Paediatric Respiratory Flashcards
What are the most common causative organisms for pneumonia in children?
- Viral
RSV, influenza A/B
Rhino/adenovirus
Usually follows a cold
What are the respiratory symptoms of pneumonia in a child?
- Respiratory
- Cough - productive indicates infection but not always present
- Dyspnoea
- Chest pain (pleuritic if older)
What are some non-respiratory symptoms of pneumonia?
- poor feeding
- Lethargy
- Altered consciousness
- Stiff neck
- abdominal pain
When should you admit a child with pneumonia?
Temperature >38 degrees and <3 months
pO2 <92% OA
RR >60
↓ Consciousness
Recurrent apnoea
What are some respiratory signs of pneumonia in children?
Tachypnoea (v sensitive to pneumonia)
↓p02 +/- cyanosis
↑ respiratory effort (Grunting, Nasal flaring, Recessions, accessory muscle use)
How may a child with pneumonia present on respiratory examination?
End-inspiratory coarse crackle over affected area + dull percussion
Bronchial breathing (hollow and low pitch, older)
What is the treatment for a child with pneumonia?
- Supportive = fluids + paracetamol
- Abx
- neonates = broad spec e.g. co-amox
- older = amoxicillin
- > 5 = amox/macrolide e.g. erythromycin
What is the causative organism of whooping cough?
Bordella Pertussis. It is gram negative
What is the natural history of whooping cough?
- Catarrhal phase
- Paroxysmal phase
- Convalescent phase
What occurs during the catarrhal phase of whooping cough?
coryzal symptoms
What occurs during the paroxysmal phase of whooping cough?
- cough development - lots of coughs with a big whoop in the middle (spasmodic cough + inspiratory whoop)
Whoop = inspiration against a closed glottis
When is the whooping cough at its worst?
At night and after feeding
Might be so bad that the child vomits
What occurs during the convalescent phase of whooping cough?
Gradual decline in symptoms but may last for 10-14 days
What are the public health implications of whooping cough?
NOTIFIABLE DISEASE
What are the investigations for whooping cough?
Prenasal swab then culture + PCR
marked lymphocytosis on FBC
What is the treatment for whooping cough?
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
How can whooping cough be prevented?
- 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
What are the complications of whooping cough?
Complications relate a lot to coughing
- Hernias - Conjunctival bleeds - Bronchiectasis - Death!
What is a wheeze?
Musical sound heard at the end of expiration,
Monophonic (one airway obstructed) or polyphonic (multiple different sizes obstructed)
What is a viral induced wheeze?
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!!!
What is multi-trigger wheeze?
URTI + other triggers e.g. exercise, allergens, cigarette smoke
Associated with ↑ risk asthma
Why can’t asthma be diagnosed in children under 5?
Don’t understand spirometry instructions
Describe the inhaler technique
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
What are 3 side effects of salbutamol?
Tachycardia
Tremor
Hypokalaemia (U wave prominence, reduced T wave, QT shortens)
↓ potassium = prolonged QTC because ↓ activity of K+ channels
What are the 4 types of hypersensitivity reaction?
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
How does an allergic reaction occur on a cellular level?
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
Why are PO steroids given during an asthma attack?
Get an immune response (eosinophil and TH2) 8-12 hours after acute asthma attack so give to prevent this
Why are NSAIDs contraindicated in asthmatics?
- 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
What is the management of asthma in under 5s (not an acute attack)?
Ix <5 - no investigations but a trial of medications
SABA + reversibility = +ve
ICS after risk assessment. Start low go slow. For interval symptoms.
What are the investigations for asthma in over 5s?
- Spirometry
- FeNO - raised in inflamed airways so see how much is breathed out
Allergy testing? IgE skin prick testing
How is the severity of chronic asthma categorised? (3)
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
What is Croup? What is the usual causative organism?
URTI
Laryngotracheobronchitis so inflammation of the larynx, trachea (mainly) and bronchi
Parainfluenza virus (also influenza and measles)
What is the the pathophysiology of Croup?
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
At what time of year is croup the most prevalent?
Autumn!
What age of children are normally affected by croup?
Children of 6 months - 3 years
How does croup normally initially present?
Initially coryzal symptoms that progresses to a barking cough (tracheal irritation)
Cough is worse at night as airways are smaller
Describe the presentation of croup as it progresses
Stridor
Respiratory Distress (think head to toe)
What is stridor?
High pitched noise heard on INSPIRATION
Due to partial obstruction of the larynx or larger airways
How would a child in respiratory distress present? Think head to toe
Nasal flaring
Grunting - voluntary closure of vocal cords to create PEEP = maintaining pressure to breath in
Recessions - subcostal, intercostal
Increased work of breathing
What is the grading for croup?
Mild - occasional cough, no stridor at rest
Moderate - frequent cough, stridor at rest
Severe - Frequent cough, stridor at rest + respiratory distress
What investigations should be done to diagnose croup?
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
What should you never do in a child with suspected croup/epiglottitis?
NEVER LOOK IN THEIR MOUTH OR LIE THEM DOWN OR DISTRESS THEM
Risks airway obstruction
What is the conservative management for croup?
Supportive - keep calm, paracetamol and good hydration
When should a child with croup be admitted?
Moderate or severe croup
<6 months olds
Known upper airway abnormality e.g. laryngomalacia or downs
Epiglottitis or FB not ruled out
What is the medical management for croup?
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
When should a child with croup be intubated?
Severe croup + sternal retraction + cyanosis
DO IMMEDIATELY
What is the epiglottis?
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!
What is epiglottitis?
Inflammation of the epiglottis
Get swelling so can obstruct airway!
What are the causative organisms for epiglottitis?
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
What are the symptoms of epiglottitis?
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
What is the management of epiglottitis?
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
What can cause chronic stridor?
Structural deformities e.g. laryngomalacia, subglottic stenosis, external compressions from lymph nodes etc
What is Waldeyer’s ring?
Tonsillar structures and MALT at the pharynx
What are the tonsillar structures in Waldeyer’s ring from inferior to superior?
Inferior - lingual (posterior 1/3 of tongue)
Palatine (classic ones)
Tubal - At opening of eustachian tube
Pharyngeal
What are the adenoids?
The pharyngeal tonsils when they become enlarged
Which structures surround the palatine tonsils?
Palatoglossal arch is anterior
Palatopharyngeal arch is posterior
What is the aetiology of tonsillitis?
Viral - Adeno, entero or rhinoviruses most commonly or EBV
Bacterial - Group A streptococcus (older children)
How does the presentation of tonsillitis differ depending on cause?
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
What is the centor criteria?
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
What is the feverPAIN criteria?
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
How can the centor and feverPain criteria be interpreted?
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
Which antibiotics should be used for tonsillitis?
Penicillin V
Clarithromycin if penicillin allergic
Don’t use amoxicillin as can cause a maculopapular rash if EBV is the cause
What are the complications of tonsilitis?
Peritonsilar Abscess (quinsy)
Scarlet Fever
Acute Glomerulonephritis
Rheumatic fever (developing countries)
What is a quinsy and what are the symptoms?
Pus in the peritonsilar space
Odynophagia, ipsilateral otalgia, hot potato voice
Uvula is deviated away from the abscess/ to the unaffected side
What is the management of a quinsy?
ENT involvement
Needle aspiration or Incision and drainage
IV abx
What are the indications for a tonsillectomy? (4)
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
What are the complications of a tonsillectomy?
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
How may a child with obstructive sleep apnoea present?
Daytime sleepiness
Hyperactive
Learning and behaviour problems - Ddx for ADHD?
What are 3 causes for obstructive sleep apnoea in children?
Secondary to large adenoids (most common reason)
Duchenne muscular dystrophy
Craniofacial abnormalities e.g. pierre-robin/Down’s syndrome
How may obstructive sleep apnoea be initially investigated?
Pulse oximetry overnight to see when they are desaturating
What drug is absolutely contraindicated in children with obstructive sleep apnoea?
Codeine!
Give paracetamol/ibuprofen or even a little oramorph just definitely not codeine
What is bacterial tracheitis?
Bacterial croup - Staphylococcus aureus, group A streptococcus, Moraxella catarrhalis, Streptococcus pneumoniae, Haemophilus influenzae
Poor response to nebulised Adrenaline
