Paediatric Respiratory Flashcards
What is pneumonia?
inflammatory condition affecting alveoli of the lungs
mc - secondary to bacterial infection
causes of pneumonia
bacterial - mc :
- streptococcus pneumoniae - 80%. high fever, rapid onset and herpes labialis. - vaccine available
- haemophilus influenzae - common in copd pts
- staph aureus - following influenza infection or pts with CF
mycoplasma pneumoniae - atypical pneumonia - dry cough and atypical chest signs/x ray finds. autoimmune haemolytic anaemia and erythema multiforme poss seen
legionella pneumophilia - atypica. hyponatremia and lymphopenia common. - secondary to infected air conditioning units.
klebsiella pneumoniae - alcoholics
pseudomonas aeruginosa - pt with CF or bronchiectasis
moraxella catarrhalis - in immunocompromised pts or those with chronic pulmonary disease
viral
fungal :
- pneumocystis jiroveci - seen in hiv pts. dry cough exercise induced desaturations and absence of chest signs
Characteristic Chest signs of pneumonia
bronchial breath sounds - harsh inspiratory and expiratory breath sounds) -
focal coarse crackles - caused by air passing through sputum in the airways
dullness to percussion - due to lung tissue filled with sputum or collapsed
What is idiopathic interstitial pneumonia?
non infective causes of pneumonia.
eg:
- cryptogenic organising pneumonia - form of bronchiolitis that might come as a comp of Rheumatoid arthritis or amiodarone therapy
CAP VS HAP
community : most pts.
if develop within 48 hrs or more of admission : hap
symptoms of pneumonia
cough
purulent sputum (rust coloured/blood stained)
dyspnoea
chest pain: poss pleuritic
fever
malaise
haemoptysis - cough up blood
delirium
signs of pneumonia
signs of systemic inflammatory response:
- fever
-tachycardia
- hypotension
-confusion
tachypnoea
reduced oxygen saturations (95% or below 88% in copd)
auscultation:
- reduced breath sounds
-bronchial breathing
-crepitations/crackles
dullness on percussion (fluid)
Investigations for pneumonia
chest x ray : consolidation - opacity on x ray film in area of infection
- poss effusion
bloods:
fbc - neutrophilia in bacterial infection (raised wbc)
urea and electrolytes:
- check for dehydration
crp: raised
blood culture
abg: if ox sats low or pt has pre-existing resp disease eg copd.
sputum sample: diagnose causative organism after culture.
legionella antibodies if intermediate-high risk pts.
Risk stratification for pneumonia
what to do based off what scores? in hospital
CURB-65
C - confusion - abbreviated mental test score 8 or less/10
U - urea over 7 mmol/l
R - resp rate 30 or more/min
B - bp stystolic 90 or less and diastolic 60 or less
65 - AGE 65 OR MORE
home based care: 0 or 1 - low risk - <3% mortality risk
hospital : 2 or more - intermediate risk - 3-15%
intensive care if 3 or more - high risk - 15% mortatility
With reference to crp, how do you assess whether to give abx to pneumonia pts or not?
crp under 20 - dont give abx
crp 20-100 - consider delayed abx prescription
crp over 100 mg/L - offer abx therapy
Risk factors of pneumonia
age under 5 or over 65
smoking
recent viral RTI
chronic resp diseases: cystic fibrosis and COPD
immunosuppression: cytotoxic drug therapy and HIV
ivdu
other non-resp co-morbidities: dm or cv
pt at risk of aspiration: those with neuro diseases such as Parkinson’s disease or those with oesophageal obstruction.
Pathophysiology of pneumonia
pathogen entered the lower respiratory tract, inflammatory cascade begins.
neutrophils migrate to infected alveoli.
release cytokines.
activate immune response and induce fever.
accumulation of fluid and pus within alveoli that impairs gas exchange,
leads to hypoxic state which is characteristic of pneumonia
pneumonia in children - mc cause
treatment in kids
s.pneumoniae - mc causative agent of bacterial pneumonia in kids
amox : 1st line
macrolides add if no response
macrolide: if mycoplasma or chlamydia suspected
in pneumonia with influenza: co-amoxiclav
characteristic features of pneumococcal pneumonia:
rapid onset
high fever
pleuritic chest pain
herpes labialis - cold sores
Mx of Pneumonia : CAP
low-severity CAP:
- amox - 1st line
- if penicillin allergic - macrolide or tetracycline
- 5 day course of abx.
Mx of moderate-high severity CAP:
- dual abx therapy with abx + macrolide
- 7-10 day course.
- beta-lactamase stable penicillin like co-amoxiclav, ceftriaxone or piperacillin with tazobactam and a macrolide in high severity.
Discharge Criteria for Pneumonia
if in the past 24 hrs they have had 2 or more of these cant discharge:
- temp over 37.5
- rr over 100 breathspm
- hr over 100 bpm
- systolic bp 90 or less
-ox sats under 90% on room air - abnormal mental status
- inability to eat without assistance.
how quick should symptoms resolve in pneumonia?
1 week - fever stop
4 week - chest pain and sputum reduced
6 week - cough and breathlessness reduced
3 months - most sx resolved poss still fatigue
6 months - normal
in pneumonia when should i repeat cxr after clinical resolution
6 weeks
ensure consolidation is resolved and no underlying secondary abnormalities eg lung tumour
What is mycoplasma pneumoniae?
atypical pneumonia - younger pts.
epidemic every 4 yrs approx.
why does atypical pneumonias not respond to penicillin’s or cephalosporins?
lack peptidoglycan cell wall
features of mycoplasma pneumonia
prolonged and gradual onset.
flu like sx classically precede a dry cough
bilateral consolidation: X-RAY
how would you investigate for a mycoplasma pneumoniae?
mycoplasma serology
positive cold agglutination test - peripheral blood smear may show rbc agglutination
management of mycoplasma pneumonia
doxycycline (tetracycline) or a macrolide - eg erythromycin/clarithromycin
or
fluoroquinolones - levofloxacin
Complications of mycoplasma pneumonia
- cold agglutins (IgM): may cause haemolytic anaemia, thrombocytopenia
- erythema multiforme, erythema nodosum
- meningoencephalitis, Guillain-Barre syndrome and other immune-mediated neurological diseases
- bullous myringitis: painful vesicles on the tympanic membrane
- pericarditis/myocarditis
gi: hepatitis, pancreatitis
renal: acute glomerulonephritis
What is legionella and tell me common how you get it?
caused by the intracellular bacterium legionella pneumophilia.
colonizes water tanks and qu might hint at air-conditioning systems or foreign holidays.
can cause SIADH leading to hyponat
features of legionella
flu-like sx including fever (over 95% pts)
dry cough
relative bradycardia
confusion
lymphopaenia
hyponatraemia
deranged lft
pleural effusion: seen in 30% pts
investigations fo legionella
urinary antigen - diagnostic
cxr : non specific:
- mid to lower zone predominance of patchy consolidation
-pleural effusions in around 30%
how to tx legionella
tx with erythromycin/clarithromycin
What is aspiration pneumonia?
happens because of foreign materials gaining entry to bronchial tree:
usually oral/gastric contents like food and saliva.
depending on acidity of aspiration a chemical pneumonitis can develop and bacterial pathogens adding to the inflammation.
Causes of aspiration pneumonia
due to incompetent swallowing mechanism like in neuro disease or injury like stroke, ms and intoxication.
iatrogenic: intubation
risk factors of aspiration pneumonia
poor dental hygiene
swallowing difficulties
prolonged hospitalisation or surgical procedures
impaired consciousness
impaired mucociliary clearance
more common sites affected for aspiration pneumonia
and why?
right middle and lower lung lobes- mc sites affected
because of the larger calibre and more vertical orientation of the right main bronchus
bacteria implicated in aspiration pneumonia
can be aerobic or anaerobic
aerobic:
- strept pneumoniae
-staph aureus
- haemophilus influenzae
- pseduomonas aeruginosa
-klebsiella: seen in aspiration lobar pneumonia in alcoholics
anaerobic:
-bacteroids
-prevotella
-fusobacterium
-peptostreptococcus
Tell me about pneumocystic jiroveci pneumonia : HIV
unicellular eukaryote
classified as a fungus but some say its a protozoa
PCP: mc opportunistic infection in AIDS
if cd4 count under 200/mm^3 - give pcp prophylaxis
features of pneumocystis jiroveci pneumonia
dyspnoea
dry cough
fever
very few chest signs
extrapulmonary signs: rare:
- hepatosplenomegaly
lymphadenopathy
choroid lesions
complication of PCP
pneumothorax
investigations in pneumocystis jiroveci pneumonia
CXR - bilateral interstitial pulmonary infiltrates but can present with other x ray findings: lobar consolidation. could be normal
Exercise- induced desaturation
sputum - usually fails to show pcp, bronchoalveolar lavage (bal) often needed to demonstrate pcp - silver stain - shows characterists cysts
mx of pneumocystis jiroveci pneumonia
co-trimoxazole
iv pentamidine - severe cases
aerosolized pentamidine - alternative - less effective with a risk of pneumothorax.
steroids - if hypoxic - po2 under 9.2kpa - steroids will reduce the risk of Resp failure by 50% and death by a 1/3
what might indicate sepsis secondary to pneumonia?
tachypnoea - raised resp rate
tachycardia - raised hr
hypoxia - low ox
hypotension- shock
fever
confusion
which cause for HAP?
methicillin-resistant staphyloccocus aureus - MRSA
atypical pneumonia causes
legions - legionella pneumophila
psittaci - chalmydia psittaci - contact with infected birds. parrot owner
m - mycoplasma
c-chlamydophila pneumoniae - mild-moderate chronic pneumonia and wheeze in school kid.
qs - q fever - coxiella burnetti - exposure to bodily fluids of animals. farmer with flu.
comps of pneumonia
sepsis
ards
pleural effusion
empyema
lung abscess
death
What is croup?
URTI
infants and toddlers
stridor caused by laryngeal oedema and secretions.
parainfluenza viruses account for most cases
epidemiology of croup
peak incidence: 6 months - 3yrs
mc : autumn
features of croup
cough - barking,seal like. worse at night
stridor - dont examine throat due to risk of precipitating airway obstruction
fever - low grade
coryzal symptoms
increased work of breathing: retraction
hoarse voice
mx of croup
single dose of oral dexamethasone - 0.15mg/kg - regardless of severity.
prednisolone alternative
emergency:
high flow ox
nebulised adrenaline/budesonide
ix of croup
clinical
cxr:
- posterior anterior view show subglottic narrowing - steeple sign
with suspected croup pt, who should you admit?
moderate or severe croup
under 3 months of age
known upper airway abnormalities eg - laryngomalacia, downs
uncertainty about diagnosis
differentials of croup
acute epiglottitis
bacterial tracheitis
peritonsillar abscess
foreign body inhalation
severity grading of croup
mild
moderate
severe
mild:
- occasional barking cough
- no audible stridor at rest
- no/mild suprasternal and/or intercostal recession
-child happy and prepared to eat, drink and play
moderate:
- frequent barking cough
- easily audible stridor at rest
- suprasternl and sternal wall retraction at rest
- no/little distress or agitation
- child can be placated and interested in its surroundings
severe:
- frequent barking cough
-prominent inspiratory (and occasionally expiratory) stridor at rest
- marked sternal wall retractions
-significant distress and agitation, or lethargy or restlessness(sign of hypoxemia)
-tachycardia occurs with more severe obstructive symptoms and hypoxemia
common causes of croup
parainfluenza
influenza
adenovirus
respiratory syncytial virus - RSV
croup used to be caused by diptheria but not anymore bc of vaccination. if it was it would lead to epiglottitis - high mortality
What is acute epiglottitis?
inflammation and swelling of epiglottis caused by infection: haemophilus influenza type b.
can get to complete obstruction of airway so life threatening.
rare now because of routine vaccination.
presentation of acute epiglottitis
rapid onset
high temp
stridor, sore throat
drooling of saliva
difficulty/pain swallowing
scared/quiet child
septic/unwell
muffled voice
tripod position -pt find easier to breathe if leaning forward and extend neck in seating position
how to make diagnosis of acute epiglottitis
direct visualisation
xray : lateral view shows swelling of epiglottis - thumb sign
how would you manage acute epiglottitis?
endotracheal intubation - protect airway
if suspect dont examine throat - risk of acute airway obstruction.
if airway closes - tracheostomy - intubate through the neck
oxygen
iv abx - eg ceftriaxone
steroids - dexamethasone
common complication of acute epiglottitis?
epiglottic abscess -
collection of pus around epiglottis.
threatens airway - life threating
tx same as epiglottis
what is bronchiolitis?
inflammation and infection of the bronchioles - the small airways of the lungs.
caused by respiratory syncytial virus - most common.
other cause: mycoplasma, adenovirus
very common in winter. poss secondary to bacterial infection.
under 1 yr.
mc under 6 months.
rarely in children upto 2 yrs old.
pathophysiology of bronchiolitis
when a virus affects airways of adults the swelling and mucus are proportionally so small that it doesnt affect breathing.
airways of infants are very small to begin with, even smallest amount of inflammation and mucus in airway has significant effect on the infants ability to circulate air to alveoli and back out.
so you get harsh breath sounds, wheeze and crackles on ausc when listening.
presentation of bronchiolitis
coryzal sx : running or snotty nose, sneezing , mucus in throat and watery eyes.
signs of resp distress
dyspnoea
tachypnoea
dry cough
poor feeding
mild fever - under 39
apnoeas - episodes where child stops breathing
wheeze and crackles on auscultation
feeding difficulties - associated with increasing dyspnoea often the reason for hospital admission
signs of resp distress in bronchiolitic pt
raised resp rate
use of accessory muscles of breathing eg: sternocleidomastoid, abdominal and intercostal muscles
intercostal and subcostal recessions
nasal flaring
head bobbing
tracheal tugging
cyanosis - due to low ox sats
abnormal airway noises
give me 3 abnormal airway noises
wheezing - whistling - caused by narrowed airways - typically heard during expiration
grunting - caused by exhaling with the glottis partially closed to increase positive end-expiratory pressure
stridor: high pitched inspiratory noise caused by obstruction of the upper airway eg croup
typical course of rsv - bronchiolitis
starts as urti with coryza
half get better spontaneous
other half: chest sx over 1st 1-2 days following coryza.
worst on day 3/4
sx last 7-10 days.
recover within 2-3 weeks.
why might you admit a bronchiolitis pt
under 3 months or an pre-existing condition like prematurity, downs or CF
50-75% less of their normal milk intake
clinical dehydration
rr over 70
ox sats under 92
moderate-severe resp distress, eg grunting, deep recessions or head bobbing
apnoeas
central cyanosis.
parent not confident in their ability to manage at home or difficulty accessing medical help from home
how would you manage bronchiolitis?
supportive
ensure adequate intake - oral/ng/iv. - avoid overfeeding full stomach will restrict breathing.
saline nasal drops and nasal suctioning. - help clear nasal secretions, prior to feeding esp.
supplementary ox: if ox sats below 92 (humidified via head box)
ventilatory support
ix for bronchiolitis
immunofluorescence of nasopharyngeal secretions may show rsv
what provides protection to newborns against RSV?
maternal IgG
What is palivizumab?
who to give to?
monoclonal antibody- targets respiratory syncytial virus.
monthly injection - prevention against bronchiolitis caused by rsv.
give to high risk babies - ex-premature and those with congenital heart disease.
not a true vaccine because it doesn’t stimulate the infants immune system.
provides passive protection by circulating the body until the virus is encountered, at which point it works as an antibody against the virus, activating the immune system to fight the virus.
levels of circulating antibodies decrease over time -thats why monthly injection is required.
ventilatory support types
high flow humidified via tight nasal cannula - delivers air and oxygen continuously with some added pressure, helping to oxygenate lungs and prevent airways from collapsing. it adds positive end-expiratory pressure to maintain the airway at the end of expiration.
continuous positive airway pressure - cpap. - sealed nasal cannula - can deliver much higher and more controlled pressures.
intubation and ventilation: insert endotracheal tube into trachea to fully control ventilation.
most helpful signs of poor ventilation
rising co2 - shows airways have collapsed and cant clear waste co2
falling PH - showing that co2 is building up - cant buffer the acidosis this creates. resp acidosis. if they are also hypoxic - type 2 respiratory fialure.
what to do, how to check severe respiratory distress ?
capillary blood gases.
What is cystic fibrosis?
A phenylalanine deletion on the CFTR (CF transmembrane conductance regulator) gene on chromosome 7, causing secretions to become much thicker. Mainly affects pancreas and lungs.
Autosomal recessive.
How does CF affect the pancreas and the lungs
Pancreas - thick pancreatic and biliary secretions block ducts, causing pancreatitis (autodigestion), cholangitis and lack of digestive enzymes in GI tract.
Causes failure to thrive, steatorrhoea and endocrine dysfunction e.g. CF diabetes.
Lungs - Impaired mucociliary clearance. Causes an obstructive pattern and thick immobile secretions = repeat S aureus and P aeruginosa infections.
Earliest presentation of CF in neonates?
Meconium ileus - Meconium isnt passed and instead causes a blockage in the intestine.
Clinical features of CF
Meconium ileus
Chronic cough, wheeze and recurrent infections (S aureus, P aeruginosa and H influenza)
Nasal polyps and sinusitis
Pancreatic insufficiency (steatorrhoea, malabsorption)
GORD
Clubbing
Investigations of CF
Newborn guthrie heel prick screening (Immunoreactive trypsinogen)
GOLD: Chlorine sweat test. Pilocarpine induces sweating. Sweat has more chlorine (>60mmol/L)
Faecal elastase (pancreatic insufficiency)
CF lifestyle advice
High calorie, high fat diet
No smoking
Regular exercise and physio
Flu vaccines
Respiratory management of CF
Chest physio and exercise
Bronchodilator (Salbutamol)
Mucolytic (Dornose Alfa)
Nebulised Tobramycin if pseudomonas
Prophylactic flucloxacillin for life
Digestive management of CF and problems caused by it (5)
High calorie high fat diet
Fat soluble vitamins (ADEK)
Pancreatic enzyme replacement (Creon)
PPI - omeprazole
Ursodeoxycholic acid (make bile more soluble)
Complications of CF + life expectancy
Life expectancy <40
CF related diabetes
Liver/biliary cirrhosis
Recurrent URTI
Malabsorption
- Delayed puberty
- Osteoporosis
- Infertility
Define Asthma
Chronic cough, dyspnoea and wheeze, characterised by reversible airway obstruction, airway hypersensitivity and inflamed bronchioles
this can be allergic/IgE mediated, or non IgE mediated (exercise, cold air and stress)
Pathophysiology of Asthma
Allergen picked up by dendritic cells and presented to Th2 cells, which respond by releasing cytokines, releasing IgE which bind to mast cells, causing mast cell degranulation. This releases histamine, leukotrienes, prostaglandin.
This causes chronic airway inflammation causing:
- Bronchoconstriction and smooth muscle spasm
- Mucus hypersecretion
Common triggers of asthma
Pollen, dust mites, grass
Cold air
Exercise
Pets
Tobacco smoke
Occupational allergens (bakers, manufacturers, lab work, welding)
Household mould
Signs/Symptoms of asthma
Episodic shortness of breath, usually after trigger exposure.
- Diurnal PEFR variation (worse at night/early morning)
- Usually dry cough
- Expiratory wheezing/dyspnoea
- Chest tightness
Asthma patient mucus microscopy result
Will contain spiral mucus plugs - casts from small bronchioles
Ix in Asthma
Spirometry:
-FEV1/FVC <80% (obstructive picture)
- Bronchdilator reversibility
FeNO (Fraction of exhaled Nitric Oxide) - 40ppb in adults, 35 in kids. (parts per billion)
GOLD: PEFR - measure multiple times a day for 2-4 weeks. >20% variability diagnostic
Patient taking regular aspirin/NSAIDs comes in with asthma-esque symptoms. what is this suggestive of?
Samter’s Triad
What is Samter’s triad?
Inflammation and swelling of the airways in response to aspirin or NSAIDs
Leads to:
- Chronic asthma-esque history
- Recurrent nasal polyps
- Aspirin intolerance
Asthma Mx Algorithm
1) SABA (Salbutamol)
2) SABA + lowdose ICS (beclometasone)
3) SABA + lowdose ICS + LTRA (montelukast)
4) SABA + lowdose ICS + LABA (Salmeterol) + LTRA in adults, - LTRA in kids.
What are the goals of stepwise mx in asthma
Aim to use the lowest effective doses possible, only stepping up if previous treatment ineffective
Step down treatment every 3 months and reasess
Annual asthma reviews for stable asthma
Give the PEFR, speech, resp and cardio ranges of moderate, severe and life threatening asthma exacerbations
PEFR
- M - 50-75% of best/predicted
- S - 33-50%
- LT - <33%
Speech
- M - normal
- S - cant complete sentences
- LT - Silent, exhausted, confused, coma
Resp
- M - RR<25/min
- S - RR>25/min
- LT - O2 sats <92%, chest silent, reduced respiratory effort or cyanosis
Cardio
- M - Pulse <110
- S - Pulse >110
- LT - Bradycardia, dysrhythmia, hypotension
Signs of acute asthma exacerbation
Progressively worsening dyspnoea
Accessory muscle usage
Tachypnoea
Cyanosis
Silent chest
Define bronchodilator reversibility
> 12% increase in FEV1, and >200ml increase in FVC
Management of acute asthma attack
Hospital if life threatening or near-fatal asthma attack (High pCO2/need for ventilation), or if bronchodilator irreversible.
- Salbutamol up to 10mg/hour (1 puff every 30-60 seconds up to 10 puffs)
- Ipratropium bromide (SAMA)
- 3-5 days oral prednisolone for ALL kids with exacerbation
- MgSO4 if PEFR <50% and no bronchodilator response
Checks to do at annual asthma review
Inhaler technique
Symptom scoring
Check HPC
Review treatment
Check growth in children, and potentially do spirometry
