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EOY4 > Paediatric Respiratory > Flashcards

Paediatric Respiratory Flashcards

1
Q

What are the most common causative organisms for pneumonia in children?

A
  • Viral

RSV, influenza A/B

Rhino/adenovirus

Usually follows a cold

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2
Q

What are the respiratory symptoms of pneumonia in a child?

A
  • Respiratory
  • Cough - productive indicates infection but not always present
  • Dyspnoea
  • Chest pain (pleuritic if older)
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3
Q

What are some non-respiratory symptoms of pneumonia?

A
  • poor feeding
  • Lethargy
  • Altered consciousness
  • Stiff neck
  • abdominal pain
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4
Q

When should you admit a child with pneumonia?

A

Temperature >38 degrees and <3 months

pO2 <92% OA

RR >60

↓ Consciousness

Recurrent apnoea

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5
Q

What are some respiratory signs of pneumonia in children?

A

Tachypnoea (v sensitive to pneumonia)

↓p02 +/- cyanosis
↑ respiratory effort (Grunting, Nasal flaring, Recessions, accessory muscle use)

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6
Q

How may a child with pneumonia present on respiratory examination?

A

End-inspiratory coarse crackle over affected area + dull percussion

Bronchial breathing (hollow and low pitch, older)

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7
Q

What is the treatment for a child with pneumonia?

A
  • Supportive = fluids + paracetamol
  • Abx
  • neonates = broad spec e.g. co-amox
  • older = amoxicillin
  • > 5 = amox/macrolide e.g. erythromycin
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8
Q

What is the causative organism of whooping cough?

A

Bordella Pertussis. It is gram negative

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9
Q

What is the natural history of whooping cough?

A
  • Catarrhal phase
  • Paroxysmal phase
  • Convalescent phase
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10
Q

What occurs during the catarrhal phase of whooping cough?

A

coryzal symptoms

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11
Q

What occurs during the paroxysmal phase of whooping cough?

A
  • cough development - lots of coughs with a big whoop in the middle (spasmodic cough + inspiratory whoop)

Whoop = inspiration against a closed glottis

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12
Q

When is the whooping cough at its worst?

A

At night and after feeding

Might be so bad that the child vomits

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13
Q

What occurs during the convalescent phase of whooping cough?

A

Gradual decline in symptoms but may last for 10-14 days

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14
Q

What are the public health implications of whooping cough?

A

NOTIFIABLE DISEASE

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15
Q

What are the investigations for whooping cough?

A

Prenasal swab then culture + PCR

marked lymphocytosis on FBC

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16
Q

What is the treatment for whooping cough?

A

Admit if <6 months old

Macrolide e.g. Clarithromycin if the onset of the cough is within the previous 21 days

Prophylaxis for siblings and parents

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17
Q

How can whooping cough be prevented?

A
  • Vaccination (although ↓ immunity throughout childhood)

Infants are routinely immunised at 2, 3, 4 months and 3-5 years.

Newborn infants are particularly vulnerable = vaccination campaign for pregnant women - OFFERED BETWEEN 28-32 WEEKS

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18
Q

What are the complications of whooping cough?

A

Complications relate a lot to coughing

- Hernias
- Conjunctival bleeds
- Bronchiectasis
- Death!
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19
Q

What is a wheeze?

A

Musical sound heard at the end of expiration,

Monophonic (one airway obstructed) or polyphonic (multiple different sizes obstructed)

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20
Q

What is a viral induced wheeze?

A

Viral illness that produces a wheeze in a susceptible individual.

Inflammation of airways + mucus plug = wheeze

No interval symptoms like in asthma e.g. episodic breathlessness/cough.

Only happens when have the infection!!!

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21
Q

What is multi-trigger wheeze?

A

URTI + other triggers e.g. exercise, allergens, cigarette smoke
Associated with ↑ risk asthma

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22
Q

Why can’t asthma be diagnosed in children under 5?

A

Don’t understand spirometry instructions

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23
Q

Describe the inhaler technique

A

Press button then inhale for 6 seconds then hold breath for 10 seconds. Shake between goes

Drink water after ICS to ↓ risk of oral thrush

Or just use a spacer

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24
Q

What are 3 side effects of salbutamol?

A

Tachycardia

Tremor

Hypokalaemia (U wave prominence, reduced T wave, QT shortens)
↓ potassium = prolonged QTC because ↓ activity of K+ channels

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25
Q

What are the 4 types of hypersensitivity reaction?

A

A = allergy = type 1 hypersensitivity = minutes

B = B cells = type 2 hypersensitivity

C = [immune] Complex = type 3

D = delayed cell mediated = type 4 = takes days

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26
Q

How does an allergic reaction occur on a cellular level?

A

Mast cells = have the antibody of allergen on cell surface (IgE) so when allergen is presented again it binds to the antibody

the mast cell degranulates = histamine + leukotriene release = allergy

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27
Q

Why are PO steroids given during an asthma attack?

A

Get an immune response (eosinophil and TH2) 8-12 hours after acute asthma attack so give to prevent this

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28
Q

Why are NSAIDs contraindicated in asthmatics?

A
  • Arachandoic acid is a precursor for both leukotrienes (COX 1) and prostaglandins (COX1&2)
  • NSAIDs inhibit COX2 so ↓ prostaglandins
  • Shunts down leukotriene pathway = ↑ leukotrienes so ↑allergy or asthma
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29
Q

What is the management of asthma in under 5s (not an acute attack)?

A

Ix <5 - no investigations but a trial of medications

SABA + reversibility = +ve

ICS after risk assessment. Start low go slow. For interval symptoms.

30
Q

What are the investigations for asthma in over 5s?

A
  • Spirometry
  • FeNO - raised in inflamed airways so see how much is breathed out

Allergy testing? IgE skin prick testing

31
Q

How is the severity of chronic asthma categorised? (3)

A

Mild
<2 relievers a week, no interval symptoms, no night symptoms, doesn’t interrupt ADLs

Moderate/Persistent
mild inhaler use, interrupts ADLs, have night symptoms >1 a month

Severe
Persistent severe - >1 day reliever use, night symptoms

32
Q

What is Croup? What is the usual causative organism?

A

URTI
Laryngotracheobronchitis so inflammation of the larynx, trachea (mainly) and bronchi

Parainfluenza virus (also influenza and measles)

33
Q

What is the the pathophysiology of Croup?

A

Poiseulles law = resistance is inversely proportional to radius

Croup = laryngeal/subglottic oedema, secretions and oedema

SO small ↓ in radius can cause massive ↑ in resistance = large ↓ in airflow = LEADS TO UPPER AIRWAY OBSTRUCTION

Children’s airways are already small so this makes everything worse

34
Q

At what time of year is croup the most prevalent?

A

Autumn!

35
Q

What age of children are normally affected by croup?

A

Children of 6 months - 3 years

36
Q

How does croup normally initially present?

A

Initially coryzal symptoms that progresses to a barking cough (tracheal irritation)

Cough is worse at night as airways are smaller

37
Q

Describe the presentation of croup as it progresses

A

Stridor

Respiratory Distress (think head to toe)

38
Q

What is stridor?

A

High pitched noise heard on INSPIRATION

Due to partial obstruction of the larynx or larger airways

39
Q

How would a child in respiratory distress present? Think head to toe

A

Nasal flaring

Grunting - voluntary closure of vocal cords to create PEEP = maintaining pressure to breath in

Recessions - subcostal, intercostal

Increased work of breathing

40
Q

What is the grading for croup?

A

Mild - occasional cough, no stridor at rest

Moderate - frequent cough, stridor at rest

Severe - Frequent cough, stridor at rest + respiratory distress

41
Q

What investigations should be done to diagnose croup?

A

Mainly a clinical diagnosis - Ix are all to manage if acutely unwell

Bed - baseline obs especially pulse ox. KEEP SATS ABOVE 92%

Bloods - VBG if really severe

Imaging - CXR not routinely done but shows steeple sign

42
Q

What should you never do in a child with suspected croup/epiglottitis?

A

NEVER LOOK IN THEIR MOUTH OR LIE THEM DOWN OR DISTRESS THEM

Risks airway obstruction

43
Q

What is the conservative management for croup?

A

Supportive - keep calm, paracetamol and good hydration

44
Q

When should a child with croup be admitted?

A

Moderate or severe croup

<6 months olds

Known upper airway abnormality e.g. laryngomalacia or downs

Epiglottitis or FB not ruled out

45
Q

What is the medical management for croup?

A

All severities get a single dose of Dexamethasone PO

Moderate - also give neb adrenaline + high flow o2

Severe - IV access for IV hydrocortisone, neb adrenaline + budenoside

Admit to ITU

46
Q

When should a child with croup be intubated?

A

Severe croup + sternal retraction + cyanosis

DO IMMEDIATELY

47
Q

What is the epiglottis?

A

Elastic cartilage that is at the entrance to the larynx

Flattens and covers trachea when swallowing to prevent aspiration

More superoanterior and oblique in children and floppier!

48
Q

What is epiglottitis?

A

Inflammation of the epiglottis

Get swelling so can obstruct airway!

49
Q

What are the causative organisms for epiglottitis?

A

Normally Haemophillus Influenzae but now there is a vaccine for this so it is Group A b-Haemolytic Streptococcus

Trauma or chemical burns can also cause

50
Q

What are the symptoms of epiglottitis?

A

Acute onset (over hours) +/- preceding viral infection
No cough
Lots of pain = can’t drink and drooling
Fever >39, looks ill
Mouth breathing, sat forward, ↑resp effort
Soft stridor

51
Q

What is the management of epiglottitis?

A

Immediate admission + input from ENT, Paeds + anaesthetics

A to E
Blood cultures

IV antibiotics - Cefuroxime for H influenzae or BenPen for GAS

Give Rifampicin to household contacts

52
Q

What can cause chronic stridor?

A

Structural deformities e.g. laryngomalacia, subglottic stenosis, external compressions from lymph nodes etc

53
Q

What is Waldeyer’s ring?

A

Tonsillar structures and MALT at the pharynx

54
Q

What are the tonsillar structures in Waldeyer’s ring from inferior to superior?

A

Inferior - lingual (posterior 1/3 of tongue)

Palatine (classic ones)

Tubal - At opening of eustachian tube

Pharyngeal

55
Q

What are the adenoids?

A

The pharyngeal tonsils when they become enlarged

56
Q

Which structures surround the palatine tonsils?

A

Palatoglossal arch is anterior

Palatopharyngeal arch is posterior

57
Q

What is the aetiology of tonsillitis?

A

Viral - Adeno, entero or rhinoviruses most commonly or EBV

Bacterial - Group A streptococcus (older children)

58
Q

How does the presentation of tonsillitis differ depending on cause?

A

Not that easy to do clinically
Both have non-specific symptoms e.g. sore throat, pyrexia, dehydration if can’t swallow

However, bacterial commonly also has exudate on tonsils and cervical lymphadenopathy

59
Q

What is the centor criteria?

A

Criteria to see how likely GAS is the causative agent for tonsillitis depending on symptoms:

C - No Cough
E - Exudate
Nodes - Cervical lymphadenopathy
Temperature - Fever >38
young OR old - +1 if young
60
Q

What is the feverPAIN criteria?

A

Criteria to see how likely GAS is the causative agent for tonsillitis depending on symptoms

Fever - >38
Purulent
Attended rapidly (within 3 days) 
severely Inflamed tonsils
No Cough/coryza
61
Q

How can the centor and feverPain criteria be interpreted?

A

Centor - 3-4 = GAS is ~40-50% likely so treat with antibiotics

FeverPAIN - 4-5 = GAS is ~65% likely so treat with abx
or 2-3 = GAS is ~35% so do rapid antigen test and treat with abx if positive

62
Q

Which antibiotics should be used for tonsillitis?

A

Penicillin V
Clarithromycin if penicillin allergic

Don’t use amoxicillin as can cause a maculopapular rash if EBV is the cause

63
Q

What are the complications of tonsilitis?

A

Peritonsilar Abscess (quinsy)
Scarlet Fever
Acute Glomerulonephritis
Rheumatic fever (developing countries)

64
Q

What is a quinsy and what are the symptoms?

A

Pus in the peritonsilar space

Odynophagia, ipsilateral otalgia, hot potato voice
Uvula is deviated away from the abscess/ to the unaffected side

65
Q

What is the management of a quinsy?

A

ENT involvement
Needle aspiration or Incision and drainage
IV abx

66
Q

What are the indications for a tonsillectomy? (4)

A

Sore throats due to tonsillitis - 5+ episodes of sore throat per year. Symptoms have been occurring for at least a year. Episodes of sore throat are disabling and prevent normal functioning

Obstructive sleep apnoea (+adenoids)

Febrile convulsions secondary to tonsillitis

67
Q

What are the complications of a tonsillectomy?

A

Primary (< 24 hours): haemorrhage in 2-3% (most commonly due to inadequate haemostasis), pain

Secondary (24 hours to 10 days): haemorrhage (most commonly due to infection), pain

68
Q

How may a child with obstructive sleep apnoea present?

A

Daytime sleepiness
Hyperactive
Learning and behaviour problems - Ddx for ADHD?

69
Q

What are 3 causes for obstructive sleep apnoea in children?

A

Secondary to large adenoids (most common reason)

Duchenne muscular dystrophy

Craniofacial abnormalities e.g. pierre-robin/Down’s syndrome

70
Q

How may obstructive sleep apnoea be initially investigated?

A

Pulse oximetry overnight to see when they are desaturating

71
Q

What drug is absolutely contraindicated in children with obstructive sleep apnoea?

A

Codeine!

Give paracetamol/ibuprofen or even a little oramorph just definitely not codeine

72
Q

What is bacterial tracheitis?

A

Bacterial croup - Staphylococcus aureus, group A streptococcus, Moraxella catarrhalis, Streptococcus pneumoniae, Haemophilus influenzae

Poor response to nebulised Adrenaline

EOY4 (22 decks)

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