Paeds - resp Flashcards
what are the most common viral causes of respiratory infections?
respiratory syncytial virus (RSV) rhinoviruses parainfluenza influenza metapneumovirus adenovirus
what are the most common bacterial causes of respiratory infections?
streptococcus pneumoniae sterptococci haemophilus influenzae bordetella pertussis mycoplasma pneumoniae
what increases the risk of respiratory infection?
parental smoking overcrowded housing, damp housing poor nutrition underlying lung disease male gender haemodynamically significant congenital heart disease immunodeficiency
whar are the classifications of respiratory infections?
upper respiratory tract infection (common cold, sore throat (pharyngitis including tonsilitis), acute otitis media, sinusitis)
Laryngeal tracheal infection (croup, bacterial tracheitis, acute epiglottitis)
bronchiolitis
pneumonia
what are the symptoms of a common cold?
acute onset rhinitis sore throat sneezing post-nasal drainage/drip cough fever non-specfic red pharynx nasal mucosal oedema
what are the common causes of the common cold (coryza)?
rhinoviruses, coronaviruses, RSV
what is pharyngitis?
pharynx and soft-palate are inflamed and local lymph nodes are enlarged and tender
what are the different types of sore throat?
pharyngitis
tonsilitis
laryngitis
what is tonsilitis?
intense inflammation of the tonsils often with a purulent exudate
what are common causes of tonsilitis?
Usually viral - most commonly caused by rhinovirus, coronavirus and adenovirus
group A beta-haemolytic streptococci, and EBV
what are the symptoms and signs of tonsilitis?
pain on swallowing
fever >38
tonsillar exudate
cervical lymphadenopathy
how do you treat bacterial tonsilitis?
1st line - amoxicillin
2nd line - clarithromycin
what is the criteria used for antibiotic prescription in tonsilitis?
the centor criteria
- presence of tonsilar exudate
- tender anterior cervical lymphadenopathy or lymphadenitis
- history of fever
- absence of cough
3 must be present
what test can be used to detect group A streptococcus pharyngitis?
rapid antigen detection test s
should be used routinely in patients with sore throat to allow immediate point-of-care assessment
what is bronchiolitis?
it is a condition characterised by acute bronchiolar inflammation
usually caused by RSV virus - 75-80% of cases
what age group does bronchiolitis usually affect, when is the common time for it to occur?
it is almost exclusively an infantile disease - commonly affecting children under 2
most common cause of serious RTU in children under one
maternal IgG provides protection to neonates
higher incidence in winter months
what can cause bronchiloitis other than RSV?
rhinovirus
influenza virus
may be secondary to a bacterial infection
what are the symptoms of bronchiolitis?
coryzal symptoms, including virus precede:
dy cough
increasing breathlessness
wheezing, fine inspiratory crackles
feeding difficulties
tachypnoea
increased work of breathing may be present - retractions, grunting, nasal flaring
what are the features of bronchiolitis that NICE recommend immediate referral for?
apnoea child looks seriously unwell to health care professional severe resp distress central cyanosis persistant oxygen sats less than 92%
what are the features of bronchiolitis that NICE recommend consider referral for?
a resp rate over 60BPM
difficulty breast feeding or inadequate oral fluid intake
clinical dehydration
how would you diagnose bronchiolitis?
largely clinical
nasopharyngeal aspirate or throat swab - RSV rapid testing and viral cultures
blood and urine cultures if child is pyrexic
FBC
ABG if severely unwell
what is the treatment for bronchiolitis?
supportive care, supplemental oxygen and mechanical ventiliation
prenisolone can be given
what is the prophylaxis for bronchiolitis and who is it given to?
monthly IM injetion of palivizumab
given to preterm babies born before 29 weeks, or babies born with chronic lung disease of prematurity before 32 weeks
also can be given to those who are severely immunocomomised
what is croup?
Viral URTI
croup is also known as laryngotracheobronchitis - common respiratory disease of childhood
what are the causes of croup?
usually parainfluenza
other causes include RSV adenovirus, rhinovirus, enterovirus
what age group does croup commonly affect?
what time of year is it common?
commonly children who are between 6 months and 3 years
Autum
what are the features of croup?
stridor (high pitched, wheezing sound caused by disrupted airflow)
barking seal like cough, which is typically worse at night
fever
coryzal symptoms
if severe there may be signs of resp distress
what are the red flag signs of rep failure?
cyanosis
lethargic/decreased level of consciousness
labored breathing
tachycardia
what are the differentials of croup?
epiglottitis inhaled foreign body acute anaphylaxis bacteria tracheitis diptheria
what is pseudomembranous croup?
aka bacterial tracheitis
rare but very dangerous
similar to viral croup but child has high fever, appears toxic and has rapidly progressive aiway obstruction with copious amounts of thick airway secretions
it is caused by staphylococcus aureus
treatment is with IV Abx, intubation and ventilation if needed
what is mild, moderate and severe croup defined as?
mild: 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
moderate: 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
severe: 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
when should you consider admission for croup?
moderate or severe croup
< 6 months of age
known upper airway abnormalities (e.g. Laryngomalacia, Down’s syndrome)
uncertainty about diagnosis (important differentials include acute epiglottitis, bacterial tracheitis, peritonsillar abscess and foreign body inhalation)
how should you diagnose and manage croup?
clinical diagnosis
mild croup - single dose of oral dexamethasone
moderate - single dose of oral dexamethasone plus nebulised adrenaline
severe - single dose oral dexamethasone plus nebulized adrenaline plus oxygen
what are causes of stidor in children?
croup
acute epiglotittis
inhaled foreign body
laryngomalacia
what is asthma?
a chronic respiratory condition characterised by reversible and paroxysmal constriction of the airways
secondary to type 1 hypersensitivity
what are the risk factors for the development of asthma?
personal or family history of atopy antenatal factors: maternal smoking, viral infection during pregnancy low birth weight not being breastfed maternal smoking around the child exposure to high concentrations of allergens (e.g. house dust mite) air pollution premature birth
what other atopic conditions are associated with asthma?
IgE-mediated atopic conditions such as
eczema
alleric rhinitis (hay fever)
what are the precipitating factors for asthma?
cold air
atmospheric pollution
NSAIDs and beta-blockers
exposure to allergens
what are the clinical features of asthma?
symptoms worse at night and early morning
symptoms that have a non-viral trigger
cough
dyspnoea
wheeze, chest tightness- episodic triggers
increased work of breathing
there may be expiratory wheeze on auscultation
reduced peak expiratory flow rate
what investigations would you perform for asthma?
spirometry - FEV1 and FVC (FEV1 will be reduced, FVC normal )
peak expiratory flow
response to bronchodilator on spirometry
CXR
also consider skin prick testing fractional expired nitic oxide - elevated sputum culture exercise testing
what are the differentials for asthma?
bronchiolitis episodic viral wheeze inhaled foreign body recurrent aspiration cardiac failure CF primary ciliary dyskinesia
how is asthma managed in children?
SABA when required
add a regular preventer - very low dose ICS or LTRA if less than 5.
Initial add on therapy - very low dose ICS plus inhaled LABA or LTRA
next consider increasing ICS dose or add LTRA or LABA
if no response to LABA consider stopping
what are the two clinical patterns of preschool wheeze?
viral episodic wheeze - wheezing only in response to viral infection and no interval symptoms. Usually resolves by 5 years. Triggered by viruses that can cause the common cold.
Multiple trigger wheeze - wheeze in response to viral infection but also to another trigger such as exposure to aeroallergens and exercise. A significant proportion go on to have asthma
what would finger clubbing suggest?
CF or bronchiectasis
how do you manage viral episodic wheeze?
treatment is symptomatic only
first-line - SABA
second line - LTRA - montelukast
how do you manage multiple trigger wheeze?
trial of either ICS or LTRA - typically for 4-8 weeks
when should you consider hospital admission for children with asthma?
if after a high dose of bronchodilator therapy they:
- have not responded adequately clinically
- if they are becoming exhausted
- have decreased oxygen sats less than 92%
- if CXR is indicated if there are unusual features or signs of severe infection
what are the classifications of a mild, moderate and severe acute asthma attack?
MILD: : SaO2 >92% in air, vocalizing without difficulty, mild chest wall recession and moderate tachypnoea
MODERATE: SpO2 >92%, PEF>50% best or predicted, no clinical features of severe asthma
SEVERE: SaO2 <92% PEFR 33-50%, cannot complete sentences in one breath or too breathless to feed or talk. Heart rate >125 (if over 5 years) or >140 (2-5 years) RR > 30 (over 5 years) or >40 (2-5 years)
LIFE THREATENING: SaO2 <92% ,PEFR <33%, silent chest, poor resp effort, cyansis, hypotension, exhaustion, confusion
how do you manage a mild to moderate acute asthma attack?
- give beta-2 agonist via a spacer - one puff every 30-60 seconds up to a max of 10 puffs
if symptoms not controlled repeat and refer to hospital
how should severe asthma attacks be managed?
if low oxygen sats give high flow oxygen
SABA via nebuliser
ipratropium bromide can be added if no response to SABA
steroid therapy should be given for 3 days
2nd line IV salbutamol - essential to monitor for salbutamol toxicity
magnesium sulphate can be considered
whar are the common causes of pneumonia in different age groups?
Newborn - organisms from the mother’s genital tract particularly group B streptococcus, E.coli, klebsiella, staph aureus
infants and young children - RSV most common, streptococcus pneumoniae, chlamydia trachomatis
Children over 5 - mycoplasma pneumoniae, streptococcus pneumoniae and chlamydia pneumoniae ar the main causes
at all ages mycobacterium tuberculosis should be considered
what are the clinical features of pneumonia in children? and what would examination show?
fever and difficulty breathing = the most common presenting symptoms
usually preceded by an upper RTI
cough
lethary
poor feeding
unwell child
localised chest, abdo or neck pain is a feature or pleural irritation and suggests bacterial infection
examination will show signs of resp distress, desaturation and syanosis
tachypnoea, nasal flaring and chest indrawing
end inspiratory coarse crackles over the affected area
classical signs of consolidation - dull percussion, decreased breath sounds and bronchial breathing
oxygen sats may be decreased
what are the investigations you would perform for pneumonia?
CXR - may confirm diagnosis but cannot differentiate between viral and bacterial
Nasopharageal aspirate - viral immunoflourenence identify viral causes
blood tests - FBC and acute phase reactants
blood cultures
how should you treat pneumonia in children?
first line treatment is amoxicillin for all children with pneumonia
for children under 5 alternatives include co-amoxiclav for tyical pneumonia (steptococcus oneumoniae) or clarithromycin for atypial pneumonia (mycoplasma pneumoniae and chlamydia trachomatis)
if over 5 years - consider macrolide (clarithromycin) if mycoplasma or chlamydia is suspected, if staoh aureus suspected the consider macrolide or flucloxacillin with amoxicillin
severe pneumonia: co-amoxiclav , cefotaxime or cefuroxime IV
when would you consider admission for pneumonia?
most cases can be managed at home, admission is indicated if:
- oxygen sats less than 92%
- severe tachypnoea
- difficulty breathing
- grunting
- apnoea
- not feeding
what is cystic fibrosis?
an autosomal recesive disorder which leads to a defect in the CF transmembrane receptor protein which causes defective ion transport in exocrine glands.
causes thickening of respiratory mucus - the lungs therfore prone to inadequate mucociliary clearance, chronic bacterial in
what is the screening for CF?
all newborn babies are screened for CF
blood spot analysis on the Gurthrie card
what are the presentations of CF at different age groups
infancy - meconium ileus, prolonged neonatal jaundice
Childhood - recurrent lower respiratory chest infection, bronchiectasis, poor appetite, rectal prolapse, nasal polyps, sinusitis
Adolescence: bronchiectasis, DM, cirrhosis and portal hypertension, distal intestinal obstruction, pneumothorax, haemoptyysis, male infetiltiy
short stature
delayed puberty
female subfertility
weight loss or poor weight gain
90% of children with CF have pancreatic eocrine insuficiency (lipase, amylase and proteases) resulting in maldigestion and malabsorption
how do you diagnose CF?
sweat test - abnormally high sweat chloride
immunoreactive trypsinogen test (new born screening)
CXR
glucose tolerance test
LFT
faecal elastase to assess pacreatic function
genetic anlysis
what could cause a false positive sweat test for CF ?
malnutrition adrenal insufficiency glycogen storage disease nephrogenic diabetes insupidus hypothyroidism G6PD ectodermal dysplasia
how do you manage CF?
MDT approach
annual review in specialist center
For ongoing respiratory disease:
twice daily physiotherapy to clear airway secretions and postural drainage, inhaled bronchodilator (salbutamol), inhaled mucolytic (dornase alpha), if they have chronic pseudomonas infection give inhaled tobramycin
GI disease:
monitoring and optimising nutrion
pacreatic insuficiency - pancreatic enzyme replacement (pancreatin), H2 antagonist or PPI (ranitidine or omeprazole), fat soluble vitamin supplementation (A, D, K and E)
liver disease - ursodeoxycholic acid
what is epiglottitis?
it s cellulitis of the supraglottis
it is a life threatening emergency due to high risk of repiratory obstruction caused by haemophilus influenzae tpe B (HiB) - Hib immunisation has led to a 99% reduction in the incidence
most common in the age group 1-6 years but can affect all age groups
** important to distinguish between epiglottitis and croup
what are the symptoms of epiglottitis?
the onset is very acute/rapid high fever and generally unwell - toxic looking child stridor drooling of slaiva increasing resp difficulty over hours sore throat tripod position
what investigations would you perform for suspected epiglottitis?
larygoscopy
lateral neck radiograph
FBC
blood cultures
how do you treat epiglottitis?
secure airway and supplemental O2
IV Abx (cefotaxime or ceftriaone or ampicillin or clindamycin)
dexamethasone can be added to reduce inflammation
inhaled adrenaline - of upper airways are compromised
intubation
once stable - oral Abx - amoxicillin or cefaclor
what are the differences in presentation between croup and epiglottitis?
Epiglottitis is rapid onset (hours), croups is days
croups has coryza prior to onset
croup has barking cough, epiglottitis usually has no cough
corup they can drink/feed
epiglottitis will have drooling saliva
epiglottitis will have a high fever
croup has rasping stridor epiglottitis is a soft stridor
in epiglottitis their voice will be weak or silent
what can cause stridor in children?
Croup – harsh loud stridor (mostly viral, 6 months to 6 years of age, harsh loud stridor, coryza, mild fever and hoarse voice)
Epiglottitis – (caused by H. influenzae type b, rare since Hub immunisation
Bacterial tracheitis – harsh loud stridor, higher fever, toxic
Inhaled foreign body – chocking on peanut, sudden onset of cough or respiratory distress
Laryngomalacia – recurrent or continuous since birth.
what is surfactant deficient lung disease?
AKA respiratory distress sydrome
caused by inadequate production of surfactant type 2 from the pneumocytes in the lungs
low surfactant leads to alveoli collapsing on expiration and this increases the energy needed for breathing
what are the risk factors for surfactant deficient lung disease?
Premature maternal DM at term multiple pregnancy fam history of RDS csection hypothermia male>female
what are the causes of secondary surfactant deficiency?
- Intrapartum asphyxia
- RTI: GB-BHS pneumonia
- Meconium aspiration pneumonia
- Pulmonary haemorrhage
- Pulmonary hypoplasia
- Congenital diaphragmatic hernia
what is the presentation of surfactant deficient lung disease?
Early signs • Tachypnoea >60 • laboured breathing • grunting • recession: subcostal and intercostal • Nasal flaring • Cyanosis • Diminished breathing sounds Late signs • Fatigue • Apnoea • Hypoxia
how do you manage surfactant deficient lung disease?
- surfactant replacement therapy: endotracheal tube
- antibiotics
- O2 : SaO2 85-93%
• Mild: via a hood
• Moderate: CPAP
• Severe : endotracheal tube - Nutrition
• If the infant is stable: IV nutrition: amino acids and lipids
• If resp status is stable: small volume of gastic feed via a tube
what causes whooping cough?
bordetella pertussis
what are the symptoms of whooping cough?
One week of coryza (Catarrhal phase), then the child develops a characteristic paroxysmal or spasmodic cough followed by a characteristic inspiratory whoop (paroxysmal phase).
Often worse at night
Often vomiting can occur
In infants the whoop may be absent, but apnoea may occur at this age
Epistaxis and subconjunctival haemorrhage may occur vigorous coughing
Paroxysmal phase may last 3-6 weeks and symptoms gradually decrease but may persist for many months (convalescent phase)
how is whooping cough diagnosed?
nasal swab
PCR and serology
how is whooping cough managed?
under 6 month - admit
- notifiable disease
- oral macrolide - clarithromycin
- houshold contacts - prophylais
- school exclusion for 48 hours followin commencing antibiotics
what are the complications of whooping cough?
subconjunctival haemorrhage
pneumonia
bronchiectasis
seizures
how should inhaled drugs be administered in children under 3?
face masks
what are the risks associated with long term use of inhaled steroids?
adrenal suppression
growth supprsion
osteoporosis
high dose steroids may cause adrenal crisis
what are some upper RTI?
rhinitis otitis media pharyngitis tonsilitis larygitis
what are some lower RTI?
bronchitis croup epiglottitis tracheitis bronchiolitis pneumonia
what can pneumococcus cause/ what is it course of infection?
consolidation of the nasopharynx
- -> upper airways mucosa infection - otitis media, sinusitis
- ->lower airway mucosal infection - bacterial bronchitis, pneumonia
- -> occult septicaemia, pneumonia with septicaemia, meningitis
what is pneumonia?
resp disease characterised byinflammation of the lung parenchyma (excluding the bronchi) with congestion caused by viruses, bacteria or irritants
what is the bronchiectasis vicious circle hypothesis?
infection –> inflammation –> impaired muco-ciliary clearance –> infection
who would be in the MDT team for CF?
paediatric pulmonologist physio dietician nurse liason primary care team teacher psychologist
what are some causes of wheeze in children?
pneumonia, pulmonary oedema, bronchogenic cyst
enlarged left atrium compressing left mainstem bronchus
chest deformity
asthma
brochiolitis
bronchitis
CF
polyps
airway obstruction - foreign body, mucus, pus, blood
