Paediatric Respiratory Disease Flashcards
What features make children susceptible to respiratory failure?
Compliant chest walls, poorly developed respiratory muscles = particularly susceptible to
respiratory failure; Early detection and prevention is cornerstone to mgmt
Which groups of paediatric patients are particularly susceptible?
Preterm infants, BronchoPulmonaryDysplasia, haemodynamically significant congenital heart disease, muscle weakness causing diseases, Cystic Fibrosis, Immunodeficiency
Presentation of URTI
Coryzal symptoms, sore throat, earache, sinusitis or stridor
Presentation of LRTI
Cough, wheeze, respiratory distress
o Moderate Distress – Tachypnoea, Tachycardia, Flaring, Accessory muscle use, Intercostal and subcostal recession, Head Retraction, Inability to feed
o Severe Distress – Cyanosis, Fatigue from work of breathing, LOC, <92% sats despite oxygen therapy
• NB: Signs of respiratory distress become less marked as exhaustion occurs
Stridor
Extrathoracic airway obstruction exaggerated during inspiration
o Inspiration is an active process; Contraction and downward movement of diaphragm with outward movement of ribs to generate negative pressure
o Airway walls are pulled apart to create negative intrathoracic pressure
o Leads to degree of inward collapse of large airways where pressure external pressure is atmospheric; hence worsens Stridor
Common cold
Most common infection in childhood; Clear/Mucopurulent discharge, nasal blockage; Most commonly Rhinovir, Coronavir, RSV
o Self-limiting, no specific curative treatment
• Analgesia by Paracetamol or Ibuprofen; Abx unnecessary as secondary infection uncommon; Cough may persist up to 4/52
Causes of sore throat
Pharyngitis
Tonsillitis
Pharyngitis
Pharynx and Soft Palate inflamed, Local LN enlarged and tender
o Viral infections – Adenovir, Enterovir, Rhinovir
o In older child, Group A haemolytic strep is a common pathogen (Pyogenes)
Tonsillitis
Form of Pharyngitis with intense Tonsillar inflammation, often Purulent
o Commonly Group-A Strep and EBV (Infectious Mononucleosis)
o Difficult to establish clinically whether viral or bacterial
o Bacterial Infection more likely to cause constitutional disturbances – Headache, Apathy, Abdominal Pain, White Tonsillar Exudate, Cervical LN
How to manage pharyngitis/tonsillitis
• Abx – Pen V or Erythromycin if Pen Allergic; Although only 1/3 are Bacterial infections
o 10 days to eradicate and prevent Rheumatic Fever
o Amoxicillin avoided as may cause widespread Maculopapular rash if EBV
• Admit if unable to swallow – IV Abx, Analgesia
Scarlet Fever, Group A Strep
Group A Strep can lead to Scarlet Fever – Most common 5-12yrs; Fever before headache and tonsillitis; Maculopapular rash with Flushed cheeks and Perioral sparing; White coated tongue, Sore and Swollen
o Only childhood rash caused bacterium; Pen V or Erythromycin to prevent complications e.g. Acute GN, Rheumatic Fever
Acute Otitis Media
Most common 6-12/12 age; 20% will have 3 or more episodes; Most common due to poor Eustachian tube shorter, more horizontal, poor function
o Otalgia, Fever; All children with fever must have ears examined
Acute Otitis Media O/E
Bright red, bulging TM with loss of normal light infection
Causes of Acute Otitis Media
Commonly caused by RSV, Rhinovir, Pneumococcus, Haemophilus, Moraxella
Glue Ear O/E and Management
Bulging appearance with pus with less inflammation; Peri-AOM
o Asymptomatic apart from decreased hearing; Commonly 2-7yrs; May cause conductive hearing loss – Interfere with development
15
o Ventilation tube insertion (Grommet)
o Adjuvant Adenoidectomy and Reinsertion Grommet if persist – Possible benefit
Management of Acute Otitis Media
Serious complications include Mastoiditis and Meningitis;
• Analgesia – Paracetamol, Ibuprofen; Regular Analgesia more effective and may be needed for up to 1 week for inflammation to resolve
• AOM mostly resolves spontaneously – Abx reduces pain duration but does not reduce HL
o Amoxicillin given if child remains unwell 2-3/7 later
o Decongestants nor Antihistamines not useful
Sinusitis
Infection of Paranasal Sinuses in Viral URTI; Secondary bacterial infection can occur with pain, swelling and tenderness over maxilla; Antibiotics and Analgesia for Acute Sinusitis
• Frontal sinuses do not develop until late childhood; Infection is uncommon in first decade
Stridor2
Harsh, musical sound due to partial obstruction of lower portion of upper airway (Upper Tracheal, Larynx); Most commonly laryngeal and tracheal infection o Mucosal inflammation and swelling can rapidly cause life-threatening obstruction • Assessed based on – Characteristic (None, Only on crying, At Rest, Biphasic Stridor), Degree of Chest Retraction (None, Only on crying, At Rest)
Presentation of obstruction
o Severe obstruction leads to Tachypnoea, Tachycardia, Agitation
o Central Cyanosis, Drooling or reduced LOC suggest impending complete obstruction
o SpO2 reliably detects hypoxaemia but is only lowered in later disease
• Total obstruction might be precipitated by examination of throat using spatula; Avoid examination unless full resuscitation is available on hand
Causes of Acute Stridor
Croup Epiglottitis Foreign body Anaphylaxis Smoke Inhalation Trauma Lymph node swelling
Croup
Laryngotracheobronchitis
• Viral Croup – 95% Laryngotracheal infections; Parainfluenza most common but others e.g. Rhinovir, RSV and influenza also similar clinical picture
• 6/12 to 6yrs of age; Peak incidence 2yrs, most common in Autumn
Presentation of Croup
Coryza and Fever; Hoarseness (due to vocal cord inflammation), Barking Cough (Tracheal Oedema
and Collapse), Harsh Stridor, Variable degree of Chest Retraction, Nocturnal symptoms
Recurrent Croup might be related to pattern of atopy
Management of Mild Croup
Mild – Stridor and Recession disappears at rest; Home management; Observe for deterioration; Admit if poor access to hospital, <12/12, parental confidence etc
• Inhaled warm moist air – Conventional but no evidence for use
• Oral steroids – Dexamethasone, Prednisolone or Neb steroids (Budesonide) reduce severity and duration of disease
o First line if chest recession noted at rest
Management of Croup in Severe Upper Airways Obstruction
Neb Epinephrine, Oxygen by face mask
o Rapid but transient improvement; Observe 2-3hrs after
o Intubation is unusual after steroid therapy
Acute Epiglottitis
Intense swelling of Epiglottis and surrounding tissues, associated with Sepsis
o Life-threatening emergency – High risk of Respiratory Obstruction
o Most common 1-6yrs but can affect all groups
• Caused by HiB; Immunisation has led to 99% reduction of disease
Presentation of Acute Epiglottitis
High Fever, Intense Throat pain (Drooling due to painful swallow), Soft Inspiratory Stridor, rapidly increasing Respiratory Distress; Immobile, Upright with Open mouth
Management of Acute Epiglottitis
Do not examine without expert; Total airway obstruction can occur
• Urgently admit; Bleep Senior Anaesthetist, Paediatrician and ENT surgeon; Transfer to ITU/Anaesthetic room
o Intubation with general anaesthetic; Rarely urgent tracheostomy is life-saving
• Only after secured airway – Blood cultures, IV Abx (E.g. Cefuroxime)
o Tracheal tube can be removed 24hrs after; Abx given 3-5/7 course
• Prophylaxis of close household contacts with Rifampicin offered
Other causes of stridor
Bacterial Tracheitis (Pseudomembranous Croup) – Similarly to Severe Epiglottitis; High Fever, Severely Unwell, Rapidly progressive obstruction with copious, thick airway secretions
o Typically, S aureus; IV Abx, Intubation, Ventilation as required
• Consider Anaphylaxis or FBO in absence of apparent infection
• Chronic Stridor – Structural problems (Intrinsic narrowing/collapse, or Extrinsic compression)
Bronchiolitis Presentation/Symptoms
Preceding Coryzal symptoms; Dry wheezy cough, tachypnoea, tachycardia, subcostal and intercostal recession, hyperinflation, fine end-inspiratory crackles, high-pitched wheeze (expiratory > inspiratory)
Bronchiolitis: Causative Organism
RSV is causative in 80%, remainder would be Parainfluenza, Rhinovirus, Adenovirus, Influenza and Human Metapneumovirus
o Co-infection will be more severe; RSV plus HMPV
Bronchiolitis: When to Admit
Apnoea, <90% RA, Inadequate fluid intake-less than 50% of normal intake, Severe respiratory distress or Tachypnoea >70, <4 weeks old, safety netting is not enough, in presence of other illnesses; CXR and Blood gases only if respiratory failure suspected
Management of Bronchiolitis
Supportive Management; Humidified Oxygen as guided by sats, Monitoring for Apnoea; No evidence from use of mist, nebulised hypertonic NaCl, Abx, Steroids or Bronchodilators
o Fluids by NGT or IV if poor intake
o NIV with CPAP, or mechanical ventilation based on severity
o Infection control (RSV is highly contagious) – hand hygiene, gowns, gloves
Prognosis and Follow up of Bronchiolitis
Most recover within 2/52, but as many as half will have recurrent; With adenovirus infections, rarely can lead to permanent damage – Bronchiolitis Obliterans
• Prevention by IM Palivizumab (Anti RSV) reduces number of admissions in high-risk preterm infants, but NNT=17; expensive and multiple injections required
Viral Episodic Wheezing
Only in response to infection; Most common
o Narrowing of small airways due to immune response and inflammation
o Often have small airway diameter at birth; Typically resolves at 5yrs presumably due to increasing airway size
o RF: Maternal smoking, family history; More common in males
Multiple Trigger Wheeze
More likely to develop into Asthma over time
o Frequent wheeze triggered by not only viruses but cold air, dust, dander, exercise
Atopic Asthma
Recurrent wheeze associated with symptoms between viral symptoms (interval) plus evidence of allergy to one or more inhaled allergens (e.g. HDM, Pollen, pets)
o Evidence based on skin prick or serum IgE
o Strongly associated with other atopic diseases such as Eczema, Rhinoconjunctivitis and Food Allergy
