Paeds respiratory Flashcards
gene and chromosome cystic fibrosis
CFTR - codes a cAMP-regulated chloride channel
F508 on the long arm of chromosome 7
Organisms which may colonise CF patients?
Staphylococcus aureus
Pseudomonas aeruginosa
Burkholderia cepacia
Aspergillus
Diagnostic test cystic fibrosis
sweat test - high sweat chloride
normal value < 40 mEq/l,
CF indicated by > 60 mEq/l
Cystic fibrosis drug
Lumacaftor/Ivacaftor (Orkambi)
Fluclox to prevent s.aureus
Investigation bronchiolitis
immunoflurescence of nasal secretions may show RSV
A 3-year-old boy is brought into the emergency department with cough and noisy breathing following a 3-day history of coryzal symptoms. On examination, he is afebrile but has harsh vibrating noise on inspiration, intercostal recession and a cough. He is systemically well
croup
A 5 month old baby, fever 38.2, coroyzal, struggling to feed< 75% of normal, RR of 70,
bronchiolitis
Pathogen croup
Parainfluenza virus
Pathogen bronchiolitis
RSV
Pathogen pneumonia
Streptococcus pneumoniae
Pathogen whooping cough
Bordetella pertussis
Investigation pneumonia
CXR
Management pneumonia in children
Amoxicillin
Macrolides may be added if there is no response to first line therapy
Mangement pneumonia ?chlamydia or ?mycoplasma
Macrolides eg erythromycin
Management pneumonia associated with influenza
co-amoxiclav
Presentation bronciolitis
coryzal
mild fever
feeding difficulties
wet cough
wheeze
breathlessness
when should children be admitted immediately with bronchiolitis 999
apnoea (observed or reported)
child looks seriously unwell to a healthcare professional
severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute
central cyanosis
persistent oxygen saturation of less than 92% when breathing air.
when should you consider hospital admission with bronchiolitis
a respiratory rate of over 60 breaths/minute
difficulty with breastfeeding or inadequate oral fluid intake (50-75% of usual volume ‘taking account of risk factors and using clinical judgement’)
clinical dehydration.
Management bronchiolitis
humidified oxygen is given via a head box and is typically recommended if the oxygen saturations are persistently < 92%
nasogastric feeding may be needed if children cannot take enough fluid/feed by mouth
suction is sometimes used for excessive upper airway secretions
Prevention of bronchiolitis
Palivizumab is a monoclonal antibody which is used to prevent respiratory syncytial virus (RSV) in children who are at increased risk of severe disease eg premature.
what time of year is croup most common
autumn
peak incidence croup
6mo-3years
features croup
stridor
barking cough (worse at night)
fever
coryzal symptoms
Indications for admission croup
< 6 mo age
known upper airway abnormality eg laryngomalacia, downs
anyone with mod/severe:
- frequent barking cough
- stridor
- wall recession
severe = distress
Xray sign croup
a posterior-anterior view will show subglottic narrowing, commonly called the ‘steeple sign’
Xray sign epiglottitis
a lateral view in acute epiglottitis will show swelling of the epiglottis - the ‘thumb sign’
Management croup - routine and emergency
- oral dex (0.15mg/kg) to everyone
emergency:
- high flow O2
- nebulised adrenaline
- neb budesonide
- ENT
features epiglottitis
rapid onset
high temperature, generally unwell
stridor
drooling of saliva
‘tripod’ position: the patient finds it easier to breathe if they are leaning forward and extending their neck in a seated position
diagnosis epiglottitis
direct visualisation (only by senior/airway trained staff)
Management epiglottitis
- ENT and anesthetics - endotracheal intubation
- O2
- IV abx
Pathogen epiglottitis
HiB
Which of EV wheeze and MT wheeze are associated with asthma
Episodic viral wheeze is not associated with an increased risk of asthma in later life although a proportion of children with multiple trigger wheeze will develop asthma
Management multiple trigger wheeze
- If > 4 significant episodes per year consider a 3 month trial of inhaled corticosteroid
- LRTA
When should whooping cough be suspected
Whooping cough should be suspected if a person has an acute cough that has lasted for 14 days or more without another apparent cause, and has one or more of the following features:
Paroxysmal cough.
Inspiratory whoop.
Post-tussive vomiting.
Undiagnosed apnoeic attacks in young infants.
Investigations whooping cough
nasopharyngeal swab PCR
anti-pertussis toxin immunoglobulin G (oral if <5, blood if >5)
Management whooping cough
Macrolide antibiotics such as azithromycin, erythromycin and clarithromycin can be beneficial in the early stages (within the first 21 days) or vulnerable patients. Co-trimoxazole is an alternative to macrolides.
when are pregnant women offered whooping cough vaccine
16-32 weeks
school exclusion whooping cough
48 hours after commencing antibiotics (or 21 days from onset of symptoms if no antibiotics )
complications whooping cough
subconjunctival haemorrhage
pneumonia
bronchiectasis
seizures
inheritance primary ciliary dyskinesia
autosomal recessive
risk factor primary ciliary dyskinesia
consanguinity
Kartagner’s triad
the three key features of PCD:
Paranasal sinusitis
Bronchiectasis
Situs Inversus
Diagnostic investigation PCD
nasal brushing or bronchoscopy (sample)
risk factors laryngomalacia
Invasive ventilation
Prematurity
Children severe acute asthma heart rate
> 140/min in children 1-5 years
125/min in children > 5 years
Children severe acute asthma respiratory rate
> 40 in children 1-5 years
30 in children > 5 years
SpO2 severe/LT
< 92%
PEF for severe acute asthma
33-50% best/predicted
PEF for life threatening
<33
Signs of life threatening
A CHEST
Agitated/altered conscioussness
Cyanosis
Hypotension
Exhaustion
Silent chest
Threatening peak flow < 33%
what is can’t complete sentences a sign of
severe acute asthma
PEF in moderate acute asthma
> 50% best or predicted
Management acute asthma in children
- SpO2 <94% or LT : highflow oxygen via a tight-fitting face mask or nasal cannula to achieve saturations 94–98%
- Inhaled B2 agonist (salbutamol) (100 micrograms via a pMDI + spacer) 1 puff every 30-60 seconds up to a maximum of 10 puffs.
- If not controlled or LT→ hospital
- Nebulised salbutamol (2.5mg if <5 years. 5mg if >5 years)
- Nebulised ipratropium bromide (250 micrograms)
- Oral prednisolone (20 mg if aged 2–5 years and 40 mg for children >5 years )
- IV hydrocortisone (4 mg/kg repeated four hourly) if can’t oral
- Nebulised magnesium sulphate (in the first hour in children with a short duration of acute severe asthma symptoms presenting with an SpO2 <92%)
- IV salbutamol
- IV aminophylline
- IV magnesium sulphate
- Anaesthetics and ICU
GP management asthma attack
- high flow O2 if SpO2 < 94
- salbutamol via a spacer 100 micrograms - 1 puff every 30-60 seconds up to a maximum of 10 puffs.
- Oral prednisolone
- Urgent rf to hospital if uncontrolled
Dosage for spacer salbutamol @ GP
(100 micrograms via a pMDI + spacer) 1 puff every 30-60 seconds up to a maximum of 10 puffs.
Dosage nebulised salbutamol
2.5mg if <5 years
5mg if >5 years
Dosage nebulised ipatropium bromide
250 micrograms
Dosage oral prednisolone
20 mg if aged 2–5 years
40 mg for children >5 years
treatment should be given for 3-5 days
When can a child be discharged after asthma attack
child well on 6 puffs 4 hourly of salbutamol.
They can be prescribed a reducing regime of salbutamol to continue at home, for example 6 puffs 4 hourly for 48 hours then 4 puffs 6 hourly for 48 hours then 2-4 puffs as required.
Investigations asthma
- spirometry with a bronchodilator reversibility (BDR) test
- a FeNO test should be requested if there is normal spirometry or obstructive spirometry with a negative bronchodilator reversibility (BDR) test
Positive spirometry result
FEV1/FVC ratio less than 70% (or below the lower limit of normal if this value is available) is considered obstructive
Positive result reversibility testing
in children, a positive test is indicated by an improvement in FEV1 of 12% or more
Positive result FeNO
in children a level of >= 35 parts per billion (ppb) is considered positive
Name the short acting asthma drugs
Beta 2 agonist: Salbutamol, terbutaline
Muscarinic antagonist: Ipratropium bromide
Name the long acting asthma drugs
Beta 2 agonist: Femeterol, salmeterol
Muscarinic antagonist: Tiotropium bromide
Management of asthma aged 5-16
- SABA
- SABA + low-dose ICS
- SABA + low-dose ICS + LTRA
- SABA + low-dose ICS + LABA
- SABA + MART (low-dose ICS + LABA)
- SABA + MART (mod-dose ICS + LABA)
- SABA + one of: high dose ICS, add drug eg theophylline, seek help)
Management of asthma aged < 5
- SABA
- SABA + 8 weeks mod-dose ICS
- if symptoms did not resolve during the trial period, review whether an alternative diagnosis is likely
- if symptoms resolved then reoccurred within 4 weeks of stopping ICS treatment, restart the ICS at a paediatric low dose as first-line maintenance therapy
- if symptoms resolved but reoccurred beyond 4 weeks after stopping ICS treatment, repeat the 8‑week trial of a paediatric moderate dose of ICS
- SABA + paediatric low-dose ICS + leukotriene receptor antagonist (LTRA)
- Stop the LTRA and refer to an paediatric asthma specialist
normal pco2
4.7 to 6.0 kPa
what is low dose ICS
< 200mcg budesonide
If moderate asthma how do you give the salbutamol? vs severe
spacer if moderate
nebulised if sev/LT
