Paediatrics - Resp and cardio (3) Flashcards
Whooping cough is caused by which organism?
Bordetella pertussis
Clinical features of whooping cough
- Week of coryza
- Paraoxysmal cough followed by inspiratory whoop (in infants this can present as apnoea)
- Cough worse at night
- Can cause vomiting
- Child goes blue or red in the face
- Epistaxis or subconjunctival haemorrhages
How long does the paraoxysmal coughing last in whooping cough?
Up to 3 months
Complications of whooping cough
- Pneumonia
- Seizures
- Bronchiecstasis
Diagnosis of whooping cough?
Pernasal swab culture or PCR
Blood results in whooping cough
Increased lymphocytes
What is the potential treatment for whooping cough and why isn’t it used in children with the cough?
Macrolide antibiotics
Not used because only effective if started during catarrhal phase
Close contacts of children with whooping cough are given what prophylaxis?
Macrolide antibiotics
Unvaccinated children should be vaccinated
Before what age is whooping cough particularly dangerous?
Before 4 months when completed primary vaccinations
Who is immunised against whooping cough?
Children (from 2 months)
and pregnant mothers from 16 weeks
What is defined as a persistent cough?
Lasting longer than 8 weeks or no improvement after 3-4 in the absence of recurrent URTI
Causes of a persistent/ recurrent cough
- TB
- Lobar collapse
- Bacterial bronchitis
- Suppurative lung disease (CF)
- Asthma
- GORD
- Aspiration of feeds (cerebral palsy)
- Inhaled foreign body
- Parental smoking
Most common causes of pneumonia in newborn?
Group B strep
Gram-negative enterococci
Most common causes of pneumonia in infants and young children?
RSV and other resp viruses
Strep pneumoniae
H. influenzae
Children over 5 - most common causes of pneumonia?
Mycoplasma pneumoniae
Strep pneumoniae
Chlamydia pneumoniae
What should always be considered as a causative organism of pneumonia in all children?
Mycobacterium tuberculosis
Common presenting symptoms of a child with pneumonia?
- Cough
- Fever
- Rapid breathing
Generally preceded by URTI
Can also have poor feeding, lethargy and an unwell child
O/E how does a child with pneumonia present?
Tachypnoea
Nasal flaring
Chest indrawing
Signs of consolidation: dullness on percussion, decreased breath sounds, bronchial breathing over affected area ARE OFTEN ABSENT IN YOUNG CHILDREN
What is the most sensitive clinical sign of pneumonia?
Increased resp rate
How would you investigate pneumonia?
- CXR
- Nasopharyngeal aspirate may identify viral causes
- Bloods (FBC, CRP, ESR) - won’t help differentiate between viral and bacterial
If child has pneumonia associated with a pleural effusion, what is seen on CXR?
Blunting of the costophrenic angle
Indications for admission of a child with pneumonia?
- Oxygen sats <92%
- Recurrent apnoea
- Grunting/ inability to maintain adequate fluid or food intake
Management of a child with pneumonia?
General supportive care - oxygen, analgesia, IV fluids to maintain hydration
Oral ABx unless severe
What is the treatment of pneumonia (Abx) in young children, those over 5 and older children?
Young - broad spectrium (co-amox)
Over 5 - amoxicillin or macrolide e.g. erythromycin
Older - Amoxicillin
What are the typical signs of a parapneumonic effusion which requires drainage?
Persistent fever despite 48 hours of ABx
Which children with pneumonia require a follow up chest xray?
Lobar collapse/ atelectasis
Two common causes of persistent bacterial bronchitis?
H. influenzae
Moraxella catarrhalis
Investigation of a child with suspected bacterial bronchitis?
Sputum culture or bronchial lavage and culture
Treatment of child with suspected bacterial bronchitis
Co-amoxiclav (high dose) and physiotherapy
3 causes of generalised bronchiecstasis?
- CF
- Primary ciliary dyskinesia
- Immunodeficiency
- Chronic aspiration
3 causes of focal bronchiecstasis?
- Previous severe pneumonia
- Congenital lung abnormality
- Obstruction by foreign body
Best investigation for suspected bronchiecstasis?
CT
Can also do bronchoscopy
Inheritance pattern of CF?
AR
Incidence of CF in caucasians?
1 in 2500 live births
Carrier rate of CF?
1 in 25
Life expectancy of someone with CF?
Mid 30-40’s
Pathophysiology of CF?
Defective protein CFTR - which is a chloride channel found in the membrane of cells. This causes abnormal ion transportation across epithelial cells.
The gene for CFTR in found on which chromosome?
7
What is the most frequent mutation causing CF?
Delta F508
Infections typically seen in CF?
Staph aureus, h.influenza
then as progresses…
Pseudomonas aeriginosa, burkholderia
How is CF diagnosed on newborn screening (3 stages)
- Heel prick - Immunoreactive trypsinogen (IRT) is raised on biochemical screening
- If IRT raised then screened for common CF gene mutations
- Infants with two mutations have sweat test to diagnose
Presentation of CF
a) Newborn
b) Infancy/ Young child
c) Older child
Newborn - Meconium ileus and screening test
Infancy/ young child - prolonged jaundice, growth faltering, recurrent chest infections, malabsorption, steatorrhoea, bronchiectasis, rectal prolapse, nasal polyp, sinusitis
Older child - DM, allergic bronchopulmonary aspergillosis, cirrhosis, intestinal obstruction, pneumothorax, reccurent haemoptysis, sterility in males
O/E of child with CF
- Wet cough (productive of purulent sputum)
- Hyperinflation of chest (air trapping)
- Coarse inspiratory crepitations
- Expiratory wheeze
- Finger clubbing if established disease
Organs affected in CF?
- Lungs - chronic infection and bronchiectasis
- Pancreas - exocrine function
- Liver - cirrhosis
- Reproductive - sterility in males
How is pancreatic exocrine insufficiency diagnosed?
Demonstrating low faecal elastase
Treatment of meconium ileus?
Surgery or gastrografin enema
How is cystic fibrosis diagnosed?
Sweat test to confirm concentration of chloride in sweat is markedly elevated (60-125) where it should be 10-40mmol/L
Confirmed by testing for gene abnormalities in CFTR protein
Management of CF
- Reviewed at least annually in specialist centre
- Measure lung function using spirometry (FEV1)
- Physiotherapy twice or more a day. Exercise encouraged
- Continuous prophylactic oral antibiotics (fluclox) and additional rescue antibiotics
- Daily nebulised antipsedomonal antibiotics
- Nebulised hypertonic saline or DNase - decreases viscosity of sputum and decreases number of exacerbations
- Azithromycin given regularly (macrolide) - immunomodulatory effect
Presentation of meconium ileus?
Inspissated meconium causes intestinal obstruction
- vomiting
- abdo distension
- failure to pass meconium within the first few days of life
If patient with CF has persistent respiratory symptoms and declining lung function what is the management?
Prompt IV therapy
Administered for 14 days via a PIC
If IV access of CF patient becomes very regular and challenging what can be inserted?
Central venous catheter (portacath)
How is pancreatic insufficiency in CF managed?
Oral enteric coated pancreatic replacement therapy with all meals and snacks
High calorie diet
Dietary intake 150% of normal - so overnight feeding with gastrostomy is increasing
Fat soluble vitamin supplements
What are the typical extrapulmonary features of CF in teens and adults?
Liver cirrhosis, portal hypertension, liver failure
Diabetes mellitus
Distal intestinal obstruction (DIOS)
Male infertility
How do you maintain good bile flow in patient with CF
Regular ursodeoxycholic acid
How would you investigate suspected TB in a child with a persistent productive cough?
- Tuberculin skin test
- Tuberculosis blood tests (Interferon gamma release assays)
- CXR - Marked hilar or paratracheal lymphadenopathy
How do you investigate sleep disordered breathing?
- Overnight pulse oximetry
2. Polysomnography - HR, resp effort, airflow, CO2 measurement and video recording
What is the most common cause of sleep disordered breathing?
Adenotonsillar hypertrophy
