Paeds Resp (ILA 3) Flashcards
List the symptoms of an upper respiratory tract infection?
coryza sore throat ear ache sinusitis stridor
List the symptoms of a lower respiratory tract infection?
wheeze
cough
use of accessory muscles
respiratory distress
What are the signs of respiratory distress?
nasal flaring head bobbing use of accessory muscles subcostal and intercostal recession tachypnoea tachycardia tracheal tug grunting poor feeding
Which signs are indicative of severe respiratory distress?
cyanosis
reduced conscious level
oxygen sats <92%
tiring / exhaustion
Define wheezing
wheezing or whistling sound made on expiration through narrow area that is polyphonic, severely affecting the wellbeing of the child
What are the differentials for wheezing?
- persistent infantile wheezing = in response to triggers e.g. cold air, dust, exercise, smoking
- viral episodic wheeze= in response to viral infections
- asthma
- CF, ciliary dyskinesia
- immune deficiency
- gastric reflux
What causes viral induced wheeze and what symptoms would you expect?
viral upper resp tract infection (usually RSV) triggering wheeze, coryza, cough and increased work of breathing
How is viral induced wheeze managed?
oxygen
salbutamol inhaler with spacer - Aim for 4 hours between needing inhaler
What does stridor sound like and how is this caused?
harsh, musical sound on inspiration due to partial obstruction from laryngeal oedema and secretions of the lower portion of the upper airway
What are the possible causes of stridor in a child?
- croup
- acute epiglottitis
- anaphylaxis
- inhaled foreign object
- laryngomalacia (congenital abnormality in larynx)
- trauma to the throat
- bacterial tracheitis
Which infections does URTI include?
common cold sinusitis otitis media pharyngitis tonsillitis
What are the most common causative pathogens of the common cold?
rhinovirus
respiratory syncytial virus
coronavirus
What is sinusitis?
infection of the upper paranasal sinuses
What are the common causative pathogens of pharyngitis?
adenovirus
enterovirus
rhinovirus
group A strep
What are the common causative pathogens of tonsillitis?
group A strep
Epstein barr virus
Describe pharyngitis
inflammation of the pharynx and soft palate
local lymph nodes are enlarged and tender
Describe tonsillitis
intense inflammation of the tonsils (form of pharyngitis)
How is pharyngitis/ tonsillitis managed?
penicillin or erythromycin for 10 days
antibiotics prescribed although only 1/3 of cases are bacterial
Which antibiotic should you avoid in tonsillitis?
avoid amoxicillin as can cause widespread maculopapular rash if tonsillitis due to infectious mononucleosis
Why are children more prone to acute otitis media?
childrens eustachian tubes are short, horizontal and function poorly so more prone to infection
Which pathogens are responsible for otitis media?
VIRAL -> RSV, rhinovirus
BACTERIAL -> pneumococcus, H. influenza, mortadella catarhalis
How does otitis media present?
pain in ear
fever
lasts for 4 days
When examining the tympanic membranes of a child with acute otitis media, what do you expect to see?
bright red
bulging
loss of normal light reflection
if acute perforation of the ear drum, pus is visible in the external canal
If a child is ill for longer than 3/4 days with acute otitis media or <2 y/o and bilateral, what should be prescribed?
amoxicillin for 5 days
Who is affected by croup?
commonly between 6 months - 6 y/o with peak incidence at 2 y/o
most commonly occurs in autumn
What is croup?
croup is an upper airway obstruction
What is the most common causative pathogen of croup?
** parainfluenza virus **
How does a child with croup present?
- harsh stridor
- barking (like a sea lion) cough
- coryza
- fever
- hoarseness
- poor feeding
symptoms worse at night
When should you admit a child with croup?
if moderate/ severe <6 months old signs of respiratory distress uncertain about diagnosis known airway abnormalities
What is the first line therapy for croup?
ORAL DEXAMETHASONE 0.15mg/kg
alternatives are oral prednisolone or nebulised budesonide
How should severe croup/ upper airway obstruction be managed?
nebulized adrenaline
high flow oxygen face mask
What is the most common causative organism of acute epiglotittis?
Haemophilus influenza type B
Why has the incidence of acute epiglotittis decreased?
there is now a H. influenza type B vaccination for infants
caused a 90% reduction in incidence
What is acute epiglotittis?
an upper airway obstruction caused by intense swelling and inflammation of the epiglottis and surrounding tissues
How does acute epiglottis present?
- fever/ septic looking child
- child cannot speak/ swallow -> saliva drools
- painful sore throat
- child sitting with mouth open to optimise airways
- soft inspiratory stridor
What should you not do if suspect acute epiglotittis in a child?
do NOT examine the throat with a spatula as can cause airway obstruction and death
How is acute epiglotittis managed?
MEDICAL EMERGENCY!!
- admit to ICU
- contant anaesthetist to intubate - urgent tracheostomy
- IV antibiotics of cefuroxime for 3-5 days
Which age group is most susceptible for bronchiolitis?
1-9 months old (90% case)
What is the most common respiratory tract infection in children?
bronchiolitis
Which pathogens are responsible for bronchiolitis?
Respiratory Syncytial virus (RSV)*** = 80%
+ parainfluenza virus , rhinovirus, human metapneumono virus
Who are at risk of bronchiolitis?
premature infants
cystic fibrosis
congenital heart disease
what is bronchiolitis?
acute bronchiolar inflammation
How does bronchiolitis present?
coryza* increased breathlessness dry, wheezy cough poor feeding SOB
Which signs are you looking for with a child suspected of bronchiolitis?
SIGNS OF RESP DISTRESS tachypnoea tachycardia subcostal and intercostal recession hyperinflation of chest fine end inspiratory crackles high pitched, expiratory wheeze
how is bronchiolitis diagnosed?
PCR analysis of nasopharyngeal secretions but normally clinical diagnosis
How is bronchiolitis managed?
supportive
humidified oxygen via nasal canulae
fluids/ NG tube if not feeding
When should you admit a child to hospital/ make immediate referral with bronchiolitis?
apnoea child looks seriously unwell severe respiratory distress central cyanosis persistent oxygen sats <92% dehydration
What can be used to prevent RSV infections?
Palivuzumab = monoclonal antibody
IM injection once a month through autumn and winter for children at high risk e.g. CF, immunocompromised, congenital heart defects, Downs syndrome
What are the most common causative organisms responsible for pneumonia?
- no causative organism identified (50%)
- Bacterial (more common in older children) - Strep. pneumoniae, H. influenza type B
- Viral (more common in younger children) - RSV*, influenza A and B
- Other - mycoplasma pneumonia, pseudomonas, E.coli
Outline the WHO criteria to consider pneumonia?
cough
difficulty breathing <14 days
increased respiratory rate (>11 months old = >40 RR)
How does pneumonia present (symptoms and signs)?
symptoms - cough, fever, SOB, increased respiratory rate, lethargy, poor feeding, unwell child
signs- tachypnoea, tachycardia, pyrexia, use of accessory muscles, nasal flaring, end inspiratory coarse crackles, decrease oxygen sats, subcostal/ intercostal recession
What are the possible complications with pneumonia?
small effusions - resolve with antibiotics
Empyema - persistent fever after 48 hrs of antibiotics - pleural collection needs draining
How is pneumonia investigated?
Chest X-ray
- dense/ fluffy opacity occupying a portion/whole lobe of a lung
If on a chest x-ray, there is blunting of a costophrenic angle, what might be suspected?
pleural effusion with pneumonia
How is pneumonia managed as an inpatient or outpatient?
- supportive care - oxygen, analgesia, fluids
- Antibiotics -
inpatient 1st line (HAP) = amoxicillin
outpatient 1st line (CAP) = benzylpenicillin
Which antibiotic should be given if it is resistant pneumonia or associated with influenza?
co-amoxiclav or add macrolide e.g. erythromycin
When should you admit a child to hospital with pneumonia?
oxygen sats <92%
recurrent apnoea
inadequate feeding and dehydrated
red flags on traffic light score - RR >60, grunting, severe chest indrawing, 3 months old and temp >38
What is atopic asthma associated with?
eczema allergies hay fever family history rhino-conjunctivitis
Describe the pathology of asthma
chronic inflammation of the lower airways secondary to hypersensitivity
reversible airway obstruction
Characterised by:
- bronchospasm / hyper responsiveness
- bronchial inflammation and swelling
- airway narrowing and formation of mucus plug
Which cells are seen in the inflammation of asthma?
mast cells
eosinophils
neutrophils
lymphocytes
What are the common symptoms and signs of asthma?
recurrent wheeze
dyspnoea
sputum production
cough
diurnal variation - worse at night and early morning - poor sleep
List some of the environmental triggers of asthma
cold exercise house dust mites pets grass pollens URTI emotional upset/ anxiety chemical irritants
how is asthma investigated and diagnosed?
SPIROMETRY/ PEAK EXPIRATORY FLOW
- diurnal variability of peak flow
- FEV1 improves by 12% after inhaling bronchodilator
- FEV:FVC <70% = obstructive pattern
- Fractional exhaled nitric oxide >35ppb
What is included in the assessment of a child with asthma?
- growth and nutrition
- peak flow/ spirometry - peak flow diary
- allergic disorders/ triggers identified
- monitor - severity and frequency, exercise tolerance, sleep disturbance, inhaler technique
How should a child with an acute asthma attack be assessed?
- determine severity of attack
- assess increased work of breathing - chest RR, chest recession, auscultation
- assess cardiovascular system - tachycardia , arrythmias or hypertension?
- consciousness level - impaired, confusion, agitation, exhaustion (life threatening)
- peak flow measured - 33-50% = severe, <33% = life threatening
- oxygen saturation- <92% = severe
- is there a trigger for the attack?
List the causes of acute breathlessness in a child?
asthma acute epiglotittis inhaled foreign object anaphylaxis pneumonia pneumothorax severe anaemia panic attacks heart failure
How is an acute asthma attack classified in a child under 5 y/o?
MODERATE - sats >92%, no clinical symptoms
SEVERE - sats <92%, HR >140, RR >40
use of accessory muscles
LIFE THREATENING - sats<92%, silent chest, poor respiratory effort, altered consciousness, cyanosis
How is an acute asthma attack classified in a child over 5 y/o?
MODERATE - sats >92%, no clinical symptoms
SEVERE- sats <92%, HR > 125, RR >30, use of accessory muscles, PEF <50%
LIFE THREATENING - sats <92%, PEF <33%, silent chest, poor respiratory effort, altered consciousness
How is an acute severe asthma attack managed?
- ABCDE
- oxygen
- nebulized beta agonist
- IV hydrocortisone
- IV salbutamol
- If child still no better, call ICU and magnesium sulphate
What should you monitor with IV salbutamol?
need cardiac monitoring (can cause T wave depression, U wave elevation, VF, tachycardia) and assess for signs of hypokalaemia
What are the treatment steps for a child between 5-16 y/o with asthma?
- SABA e.g. salbutamol - used when worsened symptoms, 2 puffs last 4 hours
- inhaled corticosteroid
- leukotriene receptor antagonist e.g. montelukast
- SABA + ICS + LABA
- SABA + switch LABA or ICS for maintenance/ reliever therapy
What are the treatment steps for a child under 5 y/o with asthma?
- SABA
- 8 week trial of inhaled corticosteroid
- if relapse with symptoms/ not controlled.. SABA + ICS + leukotriene receptor antagonist
What is used as a “preventative” treatment in asthma?
inhaled corticosteroids
e.g. beclomethasone, budesonide, fluticasone
inhaled cromones
e.g. sodium cromoglycate, nedocromil sodium
What is used as “relievers” in asthma treatment?
- short acting beta agonists (SABA)
e. g. salbutamol, terbutaline - ipratropium bromide
List the add on therapies (preventors if child not responding to treatment) for asthma?
- Long acting beta 2 agonists e.g. salmeterol, formoterol
- leukotriene receptor antagonists e.g. montelukast
- theophylline
- omalizumab
How do inhaled corticosteroids work?
decrease airway inflammation so decrease bronchial hyperactivity
What are the side effects of inhaled corticosteroids?
impaired growth
adrenal suppression
altered bone metabolism
How do you access how well controlled a child is at the asthma?
- symptoms on walking or during the night?
- how often do you get symptoms in the day?
- exercise tolerance?
- how often do you use inhaler?
- recent hosp admissions?
- recent use of oral steroids?
List the reasons for children not responding to treatment?
ABCDE A- adherence / compliance B- bad disease C- choice of drug/ device D- diagnosis E- environment
List some of the British Thoracic Society guidelines for asthma?
avoid precipitating factors
check inhaler technique
attempt step down
What causes cystic fibrosis?
defective Cystic Fibrosis Transmembrane Regulator (CFTR) on chromosome 7
CFTR is a cAMP dependent chloride channel lining ducts in the body
mutation causes increased viscosity of secretions and blockages of narrow passageways
Describe the pathology of cystic fibrosis?
in the airways…
abnormal ion transport across epithelial cells, impaired ciliary function, inflammation, thick sticky mucus in airways
in the intestine…
thick vicid meconium is produced
pancreatic ducts…
become blocked by thick secretions
abnormal function of sweat glands…
excessive concentrations of sodium and chloride in sweat
What are the complications of cystic fibrosis in infancy/newborn?
- meconium ileus - causes intestinal obstruction
- prolonged neonatal jaundice
- faltering growth - malabsorption, steattohorea
- recurrent chest infections e.g S.aureus. H. influenza
What are the complications of cystic fibrosis in young children?
- recurrent chest infections - with Pseudomonas aeruginosa , staph aureus, h. influenza (if burkholderia cepacia - need to put in isolation)
- bronchiectasis - sputum production, recurrent cough
- sinusitis
- nasal polyp
- rectal prolapse
List the signs expected in a child with cystic fibrosis?
wet cough production of purulent sputum hyperinflation of chest coarse inspiratory crepitations expiratory wheeze finger clubbing
How is cystic fibrosis diagnosed?
- gene abnormality in CFTR protein - diagnostic
- sweat test - conc. of chloride in sweat increased (60-125mmol/L)
- low faecal elastase
How can CF be detected in newborns?
biochemical screening in newborns
use the Guthrie heel prick blood test - immunoreactive trypsinogen (IRT) raised
How are cystic fibrosis respiratory symptoms managed?
- treat recurrent bacterial infections
- continuous prophylactic oral antibiotics e.g. flucloxacillin or azithromycin
- daily physiotherapy - chest percussion, postural drainage, deep breathing exercises
How is nutrition managed in cystic fibrosis?
- oral pancreatic enzyme replacement therapy
- high calorie, high fat diet
- fat soluble vitamin supplements
How is CF treated at end stage?
bilateral sequential lung transplant
Define a persistent cough?
cough that lasts more than 8 weeks or has not improved after 3-4 weeks in the absence of recurrent URTI
What is the difference between wheeze and stridor?
wheeze = polyphonic, expiratory, in LRT
stridor = monophonic, inspiratory, in URT
What is the most likely causative pathogen of whooping cough?
bordatella pertussis (gram -ve)
highly contagious and infectious
epidemic every 3-4 years
How does whooping cough present?
2-3 days of coryza in an unvaccinated child and then inspiratory “whoop” cough for >14 days
spasms of cough: worse at night, causes vomiting, cyanosis, epistaxis
How long does whooping cough last for?
paroxysmal phase for 3-6 weeks
can persist for months “100 day cough”
How is whooping cough diagnosed?
nasal swab culture/ PCR
FBC - marked lymphocytosis
How is whooping cough treated?
- azithromycin for 5 days
- school exclusion for 48 hours after starting abx- intubation for 10-14 days
- household contacts offered prophylaxis abx
- notify public health as notifiable disease
List the complications of CF in an older child
diabetes mellitus delayed puberty cirrhosis and portal hypertension infertile in males pneumothorax allergic bronchopulmonary aspergillosis
how is bacterial tracheitis caused?
staph aureus
how does bacterial tracheitis present?
RARE BUT DANGEROUS
high fever
resp distress
purulent secretions
—–> progresses to airway obstruction
how is bacterial tracheitis managed?
blood culture
secure airway
IV abx
what Is given to close contacts for acute epiglottis?
rifampicin
when are children vaccinated against whooping cough?
at 2,3,4 months and 3-5 years old
how is mild- moderate asthma attack managed?
- give a beta-2 agonist via a spacer (for a child < 3 years use a close-fitting mask) -> give 1 puff every 30-60 seconds up to a maximum of 10 puffs -> if symptoms are not controlled repeat beta-2 agonist and refer to hospital
- steroids 3-5 days
