Paeds Resp Flashcards
Winter epidemic
Epidemiology and RF for Bronchiolitis
Most common serious respiratory infection in infancy, 90% below 10months old. 2-3% of infected infants end up in hospital.
Typical Disease of U1s
Causes of Bronchiolitis
RSV - 90% of cases
Can also get coinfected with other viruses
Other: parainfluenza, rhinovirus, adenovirus, influenza, metapneumovirus
Lumen
Pathophysiology of Bronchiolitis
Virus prouduces mucus and swells the already narrow lumen of infant. Air exchange at alveoli affected
Adults=larger lumen of airways = little impact of virus
Signs on Auscultation
Signs and Symptoms of Bronchilolitis
- Coryzal Symptoms
- Cough and Breathlessnes
Others - Respiratory distress symptoms
- Mild fever and apnoea can occur
Auscultation=Fine end-inspiratory crackles +prolonged expiration/wheeze
Apnoea (Transeint cessation of respiration)
Complications of Bronchiolitis
- Respiratory Distress
Feeding difficulty due to dyspnoea (SOB) leads to admission - Bronchiolitis obliterans (permanenent damage to airways)
Typical Course of Bronchiolitis
- Starts of as URTI with Coryza
50% children get better by this stage - Chest symptoms after day 1-2
- Symptoms worst day 3-4
- Usually last 7-10 days
Full recovery made within 2 weeks
Bronchiolitis in Infancy = Increased Viral induced wheeze during childhood
Bronchilolitis is common in U1s
Protective factor for Bronchiolitis
Maternal IgG provides protection to neonates
IgG longterm
IgM short term
Investigations for Bronchiolitis
Pulse Oximetry & Routine Investigations
CBG and CXR only when Resp Failure suspected
immunofluorescence of nasopharyngeal secretions may show RSV
Indications that hospital is required for bronchiolitis
- Apnoea
- O2 Saturations <92%
- Central Cyanosis
- RR above 70 (HCP consider @ 60)
Management of Bronchiolitis
- Nasal O2 if saturations below 92%
- Nasogastric feeding for infants unable to feed
Nasal Suction with saline drops used for infant w/ excessive secretions
Ventilation may be required in extreme cases
MAB
Vaccine for Bronchiolitis
Pavlizumab - monthly vaccine given as preventative for high risk babies (premature, Congenital diseases)
Only provides passive protection - therefore require monthly topup
How to determine poor ventilation in bronchiolitis
How to determine if ventialtion is required or not
Take Capillary Blood Gas
* Rising pCO2 show airways have collapsed, unable to clear waste CO2
* Falling pH - Respiratory Acidosis, raised CO2. If hypoxic then T2 Resp Failure
What is Viral Induced wheeze
Acute wheezy illness caused by viral infections (RSV/Rhinovirus)
narrrow small airways constrict due to increase in inflammation and oedema
Common in children 1-3y
Presentation of Viral Induced Wheeze
- SOB
- May have signs of Respiratory Distress
- Expiratory Wheeze throughout chest
Episodic Viral Wheeze Vs Multiple Trigger Wheeze
- Episodic: Wheeze only when viral URTI
- Multiple: Wheeze triggered by excercise, allergens & Cigarette smoke
Risk of developing Asthma higher in multiple trigger than episodic
Management of Viral Induced Wheeze
Symptomatic treatment only
* 1st line: Salbutamol (Short acting beta 2 agnosist) or anticholinergic via spacer
* 2nd line: Montelukast or inhaled coticosteroid
* Oral Predinslone rarely used for childen outside hospital
Multiple trigger wheeze: inhaled corticosteroid or montelukast 4-8/52wk
Encourage parents to stop smoking
Both have low grade fever
Viral Induced Wheeze Vs Bronchiolitis
More complications seen in Bronchiolitis
- Bronchiolitis: ‘Wet lungs’ More secretions
- Viral Wheeze: Bronchospasm
Bronchiolitis: Days Viral Wheeze: Hours - need bronchodilators
What is Croup
URTI seen in infants & toddlers causing oedema in larynx
Common in Autumn
Epidemiology of Croup
Age and Causative viruses
- Commonly seen in children 6mths to 2 years
- Caused by Parainfluenza
- Others: Influenza, Adenovirus, RSV
Features of Croup
Hint: No Wheeze
- Stridor
- Barking cough - worse at night (tracheal oedema)
- Fever - Low Grade
- Coryzal Symptoms
- Increase work of Breathing
X rays show: Steple Sign and/or Thumb sign
Management Croup
- Manage at home with rest and hydration
- Oral dexamathasone (0.15mg/kg) given every 12hrs
- Alternative: prednislone
Emergency: high flow Oxygen & Nebulised Adrenaline
Complications of Croup
Central cyanosis, reduced level of consciousness suggest impending complete airway obstruction -> intubation
Causes of Stridor in children
Stridor: externally audible, high-pitched sound caused by turbulent
airflow due to obstruction of the upper respiratory tract
- Croup
- Acute epiglottitis
- Inhaled Foreign Body
- Laryngomalacia (congenital abnormality presents at week 4)
Parainfluenza virus
Mild, Moderate & Severe Croup
URTI seen in infants & toddlers causing oedema in larynx
Mild: Occasional barking cough
Moderate: frequent barking cough, audible stridor at rest
Severe: frequent barking cough, prominent stridor (inspiratory, sometimes expiratory) significant distress and RDS signs
What is is Acute Epiglottitis
Inflammation & Swelling of epiglottis due to infection. Life threatening.
Typically caused by Haemophilus influenza type B - Hib Vaccine Protectiv
Caution when unvaccinated child when they present with croup as it can be Epiglottitis
Presentation of Acute Epiglottitis
- Rapid Onset
- High Temperature
- Stridor
- Drooling
- Sore throat
- Tripod Position: Pt finds it easier to sit fwd with elbows on knees
Diagnosing Acute Epiglottitis
- Made by direct visualisation only by senior/airway trained staff
- X rays: Thumb sign & Steeple Sign
- X rays can also rule out foreign bodies
Must not start investigating too invasively risk of aspiration.
Management Acute Epiglottitis
Do not distress patient and inform seniors
* Endotracheal intubation to secure airway (not in all cases)
* IV antibiotics
* Oxygen
Complications of Epiglottitis
Common complication is the development of epiglottic abscess which is a collection of pus around the epiglottis.
Death can be caused if airway not secured
Pneumonia in Children
Infection of the lung tissue causing inflammation and sputum filling airways and alveoli.
* Bacterial oft caused by: Strep Pneumoniae (others Group A and B Strep, Staph Aureus etc)
* Viral: RSV, Parainfluenza, Influenza
Seen as consolidation on X ray
Signs and Symptoms of Pneumonia
in Children
- Wet cough
- Fever
- Tachypnea, Tachycardia
- Hypoxia
- Confusion
- Bronchial breath sounds: harsh breath sounds that are equally loud on inspiration and expiration
- Focal coarse crackles
- Dullness to percussion due to tissue collapse or consolidation
Investigation of Pneumonia
in Children
CXR
Throat swabs for causative organism
Complications of Pneumonia
in Children
Can be associated with a **pleural effusion ** this can become infected where it is then termed an empyema. Can lead to sepsis
Management Pneumonia
in Children
- Amoxicillin is first-line for all children with pneumonia
- Macrolides may be added if there is no response to first line therapy erythromycin, clarithromycin or azithromycin
Macrolides should be used if mycoplasma or chlamydia is suspected
In pneumonia associated with influenza, co-amoxiclav is recommended
What is Cystic Fibrosis?
CFTR GENE
Autosomal recessive disorder, causing increased viscosity of mucuos secretions, due to defective CFTR gene which codes Cl channel
1 in 2500 affected
Carrier rate is 1:25 so 25% chance
Consequence of Cystic Fibrosis
Pancreas, Airway & Testes
- Thick billiary and pancreatic secretions: blocked ducts = low digestive enzymes
- Thick airway secretions: reduce airway clearance and easy for bacteria to colonise
- Absence of Vas Deferens: Infertility
Common bacteria: Staph Aureus, P. Aeruginosa, Aspergillius
Presentation of Cystic Fibrosis
Include ssome adults
- Chronic Cough with thick sputum
- Steatorrohea with abdo pain
- Recurrent infections
- Failure to thrive - Short stature
- Nasal Polyps
- Finger Clubbing
- Rectal Prolapse - due to bulky stools
Delayed Puberty
Diabetes Mellitus
Infertility in Males
Subfertility in Females (takes longer to get pregnant)
Diagnosis of Cystic Fibrosis
- Newborn screening Day 5: blood spot test & Meconium ileus
- Sweat Test: Test sweat for Chloride levels (high) GOLD STANDARD
- Genetic Testing: CFTR mutation check during pregnancy
Meconium ileus is when meconium is sticky and thick which gets stuck in the gut and obstructs the bowel.
Cause of False +ve Sweat test: Malnutrition, Adrenal Insufficiency, Glycogen storage disease, diabetes insipidus.
Cause of Flase -ve Sweat test: Skin Oedema due to Hypoalbuanemia 2ndry to pancreatic exocrine insuffiency
Cystic Fibrosis Management
what are some of the risky bacteria?
Need Specialist MDT
* Regular physiotherapy and postural drainage
* High calorie/high fat diet
* Minimise contact with other CF patients
* Vit & pancreatic ennzyme supplementation
* Chronic infection with Burkholderia cepacia contraindication to lung transplantation (can’t have it)
Lumacaftor for Pts with delta F508 mutation, increases CFTR proteins
Pseudomonas Aeruginosa bacteria may become resistant to Abx, PA can lead to morbidity and mortality
Prognosis of Cystic Fibrosis
- Life expectancy: 47y
- Pancreatic insufficiency
- CF related diabetes requiring insulin
- Development of Liver disease
Absent Vas Deferes in most males rendering them infertile
Acute Asthma Presentation
in Children
Moderate Vs Severe Vs Life threatening
Moderate: Able to talk, SpO2 above 92%
Severe: Inability to complete sentences SpO2 below 92% PEF: 33-50% use of accessory muscles Raised HR and RRR
Life threatening: SpO2 below 92%, PEF below 33% Silent Chest, Very unresponsive, Cyanosis, Poor respiratory effort
Asthma RFs
- Atopy: Eczema, hayfever & Allergies
- FH
- Triggers include Cold air, excercise, emotions, smoking and certain drugs, dust mites.
Asthma Pathophysiology
- Bronchial inflammation leading to Oedema, excess mucus production, cellular infiltration (WBC)
- Bronchial hyperresponsiveness - exaggerrated muscle contractions to inhaled and physical stimuli leading to narrowing of airways.
Smooth muscle is always hypersensitive
Asthma Investigations
There’s no Gold Standard
- Diagnosis usually made with response to treatment
- Spirometry with reversibility testing (in children aged over 5 years)
- Direct bronchial challenge test with histamine or methacholine
- Fractional exhaled nitric oxide (FeNO)
- Peak flow variability measured by keeping a diary of peak flow measurements several times a day for 2 to 4 weeks
FEV1 is reduced FVC remains normal resulting in an FEV1:FVC ratio <80%
U5 based on history and examination, response to treatment, skin prick test can help identify sensitisation to certain allergens.
Acute Asthma Management
in Children
Mild To Moderate Bronchodilator therapy: Beta 2 agonist via spacer (can use close fitting mask), One puff every 30-60s 10 times
Steroid Therapy: 3-5 days, 2-5Y 20mg OD >5Y 40mg OD
Chronic Asthma Management
Children 5
Children 5-12
Children 5-16: SABA -> ICS -> LTRA -> LABA
Children 5: SABA -> Moderate ICS -> LTRA
If neither work consult specialist Daily Steroids may be required
General Asthma Symptoms in children
- Wheeze, cough and breathlessness typically worse at night (diurnal variation)
- Wheeze and breathlessness with non-viral triggers
- FH of atopic disease
- Interval symptoms (nocturnal cough, morning SOB)
Asthma should be suspected in any child with wheezing on more than one ocassion.
