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3ayeeeee > Paeds Resp > Flashcards

Paeds Resp Flashcards

1
Q

What are signs and symptoms of respiratory distress ?

A
  • Raised RR
  • Use of accessory muscles – sternocleidomastoid, abdominal and intercostal
  • Intercostal and subcostal recessions
  • Nasal flaring
  • Head bobbing
  • Tracheal tug
  • Cyanosis
  • Abnormal airway noises (silent, grunting, wheeze. Stridor)
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2
Q

What is wheeze ?

A
  • A whistling sound caused by narrowed airways typically heard during expiration
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3
Q

Which respiratory conditions present with wheeze ?

A
  • Viral induced wheeze
  • Acute and chronic asthma
  • Bronchiolitis
  • CF
  • Chronic lung disease of prematurity
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4
Q

What is a respiratory grunt and when is it heard ?

A
  • Caused by exhaling with the glottis partially closed to increase positive end pressure
  • Hear during respiratory distress e.g. asthma, VIW, bronchiolitis, bronchopulmonary dysplasia
  • Transient tachypnoea of new born
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5
Q

What is stridor ?

A
  • High pitched inspiratory noise caused by obstruction of the airway
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6
Q

What can cause stridor ?

A
  • Epiglottis
  • Croup
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7
Q

What is pneumonia ?

A
  • Infection of the lung tissue causing inflammation of the tissue and sputum to fill the airway and alveoli
  • Seen as consolidation on chest X-ray
  • Can be viral, bacterial or atypical bacterial
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8
Q

MCC of pneumonia

A
  • Strep pneumonia (most common)
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9
Q

Causes of pneumonia (bacterial)

A
  • Strep pneumonia
  • Group A and B step
  • Haemophilus influenza
  • Mycoplasma pneumonia (atypical)
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10
Q

Viral causes of pneumonia

A
  • RSV (MC)
  • Parainfluenza virus
  • Influenza virus
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11
Q

Presentation of pneumonia

A
  • Wet and productive cough
  • High fever (>38.5)
  • Tachypnoea
  • Tachycardia
  • Increased work of breathing
  • Lethargy
  • Delirium
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12
Q

Signs of sepsis secondary to pneumonia

A
  • Tachypnoea
  • Tachycardia
  • Hypoxia
  • Hypotension
  • Fever
  • Confusion
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13
Q

Typical respiratory exam findings of pneumonia

A
  • Bronchial breath sounds
  • Focal coarse crackles
  • Dullness to percussion
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14
Q

What are bronchial breath sounds ?

A
  • Harsh breath sounds are equally loud on inspiration and expiration
  • Caused by consolidation of the lung tissue around the airway
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15
Q

Why are there focal coarse crackles in pneumonia ?

A
  • Caused by air passing though the sputum
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16
Q

Investigations of pneumonia

A
  • Chest X-ray
  • Sputum cultures and throat swabs for culture or PCR
  • (Blood cultures plus capillary blood gas if sepsis)
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17
Q

Management of pneumonia (bacterial)

A
  • 1st line amoxicillin
  • Add macrolide (erythromycin, clarithromycin or azithromycin) to cover atypical or pen allergy
  • IV if septic or oxygen below 92%
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18
Q

Investigations for recurrent LRTIs resulting in admission and ABs

A
  • Thorough Hx
  • FBC
  • C-xray
  • Serum immunoglobulins
  • Immunoglobulin G
  • Sweat test
  • HIV
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19
Q

What is croup ?

A
  • An acute infective respiratory disease that affects young children
  • Typically 6m to 2 years
  • URTI causing oedema in the larynx
  • Usually improves in 48 hours and responds to dexamethasone
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20
Q

MCC of croup ?

A
  • Parainfluenza virus
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21
Q

Causes of croup ?

A
  • Parainfluenza virus (MCC)
  • Influenza virus
  • Adenovirus
  • RSV
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22
Q

Croup presentation

A
  • Barking cough occurring in clusters and episodes
  • Increased work of breathing
  • Hoarse voice
  • Stridor
  • Low grade fever
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23
Q

Management of croup

A
  • Most cases can be managed at home with simple supportive treatment (fluids and rest)
  • Oral dexamethasone is very effective
  • Single dose of 150mcg/kg which can be repeated if required after 12 hours
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24
Q

Stepwise management of severe croup

A
  • Oral dexamethasone
  • Oxygen
  • Nebulised budesonide
  • Nebulised adrenalin
  • Intubation and ventilation
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25
Q

How dose acute asthma present ?

A
  • Progressive worsening SOB
  • Signs of respiratory distress
  • Tachypnoea
  • Expiratory wheeze on auscultation heard through the chest
  • Chest can sound ‘’tight’’ on auscultation with reduced air entry
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26
Q

Red flag/ominous sign for acute asthma

A
  • Silent chest
  • This means that the airways are so tight that it is impossible for the child to move enough air through the airways to wheeze
  • Might be associated with reduced respiratory effort due to fatigue and is life threatening
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27
Q

Features of moderate acute asthma

A
  • Peak flow > 50% predicted
  • Normal speech
  • No accessory muscle involvement
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28
Q

Features of severe acute asthma

A
  • Peak flow < 50% predicted
  • Saturations < 92%
  • Unable to complete sentences in one breath
  • Signs of respiratory distress
  • RR > 40 in 1-5
  • RR > 30 in > 5 years
  • HR >140 in 1-5 years
  • HR > 125 > 5 years
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29
Q

Signs of life-threatening asthma

A
  • Peak flow < 33% predicted
  • Sats < 92%
  • Exhaustion and poor respiratory effort
  • Hypotension
  • Silent chest
  • Cyanosis
  • Altered GCS/confusion
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30
Q

Stapels of management of acute asthma and viral induced wheeze

A
  • Oxygen if <94% or working hard
  • Bronchodilators e.g. salbutamol, ipratropium and magnesium sulphate
  • (ABs – only if bacterial cause suspected e.g. amoxicillin or erythromycin)
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31
Q

Step up of bronchodilators

A
  • Inhaled or nebulised salbutamol (SABA)
  • Inhaled or nebulised ipratropium bromide (anti-muscarinic)
  • IV magnesium sulphate
  • IV aminophylline
32
Q

Acute asthma mild cases management

A
  • Manage as outpatient with regular salbutamol inhalers via spacer (e.g. 4-6 puffs every 4 hours)
33
Q

Stepwiese acute asthma management

A
  • Salbutamol inhalers via a spacer device starting with 10 puffs every 2 hours
  • Nebulisers with salbutamol/ipratropium bromide
  • Oral prednisolone (1mg per kg of body weight once a day for 3 days)
  • IV hydrocortisone
  • IV magnesium sulphate
  • IV salbutamol
  • IV aminophylline
  • Intubate and ventilate
  • (Step up)
34
Q

Presentation of chronic asthma

A
  • Episodic symptoms with intermittent exacerbations
  • Diurnal variability – typically worse at night and early morning
  • Dry cough, wheeze and SOB
  • Typical triggers
  • A Hx of other atrophic conditions
  • FHx of atopy
  • Bilateral widespread ‘’polyphonic’’ wheeze heard by a HCP
  • Symptoms improve with bronchodilators
35
Q

Symptoms which indicate a diagnosis other than asthma

A
  • Wheeze only related to coughs and colds are more suggestive of viral induced wheeze
  • Isolated or productive cough
  • Normal investigations
  • No response to treatment
  • Unliteral wheeze – suggest a focal lesion, inhaled foreign body or infection
36
Q

Typical triggers of asthma

A
  • Dust
  • Animals
  • Cold air
  • Exercise
  • Smoko
  • Food allergens
37
Q

Diagnosis of chronic asthma

A
  • No gold standard
  • Usually based on Hx and exam
38
Q

Investigations of chronic asthma

A
  • Spirometry with reversible testing
  • Direct bronchial challenge test with histamine or methacholine
  • Fractional exhaled nitric oxide
  • Peak flow variability – peak flow diary – several times a day for 2-4 weeks
39
Q

Long term asthma management under 5

A
  • SABA e.g. salbutamol
  • Low dose corticosteroids or leukotriene antagonists i.e. oral montelukast
  • Add the other option from step 2
  • Refer to specialist
40
Q

Long term asthma management 5-12 years

A
  • SABA e.g. salbutamol
  • Add regular or low dose CS inhaler
  • Add LABA e.g. salmeterol
  • Titrate up CS inhaler to medium dose – consider adding oral leukotriene receptor antagonist e.g. montelukast or oral theophylline
  • Increase CS to high dose
  • Refer to specialist – may require daily oral steroids
41
Q
  1. Chronic asthma management – Over 12 (same as adults)
A
  • SABA e.g. salbutamol
  • Add regular low dose CS inhaler
  • Add LABA inhaler e.g. salmeterol
  • Titrate up CS inhaler to medium - Consider trial of montelukast, oral theophylline or an inhaled LAMA i.e. titropium
  • Titrate CS inhaler to high dose
  • Combine additional treatments form step 4, including the option of an SABA
  • Refer to specialist - Add oral steroids at the lowest dose possible to achieve good control under specialist guidance
42
Q

What side effect of inhaled steroids may parents want to discuss ?

A
  • Steroids can lead to growth retardation
  • However so can poor asthma control
  • Also poor inhaler technique can lead to oral thrush
43
Q

MDI technique with space

A
  • 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
  • (Clean spacer once a month)
44
Q

What can cause Viral-Induced Wheeze ?

A
  • RSV or rhinovirus
45
Q

Why are small children vulnerable to viral induced wheeze ?

A
  • Children <3
  • Airways are small so a small amount of inflammation and oedema can restrict airflow
  • Inflammation also triggers the smooth muscle of the airways to constrict further narrowing of the space in the airway
46
Q

What law defines viral induced wheeze ?

A
  • Poiseuille’s law states that flow rate is proportional to radius of the tube to the power of 4
  • Therefore halving the diameter of the tube decreases the flow rate by 16
  • Air flowing through the narrow airways causes a wheeze, and restricted ventilation leads to respiratory distress
47
Q
  1. Factors which would suggest viral induced wheeze more than asthma ?
A
  • Presenting before the age of 3
  • No atopic history
  • Only occurs during viral infections
48
Q

Presentation of viral illness

A
  • Fever, cough and Cozyal symptoms for 1-2 days preceding onset of
  • SOB, signs of respiratory distress, expiratory wheeze throughout the chest
49
Q

Management of viral induced wheeze

A
  • Same as acute asthma
  • Oxygen if <94% or working hard
  • Bronchodilators e.g. salbutamol, ipratropium and magnesium sulphate
  • (ABs – only if bacterial cause suspected e.g. amoxicillin or erythromycin)
50
Q
  1. What is bronchiolitis ?
A
  • Inflammation and infection of the bronchioles (small airways of the lungs)
  • MCC is respiratory syncytial virus (RSV)
  • Very common in winter
  • Generally considered to occur in children under 1 year, MC in children under 6 months
  • Particularly present in ex-premature babies with chronic lung disease
51
Q

MCC of bronchiolitis ?

A
  • Respiratory syncytial virus
52
Q

Presentation of bronchioliti

A
  • Coryzal symptoms
  • Signs of respiratory distress
  • Dyspnoea
  • Tachypnoea
  • Poor feeding
  • Mild fever
  • Apnoeas
  • Wheeze and crackles on auscultation
53
Q

Typical presentation of bronchiolitis

A
  • Starts as URTI with coryzal symptoms
  • Develop chest symptoms 1-2 days following onset
  • Symptoms worsening on days 3-4
  • Usually last 7-10 days and most recover by 2-3 weeks
  • More likely to develop viral induced wheeze during childhood
54
Q

Reasons to admit for bronchiolitis

A
  • Under 3 months
  • Pre-existing conditions such as prematurity, Downs or CF
  • 50-75% of their normal intake of milk
  • Clinical dehydration
  • RR over 70
  • Oxygen sats 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
55
Q

Management of bronchiolitis

A
  • Typically only supportive
  • Ensuring adequate intake (oral, NG or IV) depending on severity
  • Saline nasal drops and nasal suctioning
  • Supplementary oxygen if sats below 92%
  • Ventilatory support
  • (little evidence that nebulised saline, bronchodilators, steroids and ABs have an impact)
56
Q

Levels of ventilator support available for bronchiolitis

A
  • High-flow humidified oxygen via a tight nasal cannula – adds positive end-expiratory pressure (PEEP) to maintain the airway at the end of expiration
  • Continuous positive airway pressure (CPAP)
  • Intubation and ventilation
57
Q

How is ventilation assessed in paeds ?

A
  • Oxygen sats
  • Capillary blood gases
58
Q

Signs of poor ventilation

A
  • Rising pCO2 – airways cannot clear CO2
  • Failing pH – showing the CO2 building up and they are not able to buffer the acidosis this creates
59
Q
  1. Bronchiolitis prophylaxis
A
  • Palivizumab
  • MCAB that targets respiratory syncytial virus
  • Monthly infection given to prevent bronchiolitis caused by RSV in high risk babies e.g. congenital heart disease or ex-premature
  • Not true vaccine, provides passive protection
60
Q

What is cystic fibrosis ?

A
  • Autosomal recessive genetic condition affect the mucus glands
  • Mutation in cystic fibrosis transmembrane conductance regulatory gene on chromosome 7
  • The genes codes for cellular channels, particularly a type of chloride channel
61
Q

Key pathology of cystic fibrosis

A
  • Thick pancreatic and biliary secretions cause blockage of the ducts resulting in a lack of digestive enzymes such as pancreatic lipase in the digestive tract
  • Low volume thick airway secretions that reduce airway clearance, resulting in bacterialla colonisation and susceptibility to airway infections
  • Congenital bilateral absence of the vas deferens in males – infertility
62
Q

Neonatal signs of CF

A
  • Meconium ileus is often the first sign of CF
  • In CF meconium is thick and sticky causing it to get obstructed (20% of cases)
  • Heel-prick test at birth
  • If not at birth then diagnosed with LRTIs, failure to thrive or pancreatitis
63
Q

Symptoms of CF

A
  • Chronic cough
  • Thick sputum
  • Recurrent resp infections
  • Loose, greasy stools
  • Abdominal pain and bloating
  • Parents may report the child tastes salty
  • Poor weight and height gain
64
Q

Signs of CF

A
  • Lowe weight or heigh
  • Nasal polyps
  • Finger clubbing
  • Crackles and wheezes on auscultation
65
Q

Causes of clubbing in children

A
  • Hereditary clubbing
  • Cyanotic heart disease
  • Infective endocarditis
  • CF, TB, IBD
  • Liver cirrhosis
66
Q

Diagnosis of CF

A
  • Newborn blood spot testing
  • The sweat test – gold standard
  • Genetic testing – transmembrane conductance regulatory gene
67
Q

Common microbial colonisers in CF

A
  • Staph aureus
  • Haemophilus influenza
  • Klebsiella pneumonia
  • E.coli
  • Burkhodheria cepacian
  • Pseudomonas aeruginosa (partially difficult to get rid of, linked to increased morbidity and mortality)
68
Q

Management of pseudomonas aeruginosa

A
  • Limit contact with others with CF
  • Can be treated with long term nebulised ABs such as tobramycin or oral ciprofloxacin
69
Q

CF management

A
  • Chest physiotherapy several times a day to clear mucus and reduce infection/colonisation
  • Exercise
  • High calorie diet
  • CREON tables to digest fats (if pancreatic insufficiency)
  • Prophylactic flucloxacillin
  • Bronchodilators e.g. salbutamol
  • Nebulised DNase (secretions less viscous and easier to clear)
  • Nebulised hypertonic saline
  • Vaccinations – pneumococcal, influenza and varicella
70
Q

Other CF management

A
  • Lung transplant (end stage resp failure)
  • Liver transplant
  • Fertility treatment
  • Genetic counselling
71
Q

Conditions to screen for in CF

A
  • DM
  • Osteoporosis
  • Vit D deficiency
  • Liver failure
72
Q

Prognosis

A
  • Median life expectancy is 47 years
  • 90% develop pancreatic insufficiency
  • Burkhodheria cepacian and Pseudomonas aeruginosa linked to worse prognosis
73
Q

What is epiglottis ?

A
  • Inflammation and swelling of the epiglottis caused by infection
  • Typically haemophilus influenza type B
  • Epiglottis can swell to the point that it completely occludes the airway
  • Now a rare condition due to haemophilus influenza type B being part of the 6 in 1 vaccine given at 2,3 and 4 months
74
Q

Epiglottis presentation

A
  • Sore throat and stridor
  • Drooling
  • Tripod position (sat forward with a hand on each knee)
  • High fever
  • Difficulty or painful swallowing
  • Muffled voice
  • Scared and quite child
  • Septic and unwell appearance
75
Q

Epiglottis management

A
  • Do not distress the patient as this could prompt closure of the airway
  • Alert a senior paediatrician and anaesthetist
  • Be prepared to intubate at any time
  • Tracheostomy may need to be done
  • Once airway secure – IV ABs (ceftriaxone) and steroids (dexamethasone)

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