Paediatric Respiratory Flashcards
paeds resp: viral infections
adenovirus influenza A and B parainfluenza I III RSV rhinovirus
paeds resp: bacterial infections
o Haemophilus influenzae o Moraxella catarrhalis o (mycoplasma) o (s. aureus) o Streptococci B haemolytic, S pyogenes Non haemolytic, S pneumoniae
rhinitis: how many a year
5-10
rhinitis: prodrome to what other conditions
pneumonia
bronchiolitis
meningitis
septicaemia
otitis media: cause
primary viral
secondary with pneumococcus/haemophilus influenzae
otitis media: to treat or not?
- Severe uni or bilateral > 6 months, severe pain > 48hrs
- Non-severe bilateral 6-23 months
- ? non-severe in older children: “the clinician should either prescribe antibiotic therapy or offer observation with close follow up based on joint decision making with the parent(s)/caregiver”
treatment of tonsilitis
nothing or 10 days penicillin. Don’t give amoxycillin. 2-7 days.
croup: organism
parainfluenzae I
croup: features
coryza
stridor
hoarse voice
barking cough
croup: how long does it last
2-4 days
croup: treatment
oral dexamethasone
epiglottitis: organism
h influenzae B
epiglottitis: features
stridor
drooling
epiglottitis: treatment
intubation and antibiotics
tracheitis: is often described as?
croup which does not get better
tracheitis: features
fever and sick child
tracheitis: organism
staph or strep
tracheitis: treatment
augmentin
bronchitis: features
endobronchial infection causing a loose rattily cough with URTI. Post-tussive vomit – “glut”. The chest is free of wheeze and creps
bronchitis: organism
haemophilus
pneumococcus
bacterial bronchitis
Bacterial bronchitis results from disturbed mucociliary clearance. Minor airway malacia, RSV/adenovirus. There is a lack of social inhibition. Infection secondary.
bronchitis: how long do coughs laast for
7-25 days
bronchitis: natural history of bacterial
- Following URTI
- Lasts 4 weeks
- 60-80% respond
- First winter bad
- Second winter better
- Third winter fine
- Pneumococcus/H flu
classifying persistent bacterial bronchitis
- Wet cough
- More than 1 month
- Remission with antibiotics
With persistent bacterial bronchitis: make the diagnosis, reassure, do not treat.
bronchitis red flags
- Age < 6 month, > 4 years
- Static weight
- Disrupts child’s life
- Associated SOB (when not coughing)
- Acute admission
- Other co-morbidities (neuro/gastro)
bronchiolitis: organisms
RSV
parainfluenzae III, HMPV
bronchiolitis: features
nasal stuffiness, tachypnoea and poor feeding. Crackles +/- wheeze can be heard
bronchiolitis: length
16 days
bronchiolitis: management
maximal observation minimal intervention
bronchiolitis: investiation
NPA
oxyggen sats
medications proven NOT to work in bronchiolitis
- Salbutamol
- Ipratropium bromide
- Adrenalin
- Steroids
- Antibiotics
- Nebulised saline
medications PROVEN to work in bronchiolitis
none
LRTI: features
- 48 hrs, fever (>38.5 C), SOB, cough, grunting
- Wheeze makes bacterial cause unlikely
- Reduced or bronchial breath sounds
LRTI: organism
o Viruses in <35% (higher in younger)
o Bacteria pneumococcus, mycoplasma, chlamydia
o Mixed infection in <40%
is a LRTI pneumonia?
Is it pneumonia or not? This question is totally academic but causes anxiety in parents. Call it pneumonia of signs are focal, there are creps and a high fever. Otherwise call it a LRTI. CXR should only confirm clinical findings.
BTS Guidelines – Community Acquired Pneumonia: investigations
CXR and inflammatory markers NOT routine
BTS Guidelines – Community Acquired Pneumonia: managment
o Nothing if symptoms are mild o (always offer to review if things get worse) o Oral amoxycillin first line o Oral macrolide second choice o Only for IV if vomiting
Antibiotics and RTI (RACH Guidelines): bronchiolitis
not indicated
Antibiotics and RTI (RACH Guidelines): croup
not indicated
Antibiotics and RTI (RACH Guidelines): acute LRTI
o Often not indicated
o Children < 2 with mild presentation rarely require antibiotics and have had pneumococcal vaccine thus further reducing their need for antibiotics
o Amoxicillin should be first line
Antibiotics and RTI (RACH Guidelines): otitis media
o Usually not indicated
o Consider amoxicillin if <2 and bilateral infection
Antibiotics and RTI (RACH Guidelines): pharyngitis/tonsillitis
o Not usually indicated
o Consider penicillin
pertusis
Pertussis is common, but vaccination reduces risk and severity. Coughing fits and vomiting and colour change. Making a secure diagnosis of whooping cough may prevent inappropriate investigations and treatment
empyaema: what is it
Empyaema is a complication of pneumonia resulting in extension of infection into the pleural space.
empyaema: treatment
antibiotics and drainage
maintain oxygenation, hydration and nutirion
empyaema: prognosis
children good
triggers for asthma
URTI, exercise, allergen, cold weather
features of a cough in asthma
dry
nocturnal
exertional
DDx for asthma
• ?viral induced wheeze (=asthma) • Foreign body • Secretions causing noise o Cystic fibrosis o Immune deficiency o Ciliary dyskinesia o Aspiration, ? GOR o Tracheo-bronchomalacia
management of asthma - goals
The goals of treatment are: • Minimal symptoms during day and night • Minimal need for reliever medication • No attacks (exacerbations) • No limitation of physical activity • Normal lung function (in practical terms FEV1 and/or PEF >80% predicted or best
how to measure asthma controle
SANE o Short acting beta agonist/week o Absence school/nursery o Nocturnal symptoms/week o Exertional symptoms/week
classes of medications used in asthma
• Short acting beta agonists • Inhaled corticosteroids (ICS) • Add ons o Long acting beta agonist o Leukotriene receptor antagonists o Theophyllines • Oral steroids
step up/down approach to management of asthma
• Start on low dose inhaled corticosteroid
o Severe may respond to minimal treatment
• Review after 2 months
o No routine test to monitor progress
o Stepping up easier than down
management of childhood asthma: step 1
SABA
spacer/MDI or dry poweder
management of childhood asthma: step 2
regular preventer
These should be added when using an inhaled B2 agonist three times a week or more. Symptomatic three times a week or more, or waking one night a week. Exacerbations of asthma in the last two years. Start with a very low dose of inhaled corticosteroids (or LTRA in the under 5s).
management of childhood asthma: step 3
- Add on LABA (BTS/SIGN)
- Add on LTRA (NICE)
- Increase ICS dose (GINA)
use of a spacer
Shake inhaler between puffs and wash spacer monthly to reduce static. Each increases delivery by 100%
nebulisers vs spacers
These are not indicated for day to day use. A spacer is quieter, quicker, valve mechanism, don’t break, portable and cheaper than a nebuliser.
acute asthma management: 1st line
SABA via spacer
SABA via spacer + prednisolone
acute asthma management: 2nd line
SABA via neb _ prednisolone
SABA + ipratropium via neb + prednisolone
acute asthma management: 3rd line
o IV salbutamol o IV aminophylline o IV magnesium o IV hydrocortisone o Intubate and ventilate
