Paediatric Respiratory Disease Flashcards
What respiratory conditions MUST I know about?
- Asthma
- LRTI
- URTI
What else would be good to know about?
- Pleural effusions
- Inhaled forgein body
- TB
- Whooping cough
A newborn presents with a harsh expiratory sound on breathing.
Form a list of differentials for stridor in this age group.
- Pharyngeal collapse
- Laryngeal atresia/webbing
- Vocal cord paralysis
- Micrognathia (small jaw e.g. in DiGeorge syndrome)
- Subglottic stenosis
An infant presents with a harsh expiratory sound on breathing.
Form a list of differentials for stridor in this age group.
- Viral croup
- Rhinitis
- Laryngomalacia
- Subglottic stenosis
- Laryngeal web/cyst
How can upper airway obstruction be subdivided?
- Supraglottic
- Glottic
- Subglottic
A small child presents with a harsh expiratory sound on breathing.
Form a list of differentials for stridor in this age group.
- Viral croup
- Bacterial tracheitis
- Forgein body
- Retropharyngeal abscess
- Tonsilar/adenoid hypertrophy
An older child presents with a harsh expiratory sound on breathing.
Form a list of differentials for stridor in this age group.
- Inhalation injury
- Foreign body
- Angioedema
- Anaphylaxis
- Trauma
- Peritonsilar abscess
- Mononucleosis
What is the most common cause of chronic upper airway obstruction in children?
Adenoid or tonsillar hypertrophy
Tell me about adenoid or tonsillar hypertrophy.
- Often due to recurrent infection/allergy/inhaled irritants
- Predisposes to recurrent/persistent otitis media
- Assess with lateral radiography
- Rx with removal
Define croup.
Viral infection of the middle respiratory tract in infants causing airway inflammation.
What are the common pathogens that cause croup?
- Respiratory syncytial virus (RSV)
- Parainfluenza virus 1, 2, 3, & 4.
A child a year old is brought in by his father because he has stridor and difficulty breathing. Croup is suspected.
What might we see on examination of the child?
- Inspiratory stridor, although may be biphasic
- Laboured breathing
- Recession (suprasternal/intercostal/subcostal)
- Wheeze, if lower airway involved
What is the most common life limiting autosommal recessive condition in caucasians?
Cystic fibrosis
What is the pathophysiology of CF?
AR defect in the CF transmembrane protein leading to defective ion transport in exocrine glands.
When and how do most people with CF present?
As a newborn via the blood spot testing done at 5-8 days
If the blood spot test doesn’t pick up CF in a newborn, how else might they present?
- Prolonged jaundice (14 days +)
- Meconium ileus
How many CF mutations can the Guthrie card pick up?
29 CFTR gene mutations
How do most children present with CF? (Not Guthrie test)
With:
- Malabsorption
- Failure to thrive
- Recurrent chest infections
How can we investigate suspected CF?
- Sweat test
- CXR
- Lung function
- Genetic testing for known CF mutations
- IRT levels
What is the positive sweat teast for CF?
Chloride levels above 60mmol/L
Part of the screening programme for CF is measuring IRT.
A parent wants to know what this means. What should you tell them.
One of the organs affected by CF is the pancreas.
This produces enzymes which normally empties into the small intestine.
In CF, the ducts from pancreas to gut get blocked, so the enzymes back up and build up.
Immunoreactive trypsin is the built up enzyme which is present in the gut.
A neonate is diagnosed with CF.
What complications should you tell the parents they might have to deal with in infancy?
- Meconium ileus
- Neonatal jaundice
- Hypoproteinaemia and oedema
A child is diagnosed with CF.
What complications should the child and parents look out for?
- Recurrent LRTIs
- Poor appetite
- Rectal prolapse
- Bronchiectasis
A child is diagnosed with CF.
What problems might they develop in their adolescence?
- Bronchiectasis
- Diabetes mellitus
- Cirrhosis and portal HTN
- Pneumothorax
- Haemoptysis
- Psychological problems
How frequently should a CF patient have a full multisystme review?
Once a year
Which HCPs are involved in the long term care of pts with CF?
- Paediatric pulmonologist
- Physio
- Dietician
- CF Nurse
- Teachers/school
- Psychologist
How can we manage pulmonary care in patients with CF?
- Physio (chest oercussion, postural drainage, deep breathing exercises)
- Antimicrobials (oral when well, IV for acute exacerbations, nebulised for chronic Pseudomonas infections)
- Other - flu vaccines, bronchodilators, mucolytics, oral azithromycin
What GI management can we do for CF?
- Laxatives and fluid intake for obstruction
- Creon
- High calorie diet
- Salt supplements
- Fat soluble vitamin supplements (multivit/E/K)
What is apnoea?
Cessation of respiratory airflow for 20 seconds or more
What are the 3 types of apnoea?
- Central
- Obstructive
- Mixed
What is the pathophysiology of central apnoea?
Medullary responsiveness is not adequate for proper respiration so muscle contraction is poor or absent
What is the pathophysiology of obstructive apnoea?
An airway obstruction causes poor or no air exchange
What are the causes of central apnoea?
- Prematurity
- Head trauma
- Toxin-mediated apnoea
What is the most common form of obstructive apnoea in children?
obstructive sleep apnoea
A child present with multiple episodes of “stopping breathing”.
What questions do you want to ask?
- HPC - how long are the episodes, how long have they been going on for, any other symptoms at the time of episodes, when do they happen (day/night/during activity). Get accurate picture of an episode, parents mnay have filmed it. Any specific triggers noticed. Any recent or current infections? Any snoring at night?
- PMH - Any pre-existing medical conditions? Congenital or genetic are most common, but also neuro/cardiac/GORD/metabolic. Do they have any touble with eating/swallowing?
- Pades Hx - were pregnancy, delivery, and neonatal period ok? Were they premature? Is the child well-behaved?
In an episode of apnoea where the child has some unusual movements, what important differential do you want to investigate/rule out?
Seizures
How should we approach examining a child with apnoea?
ABCDE with system examinations as indicated by the history.
Why is it important to ask about recent or current infections with a child presenting with apnoea?
It may be a symptom of sepsis in the child
Name 3 conditions in which obstructive sleep apnoea is commonly seen.
- Down’s Syndrome
- Sickle cell disease
- Obesity
What are the signs and symptoms specific to obstructive sleep apnoea?
- Snoring
- Sleeping in funny positions
- Breathing through mouth at night
- Signs of sleep deprivation
How is sleep apnoea diagnosed?
Hx and Ex.
By doing a sleep study, measuring breahting pattern, and resp and heart rate throughout the night.
How is OSA managed?
Treat the cause.
Make ENT referral - may need tonsils removing, or have other problem that could be corrected with surgery.
Nasal prongs.
CPAP.
Define bronchiolitis.
An acute viral infection of the lower airways that affects infants under 2 years of age.
Tell me about who bronchiolitis affects.
Infants under the age of 2.
Peaks between 3 and 6 months of age.
Most common in under 1s.
What is the most common pathogen causing bronchiolitis?
What other organisms can cause bronchiolitis?
Respiratory syncytial virus (RSV)
Adenovirus/rhinovirus/parainfluenza/influenza
What are the social and environmental risk factors for bronchiolitis?
- Older siblings
- Nursery attendance
- Passive smoking
- Overcrowding
How does bronchiolitis typically present?
1-3 day hx of coryzal symptoms with:
- persistent cough
- respiratory distress/increaded effort
- wheeze +/or crackles
A child comes in with 3 days of coryzal symptoms, a cough, tachypnoeaic, and with a wheeze.
What are you differentials?
- Bronchiolitis
- Viral induced wheeze
- Pneumonia
- Asthma
- Pulmonary oedema
- Forgein body asp
- Pneumothorax
How should bronchiolitis be managed in primary care?
Supportively:
- Good fluid intake
- Good nutrition
- Temperature control (paracetamol)
- May need supplementary O2 if referring on to hospital
How should bronchiolitis be managed in secondary care?
Still supportively mainly! (Fluids, O2, temperature control, nutrition) NG feeding may be necessary. Upper airway suction can help. CPAP if in respiratory failure.
How long does bronchiolitis tend to last?
3-7 days, with the cough settling after ~3 weeks.
What is the prognosis with bronchiolitis?
Good - majority make a full recovery.
Death is very uncommon and tends to be in those children with pre-existing cardiac or pulmonary disease.
What can we give to those at risk of contracting bronchiolitis due to RSV?
Palivizumab - first dose given before the start of the RSV season.
What is asthma?
A respiratory condition characterised by paroxysmal and reversible airway obstruction.
What are the 2 elements of an acute asthma attack?
- Bronchospasm
- Excessive production of secretions in airways
What are the typical symptoms of asthma?
- Wheeze
- Shortness of breath
- Tight chest
- Cough
What can happen if a child has undertreated asthma for a long time?
Ongoing inflammation -> airway remodelling -> fixed airway disease
How many children roughly have asthma in the UK?
About 10-15% - it is the most common chronic condition in UK children.
What other conditions are commonly associated with asthma, either in the personal hx or family hx?
Other people with asthma
Eczema
Allergies
With asthma, other than PHx and FHx of associated conditions, what should we elicit from the hx in terms of risk factors?
- Inner city environment
- Obesity
- Prematurity/low birth weight
- Smoking
- Viral infections in early childhood
A child comes to the GP because wheeze on exercise and a cough has been bothering him for some time.
What do we want to know from the HPC?
- What does it take to become breathless?
- Any specific triggers noticed? (Ask then go through options)
- When are the symptoms at their worst?
- Does it happen apart from colds?
- How does it change over time/between exacerbations
When are asthma symptoms at their worst?
At night and early in the morning
When a parent tells you a kid has a wheeze, what is it important to do?
Clarify exactly what they mean!!!!
If necessary, make some noises yourself to compare them to what the parent can hear.
How do you ask about breathlessness in children?
- Like with an adult if older child
- Ask if they keep up with other children when playing
- Ask about how well they keep up in P.E. in school
You examine a child with suspected asthma.
What signs might you elicit?
- Bilateral wheeze
- Increased work of breathing
- High pulse and resp rate
- Recessions (subcostal, intercostal, tracheal tug)
- Hyperexpansion
Talk me through the stepwise approach to asthma management in a 5-16 year old.
- PRN bronchodilators for occasional symptoms
- Add low dose inhaled corticosteroid daily for symptoms >3x a week.
- Add a leukotriene receptor antagonist
- Swap LTRA for a LABA if LTRA unhelpful
- SABA + change LABA/ICS for maintenance and reliever therapy inc. low dose ICS
- SABA + moderate dose ICS MART
- SABA + one of a) high dose ICS MART, b) additional drug e.g. theophylline, or c) refer to expert asthma specialist.
How is asthma management different in a child under 5 years old?
Its not technically asthma under 5 years old, but pre-school wheeze.
- SABA
- SABA + 8 wk trial of moderate dose ICS
- SABA + low dose ICS + LTRA
- Refer to specialist
What is classed as a moderate asthma attack in an under 5?
SpO2 under 92%
No clinical features of severe asthma
What is classed as a severe asthma attack in an under 5?
SpO2 under 92% + Too breathless to talk/feed HR over 140 RR over 40 Use of accessory muscles
What is classed as a life-threatening asthma attack in an under 5?
SpO2 under 92% Silent chest Poor respiratory effort Agitation Altered consciousness Cyanosis Normal CO2 on abg
When should PEF be measured in an asthma attack?
In all children over 5
What is classed as a moderate asthma attack in a child over 5?
SpO2 under 92%
PEF under 50% of best/predicted
No clinical features of severe asthma
What is classed as a severe asthma attack in a child aged over 5?
SpO2 under 92% PEF 33-50% best/predicted Too breathless to complete sentences/talk/eat HR over 125 RR over 30 Use of accessory muscles
What is classed as a life threatening asthma attack in a child over 5?
SpO2 under 92% PEF less than 33% best/predicted Silent chest Poor respiratory effort Altered consciousness Cyanosis
How should mild/moderate acute asthma be managed?
Acutely - bronchodilator (B2 agonist)
Steroid therapy for 3-5 days
How should severe asthma be managed in hospital?
ABCDE assessment Do an ABG High flow O2 via non-rebreath mask Salbutamol nebs with ipratropium bromide IV hydrocortisone/Oral prednisolone CXR
What dose of salbutamol and ipatropium bromide should we give kids?
5mg salbutamol
0.5mg IB
How should life threatening asthma be managed in hospital?
Inform ITU and senoirs ABCDE Magnesium sulphate IV over 20 minutes Repeat salbutamol nebs every 15 minutes or 10 mg continuously per hour. Repeat PEF every 15-30 minutes Corticosteroids
What dose of magnesium sulphate should be given in a life threatening asthma attack?
1.2-2g IV over 20 minutes
What organism causes whooping cough?
Bordetella pertussis - gram neg coccobacillus
Is whooping cough a notifiable disease?
Yes
Is whooping cough still endemic in the UK?
Yes
Who is whooping cough most serious in?
Infants under 3 months.
Considering the 2012 outbreak of whooping cough was most serious to the under 3 months, what has been introduced?
28-32 week gestation vaccination for pregnant mothers.
How long do the symptoms of whooping cough last?
6-8 weeks even when treated with abx
What does whooping cough sound like?
Drhacking coughfollowed by characteristic “whoop” where the child gasps and flails
What often follows chronic coughing in whooping cough?
Post-cough vomiting
How is whooping cough spread?
Respiratory droplets
How long is a person infective for when they have whooping cough?
For at leats 3 weeks after symptoms start
What is the nincubation period of whooping cough?
7-20 days
When should someone stay home with whooping cough?
If they are a child in school or a HCP until at least 21 days after symptoms start, or 48 hours after starting to take antibiotics
Which abx are first line for whooping cough?
Macrolides e.g. clarythromicin/azithromycin/erythromycin
What suggests an inhaled foreign body?
- Witnessed episode
- Sudden onset coughing or choking
- Recent hx of playing with or eating small objects/new foods
What suggests an ineffective cough in a child who has inhaled a foreign body?
Inability to vocalise Quiet or silent cough Inability to breath Cyanosis Decreasing LoC
How can we visualise an inhaled foreign body?
CXR
How should an inhaled foreign body be managed?
ABCDE
According to level of severity
Send to A+E if severe respiratory distress
What viruses commonly cause pneumonia in children?
- Influenza A
- RSV
- Human metapneumovirus
- VZV
What bacteria commonly cause pneumonia in children?
Strep. pneumonia (vast majority of bacterial pneumonias)
H. influenzae
Staph. aureus
K. pneumoniae
What is the most common atypical that causes children with pneumonia to be hospitalised?
Mycoplasma pneumonia
How does pneumonia typically present in an older child?
Not usually with wheeze/stridor, but respiratory symptoms (chest recession, tachypnoea) with persistent fever.
Cough, sputum, chest pain
How does pneumonia typically present in an infant?
- Cough
- Raised RR
- Grunting
- Chest recessions
- Feeding difficulties
- Irritability
- Poor sleep
- Fever
How does pneumonia typically present in a neonate?
- Grunting
- Poor feeding
- Irritability/lethargy
- Fever
- Cyanosis
- Cough
In younger children, what kind of pain does a LRTI cause?
Apparent abdominal pain, especially if lower lobe
What are the signs of respiratory distress in a child?
- Cyanosis
- Grunting
- Nasal flaring
- Tripodding
- Tachpnoea
- Chest recessions
- Abdominal breathing
- O2 sats under 95%
What differentials are there for a LRTI in a child?
- Exacerbation of asthma
- Ihaled foreign body
- Pneumothorax
- Cardiac dyspnoea
- Other causes of pneumonitis
What are the common causes of pneumonitis in children, other than infective?
- Extrinsic allergic alveolitis
- Smoke inhalation
- Gastro-oesophageal reflux
Do all children with LRTIs need admitting?
No - many can be managed as outpatients with oral antibiotics.
When is admission for a LRTI advised?
- O2 sats under 92%
- RR >70
- Tachycardia significantly higher than fever
- Cap refil .2
- Signs of respiratory distress
- Comorbidities
- Child under 6 months
How should LRTI in children be managed in hospital?
- Anitpyretics (not aspirin)
- Antibiotics (amoxicillin unless pen allergic)
What is the prognosis like for LRTIs in children?
Great - vast majority have complete resolution.
If a very unlucky hcild was to develop a comlpication of an LRTI, what might happen?
- Pneumonic consolidation
- Sepsis
- Empyema
- Lung abscess
- Pleural effusion
A child who is otherwise healthy sees the doctor on multiple occassions for chest infections. What might be going on at home that we can advise on to reduce the chances of this?
Parental smoking or second-hand smoke from others living together.
When is wheezing in a child very very unusual?
What might this suggest?
In the immediate neonatal period.
If a neonate is wheezing, there is probably a structural abnormality in the airway.
A child comes in with suspected croup (wheeze, URTI symptoms, barking cough). How should the severity be assessed?
Using the Westley clinical scoring system - into mild, moderate, and severe.
How does the Westley clinical scoring system classify croup?
0-3 = mild 4-6 = moderate 6+ = severe
Points for degree of stridor, intercostal recessions, air entry decrease, cyanosis, and LoC.
Which classes of croup need hospital assessment?
Any moderate or severe cases, or if croup is not the only likely differential.
How is croup investiagted?
It isn’t really, diagnosis is clinical, but O2 sats might be checked, and CXR or bloods may be done if it is felt this will be significantly beneficial.
How should croup be managed?
Supportively - keep child happy/calm, and comfortable e.g. control fever, ensure adequate fluid intake, and use of oxygen therapy if necessary.
Single dose oral or neubilsed steroids given in hospital.
Nebulised adrenaline can also be beneficial.
What dose of oral steroids is given for croup?
150 micrograms/kg dexamethasone PO OR
1-2 mg/kg prednisolone PO OR
2mg nebulised budesonide
