Paediatric Respiratory Medicine - URTI and LRTI's Flashcards
What is pneumonia?
Inflammation of the lung parenchyma with consolidation of alveoli
What is more likely to cause pneumonia is pre-schoolers? How is this different for older children?
Viruses > Bacteria
Vice versa for older children
What are the common causative organisms for pneumonia?
Bacteria - Strep Pneumoniae, Mycoplasma
Virus - RSV, Influenzae
What symptoms would a child with pneumonia present with?
History of URTI Fever Cough Breathlessness Post-tussive vomiting
What signs would a child with pneumonia present with?
Tachypnoea
Consolidation signs - dull to percuss, decreased breath sounds, bronchial breathing
Grunting
Crackles
Recession
What can be seen on examination of a child with pneumonia?
Sats <95%
Fever >38.5
Signs of respiratory distress
What investigations would you request if you suspect pneumonia?
For community - not necessary
FBC, CRP, Culture - blood and sputum
Nasopharyngeal aspirate
CXR
What would suggest bacterial pneumonia?
Polymorphonuclear leucocytosis
Lobar consolidation
Pleural effusion
How is pneumonia managed?
Normally at home - depend on severe signs
Amoxicillin - 1st line for 1-2 weeks
Cefaclor if pen allerfic
Erythromycin for mycoplasma
What parental advice is given for management of pneumonia?
Alternate paracetamol and ibuprofen
Continue breast feeding
Encourage fluids
Safety net
What complications can arise from pneumonia?
Empyema
Sepsis
Abscess
Pleural effusion
How can neonates present with pneumonia?
Poor feed
Irritable
Grunting
By what mechanism may neonates get pneumonia?
Aspiration of micro-organisms at delivery
What picture would neonatal pneumonia lead to?
Respiratory Distress Syndrome picture
Destruction of tissue leading to inhibition of surfactant production
What is bronchiolitis?
Viral infection of the bronchioles
What causes bronchiolitis?
Normally caused by RSV
What does Respiratory Syncytial Virus do in the upper airway?
It first affects the nasopharyngeal epithelium and then spreads to the lower airway causing
Increased mucus production
Desquamation
Bronchiolar obstruction
What age does bronchiolitis affect children?
3-6 months is most common
All under age of 2
What are the risk factors for getting bronchiolitis?
Breast fed < 2months
Smoke exposure
Siblings at school/nursery
Chronic lung disease due to prematurity
What symptoms do children with bronchiolitis present with?
1-3 days coryzal symptoms - Nasal congestion, Rhinorrhoea etc.
Dry cough
Low grade fever
Feeding difficulty
What signs would you see on examination in a child with bronchiolitis?
Tachypnoea Grunting Nasal flaring Recession Wheeze and fine crackles!
What symptoms may very young children with bronchiolitis present with?
Poor feed
Apnoea
If a child presented with coryzal symptoms, tachypnoea, flaring, recessions and a wheeze but no crackles, what diagnosis would you consider?
Viral induced wheeze
If a child presented with coryzal symptoms, tachypnoea, flaring, recessions, wheeze, crackles and a temperature over 39, what diagnosis would you consider?
Pneumonia
What differential diagnosis should you consider for bronchiolitis?
Pneumonia Croup CF Heart failure Bronchitis
What lab tests would you request if you suspect bronchiolitis?
Nasopharyngeal aspirate
Blood and urine culture
FBC
ABG - if systemically unwell
What imaging would you request for bronchiolitis and what would it show?
CXR
Hyperinflation Focal atelectasis Air trapping Flat diaphragm Peribronchial cuffing
What features would make you refer a child to hospital urgently if they had bronchiolitis?
Apnoea Child look seriously unwell Severe resp distress Central cyanosis Sats <92
What features would make you consider general hospital admission if a child had bronchiolitis?
Resp Rate >60
Inadequate fluid - 50-75% of usual
Clinically dehydrated
How is most bronchiolitis managed?
Supportive measures - fluid, nutrition, temp control
Generally self limiting
What may make a child high risk of having severe bronchiolitis?
Premature
Chronic lung disease
Congenital heart disease
Immunodeficient
How are high risk patients managed?
Prophylactic palivizumab
How is bronchiolitis managed in hospital?
Oxygen - high flow nasal cannula NG tube - feed CPAP if impending respiratory failure Ribavirin - high risk patients Possible upper airway suction
When would you discharge a child following admission for bronchiolitis?
Clinically stable
Adequate oral fluids
Maintain sats >92 for 4 hours +
What are the complications associated with bronchiolitis?
Hypoxia Dehydration Fatigue Resp failure Persistent cough/wheeze Bronchiolitis obliterans
What is the prognosis for bronchiolitis?
Usually last 7-10 days
If hospitalised, children can take unto 6 weeks to clear cough
What are the types of viral wheeze?
Episodic
Multiple trigger
What causes episodic viral wheeze?
Viral URTI
What causes multiple trigger wheeze?
Viral URTI and triggers such as smoke, allergens and exercise
What is the difference in prognosis of multiple trigger and episodic wheeze?
Multiple trigger wheeze is associated with an increased risk of developing asthma
How is a viral wheeze managed?
SABA via spacer to aim for sats of 94-98
10 puffs, 30s apart
Repeat after 15 mins
What organisms can cause croup?
Most common - parainfluenza
Can be RSV, adeno, rhino and enter virus
What does the viral infection lead to in croup?
Subglottal inflammation and oedema causing impaired vocal cord movement
At what age are children affected by croup?
6 month - 3 years
Peak at 2 years
What are the differential diagnoses for croup?
Epiglottitis
FB inhalation
Anaphylaxis
Quinsy
What are the risk factors for croup?
Male
Autumn or spring season
How would a child with croup present?
Few day history of coryza and fever
Characteristic barking cough
Stridor
Symptoms worse at night
Decreased chest sounds?
Poss resp distress?
How is the severity of croup categorised?
Mild - occasional bark, no stridor or recession, child happy
Moderate - frequent barking cough, stridor at rest, recessions, child not distressed
Severe - as above but resp. failure signs
How do you diagnose croup? What investigations would you order
Clinical diagnosis normally
FBC, CRP, U&E
CXR
Pulse oximetry
What should you not do if you suspect a child has croup?
Examine their throat - precipitate complete obstruction
How is mild croup managed?
At home with supportive measures - generally spontaneously resolve
What would cause you to consider admitting a child with croup to hospital?
History of severe airway obstruction <6months old Immunocompromised Poor fluid Poor response to initial treatment Uncertain diagnosis Significant parental anxiety
How is croup treated?
Paracetamol/ibuprofen - fever and pain
Single dose oral dexamethasone - (0.15mg/kg)
O2 and nebuliser adrenaline if severe
What is the scoring system for croup called?
Westley scoring system
What causes epiglottitis and why is it rare?
Haemophilus Influenza type B
Rare due to Hib vaccine
When do children get epiglottitis?
Between 2-6yo
How does epiglottitis present?
Symptoms develop over few hours
Sore throat - esp. swallowing
Drooling
Hot potato voice
Fever
What investigations would you do for epiglottitis?
Fibre optic laryngoscopy
Lateral neck xray - thumbprint
DONT EXAMINE THROAT - PRECIPITATE COMPLETE OBSTRUCTION
How is epiglottitis managed?
IV or oral antibiotics - senior paediatrician, ENT surgeon and anaesthetist should be present
Intubation
How does croup differ from epiglottitis?
Time - croup is over days, epiglottitis over hours
Croup has prior coryza
Epiglottitis children look toxic and unwell
Barking cough in croup
Fever much higher in epiglottitis
Epiglottitis - children can’t speak or swallow
