Paeds respiratory conditions Flashcards
- Definition of Bronchiolitis
Bronchiolitis describes inflammation and infection in the bronchioles, the small airways of the lungs.
- Causes of bronchiolitis: most common
Respiratory syncytial virus (RSV) is the most common cause.
- Bronchiolitis aetiology: explain how disease occurs
When a virus affects the airways of adults, the swelling and mucus are proportionally so small that it has little noticeable effect on breathing. The airways of infants are very small to begin with, and when there is even the smallest amount of inflammation and mucus in the airway it has a significant effect on the infants ability to circulate air to the **alveoli **and back out. This causes the harsh breath sounds, wheeze and crackles heard on auscultation when listening to a bronchiolitic baby’s chest
Bronchiolitis Occurs in what age of children? Most common in what age?
children under 1 year. It is most common in children under 6 months. It can rarely be diagnosed in children up to 2 years of age, particularly in ex-premature babies with chronic lung disease
- Presentation of bronchiolitis
- Signs of respiratory distress
- What are the 3 abnormal airway noises to be aware of in children
- Wheezing is a whistling sound caused by narrowed airways, typically heard during expiration
- Grunting is caused by exhaling with the glottis partially closed to increase positive end-expiratory pressure
- Stridor is a high pitched inspiratory noise caused by obstruction of the upper airway, for example in croup
- Criteria for admission in bronchiolitis
- Typical RSV course
Children who have had bronchiolitis as infants are more likely to have
viral induced wheeze during childhood.
- Management of bronchiolitis
- How long do bronchiolitis symptoms last usually?
Symptoms usually last 7 to 10 days total
- Most patients with bronchiolitis fully recover within …
2-3 weeks
- Ventilatory support: when is it needed?
As breathing gets harder, the child gets more tired and less able to adequately ventilate themselves. They may require ventilatory support to maintain their breathing.
- Ventilatory support: different escalations
- How do you assess ventilation?
Capillary blood gases are useful in severe respiratory distress and in monitoring children who are having ventilatory support
- When do you use capillary blood gases?
in severe respiratory distress and in monitoring children who are having ventilatory support.
- Most helpful signs of poor ventilation are:
- What is palivizumab and how does it work
Palivizumab is a monoclonal antibody that targets the respiratory syncytial virus. A monthly injection is given as prevention against bronchiolitis caused by RSV
- Who gets given palivizumab?
It is given to high risk babies, such as ex-premature and those with congenital heart disease
- What prevention treatment for bronchiolitis is available
pavilizumab
croup typically affects children aged .., however they can be older
6 months to 2 years
- Definition of croup
Upper respiratory tract infection causing oedema in the larynx
- The classic cause of croup that you need to spot in your exams, is
parainfluenza virus
- It usually improves in less than…and responds well to treatment…
It usually improves in less than 48 hours and responds well to treatment is steroids, particularly dexamethasone.
- Common causes for croup
- Parainfluenza
- Influenza
- Adenovirus
- Respiratory Syncytial Virus (RSV)
Croup used to be caused by diphtheria. Croup caused by diphtheria leads to epiglottitis and has a high mortality. Vaccination mean that this is very rare in developed countries.
- What type of infection is croup?
URTI
- Main pathology that croup causes
oedema in the larynx
croup presentation
- Croup caused by … leads to epiglottitis and has a high mortality.
diphteria
managemen of croup
- Stepwise options in severe croup to get control of symptoms:
Presentation suggesting possible epiglottis
- Epiglottitis can present in a similar way to
croup, but with a more rapid onset
- In your exams keep a lookout for a epiglottis diagnosis when a child presents with:
unvaccinated child presenting with a fever, sore throat, difficulty swallowing that is sitting forward and drooling
Epiglottitis definition
inflammation and swelling of the epiglottis caused by infection, typically with haemophilus influenza type B. The epiglottis can swell to the point of completely obscuring the airway within hours of symptoms developing. Therefore, epiglottitis is a life threatening emergency.
Epiglottitis investigation and findings
Epiglottitis management
A common complication to be aware of with epiglottitis
development of an epiglottic abscess, which is a collection of pus around the epiglottis. This also threatens the airway, making it a life threatening emergency. Treatment is similar to epiglottitis.
prognosis of epiglottitis
- Most children recover without requiring intubation.
- Most patients that are intubated can be extubated after a few days and also make a full recovery.
- Death can occur in severe cases or if it is not diagnosed and managed in time.
Pneumonia presentation
pneumonia signs
characteristic chest signs of pneumonia:
causes of pneumonia
pneumonia investigations
management of pneumonia
tests for recurrent lower respiratory trat infections in children
presentation of acute asthma
BTS/SIGN guidelines: moderate, severe and life threatening signs of an asthma attack
- Staples of management in acute viral induced wheeze or asthma are:
- Bronchodilators are stepped up as required:
Mild cases of asthma attack can be managed how?
Mild cases can be managed as an outpatient with regular salbutamol inhalers via a spacer (e.g. 4-6 puffs every 4 hours).
Moderate to severe cases of asthma attacks management
A typical step down regime of inhaled salbutamol is
10 puffs 2 hourly then 10 puffs 4 hourly then 6 puffs 4 hourly then 4 puffs 6 hourly.
salbutamol causes which side effects that you need to monitor for in an asthma attack?
monitoring the serum potassium on high doses of salbutamol as it causes potassium to be absorbed from the blood into the cells.
salbutamol causes tachycardia and a tremor.
Generally, discharge for acute asthma can be considered when the child…
6 puffs 4 hourly of salbutamol
reducing regime of salbutamol to continue at home following asthma attack, as an example:
6 puffs 4 hourly for 48 hours then 4 puffs 6 hourly for 48 hours then 2-4 puffs as required.
discharge of acute asthma involves:
Inhaled foreign body presentation/features
Sudden onset of:
cough
stridor
dyspnoea
choking
vomiting (depending on site)
If aspirated, foreign bodies are most likely to be found in…
right main bronchus as it is wider, shorter and more vertical than the left.
Causes of stridor in children: describe features, epidemiology and definition of each cause
Laryngomalacia Congenital abnormality of the larynx.
Infants typical present at 4 weeks of age with:
stridor
Inhaled foreign body Symptoms depend on the site of impaction
Features are of sudden onset
coughing
choking
vomiting
stridor
Acute epiglottitis Acute epiglottitis is rare but serious infection caused by Haemophilus influenzae type B. Prompt recognition and treatment is essential as airway obstruction may develop. Epiglottitis generally occurs in children between the ages of 2 and 6 years. The incidence of epiglottitis has decreased since the introduction of the Hib vaccine
Features
rapid onset
unwell, toxic child
stridor
drooling of saliva
Croup
Croup is a form of upper respiratory tract infection seen in infants and toddlers. It is characterised by stridor which is caused by a combination of laryngeal oedema and secretions. Parainfluenza viruses account for the majority of cases.
Epidemiology
peak incidence at 6 months - 3 years
more common in autumn
Features
stridor
barking cough (worse at night)
fever
coryzal symptoms
Whooping cough is what of respiratory infection? Caused by?
upper respiratory tract infection caused by Bordetella pertussis (a gram negative bacteria)
Whooping cough presentation
Whooping cough presentation
Whooping cough diagnostic criteria
How do you diagnose whooping cough?
management of whooping cough
- infants under 6 months with suspect pertussis should be admitted (apnoeas, cyanosis or severe couhghing fits)
- in the UK pertussis is a notifiable disease
- an oral macrolide (e.g. clarithromycin, azithromycin or erythromycin) is indicated if the onset of the cough is within the previous 21 days to eradicate the organism and reduce the spread
- household contacts should be offered antibiotic prophylaxis
- antibiotic therapy has not been shown to alter the course of the illness
- school exclusion: 48 hours after commencing antibiotics (or 21 days from onset of symptoms if no antibiotics )
- The symptoms typically resolve within 8 weeks, however they can last several months
complications of pertussis
subconjunctival haemorrhage
pneumonia
bronchiectasis
seizures
pertussis vaccination programme
- 6-in-1 vaccine – for babies at 8, 12 and 16 weeks
- 4-in-1 pre-school booster – for children aged 3 years 4 months
- If you’re pregnant – ideally between 16 and 32 weeks.
Laryngomalacia presentation including age range
4 weeks to peak 6 months
Laryngomalacia course and management
Laryngomalacia definition
Laryngomalacia is the most common congenital laryngeal abnormality characterised by flaccidity of the supraglottic structures. The larynx is soft and floppy as a result and collapses during breathing.
asthma vs viral induced wheeze differences
- Presenting before 3 years of age
- No atopic history
- Only occurs during viral infections
Asthma can also be triggered by viral or bacterial infections, however it also has other triggers, such as exercise, cold weather, dust and strong emotions. Asthma is historically a clinical diagnosis, and the diagnosis is based on the presence of typical signs and symptoms along with variable and reversible airflow obstruction.
presentation of viral induced wheeze
management of viral induced wheeze
Management of viral-induced wheeze is the same as acute asthma in children.
- Over recent years, led by the European Respiratory Society Task Force, the favoured classification for pre-school wheeze is to divide children into one of two groups:
- episodic viral wheeze: only wheezes when has a viral upper respiratory tract infection (URTI) and is symptom free inbetween episodes
- multiple trigger wheeze: as well as viral URTIs, other factors appear to trigger the wheeze such as exercise, allergens and cigarette smoke
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.
Key thing to ask in history for viral induced wheeze
history of recent viral illness
triggers: viral illness or also exercise, wheather, emotions
parents smoking?
Common virus that cause viral induced wheeze
RSV
viral induced wheeze age range
Small children (typically under 3 years)
Presentation suggesting a diagnosis of asthma
Questions to ask in a history of asthma
- FH of asthma
- triggers: exercise, emotions, infections, weather, pets?
- worse at night?
- dry or productive cough?
- wheeze?
- SOB?
- symtoms improve with salbutamol?
- parents smoking?
Presentation suggesting a diagnosis other than asthma
Typical asthma triggers
Dust (house dust mites)
Animals
Cold air
Exercise
Smoke
Food allergens (e.g. peanuts, shellfish or eggs)
Children are usually not diagnosed with asthma until they are at least….years old
2 to 3 years old
How is asthma diagnosed?
principles of using the chronic asthma stepwise ladder
Chronic asthma management in children less than 5 years
Chronic asthma management in children 5-16 years
Step1
Newly-diagnosed asthma:
Short-acting beta agonist (SABA)
Step 2
Not controlled on previous step
OR
Newly-diagnosed asthma with symptoms >= 3 / week or night-time waking
SABA + paediatric low-dose inhaled corticosteroid (ICS)
Step 3
SABA + paediatric low-dose ICS + leukotriene receptor antagonist (LTRA)
Step 4
SABA + paediatric low-dose ICS + long-acting beta agonist (LABA)
In contrast to the adult guidance, NICE recommend stopping the LTRA at this point if it hasn’t helped
Step 5
SABA + switch ICS/LABA for a maintenance and reliever therapy (MART), that includes a paediatric low-dose ICS
Step 6
SABA + paediatric moderate-dose ICS MART
OR consider changing back to a fixed-dose of a moderate-dose ICS and a separate LABA
Step 7
SABA + one of the following options:
* increase ICS to paediatric high-dose, either as part of a fixed-dose regime or as a MART
* a trial of an additional drug (for example theophylline)
* seeking advice from a healthcare professional with expertise in asthma
Maintenance and reliever therapy (MART)
a form of combined ICS and LABA treatment in which a single inhaler, containing both ICS and a fast-acting LABA, is used for both daily maintenance therapy and the relief of symptoms as required
MART is only available for ICS and LABA combinations in which the LABA has a fast-acting component (for example, formoterol)
What is MART therapy?
Maintenance and reliever therapy (MART)
a form of combined ICS and LABA treatment in which a single inhaler, containing both ICS and a fast-acting LABA, is used for both daily maintenance therapy and the relief of symptoms as required
MART is only available for ICS and LABA combinations in which the LABA has a fast-acting component (for example, formoterol)
the definitions of what constitutes a low, moderate or high-dose ICS
pneumothorax definition and typical patient description
- Pneumothorax causes
Pneumothorax investigations amd findings
- erect chest xray for simple penumothorax
- shows an area between the lung tissue and the chest wall with no lung markings. There will be a line demarcating the edge of the lung where the lung markings end and the pneumothorax begins.
- CT thorax can detect a pneumothorax that is too small to be seen on a chest x-ray. It can also be used to assess the size of the pneumothorax accurately.
- Pneumothorax acute management
Two key complications of chest drains
Chest drain position for pneumothorax
Pneumothorax Patients may require surgical interventions when:
Pneumothorax surgical management
Tension pneumothorax definition and cause
Signs of tension pneumothorax
tension pneumothorax management
Bronchiectasis definition and symptoms it results in
Bronchiectasis involves permanent dilation of the bronchi. Sputum collects and organisms grow in the wide tubes, resulting in a chronic cough, continuous sputum production and recurrent infections.
Bronchiectasis causes
Bronchiectasis symptoms
Shortness of breath
Chronic productive cough
Recurrent chest infections
Weight loss
Signs of bronchiectasis on examination include:
Bronchiectasis investigations
Bronchiectasis, The most common infective organisms are:
Haemophilus influenza
Pseudomonas aeruginosa
Bronchiectasis Chest x-ray findings include
- Tram-track opacities (parallel markings of a side-view of the dilated airway)
- Ring shadows (dilated airways seen end-on)
Test of choice for establishing the diagnosis of bronchiectasis
High-resolution CT (HRCT)
Bronchiectasis management
The key features to remember with bronchiectasis are (summary of condition)
- finger clubbing
- diagnosis by HRCT
- Pseudomonas colonisation and extended courses of 7-14 days of antibiotics for exacerbations.
episodic viral wheeze and multiple trigger wheeze management
TB is caused by which organism? Why is it difficult to culture?
Tuberculosis is mostly spread by….. Once in the body, there are several possible outcomes: (disease course)
Tuberculosis is mostly spread by inhaling saliva droplets from infected people. Once in the body, there are several possible outcomes:
- Immediate clearance of the bacteria (in most cases)
- Primary active tuberculosis (active infection after exposure)
- Latent tuberculosis (presence of the bacteria without being symptomatic or contagious)
- Secondary tuberculosis (reactivation of latent tuberculosis to active infection)
What is miliary tuberculosis.
When the immune system cannot control the infection, disseminated and severe disease can develop, referred to as miliary tuberculosis.
Latent tuberculosis is present when
Latent tuberculosis is present when the immune system encapsulates the bacteria and stops the progression of the disease. Patients with latent tuberculosis have no symptoms and cannot spread the bacteria. Most otherwise healthy patients with latent tuberculosis never develop an active infection.
When does secondary TB develop?
When latent tuberculosis reactivates, and an infection develops, usually due to immunosuppression, this is called secondary tuberculosis.
The most common site for TB
The most common site for TB infection is in the lungs, where it gets plenty of oxygen
Extrapulmonary tuberculosis refers to disease in other areas:
Lymph nodes
Pleura
Central nervous system
Pericardium
Gastrointestinal system
Genitourinary system
Bones and joints
Skin (cutaneous tuberculosis)
A cold abscess describes a..
A cold abscess describes a firm, painless abscess caused by tuberculosis, usually in the neck. They do not have the inflammation, redness and pain you expect from an acutely infected abscess.
Risk factors for TB
- Close contact with active tuberculosis (e.g., a household member)
- Immigrants from areas with high tuberculosis prevalence
- People with relatives or close contacts from countries with a high rate of TB
- Immunocompromised (e.g., HIV or immunosuppressant medications)
- Malnutrition, homelessness, drug users, smokers and alcoholics
name of vaccine for TB, who it’s offered to and how it works
TB presentation
TB investigations
CXR appearance in primary, reactivated and disseminated miliary TB
What type of sample do you need for TB cultures? How do you collect the samples?
When do you use NAAT testing in TB?
Latent and active TB treatment and other management options for TB
TB drugs and their side effects
what is the matoux test and how is ti performed?
Chronic infection with…. in CF are associated with increased morbidity and mortality
Chronic infection with Pseudomonas and Bulkholderia in CF are associated with increased morbidity and mortality
CKS admission criteria for croup
CKS suggest admitting any child with:
moderate or severe croup
< 3 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)
Clinical Knowledge Summaries (CKS) suggest using the following criteria to grade the severity:
….can be used to treat cystic fibrosis patients who are homozygous for the delta F508 mutation
Lumacaftor/Ivacaftor (Orkambi)
* is used to treat cystic fibrosis patients who are homozygous for the delta F508 mutation
* lumacaftor increases the number of CFTR proteins that are transported to the cell surface
* ivacaftor is a potentiator of CFTR that is already at the cell surface, increasing the probability that the defective channel will be open and allow chloride ions to pass through the channel pore
