Paediatrics - respiratory + ENT Flashcards
What respiratory conditions are important in children (8)?
- Pneumonia
- Croup
- Asthma
- Virally induced wheeze
- Bronchiolitis
- Cystic fibrosis
- Acute epiglottitis
- Whooping cough
What age is a neonate?
A child under 28 days
What is an infant?
A child under 1 year
What is pneumonia?
Lower respiratory tract and lung parenchyma infection which leads to consolidation on X-ray
What is the presentation of a child with pneumonia (6)?
- Productive cough
- Fever > 38.5
- Tachypnoea/cardia
- Lethargy
- Delirium
- Increased work of breathing
What are 3 chest signs of pneumonia?
- Bronchial breath signs
- Focal corse crackles
- Dullness to percussion
What are 2 signs of increased work of breathing?
- Sub/inter costal recession
- Abdominal breathing (abdomen expands)
What are 6 common bacterial causes of pneumonia?
- S. pneumoniae = MC
- Group A strep (strep pyogenes)
- Group B strep
- Staph aureus
- H. influenziae
- Mycoplasma pneumoniae (atypical bacteria)
Which bacteria is most common in neonates?
Group B strep (can live in women’s genital tract)
What sign is indicative of staph aureus pneumonia on x ray?
Pneumatoceles - air filled cysts
What extrapulmonary sign may be seen in those with M. pneumoniae infection?
Erythema multiforme
What are the common viral causes of pneumonia?
- Respiratory syncytial virus (RSV) = MC
- Parainfluenza virus
- Influenza virus
What age and what time of year are viral pneumonia most common?
Young infants during winter
How is pneumonia in children investigated (3)?
- Mostly clinical
- CXR
- Sputum culture/ viral PCR
In more severe cases blood cultures
How is pneumonia managed in children (3)?
- Antibiotics (IV if absorption problem/ severe)
- IV fluids
- Oxygen (sats < 92%)
What antibiotics are typically used for pneumonia (2)?
- Amoxicillin
- Atypical = macrolide (azithro/erythro/clarithromycin)
…however follow local guidelines
What are 2 complications of pneumonia?
- Empyema
- SEPSIS
What would point towards sepsis in terms of presentation (3)?
- More systemically unwell
- Hypotension
- Hypoxia
- Confusion
What are 6 important conditions to rule out for children with recurrent LRTI ?
- Cystic fibrosis
- Reflux/ aspiration
- Neurologic disease
- Asthma
- Immune deficiency
- Primary ciliary dyskinesia
What is croup?
Acute laryngotracheobronchitis - infection + oedema in the larynx
What age is typically affected by croup?
6 months to 3 years
What are the common causes of croup?
- Parainfluenza virus = MC
- Adenovirus
- RSV
- Influenza virus
What organism used to commonly cause croup but has decreased in prevalence due to vaccination?
Diphtheria - causes inflammation of the mucous membranes
What is the presentation of those with croup (5)?
- Barking cough occurring in clusters
- Hoarse voice
- Stridor
- Increased work of breathing
- Low fever
What are useful markers of severity of those with croup (3)?
- Extent of stridor
- Difficulty of breathing
- Distressed child
What are some respiratory red flag symptoms (4)?
- Drowsiness/lethargy
- Laboured breathing
- Tachycardia
- Cyanosis
How is croup investigated?
Mainly clinical, can do:
* FBC, U&E, CRP
* CXR
How can most cases of croup be managed (2)?
- Single dose oral dexamethasone
- Supportive management at home
How can more severe croup be managed?
Admit to hospital
What dose of dexamethasone should be used to treat croup?
0.15 mg/kg
What steps should be taken to treat very severe/ life threatening croup (5)?
- Oral dexamethasone
- Oxygen
- Nebulised budesonide
- Nebulised adrenaline
- Intubation/ ventilation
What is important for children with croup to do?
Stay off school, wash hands, prevent spread
What are 2 complications of croup?
- Otitis media
- Dehydration due to reduced intake
What are causes of wheezing in children (3)?
- Asthma
- Virally induced wheeze
- Persistent infantile wheeze
What is a bad sign of wheeze that may be heard on the chest?
Focal wheeze = may be a focal airway obstruction - e.g. foreign object
What may be a cause of persistent infantile wheeze?
Smoking in the house
What causes a viral induced wheeze?
Swelling of the airways in response to a upper respiratory tract viral infection
What age is usually affected by virally induced wheeze?
Under 3s - they have smaller airways so any swelling of the airways significantly reduces flow of air
What would suggest a virally induced wheeze as opposed to asthma?
- < 3 years old
- No atopic history
- Preceding viral infection
What is the presentation of a child with virally induced wheeze (3)?
- Expiratory wheeze throughout chest
- Viral infection for 1-2 days
- SOB
- Resp distress
How is virally induced wheeze managed?
Same as acute asthma - essentially with SABA
What is the most common chronic condition in children?
Asthma
What is asthma?
Reversible chronic inflammation of the airways leading to variable airway obstruction
What are some risk factors for the development of asthma (4)?
- Low birth weight/ prematurity
- Fam history
- Smoking in the house
- Viral bronchiolitis
What is the typical presentation of a child with asthma?
- Dry cough
- Bilateral wheeze
- SOB
- Episodic symptoms
What time of day is asthma worse?
At night + early morning
What conditions are associated with each other and make up the atopic triad?
- Allergic rhinitis
- Asthma
- Atopic dermatitis
What are triggers for asthma (7)?
- Pets
- Cold air
- Exercise
- Smoke
- Food allergens e.g. shellfish, eggs
- Dust e.g. house dust mites
- Mould
What age does asthma typically present in children?
After age 2-3
How is asthma diagnosed in children?
No gold standard test!!
If asthma is suspected a trial of medication can be implemented, if symptoms improve a diagnosis can be made.
What tests are useful if there is diagnostic doubt of asthma in children?
- FeNO (fractional exhaled nitric oxide) - measure of inflammation
- Spirometry with reversibility testing
- Peak flow diary
- Direct bronchial challenge test
What age can peak flow and spirometry be offered to children?
5 years and over
What is direct bronchial challenge test and how does it work?
Nebulised histamine or methacholine are given which provoke bronchoconstriction the level of which is monitored using spirometry. Asthmatics have a much more pronounced narrowing of airways.
How are FEV1 and FVC affected in asthma?
FEV1 reduced, FVC usually normal
FEV1:FVC < 70% if poorly controlled
What are the steps in the treatment of asthma in those over 5 years (7)?
- SABA
- ICS preventer
- LTRA
- Stop LTRA if hasn’t helped, add LABA
- Switch ICS and LABA to MART
- High dose ICS
- Refer - they may give muscarinic receptor antagonist/ theophylline
What is a MART inhaler?
Maintenance and reliever therapy - containing ICS and fast acting LABA
What is an example of a fast acting LABA?
Formoterol
What are the steps in the treatment of asthma in those under 5 years (4)?
- SABA
- Low dose ICS 8 week trial if symptoms reoccur within 4 weeks, restart ICS
- LTRA
- Refer
How often should a spacer be cleaned?
Once a month with warm soapy water, do not scrub, air dry
What are the criteria for a mild/ moderate asthma attack (2)?
- PEFR > 50% predicted
- Normal speech
What are the criteria for a severe asthma attack (5)?
- 33 < PEFR < 50%
- Sats < 92%
- Resp rate > 30 (over 5’s)/ >40 (under 5’s)
- Can’t talk/ feed
- HR > 125 or 140 (over/ under 5’s)
What are the criteria of a life threatening asthma attack (5)?
- PEFR < 33%
- Sats < 92%
- Altered conciseness/ confusion
- Cyanosis
- Silent chest (not enough air flow to make a wheeze sound)
How is a moderate - life threatening asthma attack treated (8)?
- O2
- Nebulised salbutamol/ ipratropium bromide
- Oral prednisolone
- IV hydrocortisone
- IV MgSO4
- IV salbutamol
- IV theophylline/ aminophylline
- Escalate - intubate + intensive care
What is important to monitor during an asthma attack if IV salbutamol is given?
Potassium levels as can cause hypokalaemia
