Paeds - Respiratory (Acute Conditions) Flashcards
1
Q
Severities of Asthma Exacerbation
Mild
Moderate
Severe
Life-Threatening
A
- ) Mild - peak expiratory flow rate (PEFR) >75%
- signs of respiratory distress: SOB, tachypnoea,
- expiratory wheeze on auscultation, ↓air entry
2.) Moderate - PEFR 50-75%
- ) Severe - any one of the following:
- PEFR 33-50% of best or predicted
- unable to talk properly or feed
- SATS <92%
- over 5s: RR >30, HR > 125
- under 5s: RR >40, HR > 140
- still hyperventilating so pCO2 should be reduced
- risk factors: previous asthma admissions or near-fatal asthma, repeated attendances to ED for asthma care, needing 3+ classes of asthma medication, heavy use of SABA, brittle asthma - ) Life-Threatening - any one of the following:
- PEFR < 33% of best or predicted
- sats <92% or ABG pO2 < 8kPa
- normal pCO2 (4.8-6kPA) indicates reduced resp effort
- exhaustion, cyanosis, hypoventilation, silent chest
- hypotension, altered consciousness or confusion
2
Q
Management of Asthma Exacerbation
Mild
Moderate to Severe
Stepping Down Treatment
Discharge After an Exacerbation
A
- ) Mild - can be managed as an outpatient
- regular salbutamol inhalers with a spacer (4-6 puffs every 4 hours)
- PO prednisolone for 3 days for all patients with any severity of an asthma attack - ) Moderate to Severe - steps in order:
- INH salbutamol w/ spacer: start w/ 10puffs per 2hrs
- first line: NEB salbutamol + ipratropium bromide AND PO prednisolone( 1mg/kg OD for 3 days)
- second line: IV hydrocortisone –> IV magnesium sulphate –> IV salbutamol –> IV aminophylline
- call anaesthetist and ITU for potential intubation and ventilation - ) Stepping Down Treatment
- review before next dose of their bronchodilator, if well, consider stepping down no and frequency e.g.
- stepping down INH salbutamol: 10puffs 2hrly –> 10puffs 4hrly –> 6puffs 4hrly –> 4puffs 6hrly
- consider monitoring serum potassium when on high doses of salbutamol as it can cause hypokalaemia - ) Discharge After an Exacerbation
- considered when the child is well on 6puffs 4hrly of INH salbutamol which can be lowered after discharge to 4puffs 6hrly after 2days then 2-4puffs as required
- must finish the course of steroids (typically 3 days)
- provide an individualised written asthma action plan
- provide safety-netting info for when to seek help
3
Q
Community-Acquired Pneumonia in Children
Aetiology
Clinical Features
CAP Severity in Infants (and Older Children)
A
- ) Aetiology - bacterial and/or viral infection
- newborns: organisms from mother’s genital tract e.g. group B strep, g-ve enterococci and bacilli
- infants and young children: resp viruses (RSV common), S.pneumoniae, H.influenzae
- children >5yrs: S.pneumoniae, Mycoplasma pneumonaie, Chlamydia pneumoniae - ) Clinical Features
- cough: may be associated w/ vomiting in young kids
- high-grade fever (>38.5), difficulty breathing/SOB
- localised pain (chest, neck, abdo), delirium
- signs: ↑RR, ↑HR, hypoxia, hypotension, confusion
- bacterial: >2yrs, >38.5ºC, no rhinorrhoea or wheeze, presence of localised pain (pleuritic irritation)
- viral: <2yrs, low fever, rhinorrhoea, wheeze, no pain
- chest signs: bronchial breathing, coarse crackles, dullness to percussion - ) CAP Severity in Infants (and Older Children)
- mild: RR<50 (<35), CRT <2s, mild recessions (mild breathlessness, full feeds
- mod: RR 50-70 (35-50), CRT≈2s, mod recessions, reduced feeds
- severe: RR>70 (>50), CRT>2s, unable to feed, signs of resp distress: nasal flaring, intermittent apnea, grunting (unable to complete sentences, severe recessions, signs of dehydration)
4
Q
Management of CAP in Children
Investigations
Management
Investigating Recurrent LRTIsin
A
- ) Investigations
- CXR: only used in severe/complicated cases
- sputum cultures and throat swabs for bacterial cultures and viral PCR to establish causative organism
- capillary blood gas (ABG in children)
- septic screen for very unwell children - ) Management - oral antibiotics (IV if severe)
- Abx: amoxicillin +/- macrolide (atypical pneumonia)
- mild: managed in community w/ safety netting
- mod: admission, may need O2, or support w/ feeds
- severe: bloods, CXR, IV fluids, IV antibiotics - ) Investigating Recurrent LRTIs
- underlying conditions: reflux, aspiration, neurological disease, heart disease, asthma, cystic fibrosis, primary ciliary dyskinesia and immune deficiency
- investigations inc: FBC, CXR, serum immunoglobulins, test IgG to previous vaccines, sweat test (CF), HIV test
5
Q
Bronchiolitis
Pathophysiology
Clinical Features
Signs of Respiratory Distress
Differential Diagnoses
A
- ) Pathophysiology - inflammation and infection in the bronchioles, the small airways of the lungs (LRTI)
- usually caused by the respiratory syncytial virus (RSV)
- very common in winter
- occurs in children <1yr (<6mths most common), rare in children up to 2 years (often premature babies)
- the smallest obstruction in airways in infants as a significant effect on infants’ breathing ability
- RF: breastfed < 2mths, smoke exposure, siblings in school, chronic lung disease due to prematurity - ) Clinical Features
- SOB, tachypnoea, apnoeic episodes (stop breathing)
- poor feeding, mild fever (<39), coryzal sx (viral URTI): runny nose, sneezing, mucus in throat (can cause drooling), watery eyes
- signs of respiratory distress
- auscultation: expiratory wheeze, fine inspiratory crackles (not always present) - ) Signs of Respiratory Distress
- raised respiratory rate, cyanosis (due to low sats)
- use of accessory muscles: SCM, abdo, intercostal
- intercostal and subcostal recessions, inflated chest
- nasal flaring, head bobbing, tracheal tugging
- abnormal airway noises: inspiratory crackles, expiratory wheeze, grunting, stridor - ) Differential Diagnoses
- pneumonia, croup, cystic fibrosis
- heart failure, bronchitis
6
Q
Sequelae of Bronchiolitis
Typical RSV/Bronchiolitis Course
Admission Criteria
Complications of Bronchiolitis
A
- ) Typical RSV/Bronchiolitis Course
- usually starts as a URTI w/ coryzal sx then 50% get chest sx over the first 1-2 days after onset of coryzal sx
- sx generally at their worst on day 3/4 and often last 7-10 days total and most fully recover within 2-3wks
- can have a cough for up to 6 weeks and are more likely to have viral-induced wheeze during childhood - ) Admission Criteria - managed at home unless:
- aged < 3mths, clinical dehydration, RR >70, O2 <92%
- signs of mod-severe respiratory distress, apnoeas
- poor feeding: <75% of their normal milk intake
- poor oral fluid intake: <50% of normal fluid intake
- any pre-existing condition: prematurity, Downs, CF, congenital heart disease e.g. VSD
- parents not confident in managing at home - ) Complications of Bronchiolitis
- bronchiolitis obliterans: airways become permanently damaged due to inflammation and fibrosis
- respiratory failure, hypoxia, dehydration, fatigue
- persistent cough or wheeze (very common, parents should be counselled that it can last for several weeks)
7
Q
Management of Bronchiolitis
Admission Criteria
Supportive Management
Ventilatory Support
Palivizumab
A
1.) Supportive Management - only required for most
- adequate intake: PO/NG/IV depending on severity, avoid overfeeding as a full stomach restricts breathing
- supplementary O2: if the O2 sats remain below 92%
- nasal decongestion: NEB 3% saline or saline nasal drops or nasal suctioning, particularly prior to feeding
- ventilation is assessed using capillary blood gases: assess acidosis
- other investigations: nasopharyngeal aspirate or throat swab for RSV rapid testing and viral cultures, FBC, blood/urine culture if pyrexic, CXR
- ) Ventilatory Support - used when a child is exhausted and needs support to maintain their breathing, this is stepped up until they are adequately ventilated:
- Positive End-Expiratory Pressure (PEEP): helps maintain airways after expiration, high-flow humidified O2 via a nasal cannula to deliver continuous air+O2 w/ some pressure to prevent the airway collapse
- CPAP: similar to ^^ but can deliver higher pressures
- intubation and ventilation: inset ET tube into trachea - ) Palivizumab - MAB that targets the RSV virus
- a monthly injection is given as prevention to high-risk babies: ex-premature, congenital heart disease
- not a true vaccine as it only provides passive protection until the virus is encountered
8
Q
Croup (acute laryngotracheobronchitis)
Pathophysiology
Clinical Features
Severities of Croup
Differential Diagnoses
A
- ) Pathophysiology - viral URTI –> inflammation in the mucosa anywhere between the nose and trachea
- barking cough: impaired movement of the VCs
- causative organisms inc: parainfluenza (common), RSV, adenovirus, rhinovirus, influenza, measles
- peak incidence at 2yrs but range is 3mths to 3yrs
- risk factors: male, genetics (specific gene variant) - ) Clinical Features
- hx of a 1-4 day non-specific cough, rhinorrhoea, mild fever, progressing to a barking cough & hoarseness
- symptoms are often worse at night
- signs: high-pitched stridor, normal/reduced chest sounds, signs of respiratory distress e.g. ↑RR, intercostal recession etc. - ) Severities of Croup
- mild: occasional barking cough, no audible stridor at rest, no suprasternal or intercostal recession, the child is happy and will drink, eat & play
- moderate: frequent barking cough, audible stridor at rest, suprasternal and sternal wall retraction at rest, the child will still show interest in its surroundings
- severe: marked sternal wall retractions, the child will appear distressed/agitated or lethargic or restless, tachycardia may occur if more severe obstructive symptoms are present which can result in hypoxemia - ) Differential Diagnoses
- epiglottitis: onset w/in hours, fever >38.5, can’t E+D, no barking cough, soft stridor, weak/silent voice,
- acute anaphylaxis, angioedema,
- bacterial tracheitis (high fever+HR), diphtheria
- laryngomalacia, vocal cord paralysis
- peritonsillar abscess, retropharyngeal abscess
- inhaled foreign body or noxious substance
9
Q
Management of Croup
Investigations
Management at Home
Admission Criteria
Treatment
A
- ) Investigations - CLINICAL DIAGNOSIS
- additional tests can make the child more distressed
- do not examine the throat due to risk of obstruction
- bloods: FBC, CRP, U&Es
- CXR: to identify other possible causes (foreign body)
- laryngoscopy if the illness is atypical or another cause of airway obstruction is suspected - ) Management at Home - most kids with mild croup
- sx usually resolve w/in 48hrs but may last 1 week
- explain no abx needed as it’s a viral illness
- paracetamol/ibuprofen to control pain and fever
- ensure that the child has an adequate fluid intake
- avoid infection spread: hand washing, no school
- safety netting: worsening, intermittent stridor at rest, high fever, high HR, signs of respiratory failure - ) Admission Criteria
- mod/severe croup or impending respiratory failure
- hx of severe airway obstruction, <6 months of age
- inadequate fluid intake, poor response to initial tx
- uncertain diagnosis, immunocompromised
- suspect serious differential: peritonsillar abscess, laryngeal diphtheria, foreign body, angioedema
- there is significant parental anxiety - ) Treatment
- 1 dose of PO dexamethasone (0.15mg/kg) OR pred
- O2 as required, steam inhalation is not advised
- NEB adrenaline/budesonide for temporary relief of sx in severe croup
- keep the child calm as continuing crying increases oxygen demand & causes respiratory muscle fatigue
- call ENT/anaesthetist if airway support is needed (I+V)
10
Q
Epiglottitis
Pathophysiology
Aetiology
Clinical Features
Differential Diagnoses
A
- ) Pathophysiology - inflammation of the epiglottis leading to an airway obstruction (life-threatening)
- VCs have a tightly bound epithelium which restricts the progression of swelling –> ↑pressure in small area
- children are more at risk as their tongue is larger and epiglottis is more floppy, broader, longer and angled more obliquely to the trachea - ) Aetiology
- bacterial: H. influenza (main), S. pneumoniae, group A/C strep, S.aureus, and other respiratory bacteria
- viral: HSV, parainfluenza, VZV, HIV, EBV
- candida or aspergillus in immunocompromised
- non-infective: trauma, thermal/chemical injury
- risk factors: unvaccinated from HiB (must have high suspicion) male, immunocompromised - ) Clinical Features
- 4Ds: dyspnoea, dysphagia, drooling, dysphonia
- onset is within hours and children appear toxic with a high-grade fever, sore throat and dehydration
- sx last <12hrs, no cough, soft inspiratory stridor and a muffled voice
- tripod position: leans forward on outstretched arms with neck extended and tongue out (to open airway) - ) Differential Diagnoses
- croup, inhaled foreign body, retropharyngeal abscess
- tonsillitis/peritonsillar abscess, diphtheria
11
Q
Management of Epiglottitis
General Management
Investigations
Management
Complications and Prognosis
A
- ) General Management
- avoid unnecessary observations or examinations as agitation increases the risk of airway obstruction
- secure airway before any further investigations
- maintain a calm environment, keep with their parents
- avoid supine position, visualise epiglottis in theatre
- intubation equipment should always be kept nearby - ) Investigations
- throat swabs: bacterial and viral swabs taken on intubation to aid diagnosis and management
- bloods (once airway secured): FBC, cultures, CRP
- lateral neck X-Ray (used to exclude not diagnose): thumb-print sign (swollen epiglottis, thickened aryepiglottic folds, ↑opacity of the larynx and VCs
- CT/MRI: if patient isn’t responding to initial therapy - ) Management - step by step actions:
- secure the airway: call anaesthetist or ENT registrar
- oxygen: parent can hold the mask near child’s face
- NEB adrenaline: ↓oedema of upper airway mucosa, used whilst awaiting definitive airway management
- IV Abx: cefotaxime/ceftriaxone (cover H.influenzae), can convert to oral once stable and extubated
- IV steroids: reduces supraglottic inflammation
- resus+maintenance: keep NBM until airway improves - ) Complications - epiglottic abscess
- mediastinitis: if the infection spreads to the retro-pharyngeal space (rare but severe with 50% mortality)
- DNSI: para/retropharyngeal cellulitis/abscess
- pneumonia: especially following intubation
- meningitis: complication in any HiB infection
- sepsis/bacteraemia, death (now rare)
12
Q
Whooping Cough (Bordetella Pertussis)
Pathophysiology
Vaccination
Clinical Features
Differential Diagnoses
A
- ) Pathophysiology - URTI caused by a g-ve bacillus that impairs the clearance of resp secretions
- attaches to the resp epithelium and produce toxins that paralyse the cilia and promote inflammation
- highly contagious (up to 90% of household contacts), spread via aerosolised droplets from coughing
- more common in >15s but ↑mortality in infants
- risk factors: non-vaccination and infection exposure - ) Vaccination
- pertussis vaccine is given at 2/3/4mths then a booster at 3yrs and 4mths, the immunity lasts 5-10 years
- vaccination of pregnant women provides passive immunity in the first few months of life - ) Clinical Features
- catarrhal phase w/ mild coryzal sx followed by the paroxysmal severe coughing episode phase and then the convalescent phase where the cough reduces - ) Differential Diagnoses
- bronchiolitis/viral respiratory infection
- pneumonia: bacterial/viral/mycoplasma
- asthma, tuberculosis
13
Q
Clinical Features/Phases of Whooping Cough
Catarrhal Phase
Paroxysmal Phase
Convalescent Phase
A
- ) Catarrhal Phase - lasts 1 to 2 weeks
- sx: low-grade fever, dry cough, sore throat, irritability, rhinitis, conjunctivitis
- general URTI sx means it’s rarely diagnosed at this stage - ) Paroxysmal Phase - lasts for 2 to 8 weeks
- recurrent episodes of severe coughing followed by an inspiratory gasp producing the ‘whoop’ sound
- coughing episodes are worse at night, often followed by vomiting and may cause cyanosis (if severe)
- examination: low-grade fever, facial petechiae and conjunctival haemorrhages may be present due to vigorous coughing, chest auscultation is usually normal - ) Convalescent Phase - can last up to 3 months
- cough gradually decreases in frequency and severity
14
Q
Management of Whooping Cough
Investigations Admission Criteria General Management Management Complications
A
- ) Investigations
- nasopharyngeal swab/aspirate if cough is < 2wks
- anti-pertussis toxin IgG serology if cough is >2wks and the child is <5yrs (vaccine can produce false +ve)
- anti-pertussis toxin detection in oral fluid if 5-17yrs
- FBC: lymphocytosis (+/- elevated white cell count) - ) Admission Criteria
- under 6 months of age and acutely unwell
- significant breathing difficulties: respiratory distress, apnoeic episodes, cyanosis, severe coughing
- feeding difficulties
- complications: pneumonia, seizures - ) General Management
- a notifiable disease so must inform Public Health
- advise cough can take up to 3mths to resolve and safety netting for complications
- avoid school until they have had the cough for 21 days or have had antibiotics for 5 days
3.) Management - macrolides
- clarithromycin (<1mth), or azithromycin (if >1mth)
- Co-trimoxazole if macrolides are contra-indicated
- antibiotics can reduce the period of infectivity if given early (duration of cough is less than 21 days)
- supportive: paracetamol +/- ibuprofen, fluid intake
- prophylactic abx for vulnerable close contacts:
pregnant women, unvaccinated infants or healthcare workers w/ contact with children or pregnant women
- ) Complications
- bacterial pneumonia, bronchiectasis, otitis media
- seizures, encephalopathy (rare)
- worse prognosis in unvaccinated young infants
