Paediatric Respiratory Problems Flashcards
What is apnoea
Transient breathing cessation
Causes of apnoea
Prematurity
Obstructive sleep apnoea
Treatment of apnoea in neonates
Caffeine - stimulates the respiratory centre in the brain - stopped at 34 weeks
Causes of breathlessness in children
Asthma Viral wheeze Bronchiolitis CF URTI Pneumonia
Causes or cough in children
Bronchiolitis Croup Pneumonia URTI Respiratory distress in neonates Foreign body Whooping cough
Causes of cyanosis in children
Cyanotic heart conditions - tetrology of fallot, transposition of the great arteries, total anomalous pulmonary artery drainage, tricuspid atresia
Causes of stridor in children
Laryngomalacia - most common cause
Croup
Acute epiglottitis
Wheeze in children
Viral induced wheeze LRTI - Bronchiolitis Asthma Foreign body Cystic fibrosis Ciliary dyskinesia
Presentation of asthma
Wheeze Reduced exercise tolerance Worse when sleeping Associated with atopy SOB Chest tightness Dry cough Respiratory distress Diurnal variability
(Diagnosed at 5 yo)
Investigations for asthma
- Spirometry with bronchodilator reversibility
- FeNO2 > 35ppb
- Peak expiratory flow variability
- Challenge testing
Management of asthma for under 5yo
- Salbutamol
- Low dose ICS
- Montelukast
- Refer to specialist
Features of severe asthma
Inability to complete sentences Peak flow - 50 - 33% of normal Oxygen > 93% RR > 40 in 1 - 5 years or 30 in > 5yo HR - 140 in 1- 5 years or 125 in > 5yo Cyanosis
Features of life threatening asthma
Silent chest Peak flow - less than 33% of normal Cyanosis Saturations < 92% Hypotension Altered consciousness or confusion
Management of severe asthma
- Nebulised salbutamol
- Oral prednisolone/ IV hydrocortisone
- Oxygen
- Ipratropium bromide
- Magnesium sulphate
Presentation of bronchiectasis
Recurrent chest infections
Chronic cough
Investigations for bronchiectasis
CT scan - signet ring sign
Management of bronchiectasis
Ensure adequate feeding - NGT or IV may be required
Supplementary oxygen if sats < 92%
Ventilation if required
Presentation of bronchiolitis
Wheeze Crackles on auscultation Fever Coryzal symptoms Mucous Signs of RDS Dyspnoea Tachypnoea Poor feeding
Investigations for bronchiolitis
Chest auscultation - crackles
Capillary blood gases from toe - if severe respiratory distress
Management of bronchiolitis
Supportive - oxygen
Features of cystic fibrosis
Crackles in chest
Chronic cough
Thick pancreatic and biliary secretions - Failure to thrive and pancreatitis - steatorrhoea
Thick aiway secretions - Recurrent chest infections
Congenital bilateral abscence of the vas deferens - Infertility
Complications of cystic fibrosis
Meconium ileus
Diabetes
Malnutrition
Investigations for cystic fibrosis
Heel prick test - newborn bloodspot test
Sweat test - gold standard
Genetic testing - amniocentesis or chorionic villous sampling
Management of cystic fibrosis
2-3 times a day - physiotherapy massage Exercise High carbohydrate, high fat diet Enzymes (creon) and vitamins given Prophylactic antibiotics - flucloxacillin Vaccinations Nebulised saline, DNase Salbutamol
Lower respiratory tract infections
Bronchiolitis
Pneumonia
Causative organism of bronchiolitis
Respiratory syncytial virus
Causative organism of pneumonia in different age groups
Haemophilus influenza
Streptococcus pneumonia
Mycoplasma or chlamydia
Presentation of pneumonia
High Fever Secretions Cough - wet and productive Crackles in chest - focal and course Dull to percuss Bronchial breathing SOB Tachycardia Lethergy Delirium
Investigations for pneumonia
Respiratory exam
Chest X ray - not required but can be helpful
Sputum culture
Capillary blood gas
Management of pneumonia
Haemophilus influenza - Co- amoxiclav
Streptococcus pneumonia - Amoxicillin
Mycoplasma or chlamydia - erythromycin
Presentation of obstructive sleep anoea
- difficulty sleeping - increased naps during the day
- fatigue
- lack of concentration
Chronic cough
8 + weeks
Causes of chronic cough
Persistent bacterial bronchitis
Recurrent aspiration
Bronchiectasis
Cystic fibrosis
Persisted bacterial bronchitis features
- Wet cough > 4 weeks
- Absence of other signs, symptoms and causes
- Responds to abx - co - amoxiclav 2 wks
Causes of obstructive sleep apnoea
Obesity - metabolic disorder
Adenotonsillitis
Allergic rhinitis
Down syndrome
Features of viral induced wheeze
Bronchoconstriction which responds to inhalers
Due to rhinovirus type C
Allergy to virus - wheeze triggered by virus
Symptoms of a cold and RDS
FHx
How to perform a bronchodilator reversibility test
- 4 puffs of salbutamol via spacer and MDI
- Repeat spirometry after 10 - 15 mins
- Increase in absolute FEV1 of > 12% is positive
How to do a FeNO2 test
- Empty lungs
- Close lips around the mouth piece
- Inhale deeply untill full
- Exhale slowly through a filter as a constant pace
- Need 10 seconds of exhalation
Positive FeNO2 test
> 40 ppb - adults
> 35 ppb - children
Challenge testing
Direct - use methacholine or histamine to assess drop in lung function
Indirect - exercise, mannitol inhalation, cold
What is bronchiolitis?
Inflammation of the bronchioles caused by respiratory syncytial virus
Which age group is most susceptible to bronchiolitis
6 months - 1 year
Signs of respiratory distress
Tachypnoea > 60bpm Use of accessary muscles Intercostal and subcostal recessions Nasal flaring Head bobbing Tracheal tug Cyanosis Abnormal airway noises - wheeze, grunting or stridor
Typical course of bronchiolitis
Starts with URTI with coryzal symptoms 1 - 2 days - chest symptoms Symptoms worse on day 3 - 4 Last 7 - 10 days Most patients recover in 2 - 3 weeks
When to admit a child
Aged under 3 months with a fever
Pre - existing condition such as CF, Down syndrome or prematurity
50 - 75% less of their normal milk intake
Clinical dehydration
Resp rate > 70 bpm
Moderate to severe respiratory distress - grunting, head bobbing, recessions
Apnoea
Positive end expiratory pressure (PEEP)
High flow humidified oxygen via a nasal cannula which delivers continuous oxygen and pressure to oxygenate the lungs and prevent the airways from collapsing
Continuous positive airway pressure
Sealed nasal cannula which delivers higher controlled pressure of oxygen
Palivizumab
A monoclonal antibody that targets RSV given as a monthly injection to high risk patients to prevent bronchiolitis in ex premature infants or patients with congenital heart disease
Difference between viral induced wheeze and bronchiolitis
Viral induced wheeze causes bronchoconstriction and can be treated with inhalers
At which age are you more susceptible to viral induced wheeze?
3 - 5 years old
Presentation of viral induce wheeze
Tachypnoea
Respiratory distress
Wheeze
Management of viral induced wheeze
Salbutamol inhaler
Oxygen if required
NGT or IV if required for feeding
Asthma discharge plan
Weaning inhalers - 6 puffs 4 hourly
Finish course of steroids (3 days)
Safety netting
Individualised asthma action plan
Managemnt for asthma in 5 - 12yo
- Salbutamol
- Low dose ICS
- Montelukast
- Long acting beta agonist
- Medium dose ICS + LABA - MART
- High dose ICS
Side effects of inhalers
- ICS slightly reduce growth velocity by max 1cm, dose dependent
MDI technique with a spacer
- Assemble the spacer
- Shake the inhaler
- Attach the inhaler to the correct end
- Lift the chin slightly up, can sit or stand
- Make a seal around the mouthpiece
- Spray dose
- Take 5 normal breaths
Spacer care
- cleaner once a month
- avoid scrubbing
- air dry
Age range susceptible to croup
6 months to 2 years
Croup pathophysiology
URTI causing oedema in the larynx due to parainfluenza virus
Presentation of croup
Increased work of breathing Barking cough Hoarse voice Stridor Low grade fever
Management of croup
- Oral Dexamethasone
- Oxygen if required
- Nebulised budesonide
- Nebulised adrenaline
- Ventilation and intubation
Acute epiglottitis pathophysiology
Inflammation and swelling of the epiglottis caused by haemophilus influenza B
Presentation of acute epiglottitis
Sore throat Stridor Drooling Tripod position - leaning forward High fever Painful swallowing, not moving head
Investigations of acute epiglottitis
Do not examine throat!
Lateral Xray of the neck - thumb sign
Management of acute epiglottitis
Alert senior paediatrician and anaesthetist
May need intubation or tracheostomy
IV abx - ceftriaxone
Steroids - dexamethasone
Causative organism of whooping cough
Bordetella pertussis - gram negative
Investigations for whooping cough
Nasopharyngeal swab and PCR
Bacterial culture
If cough for 2 weeks - anti pertussis toxin IgG from saliva or blood
Complications of whooping cough
Bronchiectasis
Chronic lung disease of prematurity features
Bronchopulmonary dysplasia in premature babies at 28 weeks gestation
- RDS
- require oxygen, intubation and ventilation at birth
How a diagnosis of chronic lung disease of prematurity is made
Chest Xray changes
Still requiring oxygen therapy after 36 weeks gestational age
Presentation of chronic lung disease in prematurity
Low oxygen saturations Increased work of breathing Poor feeding and weight gain Crackles and wheezes on chest auscultation Increased susceptibility to infection
Prevention of chronic lung disease of prematurity
Give corticosteroids to mothers that show signs of premature labour at less than 36 weeks gestation can stimulate surfactant production by type II pneumocytes
- Use CPAP rather than intubation and ventilation
- Using caffeine to stimulate the respiratory effort
- Not over-oxygenating with supplementary oxygen
Management of chronic lung disease of prematurity
Formal sleep study - assesses o2 sats
Oxygen at home via nasal cannula
Monthly palivizumab injection - protects against RSV
Cystic fibrosis gene mutation
Chromosome 7 - CFTR
Autosomal recessive
Meconium ileus presentation
Not passing meconium in first 24 hours
Abdominal distension
Vomiting
Signs of cystic fibrosis
Low weight or height on growth charts Nasal polyps Finger clubbing Crackles and wheezing Abdominal distention
Causes of clubbing in children
Cyanotic heart disease Infective endocarditis Cystic fibrosis TB Inflammatory bowel disease Liver cirrhosis
Causative organisms of LRTI in patients with cystic fibrosis
Staphylococcus aureus - take prophylactic flucloxacillin
Pseudomonas aeruginosa - ciprofloxacin
Monitoring cystic fibrosis
Specialist clinic visits every 6 months
- Sputum culture
- Screening for diabetes, osteoporosis, vitamin D deficiency and liver failure
Primary cilia dyskinesia features
Autosomal recessive
Common in consanguinity
Respiratory cilia - mucus accumulation and recurrent chest infections
Fallopian tubes - infertility
Complications of primary ciliary dyskinesia
Bronchiectasis
Recurrent chest infections
Failure to thrive
Kartageners triad
(Due to PCD)
Situs invertus
Paranasal sinusitis
Bronchiectasis
Diagnosis of primary ciliary dyskinesia
Nasal brushing or bronchoscopy - microscopy of ciliated epithelium of the upper airway
Management of primary diliary dyskinesia
Regular physiotherapy massages
High calorie diet
Vaccinations
Prophylactic antibiotics - flucloxacillin
Causes of bronchiectasis
Cystic fibrosis
Whooping cough
Mild croup
Seal-like barking cough
No stridor
No sternal/intercostal recession at rest
Moderate Croup
Seal-like barking cough
Stridor and sternal recession at rest
No (or little) agitation or lethargy
Severe croup
Seal-like barking cough
Stridor and sternal/intercostal recession
Agitation or lethargy
Impending respiratory failure
Minimal barking cough
Stridor may become harder to hear
Increasing upper airway obstruction
Sternal/intercostal recession
Asynchronous chest wall and abdominal movement
Fatigue, pallor or cyanosis, decreased level of consciousness or tachycardia.
RR > 70 breaths/minute - severe respiratory distress.
