Paediatric Respiratory Medicine Flashcards
What are common viral infective agents in the upper respiratory tract?
- adenovirus
- influenza A, B
- Para’flu I, II
- RSV
- rhinovirus
What are common bacterial infective agents of the upper respiratory tract?
- H influenzae
- M catarrhalis
- Mycoplasma
- S aureus
- Streptococci
- B haemolytic, S pyogenes
- Non haemolytic, S pneumoniae
What is an important feature about the management of most upper respiratory tract infections?
they are self limiting and so you should not be tempted to jump in to treatment - REVIEW
How long can an upper respiratory tract infection last?
it is very common (80%) for children to still have symptoms after 1 week and still common for some to have symptoms after 2 weeks
What is rhinitis and how is it managed?
- inflammation of the nasal tissue
- condition of winter months
- self-limiting, so no medications, just review if necessary (parents can do this)
How would you identify otitis media on otoscopy?
- erythema
- bulging drum
How do children get otitis media? What is a complication of it? How should we manage it?
- is a common, self limiting condition
- usually primary viral infection and then get secondary infection with pneumococcus/H. influenzae
- may in some instances result in rupture of ear drum
- DO NOT prescribe antibiotics
- may offer pain relief if ears very sore
How can we tell if tonsillitis/pharyngitis is viral or bacterial in nature? What should we do to treat it?
- throat swab
- you can either wait for results from throat swab to come back and then review the patient or
- you can give 10 days penicillin (but not amoxycillin in case it is cause by EBV)
What causes croup (laryngotracheobronchitis)?
tends to be parainfluenza I
What are features of croup?
- it is common
- the child is usually well
- lots of coryza (inflammation of mucous lining of nose)
- stridor
- hoarse voice
- ‘barking’ cough
- cough can often begin in the evening
How do we treat croup and when will it resolve?
- oral dexamethasone
- normally resolves over 2-3 days
What causes epiglottitis?
H. influenzae Type B
What are features of epiglottitis?
- rare
- child is systemically unwell
- stridor, drooling
What treatment is required immediately for a child with epiglottitis?
intubation and antibiotics
What do you fundamentally need to ensure about child before saying that you will offer no treatment other than review?
is the child:
- hydrated?
- oxygenated?
- well nourished?
What is tracheitis?
- lower respiratory tract infection
- ‘croup that does not get better’ i.e. still there >48 hours later
What causes tracheitis?
staph or strep secondary to viral infection in croup
What are features of tracheitis?
- biphasic stridor
- fever
- sick child
How should tracheitis be treated?
with augmentin
What causes (bacterial) bronchitis?
endobronchial infection with Haemophilus or pneumococcus
What are features of (bacterial) bronchitis?
- very common
- child is very well, parents are worried
- have loose rattly cough with URTI that may have been going on for several months (due to gathering several colds)
- post-pertussive vomit
- tends to be self-limiting
- chest free of wheeze/ crepitations
What mechanism underlies (bacterial) bronchitis?
- the cause isn’t really an infection - reduced mucociliary clearance due to damage by virus or from minor airway malacia
- infection is secondary
What is the natural history of bacterial bronchitis?
- follows URTI
- lasts 4 weeks
- first winter bad cough
- second winter better cough
- third winter cough fine
What are the 3 criteria to diagnose persistent bacterial bronchitis?
- wet cough
- lasts more than a month
- remission with antibiotics
What are red flag symptoms of respiratory infection with bacterial bronchitis?
- Age <6 mo, >4yr
- Static weight
- Disrupts child’s life
- Associated SOB (when not coughing)
- Acute admission
- Other co-morbidities (neuro/gastro)
What is the treatment for bacterial bronchitis?
do not treat, reassure and worry if there are red flag symptoms
What is bronchiolitis?
a lower respiratory tract infection of infants
What causes bronchiolitis?
- usually RSV
- others include: para’ flu III, HMPV
How does bronchiolitis present?
- tends to be child with older sibling and they are under 1 year old
- is a one off infection -can’t have it again
- child has nasal stuffiness, is tachpnoeic, poor feeding
- may detect cradles with or without a wheeze
- at christmas time!
- typical history!
What is the typical history of bronchiolitis? Learn this as it is useful to be able to tell parents what to expect from the condition depending on when they present.
cough start—-3 days later RSV attacks airway and child gets worse to feed—-2 days stable state—2 weeks recovery
How should we manage bronchiolitis?
- observe
- no medicines
In general, what 4 features characterise a LRTI?
-lasting for 48 hours or more
-fever greater than 38.5
-SOB
-cough
wheeze makes bacterial cause unlikely
What are common infective agents in LRTI?
- viruses in <35%
- pneumococcus, mycoplasma, chlamydia
- mixed infection in <40%
When would you call an LRTI, pneumonia?
-signs are focal
-crepitations
-high fever
(otherwise just call it an LRTI)
What should you do if a child has a community acquired pneumonia?
- nothing and review if symptoms are mild
- oral amoxycillin (first line) or oral macrolide (second line or in penicillin allergy e.g. clarithromycin)
- only IV if child is vomiting
What is pertussis and what are features of it?
- ‘whooping’ cough
- very common LRTI
- child has coughing fits and may vomit at end of it and change colour due to effort
What is empyema?
- complication of pneumonia
- spread of infection into pleural space
How does empyema present?
chest pain and very unwell
How would we treat empyema in a child?
IV antibiotics with or without drainage
What are features of asthma?
- chronic
- parental asthma
- wheeze!!!
- dry nocturnal cough (just after falling asleep), may be exertional too
- SOB at rest (may see cooking in of ribs with wheeze)
- variable/reversible!!!!
- responds to asthma treatment!!!!
- may be trigger identifiable e.g. URTI, exercise, allergen, cold air, other such as emotion or menstruation
What differences are there between asthma in adults and asthma in children?
- gender (affects boys and women)
- asthma can be severe
- occupational asthma uncommon
What is the suspected aetiology of asthma in children and adults?
combination of genetic, environmental and lung function factors e.g. if you had low lung function, high genetic predisposition and smoked then you would be more likely to develop asthma than if you were of low genetic risk, had great lung function and didn’t smoke
What is important to consider first in management of asthma in children?
watching and waiting if no QOL implications of symptoms
What must you have to have asthma and how can you differentiate this from a parent’s history for their child?
- WHEEZE!!!
- can ask if the wheeze sounds more like a rattle or a whistle (can never be a rattle)
How can you test whether a child has asthma?
if have suspicion do trial dose of ICS for 2 months then do a drug ‘holiday’ to see if the symptoms recur
What can be included in a differential diagnosis with asthma?
- viral induced wheeze
- foreign body, cystic fibrosis, immune deficiency (secretions cause noise)
- ciliary dyskinesia
- aspiration
- tracheo-bronchomalacia
What should you do to treat an infrequent episodic wheeze with a cold?
salbutamol
If there is a child with a preschool moist cough with no associated wheeze and no red flag symptoms, what would you consider the diagnosis to be?
bacterial bronchitis
If there is a preschool child with a dry cough, no wheeze but has red flag symptoms, what would you consider the diagnosis to be?
bronchiectasis
What are the goals of treatment of asthma?
- ‘minimal’ symptoms during day and night
- minimal need for reliever medication
- no attacks (exacerbations)
- no limitation of physical activity
How can you measure control of asthma?
closed questions:SANE:
- Short acting beta agonist
- Absence from school/ nursery
- Nocturnal symptoms
- Exertional symptoms
What is the first step in treatment for asthma?
very low dose ICS if greater than 5 years old (orLTRA if <5 years) then review after 2 months
If the first step in management is not sufficient what can be done as as second measure?
- if child >5, add inhaled LABA
- if child<5 add LTRA
If the second step is not sufficient to managing asthma, what can be done as a third measure?
child >5, stop LABA and increase ICS to low level from very low level
If the third step is not sufficient in managing asthma, what can be done as a fourth measure?
consider trials of:
- increasing ICS to medium dose
- addition of SR theophylline
- refer patient to specialist care
If the 4th stage is insufficient is managing asthma, what should be done?
- use daily steroid tablet in lowest dose providing adequate control
- maintain medium dose ICS
- consider other treatments to minimise use of steroid tablets
- refer patient to specialist care
What is the maximum dose of ICs for children?
800 mcg
What else is offered at ALL levels of management for asthma in children?
SABA as and when required (the blue inhaler) and must be with a spacer if it is a MDI
What are adverse effects of using ICS?
- height suppression (minimal)
- oral candidiasis
- adrenocortical suppression
What is the only LTRA we use for children?
montelukast
If a child is having a mild asthma attack, how would you manage it?
- SABA via spacer or
- SABA via spacer and prednisolone
If a child is having a moderate asthma attack, what should you do?
- SABA via nebuliser and prednisolone or
- SABA and ipramide nebuliser and prednisolone
If a child is having a severe asthma attack or is unresponsive to other treatments, what should you do?
- IV salbutamol
- IV aminophylline
- IV magnesium
- IV hydrocortisone
- Intubate and ventilate
How can you determine the severity of an asthma attack?
look at the patient!!!
- respiratory rate
- work of breathing
- heart rate
- oxygen saturations
- ability to complete sentences
- confusion
- air entry
