Pneumonia Flashcards
Aetiology of bronchiolitis
- It is the commonest serious infection in infancy
- Cause of the winter epidemic in UK
- Age
- Younger the age, more severe the disease
- Can present as apnoea in babies under 4 months • Rare after the age of 1
- Aetiology
- RSV–80%
- meta-pneumovirus, adenovirus and mycoplasma pneumoniae
- Dual virus infection – more severe disease
What are the clinical features of bronchiolitis?
- coryzal prodrome lasting 1 to 3 days, • followed by persistent sharp cough
- Increased work of breathing
- Hyperinflation of chest
- Fine end inspiratory crackles • High pitched wheeze
- Tachycardia
- Cyanosis or pallor
- Feeding difficulty • How to assess
How to assess severity of bronchiolitis
3 groups of factors
• Risk factors that predict severe disease • Ability to care at home
• Features that reflect severity
Features that reflect severity of bronchiolitis
- Apnoea (observed or reported)
- Hypoxia
- Persisting severe respiratory distress
- Inadequate oral intake (50-75% of usual volume, use clinical judgement)
Outline supportive management of bronchiolitis
- Good hand hygiene
- Good nursing care
- Pulse oximetry and monitor for apnoea
- Humidified Oxygen
- Nasal prongs
- Humidified high flow oxygen (AIRVO)
- No medications
- Feeds and fluids
- Supplement feeds by nasogastric tube • Consider intravenous fluids
- Severe patient
- Assisted ventilation – CPAP or ventilation
- Further tests such as Blood gas, Chest Xray
Prognosis of bronchiolitis
- Most infants recover within 2 weeks
- Upto half of infants may have recurrent episodes of cough and wheeze • Very, very rarely babies may develop bronchiolitis obliterans
Prevention of bronchiolitis
Prevention
• Monoclonal antibody to RSV
• Expensive and monthly injections
How to safely discharge a child with bronchiolitis ?
- Key safety information (written)
- how to recognise developing ‘red flag’ symptoms:
- worsening work of breathing (for example grunting, nasal flaring, marked chest recession)
- fluid intake is 50–75% of normal or no wet nappy for 12 hours
- apnoea or cyanosis
- exhaustion
- that people should not smoke in the child’s home because it increases the risk of more severe symptoms in bronchiolitis
- how to get immediate help from an appropriate professional if any red flag symptoms develop
6 month infant with cough and noisy breathing: Differential diagnosis
- Pneumonia
- Recurrent wheeze
- Other possibilities
- Recurrent aspiration
- Cystic fibrosis
- Foreign body
- Pertussis
- Beware of other illnesses
Half of all children wheeze at some point. What are the 3 patterns of wheezing?
- Viral episodic wheeze
* Multiple trigger wheeze – likely to develop into asthma over time • Asthma
What are the characteristics of Virus episodic wheeze
- Commonest type
- Due to small airways – more likely to narrow and obstruct • Aberrant response to viruses
- Episodic nature triggered by viral colds
- They have reduced small airway diameter from birth
- Risk factors
- Maternal smoking during/after pregnancy
- Prematurity
- Family history of asthma or allergy – Not a risk factor
- Commoner in males
- Resolves by 5 years of age
What are the characteristics of Multiple trigger wheeze
- Both preschool and school age children affected • Frequent wheeze triggered by many stimuli
- Viruses, cold air, animal dander, exercise
- In preschool children this label is useful • More likely to respond to steroid inhalers • More likely to develop asthma
What are the characteristics of Atopic asthma
- Usually in school age children
- Recurrent wheezy episodes
- Symptoms in between - interval symptoms
- Evidence of allergy to inhaled allergens • House dust mite, pollen, pets
- Evidence of allergy
- Positive SPT; raised IgE
- Strongly associated with eczema, rhinoconjunctivitis, food allergy • Family history of atopic disease present
- Small number have non-atopic asthma
Causes of recurrent / persistent wheezing in children
Asthma • Chronic aspiration • Recurrent anaphylaxis • Cystic fibrosis • Bronchopulmonary dysplasia (CLD of infancy) • Tracheo-bronchomalacia
Clinical features of asthma
- Symptoms worse at night and early in the morning • Symptoms that have nonviral triggers
- Exercise, pets, dust, cold air, emotions • Interval symptoms
- Between acute exacerbations
- Personal or family history of atopic disease • Positive response to therapy
How to asses Pattern and severity of asthma
- Frequency of acute symptoms
- GP visits, hospital admissions, oxygen therapy
- What triggers asthma
- Sport and general activities
- How often is sleep affected
- How severe are the interval symptoms
- Frequency of bronchodilator use • How much school is missed
signs on Examination of a child with asthma
chest usually normal
• Rarely hyperinflated chest, polyphonic wheeze, prolonged expiration • Harrison’s sulci
• Evidence of eczema, rhinitis • Check growth
• Presence of a wet cough or sputum production , clubbing or poor growth – other conditions suspected
Investigations for asthma
• Diagnosed from history and examination
• Parental description of symptoms and response to treatment is
most important in diagnosis
• Tests
• Skin prick tests to diagnose atopy and aid avoidance measures • Chest X-ray may be considered
• Tests to explore severity
• Symptom diary
• Spirometry
• Peak expiratory flow rates (PEFR) diary
• Response to treatment helpful
findings on spirometry in asthma
- Forced expiratory volume in 1 sec (FEV1)
- Blowing out as hard and as fast as possible
- Measure of air flow through large airways to bronchioles
- Response to bronchodilator • 12% improvement in FEV1
- PEFR
- Less sensitive to changes, but portable
- Increased variability
- Diurnal and day to day
Inhaled corticosteroids (preventers) side effects
- Side effects
- No clinically significant side effects when used in low doses
- Can cause a mild reduction in height velocity – catch up occurs in late childhood
- Systemic side effects with high doses - impaired growth, adrenal suppression, affects bone metabolism
- Most children require ‘very low dose inhaled steroids’
Add-on therapy for asthma in children
- Under 5 years of age
- Oral leukotriene receptor antagonist – montelukast
- Over 5 years of age
- Long acting bronchodilator (LABA)
- In addition – montelukast
- Slow release oral theophylline • High incidence of side effects
- Oral prednisolone (alternate days)
- Anti-IgE therapy (injectable) - omalizumab • Antibiotics no value
- Antihistamines, nasal steroids for rhinitis
Definition of respiratory distress
• When the child is unable to obtain adequate oxygenation despite significant efforts to breathe
• The normal gas exchange is impaired and this leads to increased effort and reduced efficacy
• OR
state characterised by increase in rate and /or effort of breathing
• A subjective difficulty in breathing
Features of respiratory distress
- Dyspnoea
- Tachypnoea
- Chest wall retraction
- Nasal flaring
- Sternal recession and head bobbing
- Other system manifestations • Cardiovascular
- Central nervous system
Causes in upper airway of stridor
- Croup
- Epiglottitis
- Bacterial tracheitis
- Foreign body inhalation
- Trauma and thermal injury
what is croup?
- Acute laryngotracheobronchitis
- Acute laryngeal and sub glottic stenosis • Causes – viruses
- Age 6 months to 6 years
- Peak incidence – second year
- Perinatal history and intubation at birth
Basic management of croup
- Treatment at home
- When to admit to hospital
- Reduce anxiety by being calm and organised
- Do not move the child from the mother
- observe carefully for signs of hypoxia or exhaustion • Do not examine the throat with a spatula
management of croup
- Steroids beneficial
- Dexamethasone and nebulised budesonide • Takes 90-120 minutes to work
- If severe
- Nebulised adrenaline
- Watch for rebound of symptoms
- If deteriorating call for urgent senior help • When to discharge
- Safety netting advice
Management of epiglottis
- Life threatening emergency
- Urgent admission
- Senior Anaesthetist, Paediatrician and ENT surgeon summoned • Intubated
- Blood culture and antibiotics
How does Bacterial tracheitis present and what is the management?
• Bacterial tracheitis • Appears toxic • Harsh stridor • Copious thick secretion • Staph. aureus Management IV antibiotics
