Paeds I Flashcards
If you have upper or lower airwway problem then what is resp symptom most likely to be? [2]
Upper: stridor
Lower: wheeze
If both - then both!
Describe what is meant by laryngomalacia [1]
Describe the structural changes that causes this condition [+]
Laryngomalacia:
- 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.
Structural changes:
- 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.
Describe the presentation of laryngomalacia [2]
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.
Symptomatic relief may be provided by hyperextending the neck during episodes of stridor
It can cause difficulties with feeding, but rarely causes complete airway obstruction or other complication
Describe the disease course of Laryngomalacia [3]
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.
Describe the three types of laryngomalacia [3]
Type I Laryngomalacia (Curling Type):
* Characterised by inward curling of the mucosa overlying the arytenoid cartilages during inspiration. This creates an omega-shaped laryngeal inlet instead of the normal V-shape.
* It’s the most common type, accounting for approximately 75% of cases.
Type II Laryngomalacia (Prolapsing Type):
* Involves prolapse of the mucosa overlying the cuneiform and corniculate cartilages into the glottis during inspiration.
* This type accounts for around 15% of laryngomalacia cases.
Type III Laryngomalacia (Posterior Displacement Type):
* Less common, only observed in about 10% of cases. It involves posterior displacement or malpositioning of the epiglottis and aryepiglottic folds.
* This type is often associated with more severe symptoms and may require early surgical intervention.
What is this ddx of LM? [1]
What previously has likely occured to this patient? [1]
How would it present differently? [2]
What is likely caused by? [1]
Subglottic stenosis
- likely previous intubations
- presents with biphasic stridor and is not limited to inspiration like laryngomalacia.
- It may also present with respiratory distress that is disproportionate to the degree of stridor.
Causes:
- The underlying causes are diverse including congenital malformations, prolonged intubation trauma or systemic diseases like Wegener’s granulomatosis.
- This differentiates it from laryngomalacia which is believed to be due to neuromuscular immaturity.
What is this ddx of LM? [1]
Laryngeal cleft
What is this ddx of LM? [1]
Laryngeal web
What is this ddx of LM? [1]
Laryngeal cyst
Describe the presentation of croup [4]
What is the classic cause of croup? [1] Which tx does it respond well to? [1] What are other common causes? [3]
Presentation:
* Increased work of breathing
* “Barking” cough, occurring in clusters of coughing episodes
* Hoarse voice
* Stridor
* Low grade fever
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. Also by:
* Influenza
* Adenovirus
* Respiratory Syncytial Virus (RSV)
Which factors would make you admit a patient with croup? [3]
CKS suggest admitting any child with:
moderate or severe croup
* < 3 months of age
* known upper airway abnormalities (e.g. Laryngomalacia, Down’s syndrome)
* uncertainty about diagnosis (important differentials include acute epiglottitis, bacterial tracheitis, peritonsillar abscess and foreign body inhalation)
How would you differentiate croup from epiglottis and foreign body aspiration [+]
Epiglottitis
Similarities
* Stridor
Differences
* Usually seen in children 3-5 years of age
* Absence of barking cough
* Muffled hot potato voice
* Tripod or sniffing position
* An incomplete vaccination history more likely to be present
Foreign body aspiration
Similarities
* Often < 3 years of age
* Stridor
* Dysphonia depending on location of foreign body
Differences
* History suggestive of possible foreign body
* Abrupt onset during daytime (croup usually night-time)
* Minimal response to adrenaline nebuliser
How would you differentiate croup from Bacterial tracheitis [3]
Bacterial tracheitis
Similarities
* Stridor
Differences
* Usually school-age
* Soft stridor 2-7 days after onset of URTI symptoms
* Significant tracheal tenderness on palpation
* Reluctant to cough because of pain
NICE guidelines, last updated in 2019, suggest the following algorithm for the management of croup:
- Primary Care [3]
- Secondary care [4]
Primary care (mild illness):
* Supportive care
* Oral dexamethasone
Parents should be advised regarding:
* The expected course of croup, including that symptoms usually resolve within 48 hours.
* The need to take the child to hospital if stridor can be heard continually, the skin between the ribs is pulling in with every breath, and/or the child is restless or agitated.
* The use of antipyretics in children distressed due to fever.
* The need to check on the child regularly, including through the night.
* Arrange follow-up, using clinical judgment to determine the appropriate interval.
Secondary care (moderate - severe illness)
* All children with moderate-severe illness should be admitted
* Supportive care
* Oral dexamethasone
* Nebulised epinephrine
* Supplemental oxygen
* The above advice should also be given
Bacterial tracheitis is most likely cause by which organism? [1]
Haemophilus influenza
Lecture
Name three further ddx for croup and how you would differentiate between them [+]
Retropharyngeal/peritonsillar abscess
* dysphagia, drooling, stridor (occasionally), dyspnoea, tachypnoea, neck stiffness, and unilateral cervical adenopathy.
* Onset is typically more gradual than with croup and is often accompanied by fever.
Angioneurotic oedema
* acute swelling of the upper airway that may cause dyspnoea and stridor.
* Fever is uncommon. Swelling of face, tongue, or pharynx may be present. Can occur at any age.
Allergic reaction
* rapid onset of dysphagia, stridor, and possible cutaneous manifestations (urticarial rash).
* Can occur at any age
* Known allergies
Describe what is meant by bronchiolitis [1]
What is the most common cause? [1]
Bronchiolitis describes inflammation and infection in the bronchioles, the small airways of the lungs.
This is usually caused by a virus. Respiratory syncytial virus (RSV) is the most common cause.
Describe the presentation of bronchiolitis [+]
Symptoms noramlly usually get worse for 3-5 days, then improves
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
Signs of Resp. 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
TOM TIP: You should become very confident in listing and spotting the signs of respiratory distress. This is very important when treating children, to distinguish between a well child and an unwell child. Your examiners will expect you to know the signs like the back of your hand.
TOM TIP: You should become very confident in listing and spotting the signs of respiratory distress. This is very important when treating children, to distinguish between a well child and an unwell child. Your examiners will expect you to know the signs like the back of your hand.
What are they? [+]
Signs of Resp. 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
Describe the course of bronchiolitis [3]
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.
Which patients should you admit w/ bronchiolitis? [+]
- 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
Describe the managment plan for bronchiolitis [+]
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.
What are the best indicators of resp. failure? [2]
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.
Which babies might be given monthly injections to protect agaisnt bronchiolitis? [2]
What injection would recieve? [1]
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.
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.
Describe the clinical dx of asthma [+]
Spirometry - The NICE guidelines suggest offering spirometry to children aged over 5-years-old if a diagnosis of asthma is being considered:
- (FEV1:FVC) ratio of less than 70% is suggestive of obstructive airway disease
Bronchodilator reversibility:
* For children aged 5 to 16-years-old, an improvement in FEV1 of >12% is suggestive of asthma
* For children aged 17 years-old and older, an improvement in FEV1 of >12%, plus an increase in volume of >200mL, is suggestive of asthma
FeNO:
- A fraction exhaled nitric oxide level of greater than 35 parts per billion (ppb) is suggestive of asthma
Peak Flow:
* The NICE guidelines suggest monitoring peak flow variability for 2-4 weeks if there is any diagnostic uncertainty
* Greater than 20% variability is considered a positive test, suggestive of asthma
* After diagnosis and treatment, peak expiratory flow can also be used as an indicator of treatment effect and a marker of clinical improvement/deterioration
Describe the features of moderate, severe and life threatening asthma in children [+]
Moderate:
- Peak flow > 50 % predicted
- Normal speech
- No features listed across
Severe:
* Peak flow < 50% predicted
* Saturations < 92%
* Unable to complete sentences in one breath
* Signs of respiratory distress
* Respiratory rate: > 40 in 1-5 years; > 30 in > 5 years
* HR: > 140 in 1-5 years; > 125 in > 5 years
Life Threatening:
* Peak flow < 33% predicted
* Saturations < 92%
* Exhaustion and poor respiratory effort
* Hypotension
* Respiratory rate:
* Silent chest
* Cyanosis
* Confusion
Describe the management plan for chronic asthma in children aged 5-16 [+]
Mild cases can be managed as an outpatient with regular salbutamol inhalers via a spacer (e.g. 4-6 puffs every 4 hours).
Moderate-severe:
1. SABA
- SABA + paediatric low-dose inhaled corticosteroid (ICS)
- SABA + paediatric low-dose ICS + leukotriene receptor antagonist (LTRA)
- SABA + paediatric low-dose ICS + long-acting beta agonist (LABA) (Don’t stop the LRTA like in adults)
- SABA + switch ICS/LABA for a maintenance and reliever therapy (MART), that includes a paediatric low-dose ICS
-
SABA + paediatric moderate-dose ICS MART
OR consider changing back to a fixed-dose of a moderate-dose ICS and a separate LABA - SABA + one of the following options: increase ICS to paediatric high-dose, either as part of a fixed-dose regime or as a MART OR a trial of an additional drug (for example theophylline) OR seeking advice from a healthcare professional with expertise in asthma
double check - as asthma guidelines may have changed
Describe the management plan for chronic asthma in children aged < 5 [+]
One. SABA
Two:. SABA + an 8-week trial of paediatric MODERATE-dose inhaled corticosteroid (ICS)
* After 8-weeks stop the ICS and monitor the child’s symptoms:
* if symptoms did not resolve during the trial period, review whether an alternative diagnosis is likely
* if symptoms resolved then reoccurred within 4 weeks of stopping ICS treatment, restart the ICS at a paediatric low dose as first-line maintenance therapy
* if symptoms resolved but reoccurred beyond 4 weeks after stopping ICS treatment, repeat the 8-week trial of a paediatric moderate dose of ICS
Three. SABA + paediatric low-dose ICS + leukotriene receptor antagonist (LTRA)
Four. Stop the LTRA and refer to an paediatric asthma specialist
What are the different definitions for low, moderate and high doses for ICS in asthma? [3]
<= 200 micrograms budesonide or equivalent = paediatric low dose
200 micrograms - 400 micrograms budesonide or equivalent = paediatric moderate dose
> 400 micrograms budesonide or equivalent= paediatric high dose.
How do you treat acute moderate asthma in children > 5? [2]
Supplementary oxygen if required (i.e. oxygen saturations less than 94% or working hard)
Bronchodilator therapy
* give a beta-2 agonist via a spacer (for a child < 3 years use a close-fitting mask)
* give 1 puff every 30-60 seconds up to a maximum of 10 puffs
* if symptoms are not controlled repeat beta-2 agonist and refer to hospital
Steroid therapy
* should be given to all children with an asthma exacerbation
* treatment should be given for 3-5 days
* 20 mg oral prednisolone for children aged 2-5 years
* 40 mg oral prednisolone for children over 5 years
Moderate asthma may be managed using oral prednisolone and beta 2 bronchodilator therapy as an outpatient.
How do you treat acute severe asthma in children > 5? [+]
- Administer inhaled salbutamol with a pressurised metered dose inhaler and spacer
- Proceed to nebulised salbutamol (2.5-5 mg) if necessary
- All children should recieve steroids
- Add nebulised ipratropium bromide
- If the patient is not responding to salbutamol or ipratropium, consult with a senior clinician
- For consideration of IV magnesium, IV salbutamol or aminophylline
- Salbutamol inhalers via a spacer device: starting with 10 puffs every 2 hours
How would you treat life threatening acute asthma in a child > 5?
Acute asthma:
- Generally, discharge can be considered when the child well on [] puffs [] hourly of salbutamol.
- They can be prescribed a reducing regime of salbutamol to continue at home, for example [] then [] then [] as required.
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.
Lecture
Describe the management of acute wheeze [+]
ABCDE approach, get help early
Assess severity
Apply high-flow oxygen (initially 15 litres via non-rebreathe mask,) titrate as needed aiming for target saturations 94-98%
Start bronchodilators:
* Burst therapy of Salbutamol (via spacer if Sats > 94% or via nebulizer if needing oxygen) and Ipratropium Bromide if severe exacerbation/poor response to Salbutamol
Give steroids
Consider IV Magnesium Sulphate if poor response to initial therapy
Also, can consider IV Salbutamol and IV Aminophylline
A potential exam scenario is discussing inhaled steroids with a parent that is worried about potential side effects. A common question is whether they slow growth.
Describe how you would discuss this answer
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.
Describe how you would tell a patient how to use an inhaler:
MDI technique without a spacer: [+]
MDI technique with a spacer: [+]
MDI technique without a spacer:
* 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
NB: 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.
A parent thinks their child might be suffering from acute asthma attack.
What would initial at home advise be for parents? [1]
Parents/carers of children with acute asthma at home, should seek urgent medical attention if initial symptoms are not controlled with up to 10 puffs of salbutamol via a spacer;
what doses of pred. should be used for acute asthma for 2-5 yr olds [1] and 5+ ? [1]
- 20 mg oral prednisolone for children aged 2-5 years
- 40 mg oral prednisolone for children over 5 years
When does CLDP usually occur? [1]
How is a dx made [1] and at what age? [1]
It occurs in premature babies, typically those born before 28 weeks gestation. These babies suffer with respiratory distress syndrome and require oxygen therapy or intubation and ventilation at birth.
Diagnosis is made based on chest xray changes and when the infant requires oxygen therapy after they reach 36 weeks gestational age.
How can you prevent CLDP:
- pre-birth [1]
- post-birth [3]
There are several measure that can be taken to minimise the risk of CLDP. Giving corticosteroids (e.g. betamethasone) to mothers that show signs of premature labour at less than 36 weeks gestation can help speed up the development of the fetal lungs before birth and reduce the risk of CLDP.
Once the neonate is born the risk of CLDP can be reduced by:
* Using CPAP rather than intubation and ventilation when possible
* Using caffeine to stimulate the respiratory effort
* Not over-oxygenating with supplementary oxygen
Describe the long term management of CLDP [2]
Babies with CLDP require protection against respiratory syncytial virus (RSV) to reduce the risk and severity of bronchiolitis.
- This involves monthly injections of a monoclonal antibody against the virus called palivizumab. This is very expensive (around £500 per injection) so is reserved for babies meeting certain criteria.
- Babies may be discharged from the neonatal unit on a low dose of oxygen to continue at home, for example 0.01 litres per minute via nasal cannula. They are followed up to wean the oxygen level over the first year of life.
You perform a chest x-ray and find a patient to have dextrocardia and bronchiectasis.
What is the most likely pathology? [1]
Name two further signs of this pathology [2]
Kartagener syndrome (aka primary ciliary dyskinesia):
- dextrocardia
- bronchiectasis
- recurrent sinisitis
- subfertility
Kartagner’s triad describes the three key features of PCD. Not all patients will have all three features. These are:
- Paranasal sinusitis
- Bronchiectasis
- Situs Inversus
Describe the clinical significance of sinitus invertus [1]
Situs inversus on its own does not cause any problems, and patients can expect to live a normal life. A small number have associated congenital heart disease, such as transposition of the great arteries.
NB: Dextrocardia is when only the heart is reversed.
