Paediatric Respiratory Conditions Flashcards
What is the medical term for croup?
Laryngotracheobronchitis
What is the typical presentation and clinical course of croup?
1 - 2 days of coryza. On the 2nd or 3rd night / early morning, awake with a barking cough. Stridor might develop after that. Barking cough / stridor only lasts 2-3 days. Viral symptoms last 7 days
What is the typical microorganism which causes croup?
Parainfluenza virus
What is the management of croup?
- Basics - minimal handling. Supplemental oxygen or respiratory support if required in severe cases. 2. Place and person - admit to hospital if worried about increased WOB or hypoxia. 3. Investigations and definitive diagnosis - clinical diagnosis 4. Management - oral prednisolone (1mg/kg), oral dexamethasone (0.15 - 0.6 mg/kg), IV dexamethasone (0.2mg/kg), nebulised adrenaline (1:1000), ETT 5. Long term
What are the two main types of croup?
Acute viral croup or recurrent spasmodic croup
What are the symptoms of epiglottis?
The four Ds Dysphagia Dyphonia Drooling Dyspnoea
What is the most common microorganism which causes epiglottis?
H. influenzae B
What is the most common microorganism which causes bacterial tracheitis?
Staphylococcus aureus (now more common than epilglottitis due to Hib vaccine)
what is the dosage of ipatropium bromide given in moderate / severe acute exacerbations of asthma?
6 yo give 8 puffs with salbutamol burst therapy (every 20 minutes for one hour)
What are the signs of respiratory distress in a child?
(Hint there are 7)
7 SIGNS OF INCREASED WOB IN KIDS
(general inspection -> obs -> hands -> face -> neck -> chest)
Cyanosis
Tachypnoea
Head bobbing (younger kids)
Grunting
Nasal flare
Tracheal tug
Intercostal and subcostal recession
What is the pathophysiology of bronciolitis?
Inflammation of the bronchioles
Often caused by infections with RSV
What is the usual causative microorganism of brinchiolitis?
RSV
In what age group is bronchiolitis most common?
<12-24 months
What does RSV tend to cause?
Bronchiolitis
What does parainfluenza virus usually cause?
croup
What is the typical presentation of Bronchiolitis?
Child < 18 months old
URTI + asthma like symptoms [cough, dyspnoea, wheeze]
(remember, can’t diagnose asthma <2)
What would you consider for “Place and Person” in a child with bronchiolitis, when deciding whether or not to admit them?
- Oxygen requirement - if requiring oxygen to maintain SpO2 > 93% admit
- Apnoeic episodes - marker of severity
- Behaviour - poor feeding, lethargy and irritability are signs of severity
- Work of breathing
What is the management of bronchiolitis?
Basics
- DRABC
- Vital Signs
Place and Person
- Assess severity
- If increased WOB, requiring O2 to maintain SpO2 > 93%, apnoeas or lethargy/poor feeding/irritabilty –> ADMIT [if RURAL - if parents are anxious / nervous / “irresponsible” or if live far away]
Ix and confirm diagnosis
- Usually aclinical diagnosis
- If diagnostic uncertainty, can do CXR
Definitive Management
- Supportive management
- Minimal handling and frequent feeds’
- Oxygen via NP / HFNP
- NGT / IV fluids if poor feeding
- Can be discharged once maintaining adequate oxygenation and adequate feeding
- Can triabl salbutamol if 2 years old to see if salbutamol responsive
Follow Up
- Follow up with GP
- Educate RE signs to return (apnoeic, lethargic, poor feeding, wheeze, increased WOB)
Braking cough = ?
Croup
Laryngotracheobronchitis
What are the causative microorganisms of croup?
95% is Parainfluenza
Can be bacterial (H. influenzae, S. aureus) = bacterial tracheitis
BONUS WOMENS QUESTION
What are the causes of menorrhagia?
Bleeding disorder
Iatrogenic (IUDs and drugs)
Thyroid dysfunction (especially hypo)
Cancer (Endometrial, cervical)
Hyperplasia of the endometrium
Fibroids (leiomyomata) and polyps
Adenomyosis and endometriosis
Chlamydia, gonorrhea and STIs
Ectopics, miscarriage, pregnancy
At what age do you get croup?
6 months - 6 years
What are the typical symptoms/ signs of croup?
What is added to make this bacterial tracheitis?
URTI followed by barking cough, hoarse voice, wheeze [even though LRTI], increased WOB
If there is also high fever + toxic looking child –> consider BACTERIAL TRACHEITIS [OR EPIGLOTTITIS FOR THAT MATTER?!]
What is the management of croup?
Basics
- DRABC
- Vitals
Place and Person
- Do they need to be admitted?
- Stridor at rest
- Requiring O2 - VERY LATE SIGN
- Increased lethargy/irritability
- Poor feeding
- Live far away [rural]
- Parents don’t seem “sensible” [rural]
Ix and Confirm Diagnosis
- Want to avoid over-investigating because can worsen
- CXR if uncertainty: steeple sign if severe
Definitive management
- Mild: D/C home and supportive care. Freqeunt small feeds and minimal handling
- Moderate:
- Oral corticosteroids:
- 1mg/kg prednisolone
- 0.15mg/kg dexamethasone
- Oral corticosteroids:
- Severe:
- Nebulised adrenaline
- plus oral steroids as above
Follow Up
- DC once no stridor at rest
- Follow up with GP a few days later
- Educate RE signs to come back in
What are the markers of severity for croup?
Stridor at rest
Poor feeding
Lethargy / irritability
Increased WOB
Reduced SpO2 is a very late sign
What is the aetiology of epiglottitis?
Haemophillus infleunzae
Or, if immunised, more likelt to be
Beta haemolytic strep
Moraxella catarrhalis
Strep pneumoniae
What are the causes of epiglottitis in an immunised child?
Group A Strep
Moraxella Catarrhalis
Streptococcus Pneumoniae
How do you differentiate between croup and epiglottitis?
Croup
- sickness comes on over a few days
- Preceeding URTI symptoms
- Not usually with high fever
- Miserable
- Loud, barking, brassy cough
- Loud, harsh stridor
- Hoarse voice
- Able to drink, not drooling
Epiglottitis
- Comes on suddenly
- No preceeding URTI symptoms
- High fever
- Flat / flopppy
- Soft, muffled cough
- Soft stridor
- Quiet voice, reluctant to speak / dysarthria
- Dysphagia and drooling
What is the management of epiglottits!
Straight to ED
Secure the airway (be prepared to perform a crycothyroidectomy)
Take bloods once intubated
Empiral antibiotics (Ceftriaxone)
Treat contacts with Rifampicin prophylactically
What is the aetiology of cystic fibrosis?
autosomal recessive mutation on chromosome 7
inteferes with CFTR gene which cuases altered ion transportation across epithelial cells
What are the clinical features of CF?
Respiratory
- Thickened secretions
- Recurrent infections
- Bronchiectasis
- Recurrent pneumothroacies
- ABPA
- Nasal polyps
- Chronic sinusitis
Pancreas
- Exocrine insufficiency (which then blocks the endocrine ducts)
- Malabsorption
- Steatorrhea
- Failure to thrive
- Recurrent pancreatitis
- T1DM
Hepatobiliary System
- Prolonged neonatal jaundice
- Hepatic cirrhosis
- Portal HT
- Fat soluble vitamin deficiency (vitamin ADEK)
- Recurrent cholecystitis
GIT
- Meconium ileus
- DIOS
Reproductive system
- Absence of vas deferens
- Delayed puberty due to malnutrition
- Infertility
What is involved in testing for CF using the Gutehrie Test?
- First Test for IRT (immunorecative trypsinogen level)
- If this is high - then test for CFTR
What is the screening test for CF?
What is the diagnostic test?
Screening test = Gutherie Heel Prick (IRT & CFTR)
Diagnostic Test = Sweat Test
If you had a child with symptoms of CF, what FIRST investigation would you order?
Sweat Test
(Sweat chloride levels >60mmol/L = diagnostic of CF)
NOT the heel prick test, this is a screening test
What is the overall management of CF?
Basics
- Explain there is NO CURE - only manage potential complications
Place and Person
- Referral to paediatrician, respiratory physician, allied health including physiotherapists and dieticians
Ix and CD
- Sweat Test if not already done
Definitive Management:
Think of each system
- Respiratory
- physiotherapy
- aerolysed mucolytics
- ABx if infection, also given resuce antibiotics
- Lung transplant (last line)
- GIT & Pancreas
- High calorie diet
- Pancreatic enzyme replacement (Creon)
- Fat solumble vitamin replacement (A,D,E,K)
- Salt replacement occasionally
- Insulin later in life
Prevntative / Ongoing
- Flu vaccine
- Pneumococcal vaccine
- NO SMOKING
- Avoid sick people
- Regular follow up
- Yearly mucous cultures taken (and at every exacerbation). Eventually get infected with pseudomonas.
- DEXA scan at puberty
*
How do you classify asthma in cenhildr?
Infreuent intermittent
- Attacks less often than every 6 weekly
- No interval symptoms
Frequent intermittent
- Attacks more often than every 6 weekly
- No interval symptoms
Persistent
- Attacks more often than every 6 weekly
- Mild: Interval symptoms fewer than 1 x per week
- Moderate: interval symptoms 1 x per week
- Severe: interval symptoms >1 x per week
How do you classify infrequent intermittent asthma?
Attacks less often than every 6 weeks
No interval symptoms
How do you classify frequent intermittent asthma?
Attacks more often than every 6 weeks
No interval symptoms
How do you classify mild persistent asthma?
attacks more frequent than every 6 weeks
interval symptoms less than once per week
How do you classify severe persistent asthma?
Attacks more frequently than every 6 weeks
Interval symptoms more than once per week
How do you classify moderate persistent asthma?
Attacks more frequently than every six weeks
Interval symptoms 1 x per week
What are interval symptoms?
What else can you ask to grade the severity of asthma?
Interval Symptoms
Night cough / wheeze
Morning cough / wheeze
Exercise tolerance
Days of school missed?
Youcan also ask
- When was the last time / has he ever / how often does he require steroids for his asthma?
- Has he been to ED / wards / ICU with his asthma?
What is the defnitive management of infrequent intermittent asthma?
SABA prn
What is the defitive management of frequent intermittent asthma?
SABA prn
+
low dose/higher dose ICS
AND/OR
LTRA
AND/OR
cromone
What is the definitive management of persistent asthma?
SABA prn
+
low dose/higher dose ICS
AND/OR
LTRA
AND/OR
cromone
+
LABA
oral CS
Name two generic types of SABA and some brand name?
Salbutamol (Vontolin)
Terbutaline (Bricanyl)
Name two different types of ICS and their brand names?
Fluticasone (Flixotide)
Budenoside (Pulicort)
Name two different types of combined ICS / LABA?
Fluticasone + Salmetorol = Seretide
Budenoside + efometerol = Symbicort
Name two types of LABA and their brand names?
Efometerol = Foradile
Salmeterol = Serevent
(usually see this combined with an ICS)
Name one generic type of LTRA and it’s brand name
Monteleukast (Singulair)
Name one type of cromone and their brand name
Cromoglycate (intal)
How do you diagnose asthma in a child?
Trial of salbutamol
(not with lung function tests or PEF until over 7-8)
In what age group would you use LABAs?
No evidence for children <5
What is the emergency management of asthma, to instruct parents of a child >6 years old, to do at home?
> 6 y.o. = maximum 12 puffs of ventolin
‘4,4,4’ rule
- 4 puffs (4 breaths per puff)
- wait 4 minutes
- 4 puffs (4 breaths per puff)
- wait 4 minutes
- 4 puffs (4 breaths per puff)
- wait 4 minutes
Then if not better, call an ambulance
/ bring in to hospital.
Can bring straight in to hospital if:
- If you are worried – call an ambulance straight away even before administering ventolin
- If are requiring ventolin more frequently than every 3-4h
- If wheezing lasts >24h and is not getting better
- If you get little or no relief from ventolin
What is the home emergency management of asthma of a child <6 years old?
< 6 y.o. = maximum 6 puffs of ventolin
‘2,2,2 rule’
2 puffs (3-4 breaths)
- wait two minutes
puffs (3-4 breaths)
- wait two minutes
2 puffs (3-4 breaths)
- wait two minutes
if not better call ambulance / bring in to hospital
other reasons to call an ambulance / seek medical attention
- If you are worried – call an ambulance straight away even before administering ventolin
- If are requiring ventolin more frequently than every 3-4h
- If wheezing lasts >24h and is not getting better
- If you get little or no relief from ventolin
