Paeds - Breathlessness & Noisy Breathing Flashcards
Name some differentials for the following combination of symptoms:
- Looks unwell
- Stridor at rest
- A dry barking cough
- RR 48/min, nasal flaring, moderate tracheal tug, intercostal and subcostal recession
- Pt appears pink in air
- Viral Croup
- Croup (parainfluenza virus)
- Epiglottitis (Haemophilus influenzae)
- Foreign body aspiration
- Anaphylaxis
- Bacterial tracheitis
- Laryngomalacia (floppy larynx)
What is Tracheal Tug?
Increase pull of diaphragm is transmitted as a downwards tug on the trachea during inspiration (retraction at the suprasternal notch)
Can be caused by:
- Increased respiratory effort
- Severe hyperinflation
- Aortic aneurysm
What is a Strawberry Neavus?
Strawberry naevi = capillary haemangioma
- Erythmatous, raised and multi-lobed tumours
- Common sites: face, scalp and back - rarely can occur in upper respiratory tract (can cause airway obstruction)
Are capillary haemangioma’s often present at birth?
No
- Can develop rapidly in 1st month of life
- Increase in size until ~ 6-9 months old then regress over a few years (typical course shown in picture)
- ~95% resolve before 10 yr old
How are capillary haemangiomas manged (if needed)?
Propranolol
Most resolve without treatment, but propranolol (beta-blocker) can be used if haemangiomas are:
- Very large
- Very nigh number
- In dangerous area e.g. near eye or throat
What are the possible complications of capillary haemangiomas?
- Obstruction e.g. airway or visual fields
- Bleeding
- Ulceration
- Thrombocytopaenia
What are the signs of anaphylaxis?
- Hypotension - Pale and sweaty
- Bronchoconstriction - Wheeze
- Airway compromise - Stridor
Angioedema often comes to mind when mentioning anaphylaxis:
- Angioedema of the face = not necessaily anaphylaxis
- But angioedema of the larynx = this would be anaphylaxis
What is Croup?
Croup = form of URTI seen in infants, also called laryngotracheobronchitis
Features:
- Stridor - due to combination of laryngeal oedema + secretions
- Barking cough (worse at night)
- Fever
- Prodrome of Coryzal symptoms - nasal discharge, sneeze, sore throat, malaise (often present for 12-48hrs before)
What age & time of year is most common for Croup?
Age: 6 months - 3 years
Autumn
Describe how an child with Croup appears for; mild, moderature and severe (severities).
Mild:
- Seal-like barking cough WITHOUT stridor OR sternal/intercostal recession at rest
- Child is happy to behave normally
Moderate:
- Seal-like barking cough WITH stridor AND sternal/intercostal recession at rest
- No agitiation or lethargy
Severe:
- Seal-like barking cough WITH stridor AND sternal/intercostal recession
- WITH agitation or lethargy (sign of hypoxaemia)
When should a child with Croup be admitted?
- Moderate or Severe Croup
- < 6 months old
- Known upper airway abnormalities e.g. Laryngomalacia or Down’s syndrome
- Uncertain diagnosis (differentials: acute epiglottitis, bacterial tracheitis, peritonsillar abscess and foreign body inhalation)
How is Croup managed?
Not for admission:
- Single dose oral dexamethasone (0.15 mg/kg) or prednisolone
For admission:
- Single dose oral dexamethasone (0.15 mg/kg) or prednisolone
- If too unwell to swallow –> inhaled budesonide (2mg nebulised) or IM dexamethasone (0.6 mg/Kg single dose)
- O2 if severe Croup or impending respiratory failure
Emergency / severe upper airway obstruction:
- High-flow O2
- Nebulised adrenaline
What are the features of acute epiglottitis?
Used to be considered a disease of childhood but due to Hib vaccine, it is more common in adults
Features:
- Commonly age < 2 yrs
- Rapid onset (hours)
- Pyrexia
- Stridor
- Dysphagia (due to throat pain)
- SoB
- Intense throat pain - prevents child speaking or swallowing
- Drooling of saliva (can occur due to airway obstruction)
- Position: tripod position in which the child is sat immobile, upright, with hands on their knees and mouth open to improve airway
What organism most commonly causes acute epiglottitis?
Haemophilus influenzae type B
(bacteria)
What are the features of an inhaled foreign body?
Typically ocurs in young children, often acute
- Cough
- Stridor
- SoB
Name some things that are ill-adivised in suspected acute epiglottitis?
The following can exacerbate the condition and cause further airway obstruction / death:
- Lie the child down - further worsens / obstructs airway
- Examine throat with spatula or palpation (too painful)
- X-ray of chest or neck
How is acute epiglottitis managed?
- Urgent hospital admission - anaethetist, paediatrician and ENT surgeon contacted
- Patent airway needs to be established e.g. naso-tracheal
- Blood culture
- IV Abx e.g. cefuroxime
- Intubation can often be removed after ~24hrs and Abx given for 3-5 days
What is bacerial tracheitis?
Also called Pseudomembranous Croup
- Fever
- SoB
- Stridor
- Hoarse cough
- Drooling
- Rapidly progressive airway obstruction /w copious thick secretions
What organism most commonly causes bacterial tracheitis?
1st = Staphylococcus aureus
2nd = streptococcus pneumoniae
How is bacterial tracheitis managed?
Emergency airway management e.g. intubation
Blood culture + IV Abx
What organisms most commonly cause Croup?
Parainfuenza viruses
Other organisms:
- Influenza
- Human metapneumovirus
- Respiratory syncytial virus (RSV)
What is Laryngomalacia?
‘Floppy larynx’
It is a congenital laryngeal disease, in which the soft immature cartilage of the upper larynx collapses inward during inhalation –> causing airway obstruction
- Biphasic stridor
- ‘Omega’ shaped epiglottis on laryngoscopy
- Monitor feeding + growth
- ~90% of cases resolve with time
What questions should you ask with a Hx of allergic reaction/ anaphylaxis?
A Hx of allergy in the presence of poorly controlled Asthma = risk factor for anaphylaxis - thus:
- Does your child have Asthma?
- If they have Asthma what treatment do they take?
- Do they take a regular preventer inhaler?
- When they had the initial reaction how much of the foodstuff or allergen had they been in contact with?
Food allergy is an example of what type of hypersensitivity?
Type I Hypersensitivity
- Antigen cross-links with two bound IgE molecules on the surface of mast cells
- This causes degranulation –> releasing pro-inflammatory mediators e.g. Histamine
What are the 5 main actions of histamine?
- Endothelial Cell Separation - local swelling & urticarial rash
- Localised irritation - localised itching
- Vasodilatation - can cause hypotension
- Bronchoconstriction - wheezing
- Mucus production - cough
When would you prescribe an EpiPen?
What would you prescribe instead if none of these are present?
- History of Anaphylaxis
- Previous cardiovascular / Respiratory involvement
- Evidence of airway obstruction
- Poorly controlled Asthma requiring regular inhaled corticosteroids
- Reaction to a small amount of allergen
- Ease of allergen avoidance
In the absence of these risk-factors (i.e. EpiPen not required) - prescribe an anti-histamine
What is the most common age for FBA (foreign body aspiration)?
< 3 years old
- ~ 80% of FBA episodes occur in children < 3 yrs
- Older children with learning difficulties are also at risk
What is aspiration of button batteries particularly dangerous / serious?
Button batteries in a moist environment can set up an electrical circuit and lead to rapid tissue erosion (e.g. oesophageal perforation) - seek senior advice immediately
With regards to viral croup, which of the following is TRUE?
- Nebulised adrenaline lasts for 12 hours
- The illness may follow an undulating course
- The child is usually toxic with a high fever
- The child has a bark like a dog
- The illness is highly infective
The illness may follow an undulating course
Viral croup often follows an undulating course with symptoms flaring at night
What are the features of bacterial tracheitis?
- sudden onset
- toxic (appear very unwell / poisoned e.g. tripod stance)
- drooling
- high fever
What is microganthia?
A condition in which the jaw is undersized (mandibular hypoplasia)
Features:
- Apnoea (temporary stop breathing in sleep)
- Inability to feed –> poor weight gain
- Noisy breathing
- Poor sleep
Causes (many congenital):
- DiGeorge syndrome
- Patau (trisomy 13)
- Edwards (trisomy 18)
- Ehlers-Danlos syndrome
- Foetal alcohol syndrome
- Juvenile idiopathic arthritis
- Noonan
- Marfan’s
What respiratory infection occurs predictably every winter?
Respiratory syncytial virus (RSV) Bronchiolitis
What is Bronchiolitis?
Bronchiolitis is characterised by acute bronchiolar inflammation
- Commonest serious respiratory infection in < 1 yr olds
- 90% of pts are 1-9 months old
- 80% of cases due to Respiratory syncytial virus (RSV)
- Higher incidence in winter (RSV epidemics)
- Most recover within 2-weeks
- Rarely illness causes permanent damage = bronchiolitis obliterans
Which organisms commonly cause Bronchiolitis?
- Respiratory syncytial virus (RSV) - most common 80%
- Mycoplasma pneumoniae
- Adenoviruses
What are the features of Bronchiolitis?
1st symptoms = coryzal symptoms (including mild fever) then:
- Dry cough
- increasing SoB
- Wheezing
- Tachypnoea
- Tachycardia
- Can have Apnoea
- Pallor or cyanosis
- Subcostal and intercostal recession
- Hyperinflation of chest:
- prominent sternum
- liver displaced downwards
- fine inspiratory crackles (not always present)
- feeding difficulties - associated with increasing dyspnoea are often the reason for hospital admission
What investigations might you do in suspected bronchiolitis?
- PCR immunofluorescence of nasopharyngeal secretions may identify RSV
- O2 sats
- CXR - often unhelpful! may show; hyperinflation, flattened diaphragm, increased hilar bronchial markings
- ABG - in severe cases to identify hypercarbia, which may require additional ventilatory support
How is Bronchiolitis managed?
Management is supportive!
- O2 - often given via head box or nasal cannulae
- Nasogastric feeding - if child can’t take in enough fluid/feed orally
- Ventilation - facemask CPAP or full invasive ventilation is needed in small %
What is the most common causative organism of pneumonia in children?
How is it treated?
Streptococcus pneumoniae
Amoxicillin (add macrolides if no response e.g. clarithromycin)
What approach is often taken for self-limiting respiratory tract infections regarding antibiotic prescription in adults / children?
No antibiotic prescribing approach or delayed Abx prescribing is used for:
- Acute otitis media
- Acute sore throat / acute pharyngitis
- Acute tonsillitis
- Common cold
- Acute rhinosinusitis
- Acute cough / acute bronchitis
When is an immediate Abx prescribing approach considered for self-limiting RTIs in children / adults?
- Children < 2-yrs with bacterial acute otitis media
- Children with otorrhoea who have acute otitis media
- Pts with acute sore throat / acute pharyngitis / acute tonsillitis when 3 or more on Centor criteria are present
What are the Centor criteria?
A set of criteria used to identify the likelihood of a bacterial infection (due to Group A Strep) in pts with a sore throat (acute pharyngitis)
Use only in pts with recent onset (≤3 days) acute pharyngitis
Criteria:
- Cough absent (+1)
- Exudate or swollen tonsils (+1)
- Tender/swollen anterior cervical lymph nodes (+1)
- Temp > 38C (+1)
-
Age 3-14 (+1)
- 15-44 = 0
- > 45 = -1
If deciding to prescribe an Abx for acute oropharyngeal infections (sore throat) what is the 1st line Abx?
Phenoxymethylpenicillin
(1st-line for acute sore throat that is suspected to be bacterial)
- If penicillin allergic –> clarithromycin or erythromycin
