Resp Flashcards
Organisms which cause bronchiolitis
RSV (80%)
Mycoplasma, adenovirus
How does bronchiolitis present
a coryzal phase preceding respiratory symptoms such as dry cough, increased work of breathing, wheezing, feeding difficulties due to dyspnoea
If patient with bronchiolitis presents to GP with bronchiolitis when should call 999 or refer to hospital
999
- RR over 70
- seriously unwell
- severe rep distress (chest recession etc)
- cyanosis
- sats less than 92
Hospital
- RR over 60
- clinical dehydration (50-75% of normal volume)
- difficulty feeding
Management of bronchiolitis
Largely supportive
Humidified oxygen via head box if sats less than 92
CPAP if impending resp failure
Examination finding of bronchiolitis
Wheeze
Fine inspiratory crackles
What causes croup
Parainfluenza viruses
Presentation of croup
Stridor
Barking cough worse at night
Fever
Corzyal symptoms
Management of croup
Give all patients 0.15mg/kg of dexamethasone
If too unwell/vomiting give inhaled budenoside or IM dexamethasone
Determine if mild, moderate or severe- admit if moderate or severe
Also admit if
- immunocompromised
- under 3 months
- chronic lung disease
- congenital heart disease
- dehydrated
Categorising croup
Mild- seal like barking but no stridor or recession at rest
Moderate- seal like barking cough with stridor and sternal recession with no agitation or lethargy
Severe- seal like barking, stridor, recession, agitation
What to do if reduced barking cough in croup
Suggests impending resp distress- call ambulance
How is croup diagnosed
Normally clinically but can do CXR
PA or lateral
PA versus lateral CXR finding in croup
PA- shows subglottic narrowing (steeple sign)
Lateral- acute epiglottis (thumb sign)
When can those with whooping cough return to school
2 days after commencing antibiotics
How does congenital diaphragmatic hernia present
Respiratory distress as bronchopulmonary hypoplasia
Hypertension
Bowel sounds on ausculation of lungs
What would cause tinking bowel sounds on auscultation
Diaphragmatic hernia
Initial management of congenital diaphragmatic hernia
NG to keep air out of the gut
If patient cyanosed intubate
Cause of stridor in a child
Foreign object
Croup
Acute epiglottitis
Laryngomalacia
What is laryngomalacia
Congenital abnormality of the larynx which presents around 4 weeks of age
Causes of snoring in a child
obesity
nasal problems: polyps, deviated septum, hypertrophic nasal turbinates
recurrent tonsillitis
Down’s syndrome
hypothyroidism
Management of acute epiglottitis
DO NOT lie patient down or examine their mouth
Imeediate referral to ENT, paediatrics and anaesthetics
Secure airway with endotracheal intubation
Blood cultures
Cephalosporin and dexamethasone
How to treat severe croup
Oxygen
Nebulised adrenaline
Best way to diagnose pertussis
Per nasal swab
PCR the most specific
Pneumonia management of children
First line - amoxicillin
Second line- add macrolide if fail to respond
Chlamydia or mycoplasma use macrolide
If influenza suspected use co-amoxiclav
Influenza pneumonia management
Co-amoxiclav
2 prognostic factors of CDH
Lung in thorax
Lungs to head ratio
What is antenatal finding of TOF or oesophageal atresia
Polyhydramnios as never swallowed amniotic fluid
How can allergic rhinitis present
Nasal discharge
Postnasal drip causes nocturnal cough
Cough can be so severe get vomiting and noisy breathing
Causes of bronchiectasis in kids
CF
Post infection like pertussis
Foreign body
Different presentations of CF
Neonates- meconeum ileus
Childhood- chronic cough, recurrent chest infections, malabsorption and pancreatic insufficiency, nasal polyps, short stature, rectal prolapse from being ill all the time
Later presentation of CF
DM
Bronchiectasis
Sterility
Cirrhosis
Management of chronic cough and recurrent infection in CF
Physio twice a day
Nubulised hypertonic saline or DNAase
ABx prophylaxis- flucloxacillin and azithromycin
Annual spirometry
Management of pancreatic insufficiency in CF
Vitamin supplementation
Creon after meals
Management of infection susceptibility in CF
Vaccination
Abx prophylaxis- flucloxacillin and azihromycin
Moderate asthma/viral induced wheeze features
PEFR at least 50% of best
Normal speech
No severe/life threatening features
Severe asthma/viral induced wheeze features
O2 sats must be greater than 91!
PEFR- 33-50% best
Inability to complete sentences
Accessory muscle use
Inability to feed
RR
- over 25 if over 12
- over 30 if 5-15
- over 40 if 2-5
HR
- over 110 if over 12
- over 125 if 5-12
- over 140 if 2-5
Life threatening asthma/viral induced wheeze features
PEFR under 33%
O2 sats less than 92%
Altered consciousness/confusion
Arrythmia
Hyotension
Cyanosis
Poor resp effort
Silent chest
Exhaustion
When to admit someone with acute asthma/viral induced attack
Life threatening
Fail to respond to bronchodilator if severe
Moderate- getting worse or has been near fatal attack previously
Factors which would lower threshold for admitting
- premature
- congenital issue
- CF
- immune deficiency
- assess cares ability
Management of acute asthma/viral induced wheeze waiting for admission
Life threatening
- maintain O2 over 94
- nebulised salbutamol
Severe
- nebulised salbutamol
Moderate
- MDI salbutamol with spacer
NOTE- if nebulsier not available use MDI
Management of asthmatic child at GP without needing hospital admission
SABA every 30-60 seconds do 10 times
If responds well to these can prescribe SABA for at home PRN
If history of atopy or confirmed asthma give oral pred course
Management of infective excacerbation of asthma
Amoxicillin
If contraindicated
- 12 and over doxycycline
- under 12 macrolide or cefaclor
Management of infective excacerbation of asthma
Amoxicillin
If contraindicated
- 12 and over doxycycline
- under 12 macrolide or cefaclor
Asthma guidelines under 5
Under 5
1. SABA
2. Paediatric moderate dose ICS for 8 weeks and monitor
- if no resolvement consider different diagnosis
- sx reoccurred within 4 weeks of stopping ICS restart low dose ICS as maintenance
- sx reoccurred beyond 4 weeks restart moderate dose ICS
3. SABA, low dose ICS, LTRA
4. Stop LTRA and refer to paediatric asthma specialist
Asthma guidelines 5-16
- SABA
- SABA+paediatric low dose ICS
- SABA+paediatric low dose ICS+LTRA
- SABA+paediatric low dose ICS+LABA (stop LTRA)
- SABA +MART combining LABA and low dose ICS
- SABA + moderate dose ICS MART
- SABA + one of;
- increase ICS mart to high dose
- add theophylline
- refer to expert
What factors are associated with worse prognosis in CF
Burkholderia or pseudomonas infection chronically
Diagnosing CF
Sweat test
CFTR gene karyotyping- can determine management
Why is genetic testing significant in CF
If suffer from delta F508 deletion mutation then can give Kaftrio- combination of ivacaftor, tezacaftor and elexacaftor
What causes whooping cough
Bordatella pertussis
What are the stages to whooping cough
Cattarheal- prodromal malaise, dry cough, sore throat
Paroxysmal- expiratory burst then subsequent gasp on inspiration giving whoop
Convalescent- improval in cough severity and frequency
What factors can trigger whooping
Cold
Exercise
Worse at night
When to suspect pertussis
If cough for over 14 days with 1 of following
- paroxysmal
- post coughing vomiting
- whoop
- apnoeic episodes in infants
Management of whooping cough
Admit if necessary
Offer antiobiotic if cough has lasted less than 21 days
- clarithomycin if less than 1 month
- clarithomycin or azithromycin if over 1 month
If contraindicated use co-trimoxazole (not licensed if under 6 weeks)
Management of contacts if been in same room over night in first 21 days
- pregnant
- unimmunised children
- working with children
Give macrolide and co trimoxazole if contraindicated
When can go back to school with pertussis
48 hours of antibiotics
21 days after cough started
Who admit for pertussis
Is 6 months of age or younger and acutely unwell.
Has significant breathing difficulties (for example apnoea episodes, severe paroxysms, or cyanosis).
Has a significant complication (for example seizures or pneumonia)
Must inform hospital before to ensure adequate isolation
Recommended diet for CF
High calories
High fat
Pancreatic enzyme replacement with every meal
What drugs are contraindicated in asthma
Beta blockers
NSAIDS
Adenosine
ACEi
Long term asthma examination findings
Hyperinflated chest
Harrison sulci- under costal margin
Why do children wheeze more when get viral infections under 5
Airways narrower
What does short stature suggest with a rectal prolapse
CF
Pathophysiology of CF
Autosomal recessive disease caused by a mutation in the CFTR (chloride channel)
Leads to reduced movement of chloride out of cells, leading to thick mucus
Which infections are common in CF people
Staphylococcus aureus
Pseudomonas aeruginosa
Haemophilus influenzae
Aspergillus fumigatus
Non-tuberculous mycobacteria
When is only do a CXR in bronchiolitis
Being transferred to ITU
May see peribronchial thickening
Management of laryngomalacia
Typically with resolve within a few months
If apnoeic episodes, cyanosis or poor feeding and development then can consider surgery- supraglottoplasty
When consider pneumonia over bronchiolitis
Fever over 39
Persistant localised crackles
What lobe are foreign objects typically seen in
Right middle lobe
Features of kartageners syndrome
Sinusitis
Bronchiectasis
Infertility
Dextrocardia
What is most common cause of pneumonia in children
Under 4s- strep pneumoniae
over 4- mycoplasma
What is dose of dexamethasone used for croup
0.15ml/kg
What is best test for diagnosing asthma
FEV1 on a spirometer
12% improvement with bronchodilator positive
Management guidelines for pneumothorax
Breathless or over 2 cm= needle aspiration -> if fails chest drain
Any intervention needs followup in 2 weeks in OPD
Under 2cm= discharge and see in OPD in 2 weeks
Pneumonia in a neonate
GBS
Gram neg enterococcus
Pneumonia in an infant and young kids
Strep p
Haemophilus influenza
Cough that worsens when cry
Croup
If spirometry fails to identify asthma what do
FeNO
If someone with desaturates quickly with meconium aspiration syndrome, what is diagnosis
Pneumothorax
What is severe complication of bronchiolitis
Bronchiolitis obliterans
What is bronchiolitis obliterans and what causes it
Repair of lung tissues is in overdrive leading to scar tissue formation
Adenovirus
How does bacterial tracheitis present
Croup like
Very high fever
Copious airway secretions
What is most common cause of bacterial tracheitis
Staph aureus
