Paediatrics- Cardio, Resp Flashcards
What is Bronchiolitis
What is it caused by
Bronchiolitis
Respiratory syncytial virus (RSV)
Bronchiolitis is very common in winter or summer
winter
Bronchiolitis is very common in winter. Bronchiolitis is generally considered to occur in children under 1 year. It is most common in children under _ ______. It can rarely be diagnosed in children up to 2 years of age, particularly in ex-premature babies with _____ _______ ____
Bronchiolitis is very common in winter. Bronchiolitis is generally considered to occur in children under 1 year. It is most common in children under 6 months. It can rarely be diagnosed in children up to 2 years of age, particularly in ex-premature babies with chronic lung disease.
Patho of Bronchiolitis
When a virus affects the airways of adults, the swelling and mucus are proportionally so small that it has little noticeable effect on breathing. The airways of infants are very small to begin with, and when there is even the smallest amount of inflammation and mucus in the airway it has a significant effect on the infants ability to circulate air to the alveoli and back out. This causes the harsh breath sounds, wheeze and crackles heard on auscultation when listening to a bronchiolitic baby’s chest.
Presentation of Bronchiolitis
- Coryzal symptoms. These are the typical symptoms of a viral upper respiratory tract infection: running or snotty nose, sneezing, mucus in throat and watery eyes.
- Signs of respiratory distress
- Dyspnoea (heavy laboured breathing)
- Tachypnoea (fast breathing)
- Poor feeding
- Mild fever (under 39ºC)
- Apnoeas are episodes where the child stops breathing
- Wheeze and crackles on auscultation
Bronchiolitis
One of the foundations of paediatrics is being able to spot the signs of respiratory distress:
- Raised respiratory rate
- Use of accessory muscles of breathing, such as the sternocleidomastoid, abdominal and intercostal muscles
- Intercostal and subcostal recessions
- Nasal flaring
- Head bobbing
- Tracheal tugging
- Cyanosis (due to low oxygen saturation)
- Abnormal airway noises
learn this of by heart!!!!!
What do these mean
Wheeze
Grunting
Stridor
Wheezing is a whistling sound caused by narrowed airways, typically heard during expiration
Grunting is caused by exhaling with the glottis partially closed to increase positive end-expiratory pressure
Stridor is a high pitched inspiratory noise caused by obstruction of the upper airway, for example in croup
How does bronchiolitis start
Explain the progression
Bronchiolitis usually starts as an upper respiratory tract infection (URTI) with coryzal symptoms. From this point around half get better spontaneously. The other half develop chest symptoms over the first 1-2 days following the onset of coryzal symptoms. Symptoms are generally at their worst on day 3 or 4. Symptoms usually last 7 to 10 days total and most patients fully recover within 2 – 3 weeks. Children who have had bronchiolitis as infants are more likely to have viral induced wheeze during childhood.
Bronchiolitis
Most infants can be managed at home with advice about when to seek further medical attention. Reasons for admission include:
- Aged under 3 months or any pre-existing condition such as prematurity, Downs syndrome or cystic fibrosis
- 50 – 75% or less of their normal intake of milk
- Clinical dehydration
- Respiratory rate above 70
- Oxygen saturations below 92%
- Moderate to severe respiratory distress, such as deep recessions or head bobbing
- Apnoeas
- Parents not confident in their ability to manage at home or difficulty accessing medical help from home
Bronchiolitis Management
Typically patients only require supportive management. This involves:
- Ensuring adequate intake. This could be orally, via NG tube or IV fluids depending on the severity. It is important to avoid overfeeding as a full stomach will restrict breathing. Start with small frequent feeds and gradually increase them as tolerated.
- Saline nasal drops and nasal suctioning can help clear nasal secretions, particularly prior to feeding
- Supplementary oxygen if the oxygen saturations remain below 92%
- Ventilatory support if required
There is little evidence for treatments such as nebulised saline, bronchodilators, steroids and antibiotics.
Bronchiolitis
As breathing gets harder, the child gets more tired and less able to adequately ventilate themselves. They may require ventilatory support to maintain their breathing. This is stepped up until they are adequately ventilated:
Explain how they do this
- High-flow humidified oxygen via tight nasal cannula (i.e. “Airvo” or “Optiflow”). This delivers air and oxygen continuously with some added pressure, helping to oxygenate the lungs and prevent the airways from collapsing. It adds “positive end-expiratory pressure” (PEEP) to maintain the airway at the end of expiration.
- Continuous positive airway pressure (CPAP). This involves using a sealed nasal cannula that performs in a similar way to Airvo or Optiflow, but can deliver much higher and more controlled pressures.
- Intubation and ventilation. This involves inserting an endotracheal tube into the trachea to fully control ventilation.
Bronchiolitis
How do you assess ventilation
Capillary blood gases are useful in severe respiratory distress and in monitoring children who are having ventilatory support.
The most helpful signs of poor ventilation are:
- Rising pCO2, showing that the airways have collapsed and can’t clear waste carbon dioxide.
- Falling pH, showing that CO2 is building up and they are not able to buffer the acidosis this creates. This is a respiratory acidosis. If they are also hypoxic, this is classed as type 2 respiratory failure.
Palivizumab is a _______ _____ that targets the respiratory syncytial virus. A _____ _______ is given as prevention against bronchiolitis caused by RSV. It is given to high risk babies, such as ex-premature and those with ________ ______ _______
Palivizumab is a monoclonal antibody that targets the respiratory syncytial virus. A monthly injection is given as prevention against bronchiolitis caused by RSV. It is given to high risk babies, such as ex-premature and those with congenital heart disease.
Palivizumab _______ protection
passive
Is Palivizumab a true vaccine
It is not a true vaccine as it does not stimulate the infant’s immune system. It provides passive protection by circulating the body until the virus is encountered, as which point it works as an antibody against the virus, activating the immune system to fight the virus. The levels of circulating antibodies decrease over time, which is why a monthly injection is required.
What is viral induced wheeze
Viral-induced wheeze describes is an acute wheezy illness caused by a viral infection. Small children (typically under 3 years) have small airways. When these small airways encounter a virus (commonly RSV or rhinovirus) they develop a small amount of inflammation and oedema, swelling the walls of the airways and restricting the space for air to flow. This inflammation also triggers the smooth muscles of the airways to constrict, further narrowing the space in the airway.
What is Poiseuille’s law
This swelling and constriction of the airway caused by a virus has little noticeable effect on the larger airways of an older child or adult, however due to the small diameter of a child’s airway, t
states that flow rate is proportional to the radius of the tube to the power of four. Therefore, halving the diameter of the tube decreases flow rate by 16 fold.
Air flowing through these narrow airways causes a ______, and the restricted ventilation leads to ________ _____
Air flowing through these narrow airways causes a wheeze, and the restricted ventilation leads to respiratory distress.
How to distinguish between Viral Induced Wheeze and Asthma?
The distinction between a viral-induced wheeze and asthma is not definitive. Generally, typical features of viral-induced wheeze (as opposed to asthma) are:
- Presenting before 3 years of age
- No atopic history
- Only occurs during viral infections
Asthma can also be triggered by viral or bacterial infections, however it also has other triggers, such as exercise, cold weather, dust and strong emotions. Asthma is historically a clinical diagnosis, and the diagnosis is based on the presence of typical signs and symptoms along with variable and reversible airflow obstruction.
Presentation of Viral Induced Wheeze
Evidence of a viral illness (fever, cough and coryzal symptoms) for 1-2 days preceding the onset of:
- Shortness of breath
- Signs of respiratory distress
- Expiratory wheeze throughout the chest
TRUE OR FALSE
viral-induced wheeze or asthma cause a focal wheeze.
FALSE
What causes focal wheeze
focal airway obstruction such as an inhaled foreign body or tumour. These patients will require an urgent senior review.
Management of viral induced wheeze
Management of viral-induced wheeze is the same as acute asthma in children.
Presentation of acute asthma
- Progressively worsening shortness of breath
- Signs of respiratory distress
- Fast respiratory rate (tachypnoea)
- Expiratory wheeze on auscultation heard throughout the chest
- The chest can sound “tight” on auscultation, with reduced air entry
A silent chest is an ominous sign. This is where the airways are so tight it is not possible for the child to move enough air through the airways to create a wheeze. This might be associated with reduce respiratory effort due to fatigue. A less experienced practitioner may think because there is no respiratory distress and no wheeze the child is not as unwell, however in reality this a silent chest is life threatening.
Explain the severity of moderate severe and life threatening asthma
Management
Staples of management in acute viral induced wheeze or asthma are:
- Supplementary oxygen if required (i.e. oxygen saturations less than 94% or working hard)
- Bronchodilators (e.g. salbutamol, ipratropium and magnesium sulphate)
- Steroids to reduce airway inflammation: prednisone (orally) or hydrocortisone (intravenous)
- Antibiotics only if a bacterial cause is suspected (e.g. amoxicillin or erythromycin)
Bronchodilators are stepped up as required:
- Inhaled or nebulised salbutamol (a beta-2 agonist)
- Inhaled or nebulised ipratropium bromide (an anti-muscarinic)
- IV magnesium sulphate
- IV aminophylline
Asthma Management
Mild cases can be managed as an outpatient with regular_________ ______ via a spacer (e.g. 4-6 puffs every 4 hours).
Mild cases can be managed as an outpatient with regular salbutamol inhalers via a spacer (e.g. 4-6 puffs every 4 hours).
Asthma Management
Moderate to severe cases require a stepwise approach working upwards until control is achieved:
- Salbutamol inhalers via a spacer device: starting with 10 puffs every 2 hours
- Nebulisers with salbutamol / ipratropium bromide
- Oral prednisone (e.g. 1mg per kg of body weight once a day for 3 days)
- IV hydrocortisone
- IV magnesium sulphate
- IV salbutamol
- IV aminophylline
If you haven’t got control by this point the situation is very serious. Call an anaesthetist and the intensive care unit. They may need intubation and ventilation. This call should be made earlier to give the best chance of successfully intubating them before the airway becomes too constricted.
Management of Asthma
Once control is established: you can gradually work your way back down the ladder as they get better:
- Review the child prior to the next dose of their bronchodilator.
- Look for evidence of cyanosis (central or peripheral), tracheal tug, subcostal recessions, hypoxia, tachypnoea or wheeze on auscultation.
- If they look well, consider stepping down the number and frequency of the intervention.
- A typical step down regime of inhaled salbutamol is 10 puffs 2 hourly then 10 puffs 4 hourly then 6 puffs 4 hourly then 4 puffs 6 hourly.
Consider monitoring the serum potassium when on high doses of salbutamol as it causes potassium to be absorbed from the blood into the cells.
It is also worth noting that salbutamol causes tachycardia and a tremor.
When do you discharge a child with acute asthma
Generally, discharge can be considered when the child well on 6 puffs 4 hourly of salbutamol. They can be prescribed a reducing regime of salbutamol to continue at home, for example 6 puffs 4 hourly for 48 hours then 4 puffs 6 hourly for 48 hours then 2-4 puffs as required.
A few other steps to consider:
- Finish the course of steroids if these were started (typically 3 days total)
- Provide safety-net information about when to return to hospital or seek help
- Provide an individualised written asthma action plan
Presentation Suggesting a Diagnosis of Asthma
- Episodic symptoms with intermittent exacerbations
- Diurnal variability, typically worse at night and early morning
- Dry cough with wheeze and shortness of breath
- Typical triggers
- A history of other atopic conditions such as eczema, hayfever and food allergies
- Family history of asthma or atopy
- Bilateral widespread “polyphonic” wheeze heard by a healthcare professional
- Symptoms improve with bronchodilators
Presentation Indicating a Diagnosis Other Than Asthma
- Wheeze only related to coughs and colds, more suggestive of viral induced wheeze
- Isolated or productive cough
- Normal investigations
- No response to treatment
- Unilateral wheeze suggesting a focal lesion, inhaled foreign body or infection
Typical Triggers of chronic asthma
- Dust (house dust mites)
- Animals
- Cold air
- Exercise
- Smoke
- Food allergens (e.g. peanuts, shellfish or eggs)
Diagnosis of Asthma
There is no gold standard test or diagnostic criteria for asthma. A diagnosis is made clinically based on a typical history and examination. Children are usually not diagnosed with asthma until they are at least 2 to 3 years old. When there is a low probability of asthma and the child is symptomatic, consider referral to a specialist for diagnosis.
When there is an intermediate or high probability of asthma, a trial of treatment can be implemented and if the treatment improves symptoms a diagnosis can be made.
There are investigations that can be used where there is an intermediate probability of asthma or diagnostic doubt:
- Spirometry with reversibility testing (in children aged over 5 years)
- Direct bronchial challenge test with histamine or methacholine
- Fractional exhaled nitric oxide (FeNO)
- Peak flow variability measured by keeping a diary of peak flow measurements several times a day for 2 to 4 weeks
Chronic Asthma
Medical Therapy in Under 5 Years
- Start a short-acting beta-2 agonist inhaler (e.g. salbutamol) as required
- Add a low dose corticosteroid inhaler or a leukotriene antagonist (i.e. oral montelukast)
- Add the other option from step 2.
- Refer to a specialist.
Chronic Asthma
Medical Therapy Aged 5 – 12 Years
Medical Therapy Aged 5 – 12 Years
- Start a short-acting beta-2 agonist inhaler (e.g. salbutamol) as required
- Add a regular low dose corticosteroid inhaler
- Add a long-acting beta-2 agonist inhaler (e.g. salmeterol). Continue salmeterol only if the patient has a good response.
- Titrate up the corticosteroid inhaler to a medium dose. Consider adding:
- Oral leukotriene receptor antagonist (e.g. montelukast)
- Oral theophylline
- Increase the dose of the inhaled corticosteroid to a high dose.
- Referral to a specialist. They may require daily oral steroids.
Chronic Asthma
Medical Therapy Aged Over 12 Years (Same as Adults)
- Start a short-acting beta 2 agonist inhaler (e.g. salbutamol) as required
- Add a regular low dose corticosteroid inhaler
- Add a long-acting beta-2 agonist inhaler (e.g. salmeterol). Continue salmeterol only if the patient has a good response.
- Titrate up the corticosteroid inhaler to a medium dose. Consider a trial of an oral leukotriene receptor antagonist (i.e. montelukast), oral theophylline or an inhaled LAMA (i.e. tiotropium).
- Titrate the inhaled corticosteroid up to a high dose. Combine additional treatments from step 4, including the option of an oral beta 2 agonist (i.e. oral salbutamol). Refer to specialist.
- Add oral steroids at the lowest dose possible to achieve good control under specialist guidance.
Inhaled Corticosteroids in Children
does it slow growth?
There is evidence that inhaled steroids can slightly reduce growth velocity and can cause a small reduction in final adult height of up to 1cm when used long term (for more than 12 months). This effect was dose-dependent, meaning it was less of a problem with smaller doses.
It is worth putting this in context for the parent by explaining that these are effective medications that work to prevent poorly controlled asthma and asthma attacks that could lead to higher doses of oral steroids being given. Poorly controlled asthma can lead to a more significant impact on growth and development. The child will also have regular asthma reviews to ensure they are growing well and on the minimal dose required to effectively control symptoms.
Good inhaler technique will reduce …
oral thrush
is salbutamol dry powder inhaler or metered dosed inhaler
metered dosed inhaler
MDI technique without a spacer:
Explain the instruction
- Remove the cap
- Shake the inhaler (depending on the type)
- Sit or stand up straight
- Lift the chin slightly
- Fully exhale
- Make a tight seal around the inhaler between the lips
- Take a steady breath in whilst pressing the canister
- Continue breathing for 3 – 4 seconds after pressing the canister
- Hold the breath for 10 seconds or as long as comfortably possible
- Wait 30 seconds before giving a further dose
- Rinse the mouth after using a steroid inhaler
MDI technique with a spacer:
- Assemble the spacer
- Shake the inhaler (depending on the type)
- Attach the inhaler to the correct end
- Sit or stand up straight
- Lift the chin slightly
- Make a seal around the spacer mouthpiece or place the mask over the face
- Spray the dose into the spacer
- Take steady breaths in and out 5 times until the mist is fully inhaled
Alternatively exhale fully before putting making a seal with the spacer, spray the dose and take one deep breath in to inhale the mist in one breath before holding for 10 seconds.
Spacers should be cleaned once a month. Avoid scrubbing the inside and allow them to air dry to avoid creating static. Static can interact with the mist and prevent the medication being inhaled.
Bacterial causes of Pneumonia?
- Streptococcus pneumonia is most common
- Group A strep (e.g. Streptococcus pyogenes)
- Group B strep occurs in pre-vaccinated infants, often contracted during birth as it often colonises the vagina.
- Staphylococcus aureus. This causes typical chest xray findings of pneumatocoeles (round air filled cavities) and consolidations in multiple lobes.
- Haemophilus influenza particularly affects pre-vaccinated or unvaccinated children.
- Mycoplasma pneumonia, an atypical bacteria with extra-pulmonary manifestations (e.g. erythema multiforme).
Viral causes of pneumonia
- Respiratory syncytial virus (RSV) is the most common viral cause
- Parainfluenza virus
- Influenza virus
Investigations for Pneumonia
A chest xray is the investigation of choice for diagnosing pneumonia. It is not routinely required, but can be useful if there is diagnostic doubt or in severe or complicated cases.
Sending sputum cultures and throat swabs for bacterial cultures and viral PCR can establish the causative organism and guide treatment. All patients with sepsis should have blood cultures. Capillary blood gas analysis can be helpful in assessing or monitoring respiratory or metabolic acidosis and the blood lactate level in unwell patients.
Pneumonia management paediatric
Pneumonia should be treated with antibiotics according to local guidelines.
Amoxicillin is often used first line. Adding a macrolide (erythromycin, clarithromycin or azithromycin) will cover atypical pneumonia. Macrolides can be used as monotherapy in patients with a penicillin allergy.
IV antibiotics can be used when there is sepsis or a problem with intestinal absorption.
Oxygen is used as required to maintain saturations above 92%.
What is CROUP
Croup is an acute infective respiratory disease affecting young children. It typically affects children aged 6 months to 2 years, however they can be older. It is an upper respiratory tract infection causing oedema in the larynx. The classic cause of croup that you need to spot in your exams, is parainfluenza virus. It usually improves in less than 48 hours and responds well to treatment is steroids, particularly dexamethasone.
The common causes for croup are:
Parainfluenza
Influenza
Adenovirus
Respiratory Syncytial Virus (RSV)
Croup used to be caused by __________ Croup caused by ______ leads to ________ and has a high mortality. Vaccination mean that this is very rare in developed countries.
Croup used to be caused by diphtheria. Croup caused by diphtheria leads to epiglottitis and has a high mortality. Vaccination mean that this is very rare in developed countries.
Presentation of Croup
- Increased work of breathing
- “Barking” cough, occurring in clusters of coughing episodes
- Hoarse voice
- Stridor
- Low grade fever
Management of Croup
Most cases can be managed at home with simple supportive treatment (fluids and rest). During attacks it can help to sit the child up and comfort them. Measures should be taken to avoid spreading infection, for example hand washing and staying off school.
Oral dexamethasone is very effective. This is usually a single dose of 150 mcg/kg, which can be repeated if required after 12 hours. Prednisolone is sometimes used as an alternative where dexamethasone in not available (e.g. by GPs).
Stepwise options in severe croup to get control of symptoms:
- Oral dexamethasone
- Oxygen
- Nebulised budesonide
- Nebulised adrenalin
- Intubation and ventilation
What is Epiglottitis
Epiglottitis is inflammation and swelling of the epiglottis caused by infection, typically with haemophilus influenza type B. The epiglottis can swell to the point of completely obscuring the airway within hours of symptoms developing. Therefore, epiglottitis is a life threatening emergency.
Why is epiglottis rare now in children
Epiglottitis is now rare due to the routine vaccination program, which vaccinates all children against haemophilus. You need to be extra cautious and have high suspicion in children that have not had vaccines. It can present in a similar way to croup, but with a more rapid onset.
In you exams keep a lookout for an unvaccinated child presenting with a fever, sore throat, difficulty swallowing that is sitting forward and drooling and suspect epiglottitis.
Presentation Suggesting Possible Epiglottitis
- Patient presenting with a sore throat and stridor
- Drooling
- Tripod position, sat forward with a hand on each knee
- High fever
- Difficulty or painful swallowing
- Muffled voice
- Scared and quiet child
- Septic and unwell appearance
Investigations of Epiglottis
If the patient is acutely unwell and epiglottitis is suspected then investigations should not be performed. Performing a lateral xray of the neck shows a characteristic “thumb sign” or “thumbprint sign”. This is a soft tissue shadow that looks like a thumb pressed into the trachea. This is caused by the oedematous and swollen epiglottis. Neck xrays are also useful for excluding a foreign body.
Management of Epiglottitis
Epiglottitis is an emergency and there is an immediate risk of the airway closing. A key point that is often talked about with epiglottitis is the importance of not distressing the patient, as this could prompt closure of the airway. If you see a child with suspected epiglottitis, leave them well alone and in their comfort zone. Don’t examine them and don’t make them upset. The most important thing is to alert the most senior paediatrician and anaesthetist available.
Management of epiglottis centres around ensuring the airway is secure. Most patients do not require intubation, however there is an ongoing risk of sudden upper airway closure, so preparations need to be made to perform intubation at any time. Intubation is often difficult and needs to be performed in a controlled environment with facilities available to do a tracheostomy (intubating through the neck) if the airway completely closes. When patients are intubated they are transferred to an intensive care unit.
Additional treatment once the airway is secure:
- IV antibiotics (e.g. ceftriaxone)
- Steroids (i.e. dexamethasone)
Prognosis of Epiglottitis
Most children recover without requiring intubation. Most patients that are intubated can be extubated after a few days and also make a full recovery. Death can occur in severe cases or if it is not diagnosed and managed in time.
A common complication to be aware of is the development of an epiglottic abscess, which is a collection of pus around the epiglottis. This also threatens the airway, making it a life threatening emergency. Treatment is similar to epiglottitis.
What is Laryngomalacia
Laryngomalacia is a condition affecting infants, where the part of the larynx above the vocal cords (the supraglottic larynx) is structured in a way that allows it to cause partial airway obstruction. This leads to a chronic stridor on inhalation, when the larynx flops across the airway as the infant breathes in. Stridor is a harsh whistling sound caused by air being forced through an obstruction of the upper airway.
What are Structural Change of sLaryngomalacia
There are two aryepiglottic folds at the entrance of the larynx. They run between the epiglottis and the arytenoid cartilages. They are either side of the airway and their role is to constrict the opening of the airway to prevent food or fluids entering the larynx and trachea. In laryngomalacia the aryepiglottic folds are shortened, which pulls on the epiglottis and changes it shape to a characteristic “omega” shape.
The tissue surrounding the supraglottic larynx is softer and has less tone in laryngomalacia, meaning it can flop across the airway. This happens particularly during inspiration, as the air moving through the larynx to the lungs pulls the floppy tissue across the airway to partially occlude it. This partial obstruction of the airway generates the whistling sound.
Presentation of Laryngomalacia
Laryngomalacia occurs in infants, peaking at 6 months. It presents with inspiratory stridor, a harsh whistling sound when breathing in. Usually this is intermittent and become more prominent when feeding, upset, lying on their back or during upper respiratory tract infections. Infants with laryngomalacia do not usually have associated respiratory distress.
It can cause difficulties with feeding, but rarely causes complete airway obstruction or other complications.
Disease Course and Management of Laryngomalacia
The problem resolves as the larynx matures and grows and is better able to support itself, preventing it from flopping over the airway. Usually, no interventions are required and the child is left to grow out of the condition.
Rarely tracheostomy may be necessary. This involves inserting a tube through the front of the neck into the trachea, bypassing the larynx. Surgery is also an option to alter the tissue in the larynx and improve the symptoms.
What is a Whooping cough
Whooping cough is an upper respiratory tract infection caused by Bordetella pertussis (a gram negative bacteria). It is called “whooping cough”, because the coughing fits are so severe that the child is unable to take in any air between coughs and subsequently makes a loud whooping sound as they forcefully suck in air after the coughing finishes.
Whats another name of Whooping cough
pertussis
Children and pregnant women are vaccinated against ______. The vaccine becomes less effective a few years after each dose
Children and pregnant women are vaccinated against pertussis. The vaccine becomes less effective a few years after each dose
Pertussis typically starts with mild ______ symptoms, a low grade fever and possibly a mild dry cough.
Pertussis typically starts with mild coryzal symptoms, a low grade fever and possibly a mild dry cough.
Presentation of Whooping Cough
More severe coughing fits start after a week or more. These involve sudden and recurring attacks of coughing with cough free periods in between. This is described as a paroxysmal cough. Coughing fits are severe and keep building until the patient is completely out of breath. Patient typically produces a large, loud inspiratory whoop when the coughing ends. Patients can cough so hard they faint, vomit or even develop a pneumothorax. Bear in the mind that not all patients will “whoop” and infants with pertussis may present with apnoeas rather than a cough
Diagnosis Whooping Cough
A nasopharyngeal or nasal swab with PCR testing or bacterial culture can confirm the diagnosis within 2 to 3 weeks of the onset of symptoms.
Where the cough has been present for more than 2 weeks patients can be tested for the anti-pertussis toxin immunoglobulin G. This is tested for in the oral fluid of children aged 5 to 16 and in the blood of those aged over 17.
Management of whooping cough
Pertussis is a notifiable disease. Therefore Public Health need to be notified of each case.
Management typically involves simple supportive care. Vulnerable or acutely unwell patients, those under 6 months and patients with apnoeas, cyanosis or patients with severe coughing fits may need to be admitted. Measures to prevent spread are important, such as avoiding contact with vulnerable people, disposing of tissues and careful hand hygiene.
Macrolide antibiotics such as azithromycin, erythromycin and clarithromycin can be beneficial in the early stages (within the first 21 days) or vulnerable patients. Co-trimoxazole is an alternative to macrolides.
Close contacts with an infected patient are given prophylactic antibiotics if they are in a vulnerable group, for example pregnant women, unvaccinated infants or healthcare workers that have contact with children or pregnant women.
The symptoms typically resolve within 8 weeks, however they can last several months. It is also known as the “100-day cough” due to the potential long duration of the cough.
A key complication of whooping cough is __________
A key complication of whooping cough is bronchiectasis.
What is CF
Cystic fibrosis (CF) is an autosomal recessive genetic condition affecting mucus glands. It is caused by a genetic mutation of the cystic fibrosis transmembrane conductance regulatory gene on chromosome 7.
There are many variants of this mutation, the most common is the delta-F508 mutation. This gene codes for cellular channels, particularly a type of chloride channel. Around 1 in 25 are carriers of the mutation and 1 in 2500 children have CF.
The key consequences of the cystic fibrosis mutation are:
- Thick pancreatic and biliary secretions that cause blockage of the ducts, resulting in a lack of digestive enzymes such as pancreatic lipase in the digestive tract
- Low volume thick airway secretions that reduce airway clearance, resulting in bacterial colonisation and susceptibility to airway infections
- Congenital bilateral absence of the vas deferens in males. Patients generally have healthy sperm, but the sperm have no way of getting from the testes to the ejaculate, resulting in male infertility
