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Phase 3a > Paeds - Resp > Flashcards

Paeds - Resp Flashcards

1
Q

Viral induced wheeze

A

Acute wheeze caused by viral infection

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2
Q

Viral induced wheeze pathophsy

A

Small kids have small airways. Viral infections cause some inflam and oedema + smooth muscle contraction in the airways.

Negligable in older airways but big flow reduction in small kids as dictated by Poiseuille’s Law (Flow rate proportional to radius to the power of 4) - half the diameter = flow rate decreases by 16

-> wheeze; restricted ventilation + RESP DISTRESS

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3
Q

Viral induced wheeze prognosis

A

Tends to be a FHx

Some kids are more prone to it and they tend to be at increased risk of developing ASTHMA when older

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4
Q

Viral Wheeze vs Asthma

A

Viral wheeze specifically tends to be:

  • In younger kids (< 3 y/o)
  • Only occurs in viral infection. Asthma is also exacerbated by factors like exercise, cold, allergies, strong emotions etc
  • No atopic history

However, this is not definitive and there is a lot of overlap

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5
Q

Viral induced wheeze Px

A

Viral infection for a 1-2 days and then:

  • SOB
  • Signs of RESP DISTRESS
  • EXPIRATORY WHEEZE throughout chest
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6
Q

Viral induced wheeze Mx

A

Same as acute asthma

  1. Supplementary O2
  2. Bronchodilators (salbutamol, ipratropium bromide, magnesium sulphate, aminophylline - step up as required)
  3. Steroids (prednisolone or hydrocortisone)
  4. Abx only if infection at least suspected

For mild can usually be managed with outpatient salbutamol

Mod - severe = step up as required:

  • salbutamol (10 puffs/2hrs)
  • Nebulisers
  • Prednisoline
  • Hydrocortisone
  • IV MgSO4
  • IV salbutamol
  • IV aminophylline
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7
Q

When can kids be discharged after a mod-severe viral induced wheeze

A

ONce they are well on 6 puffs of salbutamol every 4 hours

  • Must step down to at least this before discharge

Continue reducing at home till only taking as required

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8
Q

Epiglottitis aet

A
  • HAEMOPHILUS INFLUENZAE type B (HiB) - most severe
  • same pathogens that can cause pharyngitis (EBV, strep A, Mycoplasma pneumoniae, neisseria Gonorrhoea etc) - less common tho

More likely to get if immunocompromised

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9
Q

Epiglottitis epid

A
  • Previously most common in children 2-4 y/o
  • Now rare due to Hib vaccine
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10
Q

Epiglottitis Sx

A
  • Fever + sore throat
  • Dysphagia
  • SOB
  • STRIDOR
  • Drooling

May TRIPOD in an effort to get in more air

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11
Q

Epiglottitis Dx

A

Acutely: clinical Dx
- Hx of immunocompromise/no immunisation
- LATERAL CERVICAL X-RAY -> Thumb sign (helps confirm)
- Laryngoscopy = GOLD

(avoid looking in airways as may agitate child)

Microbio:

  • GRAM -VE COCCOBACILLI, usually ENCAPSULATED (HiB)
    - Unencapsulated = Non-Typable Haem Influ
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12
Q

Epiglottitis Tx

A

DOXYCYCLINE or CO-AMOXICLAV (for HiB)

(HiB not susceptible to macrolides i.e. clari/erithromycin + oft resistant to amoxicillin)

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13
Q

Croup

A

Acute Laryngo-tracheobronchitis - the inflam causes partial obstruction -> Stridor + sob

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14
Q

Croup Epidemiology

A
  • esp in kids 6 MONTHS to 6 YRS but particularly in <3 y/o
  • More common in autumn (+ early winter)
  • 1 in 6 kids affected at least once in life
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15
Q

Croup aet

A

Main cause = PARAINFLUENZA VIRUS

  • Resp syncitial virus
  • Flu A
  • Other resp viruses: EBV, Rhino, Adeno
  • Measles (RNA paramyovirus)

Can uncommonly get bacterial croup - more severe

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16
Q

Croup Sx

A
  • Fever, Hoarse voice
  • BARKING COUGH
  • STRIDOR (milder than epiglottitis but in the same way worsens if distressed)
  • Increased resp effort: intercostal recessions, cyanosis
  • Worse at NIGHT; may improve in cooler air
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17
Q

Croup Tx

A
  • Mild: Single dose of DEXAMETHASONE - improves inflam and Sx
  • Severe: may need admission -> monitor, O2 supplement + NEBULISED BUDESONIDE (ics)
  • If v concerned airway may close up -> NEBULISED ADRENALINE
  • Keep the child calm - crying exacerbates
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18
Q

Croup Dx

A

Clinical

  • Throat swabs for causative organism
  • Lateral cervical X-ray in severe/atypical can show -> ‘Steeple sign’ - SUBGLOTTIC NARROWING
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19
Q

DDx for resp distress

A
  • Epiglottitis
  • Croup
  • Foreign body aspiration
  • Asthma attack
  • Bacterial tracheitis (high fever + rapidly progressing resp distress)
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20
Q

Bronchiolitis

A

Widespread chest infection causing infalm + congestion of bronchioles

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21
Q

Bronchiolitis epid

A
  • Typically in kids 1-12 months - rare kids older than that
  • Mainly in winter
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22
Q

Bronchiolitis main causative organism

A

Resp Syncitial Virus

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23
Q

Bronchiolitis Sx

A
  • Cough
  • Wheeze
  • Increased breathing effort
    • Intercostal recession
    • Grunting
    • Nasal flaring
  • Tachypnoea
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24
Q

Bronchiolitis Dx

A

Mainly clinical

CXR id severe / worried about complications

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25
Q

Bronchiolitis Mx

A

Prophylaxis: Give PALIVIZUMAB if high risk

  • Supportive: Hydration; Nutrition; Fever management
  • O2 Therapy -> may need to escalate to ventilation if severe
  • Antiviral: RIbavirin if v severe
26
Q

Bronchiolitis complication

A

BRONCHIOLITIS OBLITERANS (aka popcorn lung) - rare chronic complication

Caused by overactive cellular repair and build-up of scar tissue following inflam (could be from inhaling harmful substance, not just infection).

Scarring -> narrowing + reduced O2 absorption

Can be progressive -> resp failure

Oft a complication seen in lung transplant patients due to organ rejection

27
Q

Asthma

A

Heterogenous inflam disease of airways -> chronic inflammation -> bronchospasm -> narrowing -> airflow obs
- Typically episodic

28
Q

Characteristic factors

A
  • Airway hyperresponsiveness
    • Bronchiole inflammation
    • Mucus hypersecretion
  • Airway obstruction (REVERSIBLE)
29
Q

What are the 2 main types of asthma

A

Allergic (70%) - ie Extrinsic asthma

  • Linked to exposure to common allergens (pollen, dust mites, mould)
  • Typically presents in childhood
  • Theory:
    - Genetics + hygiene hypothesis
  • Immune mechanism:
    - IgE MEDIATED - Type 1 hypersensitivity

Non-allergic (30%) - ie Intrinsic

  • Linked to other conditions like COPD
  • Can be later onset
  • Harder to treat
30
Q

Asthma epidm

A
  • nearly 10% of kids in UK have
  • 3 deaths/day in UK (typically in younger people)
  • Both over + underdiagnosed - non-specific symptoms
31
Q

RFx for asthma

A
  • FHx
  • PHx of atopy
32
Q

Asthma Sx

A
  • Cough
  • SOB
  • Wheeze (widespread during acute episode)
  • Chest tightness
  • Diurnal variation
  • Reversible Sx (tho can become irreversible if chronically poorly controlled -> scarring)

Triggered by allergenic factors

33
Q

Asthma allergic pathway

A

For T2-hi asthma:

  • Dendritic cells recognise + present allergen peptides to naive t cells
  • Th2 pathway -> CYTOKINES (IL-4, 5 + 13)
  • B cells -> IgE release -> bind to primed mast cells -> degranulation
  • Airway SM contraction

Need initial sensitisation first

34
Q

Asthma Neutrophilic pathway

A

T2-lo asthma (non-allergic):

  • Epithelium produces ALARMINs
  • Dendritic cell -> Naeive T helper -> Th1 + 17 -> Neurophils
    - release of IFNg + TNFa
35
Q

Asthma Dx

A
  • Focussed Hx
  • SERIAL PEAK FLOW
  • SPIROMETRY (airflow capacity)
  • If unclear FeNO testing

Trial a SABA to see if it works

36
Q

Asthma Tx

A
  • Personalised Asthma plan
  • Metered dose inhaler + spacer - teach technique (+ avoid triggers)
  • SABA as required + very low / low dose ICS (200 mcg/day - e.g. Clenel)
  • Add LTRA (under 5s) or LABA (over 5s) if needed
  • Can increase ICS to low dose (400 mcg) then medium dose (800 mcg) as required
  • Can add theophylline + refer to specialist if needing high dose therapy

If refractory - daily oral steroids alongsidemedium dose ICS - try to reduce oral steroids when possible tho

http://scottishpaeds.org.uk/wp-content/uploads/2021/05/Asthma-mx-summary-BTS-2019.png

37
Q

Cystic fibrosis

A

Progessive Autosomal Recessive condition affecting CHLORIDE CHANNELS

38
Q

CF Epidem

A
  • 1/2500 kids in UK are likely to have CF
  • 1/25 carriers
  • Median life expectancy = 47 yrs
39
Q

CF aet

A

Mutations in CFTR gene on chromosome 7 - cause CHLORIDE CHANNEL defects -> thick mucus secretions.

Most common is Delta-F508 -> abnormal GLYCOSYLATION + subsequant DEGRADATION of CFTR protein before it reaches cell membrane.

Also disrupts Epithelial sodium channels as when less chloride actively transported -> increased passive REABSORPTION of sodium -> MORE CHLORIDE + LESS WATER in secretions

40
Q

CF RFx

A
  • FHx
  • Caucasians
41
Q

CF Px

A
  • Neonates = delayed, viscous meconium. Possibly meconium ileus.
  • Infants: salty sweat; FALTERING GROWTH, Recurrent chest infections
  • Toddlers: failure to thrive, recurrent chest infections, MALABSORPTION
  • Delayed puberty
  • Infertility in males due to absence of vas deferens
42
Q

CF Dx

A
  • SCREENING: Neonatal blood spot test -> RAISED blood IMMUNOREACTIVE TRYPSINOGEN
  • SWEAT TEST (chloride conc in sweat)
  • Genetic testing

Also - FECAL ELASTASE (to confirm reduced pancreatic function - will be low)

43
Q

CF Mx

A
  • Daily CHEST PHYSIO + exercise (shift mucus)
  • Prophyl Abx (for chest infections)
  • MUCOLYTICS:
    • Nebulised hypertonic saline
    • Nebulised DNase (Dornase alfa)
  • Pancreatic enzyme supplementation + fat-soluble vit supps / high calorie diet (as pancreatic secretions affected)
  • Regular flu vaccine + PNEUMOCOCCAL vaccine
  • Consider lung transplants if end-stage pulm disease

Also fertility treatment + genetic counselling for family

44
Q

How often are pts with CF followed up + what is being checked

A

Typically followed-up every 6 months:
- Check sputum for colonisation e.g. from pseudomonas
- Screen for DIABETES, OSTEOPOROSIS, VIT D DEF, LIVER FAILURE

45
Q

Causes of wheeze

A

Recurrent:

  • Persistent infantile wheeze
  • Viral episodic/induced wheeze (typically <6 yrs)
  • Asthma (typically in kids >6 yrs)

Other:

  • CF
  • Chronic lung disease of newborn
  • Tracheo-bronchomalacia (insp stridor due to airways occasionally collapsing in on themselves)
  • Ciliary dyskinesia (wet cough; no gut problems)
  • GORD
  • Chronic aspiration
  • Immunodef
  • Persistent bacterial bronchitis
46
Q

Acute asthma management

A
  • O2 supp if needed (in life threatening esp)
  • Beta agonist - Inhaled/Nebulised SALBULTAMOL (10 puffs - keep repeating with little breaks between each block until improve)
    - Consider adding ipratropium bromide and then MgSO4 if not responding to SABA alone
  • Steroids: Prednisolone 1 mg/kg or IV hydrocrotisone (oral intake difficult)
    - usually ~3 days but keep for longer if needed

May need IV SALBUTAMOL bolus if v severe
- IV MgSO4 if the kid not responding to 1st line stuff

Other: IV Aminophylline if life-threatening + not responding

47
Q

Examples of ICS

A
  • Becolmethasone
  • Budesonide
  • Fluticasone
48
Q

Example of LABA

A
  • Saleterol
  • Formoterol

Always given in a combined inhaler with ICS to ensure taking both of them

49
Q

Causes of failure to respond to asthma meds

A
  • Adherence
  • Wrong diagnosis
  • Environmental factors (esp smoking)
  • Choice of meds/devices
  • Bad disease severity
50
Q

SE of ICS

A
  • Sore mouth/throat
  • Hoarse voice
  • Cough
  • ORAL THRUSH

Long term:

  • Temporarily impaired growth (must monitor)
  • Suppresses adrenals - uncommonly people can go into adrenal crisis

(Risk of osteoporosis not greatly raised)

Minimise dose + maximise targeting

51
Q

Main causative organism for LRTI/persistent wheeze in kids

A

Resp Syncitial Virus - 0.5-2% hospitalised
- tends to be most severe cause of viral pneumonia in kids

52
Q

Pneumococcus action

A

Colonises the NASOPHARYNX

  • Infect upper airways -> Otitis media + sinusitis
  • Lower airways -> Bacterial bronchitis + Pneumonia (typically complicated e.g. with effusion)

Can caused ‘OCCULT’ SEPTICAEMIA; Pneumonia with associated septicaemia + MENINGITIS

53
Q

Pneumonia Definition + stages

A

Inflammation of lung parenchyma (excluding bronchi); visible on XR-> Congestion

  • Red hepatisation - increased infiltration of blood cells
  • Grey hepatisation - immune cells start breaking down
  • Resolution
54
Q

Pneum Dx

A

Cough And/or Difficulty breathing (<14 days - i.e. its acute) AND increased resp rate

  • > 2 months old - >60 breaths /min = high
  • 2-11 months = >50/min
  • > 11 months = > 40/min

On CXR (NOT DONE ROUTINELY):
- DENSE/fluffy OPACITY in portion/whole of LOBE or lung
- May or may not have AIR BRONCHOGRAMS

55
Q

What is indicative of bacterial pneum

A
  • FEVER > 38.5 C
  • CHEST RECESSION
  • RESP rate > 50/min

Up until 3 y/o

In older kids SOB/diff breathing more common

56
Q

Most common bacterial causes of pneumonia

A
  • Pneumococcus
  • HiB
  • S aureus
  • K pneumoniae
  • Mycobacterium TB
57
Q

Common viral causes of pneumonia

A
  • RSV
  • Flu A + B
  • Paraflu
  • Adenovirus
  • Human metapneumovirus

Just take a swab anyway if kids have pneum

58
Q

What time of year is resp infections in kids most common

A

Autumne - BACK TO SCHOOL

59
Q

Unusual causes of pneum

A

Mycoplasma pneumoniae
Chlamydia spp.
Pseudomonas spp.
Escherichia coli
Measles
Varicella
Strep A
Pertussis
Histoplasmosis and toxoplasmosis

In HIV more are possible e.g. Pneumocystis jiroveci, TB

60
Q

Bacterial bronchitis vs Pneumonia

A

Pneum in parencyma while bronchitis is in larger airways

Bacterial bronchitis is a main cause of persistant cough (> 3wks)
- Acute presentation is pretty similar for both

61
Q

Bacterial bronchitis Mx

A
  • 6 wk Abx
  • Bronchoscopy if not responding
    • HiB; Morexella etc
62
Q

Bronchiectasis Mx

A
  • Prophylactic ABx
  • CHest physio + exercise (to improve mucocillary clearance)

Phase 3a (26 decks)

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