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Paediatrics > Paediatric respiratory > Flashcards

Paediatric respiratory Flashcards

1
Q

Definition of croup

A

Narrowing of the larynx and subglottis caused by inflammation
AKA laryngo-tracheobronchitis

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2
Q

Cause of croup

A 
Most commonly viral (parainfluenza virus)
Occasionally allergic (episodic, no preceding viral-type illness)
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3
Q

Clinical features of coup

A 
Hoarse voice
Brassy/Barking cough
Stridor
Breathlessness
Preceding viral illness few days prior
Symptoms occur in the middle of the night, child well during the day
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4
Q

Management of croup

A

Usually do not require specific therapy
If stridor at rest:
- Oral dexamethasone (4-6 hours to take effect, observe and ensure no stridor at rest before d/c)
- nebulised adrenaline if severe respiratory distress (only lasts couple of minutes)
- if requires oxygen (rare), admit to a paediatric ICU + intubate and ventilate
(supplemental oxygen means pre-terminal, as there is very severe narrowing)

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5
Q

Common causes of Bronchiolitis

A 
RSV - most common and most severe
Most common respiratory viruses can cause bronchiolitis
- influenza A
- influenza B
- parainfluenza
- human metapneumovirus
- rhinovirus
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6
Q

Clinical features of bronchiolitis

A 
Preceding URTI 2-3 days
increasing wheeze and respiratory distress over few days
Cough
Increased work of breathing
Poor feeding (infants)
Gradual resolution over few days
Cough may take weeks-months to resolve
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7
Q

Management of bronchiolitis

A

No role for antivirals or antibiotics
Trial bronchodilators if older than 6m, especially if history suggestive of atopy
+/- hypertonic saline (evidence unclear)
Supportive care if required: oxygen, small frequent feeds, CPAP rarely needed, stomach decompression if respiratory distress after feeds or NG tube feeding

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8
Q

Incidence of cystic fibrosis in Australia

A

1/2500 births

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9
Q

Screening for Cystic fibrosis

A

Two-stage:

  1. Immunoreactive trypsinogen (IRT) on heel prick - misses approx 15%
  2. Sweat test (gold standard)
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10
Q

Defect in cystic fibrosis

A

Cystic fibrosis transmembrane conductance regulator gene (CFTR) on chromosome 7

Leads to sodium channel defect - Na not excreted into secretions - no osmotic gradient for water to enter secretions - thick, sticky secretions

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11
Q

Most common mutation in cystic fibrosis

A 
Delta F508 (70%)
>1800 different mutations have thusfar been identified, usually less severe presentations
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12
Q

Management of acute asthma

A

Salbutamol and ipratropium bromide(atrovent) by MDI + spacer (nebuliser if on high flow oxygen) - 3 doses every 20 minutes
If not improved - continuous salbutamol
Magnesium sulphate (up to 2 doses)
If still refractory, call for help from anaesthetist, aminophylline or IV salbutamol
CPAP/intubation as indicated
Once stabilised, give oral prednisolone 2mg/kg - observe for 4-6 hours, d/c home if requiring salbutamol MDI 3 hourly or less (only 1mg/kg/day prednisolone if needed after initial dose)

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13
Q

Doses for drugs in asthma attack

A 
Under 6: 
Salbutamol MDI: 6 puffs
Salbutamol neb: 2.5mg
Ipratropium MDI: 4 puffs
Ipratropium neb: 250 mcg
Over 6:
Salbutamol MDI 12 puffs:
Salbutamol neb: 5mg
Ipratropium MDI: 8 puffs
Ipratropium neb: 500 mcg
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14
Q

Dose of adrenaline nebuliser in croup management

A

0.5mgs/kg up to maximum of 5mg

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15
Q

Long term asthma management

A

Trigger avoidance
Ventolin PRN (if mild, infrequent)
Ventolin x2 before sport if exercise induced
If more frequent/severe:
Add preventer: inhaled corticosteroid (fluticasone, budenoside etc.) OR montelukast (leukotriene antagonist)
IF preventer insufficient:
double dose
Add long-acting agent (montelukast or LABA - salmeterol)

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16
Q

Why are bronchodilators usually ineffective in bronchiolitis

A

Babies are born with only cholinergic receptors in their airways, no adrenergic receptors, and their smooth muscle is less responsive.
Over the first 18 months, there is a transition to adrenergic receptors in the airways, thus bronchodilators can be trialled in children older than 6m as may be some effect due to transition period

17
Q

Fluids to prescribe in acute respiratory distress

A

Normal saline + 5% dextrose
Volume: 2/3 maintenance fluids (4,2,1 rule)
Give only 2/3 due to risk of SIADH from respiratory distress, prevent pulmonary oedema which will lead to poorer oxygenation

18
Q

Overall cause for hypoxia in children

A

V/Q mismatch

19
Q

Definition of a stridor

A

An inspiratory noise caused by an extrathoracic obstruction of the airways

20
Q

Causes of stridor

A

Intraluminal: foreign body, haemangioma, vocal cord palsy
Luminal: croup, malacia,
Extraluminal: Vascular ring, cystic hygroma

21
Q

Assessing severity of acute asthma attack

A

Mild: normal mental state, speak in sentences, no acc. muscle use, sat over 95% on air
Mod: normal mental state, some acc. muscle use, tachycardia, short sentences
Severe: Agitated/distressed/confused, moderate to marked acc. muscle use, speak in words, sats not maintained on room air (less than 92%)

22
Q

Saturation at which to oxygenate a child

A

90-92%

23
Q

Categories of asthma

A

Infrequent episodic (75%)
- 1-5 exacerbations per year, only requiring treatment during episode, asymptomatic between episodes, most only have one episode per year
Frequent episodic (22%)
- more than 6 episodes per year (every 6-8 weeks), some minimal interval symptoms (e.g. with exercise or at night), may benefit from low-dose preventer, particularly during winter/leading up to trigger period)
Persistent/Chronic (3%)
- symptoms most days, acute episodes often more severe than intermittent, always on a preventer, often higher levels and/or more than one, followed by GP and paediatrician

24
Q

Role of ipratropium bromide (artrovent) in asthma

A

Not often used in home setting

Used in “rescue doses” in first hour of exacerbation with salbutamol

25
Q

Indications for a preventer in asthma

A

Symptoms more than 2-3 times per week

Frequent episodic type asthma

26
Q

Efficacy of delivery of different routes of asthma medications

A

MDI: 15%
MDI + Spacer: 30%
Nebuliser: 10% drug delivery to airways

27
Q

Indications for PICU admission in asthma

A 
Not responding to standard therapy
Requirement of Magnesium or IV salbutamol
Hypoxia not responding to O2
Hypercarbia
Exhaustion
Require CPAP, BiPAP or ventilation
28
Q

Dexamethasone oral dose for children

A

0.15mg/kg

29
Q

Clinical presentation of cystic fibrosis not picked up on screening

A 
Chronic productive cough
Clubbing
Nasal polyps
\+/- growth delay
\+/- liver disease secondary to cholestasis
Male infertility
Urinary incontinence
Diabetes secondary to endocrine pancreatic insufficiency
30
Q

Complications of cystic fibrosis

A 
Bronchitis
Pneumonia
Pleural effusion
Bronchiectasis
Sinusitis
Meconium ileus
Osteoporosis
Drug allergy
31
Q

Management of cystic fibrosis

A

Minimise other causes of lung damage (smoking, GORD)
Mucous clearance - daily physio
Prevent bacterial infection (prompt Abx)
Promote normal growth (high energy diet, pancreatic supplementation PRN, +/_ PEG feeds overnight)
Identification and treatment of complications promptly as they arise

32
Q

Causes of pneumonia in cystic fibrosis

A

Lobar: pneumococcus, haemophilus
Round: staph aureus, maybe pneumococcus (IV Abx required)

33
Q

Antibiotics considered in paediatric pneumonia

A

Mild: Oral amoxicillin
Moderate (requiring admission): IV benzylpenicillin
Severe: likely staph - cefataxime OR flucloxacillin _ cephtriaxone
Critical/ICU: (want to cover MRSA) - vancomycin

34
Q

Pathogens responsible for paediatric pneumonia

A 
Viral infections (influenza, parainfluenza, RSV, adenovirus)
Bacterial: pneumococcus, strep pyogenes, nontypal haemophilus influenza, staph aureus if multilobar, severe, GBS most common cause in neonates
Atypical: more common in adolescents (mycoplasma, - chlamydia in neonates)
35
Q

Indications for antibiotics in otitis media

A 
Severe symptoms (pain, perforation)
Under 2y/o
Indigenous
Immunocompromise
Cochlear implant
Unable to follow up later
36
Q

Management of acute otitis media

A

Children over 2: analgesia alone for 24-48 hours unless physically unwell (if no improvement, start Abx)

Oral amoxycillin 15mg/kg up to 500mg 8 hourly for FIVE DAYS

(cefuroxime if penicllin allergic - only comes in tablets, will have to crush for younger kids)

37
Q

Management of perforated TM

A

Review in 6m
Should heal within few days, if still discharging after a week, return to Dr
Swim if using ear wraps/plugs

38
Q

Management of recurrent AOM

A

Augmentin duo forte if recurrent AOM in 4 week period - likely was resistant bug (or bactrim if penicillin allergic)

Grommet if 3+ AOM in 6 month period (+ adenoidectomy if nasal symptoms also experienced)

Paediatrics (20 decks)

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