylactic antibiotics for close contacts that are vulnerable
Complication of whooping cough
Bronchiectasis
Presentation of pneumonia in children
Cough
High fever
Tachypnoea
Tachycardia
Increased work of breathing
Lethargy
Confusion
Cyanosis
characteristic signs of pneumonia on examination
Bronchial breath sounds
Focal coarse crackles
Dullness to percussion
Causes of pneumonia in newborns
Organisms from the mothers genital tract- group B strep, gram negative enterococci
Bacterial causes of pneumonia in infants and young children
Strep pneumoniae
Haemophilus influenzae
Staph aureus
Chlamydia
Causes of pneumonia in children over 5
mycoplasma pneumoniae, strep pneumoniae
Which microorganism may cause an atypical pneumonia with extra-pulmonary manifestation such as erythema multiforme
Mycoplasma pneumoniae
Viral causes of pneumonia
RSV, parainfluenza virus, influenze
Diagnosis of pneumonia
Chest x ray (not routinely required)
Sputum cultures, throat swabs, bacterial culture and viral PCR to establish causative agent
Capillary blood gas if unwell to monitor respiratory acidosis
Blood cultures if concern about sepsis
Management of pneumonia
- amoxicillin = first line
Add macrolide (e.g. erythromycin or clarithromycin) if concern for atypical
May need IV if severely unwell- co-amoxiclav
IV fluids
Oxygen
Indication that a child with pneumonia need to be admitted
- hypoxaemia <92%
- sever dehydration
- Toxic appearance
- moderate to severe resp distress (RR >70 for infants, >50 for older, recessions, flarring etc)
- underlying conditions (e.g neuromuscular)
- complication such as effusion
- failure of outpatient therapy
What is the inheritance of cystic fibrosis
Autosomal recessive
Genetic mutation in CF
mutation of the cystic fibrosis transmembrane conductance regulatory (CFTR) gene on chromosome 7
Most commonly the delta F508 mutation
Pathophysiology of cystic fibrosis
Mutation in the CFTR which a protein channel which transmits chloride
Leads to thick sticky secretions in different locations of the body:
- pancreatic and biliary secretions- caused blocking of the ducts and reduced pancreatic and digestive enzymes
- airway secretions - damages ciliary function causing reduced airway clearance and bacterial colonisation
How may CF present in a newborn
Meconium ileus- failure to pass Meconium within 24 hours . May also have abdominal distention and vomiting
How may CF present in children
Recurrent lower respiratory tract infections
Failure to thrive
Pancreatitis
Symptoms of cystic fibrosis
- chronic cough
- thick sputum
- recurrent resp tract infections
- steathorrea
- abdominal bloating and pain
- salty taste when parents kiss them
- failure to thrive (poor weight and height gain)
- finger clubbing
Causes of clubbing in children
Cyanotic heart disease
Infective endocarditis
Cystic fibrosis
Tuberculosis
Inflammatory bowel disease
Liver cirrhosis
How is cystic fibrosis diagnosed
Usually picked up on newborn blood spot test
Sweat test is gold standard
Genetic testing during pregnancy can be done
How does the sweat test for CF work ?
Pilocarpine is applied to a patch of skin
Electrodes are placed either side of the patch and a current is passed between
This causes the skin to sweat
Sweat is collected by gauze and sent to lab for chloride concentrations to be measured
Chloride above 60mmol/l is diagnostic.
Which bacterial colonisers may affect children with cystic fibrosis
Staphylococcus aureus
Pseudomonas aeruginosa
Haemophilus influenza
Klebsiella pneumoniae
E.coli
Management of cystic fibrosis
- chest physiotherapy
-exercise - high calorie diet
- creon tablets (help digest fats with pancreatic deficiency)
- prophylactic antibiotics (flucloxacillin)
- bronchodilators such as salbutamol
- nebulised hypertonic saline
-fertility treatment
Management of cystic fibrosis
- chest physiotherapy
-exercise - high calorie diet
- creon tablets (help digest fats with pancreatic deficiency)
Complications of cystic fibrosis
Pancreatic insufficiency
- cystic fibrosis related diabetes
Liver disease
Infertility
Median life expectancy of cystic fibrosis
47
Why are most men with cystic fibrosis infertile
They have an absent vas deferens
What does a normal pCO2 on acute asthma attack suggests
Life threatening asthma- suggests tiring of the patient as can no longer compensate with hyperventilating
What are the most common causes of cardiac arrest in children
Respiratory causes such as bronchiolitis - leads to hypoxia
What does sudden onset of a monophonic wheeze, particularly in the right lower lobe suggest?
Inhaled foreign body
How is an inhaled foreign body diagnosed
Chest x ray
How does an inhaled foreign body present
sudden shortness of breath, non productive cough, focal site chest findings such a monophonic wheeze in right lower lobe
What may be a cause of noisy breathing in infants who are otherwise well?
Laryngomalacia
What is the best way to confirm pertussis diagnosis
Per nasal swab
Chronic infection with which organism is a contraindication to lung transplant if CF
Burkholderia cepacia
What is the treatment of whooping cough
azithromycin or clarithromycin if presentation within previous 21 days
What treatment should be given to all children who have an asthma attack
steroids post attack- oral pred 40 mg for 5 days
what is the most appropriate investigation to confirm suspected acute epiglotittis
direct visualisation of inflammed tissue from a senior anaesthetist
What sign of croup indicate for admission
audible stridor at rest
If croup is still not controlled with oral dexamethasone what should be used next?
oxygen and nebulised adrenaline
What type of reaction is asthma
type I hypersensitivity reaction
How can the features of life threatening asthma be remembered
33,92 CHEST
Cyanosis
hypotension
exhaustion
silent chest
tachyarrhythmias
what should reversibility of bronchodilator suggests asthma ?
at least 12%
what is the discharge criteria post asthma attack?
salbutamol only needed 3-4 hourly
PEF > 75%
SpO2> 94%
what is a low dose paediatric ICS dose?
less than 200 micrograms
what is a moderate dose paediatric ICS dose?
200-400 micrograms
what is a high dose paediatric ICS?
> 400 micrograms
give an example of an ICS
budesonide
Give an example of a LTRA
montelukast
What peak flow variability is suggestive of asthma
> 20% variability
Management of asthma in under 5s
1- salbutamol
2- salbutamol plus a 8 week trial of a moderate dose ICS
- if no improvement then likely a different diagnosis
- if recurrence within 4 weeks of stopping then try low dose ICS maintenance dose
- if recurrence after 4 weeks of stopping repeat 8 week trial
3- SABA + ICS +LTRA
4- specialist help
