Paediatric Respiratory Flashcards
Give 5 predisposing factors for bronchiolitis
Winter Premature Heart defect Weakened immune system <2 years old Smoke exposure Breast fed for <2 months
Which virus is the main cause of bronchiolitis?
Respiratory syncytial virus (RSV)
Describe the pathophysiology of bronchiolitis
Bronchioles are 2mm wide with no cartilage or submucosal glands. A viral infection causes the goblet cells to produce excess mucus and the bronchioles to constrict, resulting in inflammation.
Cells, oedema and mucus in the airways causes a ball-valve effect which results in hyperinflation, increased airway resistance, atelectasis and V/Q mismatch
How does bronchiolitis present?
Low grade fever, rhinorrhoea, cough and feeding difficulties increasing over 2-5 days
On examination= Tachypnoea, grunting, nasal flaring, costal recession, expiratory wheeze, hyperinflated chest, crackles, cyanosis
How is bronchiolitis investigated?
Nasopharyngeal aspirate- RSV rapid test + viral culture Blood + urine culture FBC ABG Chest xray if atypical presentation
How is mild bronchiolitis managed if at home?
Sit baby up Give oral fluids Keep an eye on wet nappies Vapour rubs Salt water drops
When should a bronchiolitis patient be admitted to hospital?
O2 sats <92% RR >70 Respiratory distress Central cyanosis Clinical dehydration
How is bronchiolitis managed in hospital?
Nasal cannulae O2 NG tube feeding Consider CPAP Upper airway suctioning IV fluids if dehydrated
No role for Abx, steroids or bronchodilators
Give 3 complications of bronchiolitis
Hypoxia Dehydration Fatigue Respiratory failure Persistent cough/wheeze Bronchiolitis obliterans- airways permanently damaged
Give 2 risk factors for asthma development
Atopy Low birth weight Viral bronchiolitis Prematurity Parental smoking Family history
Give 4 triggers for asthma
Cold air Exercise Dust Animal hair Viral infection Pollen
What is the pathophysiology of asthma?
Susceptible individuals have an exaggerated response to certain triggers. Dendritic cells present allergens to Th2 type T cells which then leads to a disproportionate immune response.
Cytokines released and there is excessive proliferation of mast cells, eosinophils and dendritic cells. This results in bronchoconstriction and an inflammatory process.
Give 4 clinical features of asthma
Episodic wheeze Worse at night Cough SOB (induced by triggers) Chest tightness
How is asthma diagnosed?
Clinical diagnosis Spirometry- obstructive pattern which will revert after bronchodilator Peak flow Exhaled NO Chest x-ray
Describe the stepwise approach to asthma management
Step 1= SABA (Eg salbutamol) + low dose ICS (beclomethasone)
Step 2= add LTRA (Montelukast)
Step 3= add LABA (Salmeterol)
Step 4= increase ICS or add LAMA/theophylline
Step 5= oral steroids
What general advice can be given about managing asthma?
Monitor compliance to daily inhalers
Bring personalised asthma plan to all appointments
Teach inhaler technique
Return to GP if: limitation on daily activities, waking at night, using blue inhaler more than 2 times a week
What is the criteria for a mild asthma exacerbation?
> 92% O2 sats in air
Moderate tachycardia
What is the criteria for a moderate asthma exacerbation?
<92% O2 sats in air
Breathless
No accessory muscle use
What is the criteria for a severe asthma exacerbation?
<92% O2 sats in air
PEFR 33-50% of predicted
Cannot complete sentences
If >5 years: HR>125, RR>30
If 2-5 years: HR>140, RR>40
What is the criteria for a life-threatening asthma exacerbation?
<92% O2 sats in air PEFR <33% of predicted Silent chest Poor respiratory effort Cyanosis Confusion Hypotension Exhaustion
How is an acute asthma exacerbation managed?
High flow O2
Nebulised salbutamol
Ipratropium bromide
Short course of steroids
IV salbutamol
Magnesium sulfate
Which gene causes cystic fibrosis?
CFTR gene
How does cystic fibrosis affect the respiratory system?
CFTR gene found on epithelial cells and submucosal glands.
Lack of CFTR protein means Cl- ions do not move across the cell membrane out of the cells. This means Na+ movement via the ENaC channel into the cells is reduced.
This makes the secretions salty and thicker so there is reduced mucus clearance.
How does cystic fibrosis affect the pancreatic system?
Thick secretions block the pancreatic duct which damages the pancreas and results in pancreatic insufficiency
How does cystic fibrosis affect the GI system?
Thick secretions cause viscous mucus which can cause bowel obstruction, cholestasis and CF related liver disease
How does cystic fibrosis affect the reproductive system?
Congenital absence of vas deferens in men means they are infertile.
How might cystic fibrosis present in neonates?
Meconium ileus
Failure to thrive
Neonatal jaundice
How might cystic fibrosis present in infants?
Failure to thrive
Recurrent chest infections
Steatorrhoea
How might cystic fibrosis present in childhood?
Rectal prolapse
Nasal polyps
Sinusitis
How might cystic fibrosis present in adolescence?
Diabetes mellitus Chronic lung disease Gallstones Liver cirrhosis Distal intestinal obstruction syndrome
What signs on examination might be suggestive of CF?
Clubbing Nasal polyps Hyperinflation of the chest Faecal mass on abdominal palpation Scars from surgeries Thin- pancreatic insufficiency- cannot process fat
How is CF diagnosed?
Heel prick testing at birth
Chloride sweat test
What tests are done to monitor CF?
Chest x-ray Sputum sample Glucose intolerance test Faecal elastase Genetic analysis LFTs and coagulation Bone profile Lung function tests Chest CT FBC, U+Es HbA1c Vitamins A,D,E,K
Who is involved in the Cystic Fibrosis MDT?
Respiratory consultant, Paediatrician, Dietician, CF specialist nurse, physiotherapist
How is CF managed?
Patient and family education 2x daily physiotherapy Hypertonic saline Pancreatic enzyme supplementation Fat soluble vitamins- A,D,E,K Monitor growth High calorie drinks for weight gain Treat all respiratory infections with 2 weeks of high dose Abx Manage complications as they arise
Give 4 potential causes of bronchiectasis
Cystic fibrosis
Chronic lung infection–> influenza, measles, adenovirus, strep pneumonia, TB
Immunodeficiency
Primary ciliary dyskinesia
Post-obstructive- foreign body inhalation
Congenital
Give 5 clinical features of bronchiectasis
Productive chronic cough Purulent sputum Chest pain Wheeze Breathless on exertion Haemoptysis Recurrent LRTIs Clubbing Crackles
How is bronchiectasis managed?
Chest physiotherapy
Antibiotics for LRTIs
Bronchodilators for wheeze
Give 4 risk factors for pneumonia
Not vaccinated against influenza Household overcrowding Malnutrition Immunocompromised Parental smoking Indoor pollution eg. wood fires
What is the main viral cause of pneumonia in children?
RSV
What is the main bacterial cause of pneumonia in children?
Strep pneumoniae
H influenzae type B
What is the main fungal cause of pneumonia in children?
Pneumocystis jiroveci (HIV patients)
Give 5 clinical features of pneumonia
Cough Fever SOB Feeding problems Convulsions Fever Tachycardia Hypoxia Agitation Chest wall recessions Wheeze Hypothermia Dehydration
How is pneumonia managed?
Initiate sepsis 6
Controlled O2 therapy if sats <92% IV Fluids to restore any dehydration Antibiotics for 14 days- amoxicillin/co-amoxiclav +/- erythromycin, azithromycin, clarithromycin Paracetamol/ibuprofen Encourage oral fluids
What is an episodic viral wheeze?
Wheezing only in response to viral infection and no interval symptoms
What is multiple trigger wheeze?
Wheeze in response to viral infection as well as other triggers such as aeroallergens and exercise. Precursor for asthma.
How is a viral induced wheeze managed?
Assess severity of wheeze
Controlled O2 therapy
Nebulised salbutamol
Monitor PEFR
SABA and short course of oral steroids
Paracetamol + ibuprofen
Follow up at GP in 48 hours
Give 3 risk factors for Croup
Male
Autumn/Spring time
6 months to 3 years old
What is the pathophysiology of croup?
URTI causing mucosal inflammation between the nose and trachea. Can impair movement of the vocal cords.
Usually a viral cause- parainfluenza virus, RSV, adenovirus, rhinovirus, enterovirus, measles.
Describe the clinical features found in mild, moderate and severe croup
Mild: occasional barking cough, no audible stridor, no suprasternal or intercostal recession, child is happy, will eat and drink + play, rhinorrhoea
Moderate: frequent barking cough, audible stridor, hoarse voice, fever, suprasternal and sternal wall retraction, child not distressed
Severe: frequent barking cough, prominent stridor, sternal wall retractions, child distressed and agitated, restless, lethargic. Tachycardia, cyanosis, laboured breathing
When should a child be admitted for croup?
<6 months old Immunocompromised Poor fluid intake Poor response to treatment Uncertain diagnosis Parental anxiety
How is croup managed in hospital?
Oral dexamethasone or prednisolone (single dose)
Nebulised adrenaline
O2 therapy
How is croup managed at home?
Will resolve in 48 hours
Can use ibuprofen/paracetamol
Adequate fluid intake
Oral steroid single dose
What are the clinical features of epiglottitis?
Cough Drool saliva Fever >38.5 Soft stridor Weak/silent voice Dehydrated
How is epiglottitis managed?
Do not examine child as this can cause them to become distressed and the airway to close
Establish airway + give O2
Why is epiglottitis rare in the UK?
Caused by H. influenza type B (HiB) which is vaccinated against in the UK
What is the pathophysiology of Whooping Cough?
Caused by Bordetella Pertussis (Gram negative bacillus) spread by aerosolized droplets.
Bacteria attach to the respiratory epithelium and produce toxins which paralyse the cilia and promote inflammation. This prevents mucus clearance
Describe the 3 stages of whooping cough
Catarrhal phase= 1-2 weeks. Rhinitis, conjunctivitis, irritability, sore throat, low grade fever, dry cough
Paroxysmal phase= 2-8 weeks. Severe paroxysms of coughing followed by inspiratory gasp producing the ‘whoop’ sound. Vomiting following coughing, cyanosis
Convalescent phase= up to 3 months. Cough decreases in frequency and severity.
How is Pertussis investigated?
Nasopharyngeal aspirate
Anti-pertussis toxin IgG serology
FBC
When should a child with pertussis be admitted?
<6 months and acutely unwell
Significant breathing difficulty
Feeding difficulties
Complications- pneumonia, seizures
How is pertussis managed?
<1 month old= Clarithromycin
>1 month old= Clarithromycin or Azithromycin
Paracetamol/ibuprofen
Fluid intake
Avoid nursery/school
Give 3 risk factors for TB
Immunocompromised From high prevalence area Exposure to others with TB <5 years old Malnutrition
What bacteria causes TB?
Mycobacterium Tuberculosis
Give 5 features of TB
Persistent cough Haemoptysis Night sweats Losing weight Losing appetite Lymphadenopathy Fever Failure to thrive
Give 4 investigations for TB
Chest x-ray
Mantoux test
Interferon gamma release assay
Lymph node biopsy
How is TB treated?
Isoniazid- 6 months
Rifampicin- 6 months
Pyrazinamide- 2 months
Ethambutol- 2 months
Give 2 risk factors for foreign body inhalation
1-3 years old
Eating small, crunchy foods
Allowed to play with small toys
Give 3 clinical features of foreign body inhalation
Coughing Choking Wheeze Unilateral breath sounds Increased RR Reduced O2 sats Reduced breath sounds
How is foreign body inhalation managed?
Most often in right bronchial tree
Chest x-ray
Direct bronchoscopy- remove foreign body with forceps
Give 3 potential complications of foreign body inhalation
Pneumonia Pneumothorax Lung abscess Bronchiectasis Death
Give 4 risk factors for tracheomalacia
Congenital Treatment for oesophageal atresia Heart anomalies Mass pushing on trachea Recurrent infections Tracheostomy tubes
What is the pathophysiology of tracheomalacia?
C-shaped cartilage rings around the trachea are wider and more U-shaped causing the posterior membrane to restrict airflow and interfere with breathing.
OR
A cyst or mass can press on the trachea, restricting airflow
Airway will collapse when breathing
Give 4 clinical features of tracheomalacia
High pitched breathing Stridor Exercise intolerance Frequent infections Noisy cough Breath holding Choking during feeding Blue spells
How is tracheomalacia managed?
Goes away with time
Surgery- support trachea
Give 3 common causes of pleural effusion
Infection Pneumonia Chest surgery Fluid retention Lupus
Give 3 clinical features of pleural effusion
SOB
Fever
Increased HR
Chest pain
How is a pleural effusion investigated?
Chest x-ray
Fluid biopsy
FBC, CRP, U+Es
How is a pleural effusion managed?
Antibiotics (if bacterial infection)
Steroids (if autoimmune)
Chest drain
Video assisted thoracoscopic surgery
What is apnoea?
Temporary cessation of breathing, especially during sleep
Give 3 causes of apnoea
Obesity
Sickle cell
Down’s syndrome
Enlarged tonsils
What is the pathophysiology of apnoea?
Muscles around the airway relax and weaken. The muscles cause the airway to collapse in on itself which restricts breathing. If the person is asleep, they will jerk awake due to hypoxia.
Give 3 clinical features of apnoea
Snoring Sleeping in unusual positions Tired in the daytime Aggressive/hyperactive Headache Poor concentration
