Paediatric Respiratory Flashcards
What are URTIs characterised by?
Fever
Presentation of URTIs
Fever
Runny nose
Sore throat
Who is URTIs especially common in?
Children
How much of URTIs are self limiting?
. 99%
How many times a year can a child get rhinitis?
5 - 10 per year - VERY common
When do children get rhinitis?
Week 35 of the year
Winter months
Stops generally when clocks go forward
What causes rhinitis?
Rhinovirus
What is rhinitis a prodrome to?
Other invasive illnesses
- pneumonia / bronchiolitis
- meningitis
- septicaemia
How long does a cold normally last for?
11 days but can last longer
Causation of otitis media
Primary viral infection
Secondary infection with pneumococcus / H flu
Presentation of otitis media
Pain
Redness (erythema)
Bulging drum - pushed forward
Drum no longer transparent and shiney
What is otitis media characterised by?
Pain
Redness
How long does an ear ache usually last?
A week is common
What can happen in otitis media?
Spontaneous rupture of drum
Treatment of otitis media
Analgesia
Oxygen
Hydration
What does NOT usually help in respiratory problems in childhood?
Antibiotics
Is tonsillitis / pharyngitis common?
Yes
Can you tell if tonsillitis / pharyngitis is bacterial or viral?
Cannot tell by looking at the throat
Throat swav
How long does a normal sore throat last?
Usually 2 days
More than one day but less than a week
Treatment of tonsillitis / pharyngitis
Nothing or
10 days penicillin
What is NOT to be given in tonsillitis / pharyngitis?
Amoxycillin
What causes croup / LTB?
Para flu I
Presentation of croup / LTB
Stridor Coryza Hoarse voice "Barking" cough that sounds like a seal Well
When does croup occur?
Comes on about 10 pm and wakes up coughing
Parents terrified
Alright in a few hours
Repeats next day
Treatment of croup
Oral dexamethasone
How common is epiglottitis?
Rare as everyone is vaccinated against the causative organism
What is epiglottis caused by?
H influenzae type B
Presentation of epiglottitis
Toxic
Stridor
Drooling
Dehydration
Treatment of Epiglottitis
Intubation
Antibiotics
Examples of some URTIs
Rhinitis Tonsillitis / pharyngitis Otitis media Croup / LTB Epiglottitis
Common agents causing LRTIs
Bacterial overgrowth - strep pneumoniae - h influenzar - chlamydia pneumonia Viral infection - RSV - parainfluenza III - influenza A and B - adenovirus - Rhinovirus
Principles of management of LRTIs
OXYGENATION
HYDRATION
NUTRITION
LRTIs
Bronchitis
Bronchiolitis
Pertussis
How common is bronchitis?
VERY common
What age gets bronchitis?
6 months - 4 years
Presentation of bronchitis
Loose wet rattly cough
Post tussive vomit - “glut”
chest free of wheeze / crep
Child VERY well
Causative organisms of bronchitis
Haemophilus
Pneumococcus
Cyclical pattern of the symptoms of bronchitis
Symptoms last the whole of winter
nursery etc and children get loads of viruses
Switches off mucociliary escalator
- the only way to clear the secretions is to cough - so symptoms of cough and rattle
Takes two weeks to resolve
Then get another virus - and this carries on the cycle
Pathology of bronchitis
Disturbed mucociliary clearance
- RSV / adenovirus
Bacterial overgrowth is secondary
How long does the cough of bronchitis last for?
> 2 weeks
Red flags for bronchitis
age < 6 months and > 4 y /o Static weight Disrupts childs life Associated SOB when not coughing Acute admission Other co morbidities (neuro/gastro)
Treatment of persistent bacterial bronchitis
DO NOT TREAT
Reassure
Who does bronchiolitis affect?
30-40% of all infants
Causative organisms of bronchiolitis
RSV mostly
Paraflu III
HMPV
Presentation of bronchiolitis
Nasal stuffiness Tachypnoea Poor feeding Crackles +/- wheeze Wet cough
Natural history of bronchiolitis
Gets worse 2 - 5 days after the start of the cough
Stabilise after about a week of onset of symptoms
Recovery
Investigations of bronchiolitis
Clinical
- NPA
Oxygen sats show severity
Treatment of bronchiolitis
DO NOT USE MEDICATIONS
Dont send home if still getting worse
Maximal observation, minimal intervention
When can a child go home with a LRTI?
Once stabilising and if oxygen, hydration and nutrition are okay
Duration of bronchiolitis
50% have symptoms that last 2 weeks
Diagnostic criteria of bronchiolitis
< 12 months
One off (NOT recurrent)
Typical history
When are RSV cases more prominent?
Winter
Presentation of LRTI
48 hours Fever > 38.5C SOB cough grunting reduced or bronchial breathing sounds
What does a wheezy chest indicate about the cause?
unlikely to be BACTERIAL
Only call a LRTI pneumonia if…..
Signs are focal i.e. in one area
Creps
High fever
Treatment for community acquired pneumonia
NOTHING if symptoms are milk
- hydration, oxygenation and nutrition = okay
Always offer review if symptoms get worse
Oral amoxicillin first line
Oral macrolide second line
What is the only indication for IV antibiotics in LRTI?
Vomiting
Is pertussis common?
Yes
What does vaccination of pertussis do?
Reduces risk
Reduces severity
Presentation of pertussis
coughing fits
whooping cough
vomiting
colour change
Do you treat otitis media with antibiotics?
NO
unless age < 2 yrs and bilateral OM - use oral amoxycillin
Do you treat bronchiolitis with antibiotics?
NO
Do you treat tonsillitis with antibiotics?
Yes if you know it is a strep cause
Do you treat bronchitis with antibiotics?
NO
Do you treat LRTI / pneumonia with antibiotics?
No unless - 2 day fever - cough - focal signs i.e. one side use amoxicillin
What does no wheeze indicate?
NO asthma
Presentation of asthma
Literally "panting" Wheeze Cough - dry - nocturnal - exertional SOB at rest Atopy
Triggers of asthma
URTI
exercise
cold weather
Allergen
Causes of asthma
Genes
- heterogenous condition
Environment
When can asthma present?
Infant childhood adult exertional occupational
The multiple hits of asthma
Genes Inherently abnormal lungs Early onset atopy Late (env) exposures - Rhinovirus - Exercise - smoking
Key words of defining asthma
Wheeze
Variability
Responds to treatment
Investigations for asthma
THERE IS NONE in children
Criteria for diagnosis of asthma (ideally)
WHEEZE - with and without URTI SOB at rest Parental asthma Responds to treatment
Common associations of asthma
Atopy FH Eczema Hay fever Food allergies
Features of an asthmatic cough
Dry
Nocturnal
Exertional
First line treatment for suspicion of asthma
ICS for 2 months
To prevent false positive responses for asthma, what can be done?
Inhaler holidays
Differential diagnosis of asthma
Onset < 5 - congenital - CF - PCD - bronchitis - foreign body onset > 5 - dysfunctional breathing - vocal cord dysfunction - habitual cough - pertussis
Goals of asthma treatment
“minimal symptoms” during day and night
minimal need for reliver medication
No attacks (exacerbations)
no limitation of physical activity
SANE questions
Short acting beta agonist / week
Absence school / nursery
Nocturnal symptoms / week
Exertional symptoms / week
How Is control of asthma measured?
SANE
Treatment of asthma
- start on low dose ICS
- review after 2 months
step up step down approach - regular preventer if needed
- very low dose ICS or LTRA (< 5s) - initial add on preventer
- add on LTRA or Increase ICS dose or add on LABA (different guidelines say different things)
Classes of asthma medications
Short acting beta agonists ICS Long acting beta agonists* Leukotriene receptor antagonists * Theophyllines* Oral steroids
- = add ons
Children differences in management of asthma compared to adults
Max dose ICS 800 microg (<12 y/o) No oral B2 tablet LTRA first line preventer < 5s No LAMAs Only two biologicals
Criteria for gaining a regular preventer
Diagnostic test B2 agonists > 2 days a week Symptomatic 3x a week or more Waking one night a week Exacerbations of asthma in last 2 years (grey area)
Adverse effects of ICS
Height suppression 0.5-1cm
Oral candidiasis
What do you have to use a LABA with?
ICS
What can LTRAs come as for reluctant toddlers?
Granules
What do you do if on high dose ICS or regular oral steroids?
Refer
Two types of delivery systems of asthma medications
MDI / spacer
Dry powder spacer
Lung deposition of asthma medication with and without spacer
Without = < 5% With = < 20%
What must you do when using a spacer?
Shake inhaler in between puffs
Wash it monthly to reduce static
Which age group cannot use dry powder devices?
< 8s
but licensed for < 5s
Extra / other management of asthma
Stop tobacco smoke exposure
Remove environmental triggers
- cat, dogs
What do air ionisers do to a cough?
INCREASE the cough and so make the situation worse
What is chronic maintenance treatment for asthma?
Inhaled steroids
What is acute treatment for asthma?
Oral steriods
3 signs of a chest infection in children
Fever
Focal crepitations on auscultation
Why can a cough with sputum present with large amounts of vomiting?
The swallowing of the mucus
Presentation of increased work of breathing in a baby
Nasal flaring Poor feeding Accessory muscles - subcostal / intercostal recession Tracheal tug Head bobbing
Causes of a 18 month old body with a cough
Common - Asthma - Bronchitis Serious / rarer causes - CF - Bronchiectasis - Foreign body - Immune deficiencies - Congenital airway problems
Features of cough in bronchitis
RATTLE
Productive
What type of noise does wheezing produce?
Whistling
What does a wet cough indicate?
Infection
What type of cough does pertussis give?
DRY cough
Parotisms - fits of them
Sometimes when children cough they vomit. Is this normal?
Yes
Why are babies sick sometimes slimey when they have a cough?
Mixed with saliva
Pathology of a viral infection on the lungs
Disrupts normal epithelium
Commensals become invasive infection and cause a bacterial infection
Is the bacteria for whooping cough a commensal?
No
How many people with the vaccine for whooping cough still get it?
1 in 500
Is whooping cough common?
Yes, very
Presentation of whooping cough
Prodromal symptoms
- coryzal symptoms
Cough and vomit > 2 weeks
Coughing fits then a big breath in
Treatment of whooping cough
Azithromycin
What does the Ax treatment in whooping cough no treat?
The actual cough
What is a wheeze due to a problem in?
Small airways
What are crackles due to a problem in?
Alveoli
What are transmitted sounds?
When listen to the childs mouth and see if it is the same sound
What do you not do in croup?
Look at airway
When do you admit croup?
< 6 months
Abnormal airway
Severe
Treatment of croup
Dexamethasone
Adrenaline if severe
Investigation for pertussis
Nasal swab
What examination is contraindicated in croup and why?
Throat exam
Risk of airway obstruction
What is palivizumab and what is it used for?
Monoclonal antibody to prevent RSV in children who are at risk of severe disease
Who is at risk of developing severe RSV?
Premature infants
Infants with lung or heart abnormalities
Immunocompromised infants
Is whooping cough a notifiable disease?
Yes
What is the commonest cause of stridor in children?
Laryngomalacia
Treatment of viral induced wheeze
- Short acting bronchodilator therapy
2. Oral Montelukast or inhaled corticosteroids if didn’t help
Should a child with whooping cough be excluded from school?
Yes - for 48 hours after commencement of antibiotics
