Paeds Resp Flashcards
clinical features of asthma?
dry cough with wheeze and SOB
symptoms worse at night and early morn
personal or family Hx of atopic disease
+ve response to asthma therapy
episodic symptoms with itnermittent exacerbations
bilateral widespread polyphonic expiratory wheeze on auscultation
non viral triggers
Ix to diagnose asthma
typical Hx and examination
if high probability then trial tx to see if symptoms improve
if diagnostic doubt then:
- spirometry (needs to be <80%) with reversibility testing
- peak flow variability
children not usually diagnosed until 2/3 yo
Tx of asthma is under 5 yo
- SABA: salbutamol as required
- low dose corticosteroid (e.g. beclometasone) or leukotriene antagonist (montelukast)
- add other option from step 2
- refer to specialist
Tx for asthma is age 5-12yrs?
- SABA: salbutamol as required
- low dose corticosteroid e.g. beclometasone
- add LRTA (montelukast)
- swap LRTA for SABA (salmeterol)
- increase dose of inhaled corticosteroid to medium dose.
- refer to specialist (might need oral steroids)
Tx of asthma for >12yo?
(same as adults)
- SABA: salbutamol as required
- low dose corticosteroid e.g. beclometasone
- add LABA (salmetarol)
- titrate corticosteroid inhaler to medium dose + consider adding leukotriene receptor antagonist (montelukast) or oral theophylline or LAMA
- increase dose of inhaled corticosteroid to high dose. + option of oral salbutamol.
- refer to specialist (might need oral steroids)
what is the step wise control of acute asthma attack in children?
- salbutamol inhalers via inhaler (10 puffs every 2 hrs)
- nebs with salbutamol/ipatropium bromide
- oral prednisolone
- IV hydrocortisone
- IV magnesium sulphate
- IV salbutamol
- IV aminophylline
- if not got control call aneasthetist + ITU (may need intubation and ventilation)
sign of moderate asthma attack?
peak flow >50% predicted
normal speech
no features of severe of life threatening attack
clinicl features of a severe asthma attack?
peak flow <50% predicted
sats <92%
unable to complete sentences in one breath
signs of resp distress
RR>40 (1-5yrs)
RR>30 (>5yo)
HR>140 (1-5yrs)
HR>125 (>5yo)
clinical features of life threatening asthma
peak flow <33% predicted
sats <92%
exhaustion and poor resp effort
hypotension
silent chest
cyanosis
altered consiousness/confusion
what is stridor?
harsh high pitched inspiratory sound due to partial obstruction of lower portion of upper airway (upper trachea and larynx)
causes of stridor
croup (viral laryngotracheobronchitis) - most common!!
epiglottitis
bacterial tracheitis
laryngeal or oesophageal foreign body
retropharyngeal abscess
allergic laryngeal oedema
diphtheria
common cuases fro croup?
parainfluenza - most common!!
influenza
adenovirus
resp syncytial virus (RSV)
clinical features of croup?
- increased work of breathing
- barking cough
- hoarse voice
- stridor
- low grade fever
(oedema and inflammation of trachea, larynx and bronchi)
Mx of croup ?
most cases = supportive Tx (fluids and rest)
sit the child up and comfort them
oral dexamethasone single dose (repeated after 12hrs)
O2
if doesnt work then nebs budesonide then adrenaline
last resort - intubation and ventilation
what is epiglottitis?
inflammation and swelling of epiglottitis cuased by infection typically heamophilus influenza type B
clincial features of epiglottitis?
- sore throat
- stridor
- drooling
- tripod position (sat forward with hands on knees)
- high fever
- difficulty or painful swallowing
- muffles voice
- scared adn quiet
- septic and unwell apperance
Ix for epiglottitis?
lateral xray of neck shows ‘thumb sign’ (cuased by oedematous and swollen epiglottis)
neck xray can also exclude foreign body
Mx of epiglottitis?
keep the child calm
ensure airway is secure
most dont need intubation
once airway secure: IV abx (ceftriaxone) and steroids (dexamethasone)
common complication of epiglottitis?
epiglottic abscess
what is bronchiolitis?
inflammation of the bronchioles usually by a virus (respiratory syncytial virus is most common cause)
clinical featuers of a child with bronchiolitis?
- coryzal zymptoms: rhinorrhea, sneezing, mucus in throat, watery eyes
- signs of resp distress (raised RR, use of accessory muscles, intercostal recessions, nasal flaring, head bobby, cyanosis)
- dyspnoea
- tachypnoea
- poor feeding
- mild fever
- wheeze and crackles on auscultation
** no active bronchoconstriction
what is wheezing?
whistling sound caused by narrowed airways typically heard during expiration
what are the indications for admission of a child with bronchiolitis?
- age under 3 months
- pre existing condition e.g. downs or cystic fibrosis
- 50-75% or less of normal intake of milk
- clinical dehydration
- resp rate > 70
- o2 sats below 92%
- moderate to severe resp distress
- apnoeas
Mx of bronchiolitis?
supportive Mx!!
- ensure adequate intake (NG tube or IV fluids)
- saline nasal drops + nasal suctioning
- supplementary o2 if sats are <92%
- ventilatory support if required (high flow humidified o2, CPAP, intubation and ventilation)
** asthma tx is useless as there is no bronchoconstriction in bronchiolitis
whats the best way of assessing ventilation in a child with resp distress?
capillary blood gases taken from the heel to see rising pCO2 and falling pH
what is the role of palivizumab in bronchiolitis?
it is a monoclonal antibody that targtes syncytial virus -> monthyl injection given as a prevention against bronchiolitis caused by RSV.
given to high risk babies (e.g. congenital heart disease)
what is viral induced wheeze?
children who have a viral chest infection get a wheeze (rhinovirus type C is most common)
** occurs commonly around one year of age
differentials of a child with a wheeze?
- neonatal resp distress
- allergy
- asthma / preschool wheeze
- viral induced wheeze
- foreign body aspiration
- bronchomalacia
why is it important to use spacers in children
better deposition of medicine
reduces chance of oral thrush and hoarse voice
how to administer medication via inhaler to <4yo
use a volumatic spacer + meter dose inhaler + MASK to help
shake the inhaler, seal mask onto baby’s face,
need to tilt the space upwards to open valve, puff the inhaler, hold on for 10 secs
how to clean a spacer
pull apart
wash with soap and warm water
AIR DRY!!!
*change every 6 months
defintion of acute and chronic cough
acute: < 4wks
chronic: > 4 wks
Ix in a child with a chronic cough?
- cxr
- bloods: immune screen, allergy markers
- lung function test (if old enough)
tx of rhinitis?
steroid nasal spray
antihistmines
clinical signs of rhinitis?
throat clearing, snoring, blocked nose, bad breath, worse in morning but clears throughout day
tx of GORD?
trial of PPI, gaviscon
2 main purposed of bronchoscopy?
- Microbial samples: Stubborn/resistant infections
- Assess Airways
what is tracheobronchomalacia?
floppy airways - flaccidity of supporting cartilage
tx for tracheobronchomalacia?
- nothing rlly (symptomatic mx)
prophylactic abx/physio
CPAP
surgery - if rlly severe - to stent airwasy
what is bronchiectasis?
abnormla dilatation and distortion of the bronchial tree
gold standard ix for bronchiectasis?
high resolution ct
key findings of bronchiectasis on ct
signet ring sing
gold standard ix for bronchiectasis?
ct scan with contrast
tx for bronchiectasis?
- prophylactic abx
- physio
- aggressive tx of LRTI
- nutrition
- regular monitoring incl. lung function
clinical features of community acquried pneumonia
tachypnoea
pyrexia
cough
increased work of breathing
tx for cap
non severe - oral abx for 5-7 days (amoxicillin)
severe - iv (amoxicillin or cefuroxine) abx
ix for cap
cxr / bloods not needed! can just diagnose from hx and examination
what is the usual presentation of cystic fibrosis?
- found in newborn bloodspot test screening
- meconium ileus presentation
- later in childhood - recurrent LRTI, failure to thrive or pancreatitis
what is meconium ileus?
not passing meconium in the first 24hrs of life due to the meconium being thick and sticky and getting caught in the bowel
also presents with abdo distention + vomiting
symptoms of cystic fibrosis if not picked up by screenign or meconium ileus?
- chronic cough
- thick sputum production
- recurrent LRTIs
- loose, greasy stools (steatorrhea)
- abdo pain and bloating
- salty skin
- poor weight and height gain (failure to thrive)
diagnosis of cystic fibrosis?
screening (heel prick tesT)
sweat chloride test (gold standard) - chloride >60mmol/L
genotyping
Mx of cystic fibrosis?
- chest physio
- exercise
- high calorie diet
- CREON tablets to digest fats (due to pancreatic insufficiency)
- prophylactic flucloxacillin
- salbutamol inhalers
- vaccinations
which bacteria has a high rate of mortality in cystic fibrosis patients?
pseudomonas aeruginosa
name some complications that need to be screened for in cystic fibrosis?
- diabetes,
- osteoporosis
- vitamin D deficiency
- liver failure
preventer inhalers used in children?
- corticosteroids e.g. beclometasone, budesonide
- LAMA e.g. salmeterol, formoterol
- combo of the two
SE of inhaled corticosteroids?
hoarse voice and oral thrush
can have systemic SE, but usually dose not high enough
SE of LAMAs
tachy and tremor
what is stridor?
abnormal resp sound characterised by high pitched (predominantly inspiratory) noise
causes by upper airway obstruction e.g. laryngomalacia, croup
what is wheeze?
abnormal resp sound characterised by high pitched (expiratory)
causes by lower airway obstruction e.g. asthma, COPD
what is whooping cough
also known as pertussis
it is an URTI caused by a gram -ve bacteria
what bacteria causes pertussis?
bordetella pertussis
presentation of pertussis?
mild coryzal symptoms (low grade fever and dry cough)
followed by coughing fits -> loud inspiratory whoop when coughing ends
pts can faint or vomit w coughing fits
how do you diagnose pertussis?
nasopharyngeal or nasal swab with PCR testing or culture (to identify bordetella pertussis)
Mx for whooping cough?
- notify public health england
- supportive care usually
- may need admitting (<6 months, apnoeas, cyanosis)
- abx: azithromycin/erythromycin
- if in contact and vulnerable (e.g. pregnant) then prophylactic abx
how long does it take for whooping cough to resolve
typically within 8 wks
can take longer - ‘called the 100 day cough’
