Paediatrics: Respiratory Flashcards
What is bronchiolitis? upper or lower resp tract?
Inflammation + infection of the bronchioles
- Lower resp tract infection
What is bronchiolitis usually caused by?
Usually viral
- RSV (respiratory syncytial virus)
What proportion of children get Bronchiolitis in their first year of life? during what season?
1/3
in winter
What age is Bronchiolitis common in?
usually in kids <18 months (mostly <6 months)
Describe the pathophysiology of Bronchiolitis
viral infection => excess mucus production + oedema + inflam (of tiny bronchioles) => obstruction of airflow in and out of chest
Bronchiolitis presentation?
bad feeding and bad breathing
- Coryzal symptoms (snotty nose, sneezing, mucus in throat, watery eyes)
- Syns of resp distress (dyspnoea, tachypnoea, tachycardia, poor feeding, mild fever, apnoea, wheeze)
What is the typical history/course of a child presenting with Bronchiolitis ? describe the days
5 month old with URTI Coryzal symptoms => chest symptoms (day 1-2) => symptoms at their worst day 3-4 => symptoms last total 7-10 days
when would a child with bronchiolitis have to be admitted to hospital ? (7)
- <3 months
- oxy sats <92%
- reduced feeding
- moderate-severe resp distress
- apnoeas
- RR > 70
- clinically dehydrated
Bronchiolitis management?
supportive
- ensure adequate intake (oral, NG, IV)
- nasal suctioning
- supplementary oxygen
- ventilatory support
(- paracetamol if fever)
what advice should you give about Bronchiolitis and feeding?
ensure adequate intake but do not overfeed as it will restrict breathing (full stomach)
How long can the cough from bronchiolitis last?
disease course is usually 7-10 days but the cough can last up to 6 weeks
What is viral induced wheeze?
Acute wheezy illness caused by viral infection
Describe the pathophysiology of viral induced wheeze?
small children so small airway encounter virus => inflam + oedema + trigger smooth muscle constriction => restricts airflow => wheeze and resp distress
why do adults not get viral induced wheeze?
the inflam and aimed has little effect on larger child or adult due to the larger airways
Viral induced wheeze presentation ?
- Evidence of viral disease (fever, cough, coryza)
- Plus: sob, signs, of resp distress, expiratory wheeze
on auscultation of the chest, where will the VIW wheeze be heard? focal or throughout? what other condition causes similar finding?
wheeze will be throughout chest
- (neither asthma nor VIW causes focal wheeze)
What is acute asthma exacerbation?
rapid deterioration in the symptoms of asthma
name some triggers of acute asthma (7)
- infection
- exercise
- cold weather
- high emotion
- dust
- animals
- fod allergies
Acute asthma presentation?
- sob
- sings of resp distress
- expiratory wheeze
on auscultation, what chest finding might you find in acute asthma ? explain (2)
- expiratory wheeze (throughout the chest)
- silent chest (no noise due to airway so tight => no airflow) life threatening
what might you see in a life threatening acute asthma exacerbation? peak flow? sats? other signs (A-E) ?
- peak flow < 33%
- sats < 92%
- exhaustion and poor resp effort
- hypotension
- silent chest
- cyanosis
- altered consciousness
name some of the classes of drugs used in management of acute asthma ?
- Bronchodilators
- Steroids
- Supplementary oxygen
- Abx
name 3 bronchodilators used in acute asthma management?
- salbutamol
- ipratropium
- Mg sulphate
describe the stepwise management of acute asthma? (7)
1) salbutamol inhalers via spacer device (10 puffs every 2 hrs)
2) nebuliser salbutamol/ipratropium bromide
3) Oral prednisolone
4) IV hydrocortisone
5) IV Magnesium sulphate
6) IV salbutamol
7) IV aminophylline
what electrolyte might you want to monitor during acute asthma management?
check serum K while on high dose salbutamol as can cause hypokalaemia
name 2 (3) side effects of salbutamol
tachycardia + tremor
(does also cause hypokalaemia)
What is the commonest chronic condition in children?
Asthma
what is + Describe the pathophysiology of chronic asthma
chronic inflammatory airway disease leading to variable airway obstruction
- hypersensitive + slightly inflamed airway responds to stimuli => constrict => airway obstruction
What type of airway obstruction is there in asthma?
reversbile airway obstruction
Describe the symptoms and variability of chronic asthma
dry cough, wheeze, sob
- episodic symtoms with intermittent exacerbations, diurnal variability, triggers + FHx of atopy
what factors would move you away form a diagnosis of asthma?
- wheeze only related to coughs and cold (viral induced wheeze)
- productive cough
- no response to bronchodilators
- unilateral wheeze
what could a unilateral/focal wheeze indicate? (2)
- inhaled foreign body
- infection
How is asthma diagnosed?
often made clinically
- spirometry with reversibility testing, peak flow variabilty
- kinda confirmed if the treatment is successful
Describe the long term management of asthma? (5)
stepwise approach
1) inhaled salbutwmal as prequired
2) los dose corticosteroid inhlaer
3) LABA inhaler
4) leukotriene agonist
5) titrate up ICS
What is pneumonia ?
infection of the lung tissues causing inflammation of lung tissues and sputum filling airway + alveoli
Pneumonia presentation (7)
- cough
- high fever (>38.5)
- tachypnoea
- tachycardia
- increased work of breathing
- lethargy
- Delirium
(resp distress)
what is the cough typically like in pneumonia?
wet + productive
what chests sounds might you find in pneumonia ?
- bronchial breath sounds
- focal corase crakcles
- Dullness to percussion
what is the most common bacterial cause of pneumonia ? plus other bacteria (4 other)
- Strep pneumonia (most common)
- GAS
- GBS
- S. aureus
- H. Influenza
what is the most common viral cause of pneumonia ? plus 2 others?
- RSV (most common)
- parainfluenza
- influenza
What investigations might you do for suspected pneumonia ?
CXR: not routinely required but useful if in doubt
- Sepsis screen
Pneumonia manament ?
Abx: amoxicillin (IV if sepsis)
- Oxygen as required (maintain above 92%)
what is another term for croup?
Acute larygotracheobronchitis
What is croup ? who does it affect?
acute viral URT infection affecting children aged 6 months - 3years
when is the peak age for children affected by croup ?
2 years
what is the most common cause of croup? plus other?
para influenza virus
- influenza, adenovirus, RSV
describe the physiology that causes stridor?
caused by obstruction in upper airway
Describe the presentation of croup?
- increased work of breathing
- Barking cough
- hoarse voice
- stridor
- low grade fever
describe the management of croup?
most cases managed at home (guide + rest), conforms + calm the child
- Single dose oral dexamethosone
- Oxygen as required (>92%)
- nebuliser Ad (provide relief of symptoms)
- Intubation + ventilation
What scale categorises croup presentation into mild/moderate/severe croup?
Westley Croup Score
describe the time course of croup vs epiglottis ?
- Croup: days
- Epiglottitis: hours
Describe the features prior in croup vs epiglottis ?
- Croup: coryza
- Epiglottitis: none
Describe the cough in croup vs epiglottis ?
- Croup: Barking
- Epiglottitis: slight if any
Describe the mouth in croup vs epiglotittis ?
- Croup: closed
- Epiglottitis: drooling saliva
describe the fever in croup vs epiglottis ?
- Croup: <38.5 degrees
- Epiglottitis:>38.5 degrees
describe the voice in croup vs epiglotittis?
- Croup: hoarse
- Epiglottitis: potato
What is Epiglottitis ?
life threatening inflam + swelling of the epiglottis by usually infection => airway obstruction
What is the most common cause of Epiglottitis ?
HiB
why are the rates of Epiglottitis a lot lower now?
a lot rarer now due to HiB vaccination (most common cause)
what non-infectious causes of epiglottis are there? (2)
- thermal: steam
- direct trauma: blind sweep to remove foreign body
4 Ds: dyspnoea, psyyhagia, drooling and dysphonia is the common presentation for what condition?
epiglotittis
describe the presentation of Epiglottitis ?
- sore throat + stridor
- drooling
- tripod position
- high fever
- difficulty or painful swallowing
- hot potato voice
What investigations do you do in suspected epiglottis ?
if suspected + patient unwell then no not perform any investigations
- do not examine!
- xray
what might X-ray of patient with Epiglottitis show? why useful?
lateral Xray of neck shows thumb sign + thickened aryepiglottic folds
- useful to exclude IFB
What is the management of epiglottis ?
Medical emergency (risk of airway closing), do not distress the child (can prompt airway closure)
1) secure the airway: May need intubation
2) oxygen: can be held by the parent
3) nebuliser Ad: buys time while awaits definitive management
4) IV Abx
5) IV steroids (dexamethasone - reduce oedema + swelling)
what Abx would you consider for Epiglottitis
IV ceftriaxone - covers HiB
What is larygomalacia? affects who?
condition affecting infants when immature larynx (above vocal cords) is abnormally structured => airway obstruction
Describe the structural changes in larygomalacia? pathophysiology
- shortened aryeppiglottic folds => characteristic omega shape
- Immature supraglottic fold has less tone => more floppy on inspiration => partial obstruction
Laryngomalacia presentation? what makes it worse?
chronic inspiratory stridor, intermittent
- worse when feeding/ lying on back/upset
what investigations might you do for suspected Laryngomalacia?
laryngoscopy (flexible endoscopy)
Laryngomalacia management
no intervention required, child is left to grow out of it
- severe cases (rare): can be life threatening: ABCDE, consider surgical intervention
what percentage of Laryngomalacia cases self-resolve?
99%
What is whooping cough?
highly infectious bacterial upper respiratory tract infection that causes coughing fits
Describe the coughing fits in whooping cough?
coughing fits are sos ever such that child is unable to take breaths between + then Mae whooping noise as they forcefully suck in air
Name the pathogen that causes whooping cough?
Bordatella pertussis
describe the gram staining and shape of the pathogen causing whooping cough?
gram negative bacillus
when vaccinations against pertussis?
- children (2,3,4 months and 3 yrs + 4 months)
- pregnant women
after how many years does pertussis immunity wane in children?
5-10years
describe the presentation of whooping cough? course
- starts with mild Coryzal symptoms, low grade fever + dry cough
- Then more sever coughing fits (paroxysmal cough)
what can severe coughing fits in whooping cough cause ?
- fainting
- vomiting
- pneumothorax
instead of a cough, how may infants with whooping cough present?
apnoeas
How is whooping cough diagnosed?
- nasopharyngeal or nasal swab with PCR testing or bacterial cultures
- > 2 weeks: anti-pertussis toxin IgG serology
Whooping cough management?
- Notifiable disease: notify public health
- supportive care
- Abx
what Abx for whooping cough?
Clarythromycin (macrolide) for pertussis
when would a child get admitted for whooping cough? (5)
- If acutely unwell
- < 6 moths
- apnoeas
- cyanosis
- severe coughing fits
how long can the cough in whooping cough last for?
Symptoms typically resolve within 8 weeks
Whats another term for chronic lung disease of prematurity?
bronchopulmonary dysplasia
What is CLDP?
chronic lung disease of prematurity
- occurs in premature babies (<28 weeks): suffer with RDS + require oxygen therapy or intubation+ventilation
How is CLDP diagnosed?
- Based on CXR changes
- When abby requires oxygen therapy after 26 weeks gestational age
Features of CLDP?
- Low oxygen sats
- increased work of breathing
- Poor feeding + weight gain
- Increased susceptibility to chest infection
what might be heard on auscultation of infant with CLDP?
crackles and wheeze
What is done to prevent CLDP? antenatal? neonatal? (3)
- Antenatal: Corticosteroids (betamethosone) to mother showing sings of premature labour
Neonatal:
- CPAP (rather than intubation + ventilation)
- using caffeine to stimulate resp effort
- not over oxygenating
what type of inheritance is cf?
autosomal recessive
1 in how many people are cf carriers?
1 in 25
cf is caused by a genetic mutation to which gene? on which chromosome ?
CFTR gene on chromosome 7 (delta-F508)
which 4 systems does cf affect?
- Resp tract
- Pancreas
- GI tract
- Reproductive tract
how does cf affect the pancreas? pathophysiology?
Thick pancreatic + biliary secretions => blockage of ducts + lack of digestive enzymes in the digestive tract
in cf, which enzyme is especially low?
Pancreatic lipase
how does cf affect the airways? pathophysiology?
Low vol thick secretions => reduced airway clearance => bacterial colonisation => susceptibly to airway infections
how does cf affect the reproductive tract?
Congenital bilateral absence of vas deferent in males (=> male infertility)
meconium ilues in path-pneumonic with what condition?
Cystic fibrosis
when is cf usually picked up? normal presentation?
Usually picked spat new born screening (newborn blood spot test)
what are the main symptoms of cf?
- Chronic cough
- Thick sputum production
- Recurrent resp tract infection
- Abdo pain + bloating
- Failure to thrive
- Steatorrhoea
how might cf affect stool? why?
Loose greasy tools (steatorrhoea)
- Due to low lipase enzymes
child presents with nasal polyps. what is your top differential?
Cystic fibrosis - strongly suspect cf in a child with nasal polyps
what 3 tests could be done to investigate for cf? which gold standard?
- Newborn blood spot testing
- Sweat test (gold standard)
- Genetic testing (CFTR gene)
when could genetic testing for cf be done? (2)
- Antenatally (amniocentesis, CVS)
- Newborn blood test
describe the chloride sweat test. testing for what? over what value indicates disease?
Gold standard test for CF
- Check chloride conc of sweat (induced with electrodes)
- >60ml/L => CF
Describe the management of CF?
- Chest physiotherapy several times per day to clear mucus
- Exercise and high cal diet
- CREON tablets (to replace lipase enzymes)
- Prophylactic flucloxacillin to reduce infection risk
Which bacteria’s chronic infection is associated with worsening lung function + must be treat aggressively in cf patients?
Pseudmona Aeruginosa
(used to have peer cf groups but now not anymore because of the risk of spreading it among cf patients - it is advised for cf patient to avoid other cf patients because of the risk of this infection)
What is the life expectancy of patient with cf?
47 years
cf prognosis: how many patients develop pancreatic insufficiency?
90%
cf prognosis: what proportion of patients develop CF related diabetes
50%
What is another name for primary ciliary dyskinesia?
Kartagener’s syndrome
what genetic inheritance is primary ciliary dyskinesia ? (PCD)
autosomal recessive condition
what does PCD affect?
motile cilia of various different cells of body
Kartageners syndrome airway pathophysiology?
PCD
caused by dysfuction of motile cilia (resp tract) => build up of mucus in lungs => infection risk (just like in cf)
other than the airways where can karageners affect?
Dysfunction of cilia in fallopian tube and sperm flagellum dysfunction => decreased/abscent fertility
PCD has a strong association with what other condition
situs inversus
what karagener’s triad presentation?
PCD
- Paranasal sinusitis
- bronchiectasis
- situs inversus
what might a patient with PCD complain of?
recurrent RTI
what investigation would you do for PCD?
sample of ciliated epithelium
PCD management ?
similar to cf
- Daily physio
- High cal diet
- Abx
what is bronchiectasis?
abnormal dilation of the airways with associated description of bronchial tissue
Bronchiectasis commonly occurs as a result of what condition?
CF
describe the pathophysiology of bronchiectasis as a result of infection?
infection => inflam => structural damage within bronchial walls => dilation + reduced number of cilia => increased infection risk
What are the causes of bronchiectasis ? (3)
- Post infectious (sever LRTI - strep pneumonia)
- Primary ciliary dyskinesia
- Post obstructive (foreign body aspiration)
what 4 changes to the bronchi does Bronchiectasis cause?
- Dilation of bronchi
- Scarring of bronchi
- Brachial wall thickening
- Destruction of cilia
common clinical feature of bronchiectasis ? (6)
Hx of chronic productive cough
- chest pain, wheeze, breathlessness on exertion, recurrent LRT infections
what investigations would you do for bronchiectasis? gold standard?
- CXR
- High resolution CT (HRCT) - gold standard
- Underlying pathology (sweat test for cf)
what would you see on CXR of Px with bronchiectasis? (2)
- Bronchial wall thickening
- Airway dilation
management of bronchiectasis?
- treat underlying cause
- chest phsyiotherapy
- Abx
