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3A > Paediatric Respiratory > Flashcards

Paediatric Respiratory Flashcards

1
Q

What is croup?

A

Laryngotracheobronchitis - an upper respiratory tract infection causing oedema and inflammation of the larynx.

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2
Q

What is the most common cause of croup?

A

Parainfluenza virus type 1 and 3
Other causes include influenza, adenovirus and respiratory syncytial virus

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3
Q

How does croup present?

A

Seal-like barking cough
Hoarse voice
Stridor
Respiratory distress

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4
Q

How is croup diagnosed?

A

Clinical diagnosis
May do chest x ray to exclude foreign objects
X-ray will show steeple sign (narrowed trachea)

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5
Q

How is croup treated

A

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

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6
Q

Complications of croup

A

Otitis media, dehydration, superinfection (e.g. pneumonia)

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7
Q

What is acute epiglottitis

A

Inflammation and oedema of the airway leading to narrowing of the supraglottic aperture- can lead to complete airway obstruction

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8
Q

What age group are typically affected by croup?

A

6 months to 3 years

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9
Q

What time of year is croup common?

A

Late autumn winter

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10
Q

What age group are commonly affected by epiglottitis

A

Ages 1 -6

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11
Q

What is the most common cause of epiglottitis

A

Haemophilus influenza type B

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12
Q

How does epiglottitis present?

A

Acutely ill child
Fever
Can’t speak or swallow
Drooling
Tripoding position (hands on knees)
Hoarse voice - hot potato voice

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13
Q

How should epiglottitis me diagnosed?

A

Do not examine! - can cause complete airway obstruction
Usually treatment is commenced immediately
May X ray to rule out foreign body - shows thumb sign

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14
Q

Treatment of epiglottitis

A

O2
Nebulised adrenaline
IV antibiotics - ceftriaxone
May need to intubate or tracheotomy

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15
Q

What is bronchiolitits

A

Viral infection of the bronchioles

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16
Q

What is the most common cause of bronchiolitis?

A

Respiratory syncytial virus

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17
Q

Who is commonly affected by bronchiolitis

A

Children under 2

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18
Q

When is bronchiolitis most common?

A

Winter and spring

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19
Q

Risk factors for bronchiolitis

A

Breastfeeding < 2 months
Smoke exposure
Older sibling in nursery or school
Chronic lung disease of prematurity

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20
Q

Presentation of bronchiolitis

A

May have coryzal prodrome
Low grade fever
Cough
Tachypnoea
Wheeze
Poor feeding
Signs of resp distress- nasal flaring, tracheal tug, head bobbing, grunting

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21
Q

Diagnosis of bronchiolitits

A

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

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22
Q

What are some signs of respiratory distress in paediatrics?

A

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

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23
Q

Which children with bronchiolitis should be admitted?

A
  • 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)
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24
Q

Management of bronchiolitis?

A

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

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25
Q

What ventilatory support may be given to infants with bronchiolitis?

A

High flow humidified oxygen (adds PEEP- positive end-expiratory pressure)
CPAP
Intubation and ventilation

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26
Q

Signs of poor ventilation on capillary blood gas

A

Rising CO2
Falling pH

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27
Q

What may be given to prevent bronchiolitis in certain infants?

A

Palivisumab vaccination

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28
Q

What is palivisumab

A

It is a monoclonal antibody to RSV which is given as a monthly injection to prevent against bronchiolitis

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29
Q

Which infants may be given palivisumab?

A

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

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30
Q

What is a potential severe complication of bronchiolitis

A

Bronchiolitis obliterans - permanent damage to the airways

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31
Q

What is viral induced wheeze

A

An acute wheezy illness triggered by viral infection

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32
Q

Why do children get viral induced wheeze?

A

Because they have smaller airways so the inflammation and oedema caused by viral illness can cause a large restriction in airflow

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33
Q

Who is most commonly affected by viral induced wheeze?

A

Children under the age of 6 - usually under 3

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34
Q

What are the two types of viral induced wheeze

A

Episodic viral wheeze and multi-trigger wheeze

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35
Q

Describe episodic viral wheeze

A

Wheezing that occurs just when there is clinical evidence of a upper respiratory tract infection- there will be absence of symptoms between these periods

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36
Q

Describe multi-trigger wheeze

A

Discrete exacerbations of wheezing but also symptoms of wheezing in between episodes which my be associated with triggers such as allergens, emotions and activity

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37
Q

What can be used to predict the development of asthma in viral induced wheeze?

A

The asthma predicative index

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38
Q

Explain the asthma predictive index

A

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

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39
Q

Acute treatment of viral induced wheeze

A

Same as asthma:
- salbutamol
- ipatropium bromide if severe
- oral steroids

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40
Q

Long term treatment of viral induced wheeze

A
  • salbutamol in exacerbations
  • if multi-trigger consider inhaled corticosteroids if >4 episodes a year.
  • If no response to corticosteroids can try LTRA
41
Q

What is asthma

A

A chronic respiratory disorder characterised by paroxysmal constriction of the airways

42
Q

RF for asthma

A

Genetic predisposition
Atopic increases risk
Low birth weight and prematurity
Parental smoking
Viral bronciolitis in early life

43
Q

Triggers for asthma

A

Cold air, UPTI, allergens, chemical irritants, activities, emotional upsets, parental smoking

44
Q

How does asthma present

A

Episodic wheeze that is often worse at night
Dry cough
Shortness of breath

45
Q

How is asthma diagnosed?

A

Spirometry - shows an obstructive pattern- reversible with bronchodilators
Chest x ray shows hyperinflation
Peak flow rate- shows variation

46
Q

Results of spirometry in asthma

A

FEV1 reduced
FVC normal
FEV1/FVC - <70%
Reversible

47
Q

Management of asthma

A

Step 1: salbutamol (SABA)
Step 2: add inhaled corticosteroids (budesonide)
Step 3: add a long acting beta-2 antagonist (Salmeterol)
Step 3: increase steroid dose and add leukotriene receptor antagonist or oral theophylline
Step 4: increase steroid dose and refer to specialist

48
Q

Management of acute asthma attack

A

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

49
Q

Signs of moderate asthma exacerbation

A

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)

50
Q

Signs of acute severe asthma exacerbation

A

Peak flow < 50% of predicted
SPO2< 92%
Unable to complete sentences
Resp rate >40 (3-5), >30 (>5)
HR >140 (1-5), >125 (>5)

51
Q

Signs of life threatening asthma exacerbation

A

Peak flow <33%
SpO2 <92%
Silent chest
Cyanosis
Hypotension
Poor resp effor
Confusion
Exhaustion

52
Q

What is whooping cough caused by?

A

Bordatella perstussis ( a gram negative bacteria)

53
Q

How does whooping cough present?

A

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

54
Q

Diagnosis of whooping cough

A

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

55
Q

Management of whooping cough

A

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

56
Q

Complication of whooping cough

A

Bronchiectasis

57
Q

Presentation of pneumonia in children

A

Cough
High fever
Tachypnoea
Tachycardia
Increased work of breathing
Lethargy
Confusion
Cyanosis

58
Q

characteristic signs of pneumonia on examination

A

Bronchial breath sounds
Focal coarse crackles
Dullness to percussion

59
Q

Causes of pneumonia in newborns

A

Organisms from the mothers genital tract- group B strep, gram negative enterococci

60
Q

Bacterial causes of pneumonia in infants and young children

A

Strep pneumoniae
Haemophilus influenzae
Staph aureus
Chlamydia

61
Q

Causes of pneumonia in children over 5

A

mycoplasma pneumoniae, strep pneumoniae

62
Q

Which microorganism may cause an atypical pneumonia with extra-pulmonary manifestation such as erythema multiforme

A

Mycoplasma pneumoniae

63
Q

Viral causes of pneumonia

A

RSV, parainfluenza virus, influenze

64
Q

Diagnosis of pneumonia

A

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

65
Q

Management of pneumonia

A
  • 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
66
Q

Indication that a child with pneumonia need to be admitted

A
  • 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
67
Q

What is the inheritance of cystic fibrosis

A

Autosomal recessive

68
Q

Genetic mutation in CF

A

mutation of the cystic fibrosis transmembrane conductance regulatory (CFTR) gene on chromosome 7
Most commonly the delta F508 mutation

69
Q

Pathophysiology of cystic fibrosis

A

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

70
Q

How may CF present in a newborn

A

Meconium ileus- failure to pass Meconium within 24 hours . May also have abdominal distention and vomiting

71
Q

How may CF present in children

A

Recurrent lower respiratory tract infections
Failure to thrive
Pancreatitis

72
Q

Symptoms of cystic fibrosis

A
  • 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
73
Q

Causes of clubbing in children

A

Cyanotic heart disease
Infective endocarditis
Cystic fibrosis
Tuberculosis
Inflammatory bowel disease
Liver cirrhosis

74
Q

How is cystic fibrosis diagnosed

A

Usually picked up on newborn blood spot test
Sweat test is gold standard
Genetic testing during pregnancy can be done

75
Q

How does the sweat test for CF work ?

A

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.

76
Q

Which bacterial colonisers may affect children with cystic fibrosis

A

Staphylococcus aureus
Pseudomonas aeruginosa
Haemophilus influenza
Klebsiella pneumoniae
E.coli

77
Q

Management of cystic fibrosis

A
  • 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
78
Q

Management of cystic fibrosis

A
  • chest physiotherapy
    -exercise
  • high calorie diet
  • creon tablets (help digest fats with pancreatic deficiency)
79
Q

Complications of cystic fibrosis

A

Pancreatic insufficiency
- cystic fibrosis related diabetes
Liver disease
Infertility

80
Q

Median life expectancy of cystic fibrosis

A

47

81
Q

Why are most men with cystic fibrosis infertile

A

They have an absent vas deferens

82
Q

What does a normal pCO2 on acute asthma attack suggests

A

Life threatening asthma- suggests tiring of the patient as can no longer compensate with hyperventilating

83
Q

What are the most common causes of cardiac arrest in children

A

Respiratory causes such as bronchiolitis - leads to hypoxia

84
Q

What does sudden onset of a monophonic wheeze, particularly in the right lower lobe suggest?

A

Inhaled foreign body

85
Q

How is an inhaled foreign body diagnosed

A

Chest x ray

86
Q

How does an inhaled foreign body present

A

sudden shortness of breath, non productive cough, focal site chest findings such a monophonic wheeze in right lower lobe

87
Q
A
88
Q

What may be a cause of noisy breathing in infants who are otherwise well?

A

Laryngomalacia

89
Q

What is the best way to confirm pertussis diagnosis

A

Per nasal swab

90
Q

Chronic infection with which organism is a contraindication to lung transplant if CF

A

Burkholderia cepacia

91
Q

What is the treatment of whooping cough

A

azithromycin or clarithromycin if presentation within previous 21 days

92
Q

What treatment should be given to all children who have an asthma attack

A

steroids post attack- oral pred 40 mg for 5 days

93
Q

what is the most appropriate investigation to confirm suspected acute epiglotittis

A

direct visualisation of inflammed tissue from a senior anaesthetist

94
Q

What sign of croup indicate for admission

A

audible stridor at rest

95
Q

If croup is still not controlled with oral dexamethasone what should be used next?

A

oxygen and nebulised adrenaline

96
Q

What type of reaction is asthma

A

type I hypersensitivity reaction

97
Q

How can the features of life threatening asthma be remembered

A

33,92 CHEST
Cyanosis
hypotension
exhaustion
silent chest
tachyarrhythmias

98
Q
A

3A (32 decks)

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