Paeds Resp Flashcards
1
Q
What is pneumonia?
A
Infection of the lower respiratory tract and lung parenchyma causes inflammation of the lung tissue & sputum filling the airways and alveoli
2
Q
What are resp distress symptoms
A
tracheal tug
intercostal + diaphragm recession
nasal flaring
RR>60
accessory muscle use
wheeze
stridor
cyanosis
head bobbing
3
Q
What is wheeze
A
obstructed lower airway
Expiratory whistle
asthma
bronchiectasis
CF
bronchiolitis
4
Q
what is stridor
A
obstructed upper airway
high pitched harsh inspiration
croup
epiglottitis
laryngomalacia
foreign body
5
Q
What is order of choice of oxygen supplementation
A
high flow O2
CPAP
intubation
6
Q
How does pneumonia present?
A
- Usually precede an upper respiratory tract infection
- Cough (typically wet and productive)
- Fever
- SOB
- poor feed
- Lethargy
- Increased work of breathing
7
Q
What are the characteristic auscultation chest signs of pneumonia?
A
Bronchial breathing
Focal coarse crackles
Dullness to percussion
8
Q
Is bacterial or viral pneumonia more common in young infants
A
viral pneumonia is more common in young infants
9
Q
What are the signs of pneumonia?
A
Tachypnoea (raised respiratory rate)
Tachycardia (raised heart rate)
Hypoxia (low oxygen)
Hypotension (shock)
Fever
Confusion
10
Q
What is the most common cause of pneumonia in neonates
A
Group B Strep, E coli, Klebsiella, Staph Aureus
11
Q
What is the most common bacterial cause of pneumonia in children?
A
Streptococcus pneumonia
12
Q
What is the most common cause of pneumonia in infants?
A
Strep pneumoniae, HiB, Chlamydia
haemophilus influenzae type b
13
Q
What is the most common cause of pneumonia in school age children?
A
Strep pneumoniae, Mycoplasma pneumoniae, Haemophilus influenza,
Staph Aureus, group A Step,
14
Q
What are the typical XRay findings of pneumonia?
A
upper lobe consolidation
15
Q
What are the viral causes of pneumonia?
A
Respiratory syncytial virus (RSV) (MC)
Parainfluenza virus
Influenza virus
16
Q
What Xray findings would you see for Staphylococcus aureus pneumonia?
A
pneumatocoeles (round air filled cavities) and consolidations in multiple lobes.
17
Q
What are the investigations of pneumonia?
A
Clinical
FBC + bloods
Sputum culture and Gram stain:
CXR - fluid in the lungs (associated with Staph)
18
Q
What is 1st line antibiotic for pneumonia?
A
Amoxicillin
Neonates: Broad spec IV Abx
Infants: Amoxicillin/Co-Amoxiclav
Over 5s: Amoxicillin/Erythromycin
19
Q
What antibiotic is added to cover atypical pneumonia or in case of patient with penicillin allergy?
A
macrolide - erythromycin, clarithromycin or azithromycin
20
Q
Name complications of pneumonia
A
Respiratory failure
Sepsis
Pleural effusion (in 1/3 cases)
Empyema
Lung abscess
Risk of parapneumonic collapse and empyema if so follow up at 4-6 weeks with a fluid sample
21
Q
When should child be admitted for pneumonia
A
<93% O2 stat
22
Q
What is croup
A
Acute laryngotracheobronchitis due to parainfluenxa virus
upper respiratory tract infection causing inflammation in the larynx
23
Q
What is the classic cause of croup
A
parainfluenza virus
24
Q
What is the epidemiology of croup
A
Peak incidence 6 months to 3 years
MC in autumn and winter
more common in male, preterm, and those with underlying resp disease
25
Name 3 causes of croup
*Parainfluenza* - MC
Influenza
Adenovirus
Rhinovirus
26
What did croup used to be commonly caused by and what did it lead to?
Croup caused by diphtheria leads to epiglottitis
27
what is the pathophysiology of croup?
Viral infection --> inflammation of the upper airway with oedema formation and infiltration of inflammatory cells --> narrowing of subglottic airway (inspiratory stridor) and increased work of breathing
28
What is mild croup
Occasional barking cough
No audible stridor at rest
No or mild suprasternal and/or intercostal recession
The child is happy and is prepared to eat, drink, and play
29
what is moderate croup
Frequent barking cough
Easily audible stridor at rest
Suprasternal and sternal wall retraction at rest
No or little distress or agitation
The child can be placated and is interested in its surroundings
30
what is severe croup
* Frequent barking cough
* Prominent inspiratory (and occasionally, expiratory) stridor at rest
* Marked sternal wall retractions
* Significant distress and agitation, or lethargy or restlessness (a sign of hypoxaemia)
* Tachycardia occurs with more severe obstructive symptoms and hypoxaemia
31
When do you admit a child with croup?
moderate or severe croup
< 3 months of age
stridor at rest
known upper airway abnormalities (e.g. Laryngomalacia, Down's syndrome)
32
What are respiratory failure red flag signs?
- Drowsiness
- Lethargy
- Cyanosis
- Tachycardia
- Laboured breathing
33
How does croup present on examination?
- 1-4 days history of non-specific rhinorrhea (thin, nasal discharge), fever and barking
cough
- Worse at night
- Stridor
- Decreased bilateral air entry
- Tachypnoea
- Costal recession
34
How is croup diagnosed?
- clinical dx
- FBC, CRP U+E
- CXR - posterior-anterior angle
35
What are the XRay signs of croup?
posterior-anterior
steeple sign = subglottic narrowing
36
How is croup managed?
- *Single dose oral dexamethasone 0.15mg/kg*
- Paracetamol/Ibuprofen for fever/sore throat
- Admission if moderate/severe and consider if dehydrated
- Nebulised adrenaline for relief of severe symptoms
- Oxygen if required
- Monitor for needed ENT intervention if suspected airway blockage
37
What are complications of croup?
- Bacterial Superinfection: (S. Aureus, pseudomembranous croup, thick green secretions Tx IV fludox)
- Otitis Media
- Dehydration due to reduced fluid intake
38
What is asthma?
chronic reversible airway obstruction characterised by mucus hyper-secretions, airway hyper-responsiveness and inflammation
39
What are causes/RH of asthma?
- FHx atopy
- PHx atopy
- Samter's Triad
- Hygiene hypothesis
- Genetic
- Prematurity
- Low birth weight
- Parental smoking
- Viral bronchiolitis in early life
- Cold air
- allergen eg dust pollution
40
patients with asthma also suffer from other IgE-mediated atopic conditions such as
atopic dermatitis (eczema)
allergic rhinitis (hay fever)
41
How does asthma present clinically?
Persistent recurrent resp distress with wheeze, worse at night and in morning
- Episodic symptoms with intermittent exacerbations
- Dry cough often worse at night
- SOB
- Wheeze
- Reduced peak flow
- Expiratory wheeze on auscultation
42
What is harrisons sulci
muscles insertions at diaphragm visible
associated with chronic asthma
43
How is asthma investigated >5 y/o
- PEF diary -> 20% variable in 2-4 week period
- CXR (hyperinflation)
- FEV1:FVC < 0.8
- Bronchodialtor >12% reversibility
44
What would spirometry investigation for asthma show?
- FEV1 significantly reduced
- FVC normal
- FEV1:FVC may be <70% if poorly controlled
- Reversible spirometry is highly suggestive of asthma
45
How is asthma investigated <5 y/o
clinical
same as viral wheeze
46
What would Fractional exhaled nitric oxide (FeNO) show for asthma?
High FeNO levels indicate your airways are inflamed or irritated.
>35ppb
47
What is the management plan for asthma for children >5 (7 steps - same as adults)
1: SABA (Salbutamol)
2: SABA + paediatric low-dose inhaled corticosteroid (ICS)
3: SABA + ICS + LTRA (Montelukast)
4: SABA + ICS + LABA (Salmeterol)
5: SABA + maintenance and reliever therapy (MART) and low dose ICS
Step 6: SABA + MART paediatric moderate-dose ICS
Step 7: SABA + MART High dose ICS (>400mcg), referral specialist care
48
How is life threatening asthma classified?
Sp02 <92&
PEFR <33%
silent chest
altered GCS
cyanosis
decreased effort to breathe
poor resp effort
49
How is severe asthma classified?
Sp02 <92&
PEFR 33%-50%
RR>30 (under 5)
RR >40 (over 5)
too breathless to feed talk
HR >140 (under 5s)
HR >125 (over 5s)
use of accessory muscles
audible wheeze
50
How is mild-moderate asthma classified?
Peak flow 50%-75%
Breathless
SpO2 >92%
feeding well
talking in sentences
wheeze
51
what is the management for Moderate to severe cases of asthma
1. Nebulisers Salbutamol 10 puffs + spacer + PO Pred
+
2. Nebulisers ipratropium bromide +/- MgSO4
+
3. IV aminophylline
+ O2 if SpO2 <94%
52
When can a child be discharged after asthma admission
* stable on their discharge medication (i.e. no nebulisers or oxygen) for 12-24 hours
* inhaler technique checked and recorded
* PEF >75% of best or predicted
discharge can be considered when the child well on 6 puffs 4 hourly of salbutamol.
53
What is benefit of a spacer
increase bioavailable drug by keeping neb in vacuum for longer
prevents thrush
easier to administer
avoid breathing med too fast
54
What is total control for asthma defined
no daytime Sx
no acute attacks
no exercise Sx
no night waking
can consider decrease Tx if with control >3 months
55
What can contribute to poor control of asthma
adherence
bad disease
choice of drugs
environment
56
What type of resp failure is asthma attack
Type 2
hypercapnic
high CO2
57
What is viral-induced wheeze
recurrent viral induced wheeze <5 years old due to lung immaturity
self resolving by 5
Episodic Wheeze - a symptom of viral URTI and symptom free in between events
Multiple trigger Wheeze - URTI and other factors trigger wheeze
58
What are 2 RF for viral-induced wheeze
maternal smoking
prematurity
59
What is airway inflation worse in children than adults?
due to the small diameter of a child’s airway, the slight narrowing leads to a proportionally larger restriction in airflow
(Poiseuille’s law = halving the diameter of the tube decreases flow rate by 16 fold)
60
How does viral-induced wheeze present
Evidence of a viral illness (fever, cough and coryzal symptoms) for 1-2 days preceding the onset of:
- Shortness of breath
- Signs of respiratory distress
- Expiratory wheeze throughout the chest
61
What are the typical features of viral-induced wheeze as opposed to asthma
Presenting before 3 years of age
No atopic history
no diurnal variation
Triggered by viral infection otherwise systemically well
62
How is viral-induced wheeze managed?
same as acute asthma
1. SABA inhaler via spacer maximum of 4 hourly up to 10 puffs
2. SABA and ICS trial for 8 weeks
3. SABA + ICS + LTRA
4. escalate
63
What is Bronchiolitis
inflammation and infection in the bronchioles, the small airways of the lungs.
widespread wheeze
64
What is the epidemiology of Bronchiolitis
under 1 year
MC in under 6 months
Most commonly caused by RSV (Respiratory Syncytial Virus)
65
Risk factors for Bronchiolitis
- CHD (congenital heart disease)
- preterm
- CF
- winter
- immunodeficiency
- smoke exposure
66
What is the course of Bronchiolitis?
Symptom onset in 2-5 days after URTI w coryzal symptoms
~ 9 days of Sx, day 5 is peak
half get better half get chest symptoms following the onset of coryzal symptoms
67
What are signs of respiratory 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
68
What are the clinical features of Bronchiolitis?
- Low grade fever
- Rhinorrhea and nasal congestion
- Cough
- Reduced feeding
- Respiratory distress
- Inspiratory crackles
- decrease wet nappies
69
What are Coryzal symptoms
running or snotty nose, sneezing, mucus in throat and watery eyes.
70
What is wheezing
whistling sound caused by narrowed airways, typically heard during expiration
71
What is grunting?
caused by exhaling with the glottis partially closed to increase positive end-expiratory pressure
72
What is stridor
high pitched inspiratory noise caused by obstruction of the upper airway, for example in croup
73
How is Bronchiolitis investigated
Generally clinical - widespread wheeze
Nasopharyngeal aspirate for RSV culture
FBC, Urine, Blood gas if severely unwell
CXR - not used usually but shows hyperinflation, air trapping and flattened diaphragm
74
How is Bronchiolitis managed?
Supportive management from home
75
What indicates urgent hospital admission for Bronchiolitis
- Apnoea
- Resp Rate > 70
- Central cyanosis
- SpO2 < 90%
- 50-75% fluid dehydration
76
How is bronchiolitis prevented?
IM Palvizumab against bronchiolitis (monthly monoclonal IgG injection)
provides passive immunity
77
Who Palvizumab given to
preterm
CHD
CF w/ lung defect
immunocompromised
78
What indicates hospital admission for Bronchiolitis
- Resp Rate > 60
- 50-75% fluid intake
- clinical dehydration
79
What is the inpatient management for Bronchiolitis
- Oxygen to bring SpO2 up
- Fluids
- CPAP if in respiratory failure
- Suctioning of secretions
- Ribavirin for severe cases
- No evidence for bronchodilatory, antibiotics or steroids in bronchiolitis
80
What is complication of Bronchiolitis
bronchiolitis obliterans
81
What is bronchiolitis obliterans
post transplant or recurrent infection
severe scarring
"popcorn lung"
HRCT = mosaic pattern
FEV1 : FVC 16-20%
82
What is cystic fibrosis?
auto rec ΔF508 on CFTR gene of C7
decrease CFTR expression = more Na and Cl retention affecting mucus glands
83
What is the pathophysiology of cystic fibrosis
lungs = impaired mucociliary clearance
GIT = impaired absorption due to thicker secretions
pancreas = B islet damage + decrease enzyme secretion
liver = biliary stasis
84
How is cystic fibrosis detected
screened for at birth with the Guthrie heel prick (newborn bloodspot tes).
85
What is the Guthrie heel prick
serum immunoreactive trypsin
5-9 days of life
also sickle cell
congential hypothyroid
86
What are symptoms of cystic fibrosis in neonate
failure to pass meconium <48hrs
87
How is meconium ileus treated
Gastrografin
88
What are symptoms of cystic fibrosis in infant
jaundice
failure to thrive
recurrent chest infections
89
What is MC caustive organism of recurrent chest infections in cystic fibrosis
P. aeruginosa in adults
S. aureus in kids
90
How is P. aeruginosa treated
ciprofloxacin
91
What are symptoms of cystic fibrosis in child
bronchiectasis
nasal polyps
sinusitis
92
What are symptoms of cystic fibrosis in older childer
Congenital bilateral absence of vas deferens (infertile) (98% of males)
bronchopulmonary aspergillosis
93
What is meconium ileus
first stool (meconium) is thick and sticky and can cause bowel obstruction
presents as not passing meconium within 24 hours, abdominal distention and vomiting.
94
If cystic fibrosis is not diagnosed at birth how does it usually present?
recurrent lower respiratory tract infections, failure to thrive or pancreatitis.
95
What are the symptoms of cystic fibrosis?
- Chronic cough
- Thick sputum production
- Recurrent respiratory tract infections
- Loose, greasy stools (steatorrhoea) due to a lack of fat digesting lipase enzymes
- Abdominal pain and bloating
- salty secretions
- failure to thrive
96
What are the signs of cystic fibrosis?
Low weight or height on growth charts
Nasal polyps
Finger clubbing
Crackles and wheezes on auscultation
Abdominal distention
97
What are DDx for finger clubbing
Hereditary clubbing
Cyanotic heart disease
Infective endocarditis
Cystic fibrosis
Tuberculosis
Inflammatory bowel disease
Liver cirrhosis
98
What are the three methods of diagnosing cystic fibrosis?
- Newborn blood spot testing (guthrie heel prick)
- The sweat test - more than 60mmol/l Ch (GOLD STANDARD)
- Genetic testing CFTR gene during pregnancy by amniocentesis or chorionic villous sampling, or as a blood test after birth
99
What is the sweat test
Pilocarpine applied to skin
Electrodes are placed
sweat is absorbed on filter paper and tested for chloride concentration
more than 60mmol/l = CF
100
Name two key microbial colonisers of cystic fibrosis?
Staphylococcus aureus and Pseudomonas aeruginosa
Burkhodheria cepacia
101
What long term prophylactic antibiotics do people with csystic fibrosis take?
flucloxacillin
102
how is cystic fibrosis managed?
lungs = chest physio 2x daily (clearence, breathing techniques, mucoactive agents = sinase + lumacaftor + hypertonic saline
panc = CREON + OGTT annually <10 y/o
GI = high cal high fat diet
liver = LFT annual screen
- Bronchodilators inhalers
- Nebulised DNase (dornase alfa) makes secretions less viscous
- Vaccinations including pneumococcal, influenza and varicella
- lung transplant - last line
Fertility treatment
Genetic counselling
103
what are Cf patients monitored for
sputum for colonisation
diabetes
osteoporosis
vitamin D deficiency
liver failure
104
how is pseudomonas managed in CF
long term nebulised antibiotics such as tobramycin. Oral ciprofloxacin is also used.
Cystic fibrosis clinics have separate clinic rooms for children with pseudomonas to minimise the risk of transmission
avoid contact with other children with cystic fibrosis
105
When is lung transplant CI in cystic fibrosis
burkholderia infections
106
What is laryngomalacia
congenital floppy larynx
self resolving
inc risk of GORD --> PPI
107
what is kartagener
primary ciliary dyskinesias
triad of bronchiectasis, sinusitis, and situs inversus
108
How is cystic fibrosis progression monitored
chrispin norman score
109
What is Epiglottitis?
acutely inflamed epiglottis in 6-12y due to HiB
life threatening emergency
110
How does Epiglottitis present?
dysphagia, drooling, and distress
dehydration
Tripod position, sat forward with a hand on each knee
111
how is Epiglottitis diagnosed?
- call ent + anaesthetists
- DO NOT examine airway
- CXR lateral view - Thumb sign --> epiglottis swelling
FBC, laryngoscopy
112
how is Epiglottitis managed?
secure the airway first
- intubation/O2
- Nebulised adrenaline
- IV Abx - Ceftriaxone
113
what Abx is given to Epiglottitis close contacts
Rifampicin
HiB vac
114
what typically causes Epiglottitis
Haemophilus influenzae type b
