Resp Flashcards
What is the definition of a wheeze?
Wheeze was defined to the parents as wheezing or whistling sounds, breathlessness, or persistent troublesome cough severely affecting the well-being of the infant or child
What could be the causes for recurrently wheezing children?
Persistent infantile wheeze
- small airways / smoking / viruses
Viral episodic wheeze
- no interval symptoms / URI triggered
Asthma (Multiple trigger wheeze)
- persistent symptoms / FH / atopic
Other causes
What are the characteristics of a viral episodic wheeze?
No interval symptoms
No excess of atopy
Likely to improve with age
No benefit from regular inhaled steroids
Use bronchodilators
May use oral steroids
? brief HIGH dose inhaled steroids / Montelukast
What could be the other causes of a viral episodic wheeze?
Cystic Fibrosis
CLDN
Tracheo-bronchomalacia
Ciliary dyskinesia
Gastro-oesophageal reflux
Chronic aspiration
Immune deficiency
Persistent bacterial bronchitis
Background for asthma
Most common respiratory disorder in children
Genetic pre-disposition
Environmental factors:
Cigarette smoke
Air allergens
Inflammation and hyperactivity of lower airways
Children still die as a result of their asthma
History of asthma
Recurrent episodes of:
Wheeze
Cough (> at night)
Breathlessness
Symptoms exacerbated by:
Respiratory infections
Air allergens
Exercise
Cold
Can have significant impact on quality of life
Examination of asthma
Cough
Respiratory distress
Bilateral wheeze
+/- Decreased air entry
Investigation of asthma
Acute presentation:
Peak flow if able
Chronic asthma:
Peak flow diary
Spirometry
Exhaled nitric oxide
?Skin prick tests for air allergens
What is the management for acute asthma in children?
Oxygen if needed
B-agonist ++
Prednisolone 1 mg/kg (IV hydrocortisone) (?benefit in preschool viral wheeze)
IV salbutamol bolus
Aminophylline / MgSO4 / Salbulatmol Infusion
What are the primary preventer medications for asthma in children
Inhaled steroids
- Beclomethasone
- Budesonide
- Fluticasone
- (Ciclesonide)
- (Mometasone)
(Inhaled Cromones)
- Sodium Cromoglycate
- Nedocromil Sodium
What are the primary relivers of asthma in children?
B2-agonists
- Salbutamol
- Terbutaline
Ipratropium bromide
What are some add- on therapies for asthma?
Long acting B2-agonists
- Salmeterol
- Formoterol
Leukotriene receptor antagonists
- Montelukast
Theophyllines
Omalizumab (Anti IgE)
Protexo (High IGE)
Examples of inhaled steroids
Beclomethasone dipropionate
≈
Budesonide
≈
0.5 x Fluticasone propionate
What are the principles of steroid usage in asthma for children?
Lowest effective dose
Minimise oral deposition
Minimise G-I absorption
What are the principles of reliever usage in children?
Age-appropriate device
Easy to use
Portable
Dosage not critical
What is always used in all ages for children?
Spacers and MDI de rigeur for steroids in all ages.
When should turbohalers be used?
Turbohaler probably useful in older children, but ?point in under 5s
When should relievers in DPI form be used?
Relievers in DPI form are probably not important until age 6-8 years and independent.
Nebulisers are not often (if ever) needed.
Stepwise mgmt in asthma in children aged 5-12 years
- Mild intermittent asthma - inhaled short acting B2 agonist as required
- Regular preventer therapy -add inhaled steroid 200-400mcg/day - other preventer drug is steroid inappropriate
- Add- on therapy -
3a. Add inhaled long acting B2 agonist (LABA)
3b. Assess asthma control - If LABA good continue LABA
If benefit from LABA but still not good enough increase steroid to 400mcg a day
No response to LABA - Stop LABA and increase steroid to 400 - if control still inadequate try other therapies like LRA or SR theophylline - Persisten poor control - increase steroid to 800mcg a day
- Continuous or frequent use of oral steroids - refer patient to respiratory paediatrician - Use daily steroid in lowest dose providing adequate control - Maintain high dose inhaled steroid at 800mcg/day
What if the patient fails to respond to asthma treatment? (In order of importance)
Adherence (Compliance)
Diagnosis
Environment
Choice of drugs/devices
Bad disease
What is the rule of thirds in adherence?
Adequate
Not at all
Partial
SE of inhaled steroids
Long term ICS:
Adrenal suppression
Growth suppression
Osteoporosis
Adrenal crisis
Impaired cortisol production
slows short/medium term growth- this study was in relatively mild asthma and several others have found similar effects - no effect on adult height
Examples of upper respiratory infections in children
Rhinitis - viral
otitis media - both
pharyngitis - viral
tonsilitis - both
laryngitis - viral
Lower resp infections
Bronchitis - both
croup - viral
epiglottitis - bacterial
tracheitis - both
bronchiolitis - viral
pneumonia - both
Features of Respiratory Syncytial Virus
Annual epidemics
60% + of infants
[30% + of population]
20 –30% LRTI - Lower respt
0.5-2% of infants hospitalised
Mean admission 3 days UK
Mortality very low
Long term morbidity
What are some RSV induced LRTIS in early childhood?
Wheezy bronchitis
Viral exacerbation of asthma
Bronchiolitis
Pneumonia
Croup
What are some rhinovirus induced LRTIS in early childhood?
Wheezy bronchitis
Viral exacerbation of asthma
Bronchiolitis
Pneumonia
Croup
What causes acute stridor in children?
Croup
Acute epiglottitis
Background of croup
Common ages 6m – 6 yrs
Viral cause:
Most commonly parainfluenza
Inflammation of upper airway
Oedema in subglottic area causing narrowing of trachea
History of croup
Symptoms often start/worsen at night
Preceding coryzal illness
Low-grade fever
Hoarse voice
Barking cough
Inspiratory stridor
Can have recurrent episodes
Take history to exclude:
Inhalation of foreign body
Epiglottitis
Examination of croup
Keep the child calm
Barking cough
Stridor
Respiratory distress
Do not examine the throat or cause unnecessary upset
Management of croup
Mild croup can be managed at home with close observation
Keep the child calm
Airway
Oxygen if required
Breathing
Oral Dexamethasone
Nebulised budesonide
Nebulised adrenaline (transient)
Circulation
Disability
Features of croup?
Viral – usually para flu
Spring/autumn
Self limiting
Worse at night
Barking seal like cough
Stidor
Recession
Steroids
Acute epiglottitis features
Haemophilus influenza type B
Severe acute illness
What can meningococcus cause in children?
Septicaemia
Meningitis
v occ chronic forms
What can Haemophilus influenzae B cause?
Epiglotitis
Meningitis
Pneumonia
What can pneumococcus cause?
Colonisation of nasopharynx
Upper airways mucosa infection
- Otitis Media – acute/chronic
- Sinusitis
Upper airways mucosal infection - - - Bacterial bronchitis
- Pneumonia acute/chronic
‘IPD’
- ‘occult’ septicaemia
- Pneumonia with septicaemia
- Meningitis
What is pneumonia?
respiratory disease characterized by inflammation of the lung parenchyma (excluding the bronchi) with congestion caused by viruses or bacteria or irritants
What are the key features of pneumonia?
Congestion
Red hepatization
Gray hepatization
Resolution
Background for Pneumonia
Caused by:
Bacteria
Strep pneumoniae
Mycoplasma
Viruses (most common in pre-school)
Aspiration
History for Pneumonia
Coryzal for 5 days
Fever 39.5 for 2 days
Cough day and night, sounds wet, no sputum
Off food and lethargic
Seems out of breath when moves around
General examination of pneumonia
Flushed, moderately unwell and mildly dehydrated.
Fever 39.8°C
SaO2 89% in air, heart rate 124/min
Growth 25th centile
Not clubbed
Chest examination of pneumonia
Inspection
Asymmetrical chest movement
Mild intercostal recession
No chest wall deformity/scars
Palpation
Trachea/apex beat not displaced
Percussion
Dull right upper anterior chest
Auscultation
Bronchial breathing right apex
Vocal resonance increased right upper zone
Management of pneumonia
Determine if viral or bacterial
Viral LRTI
Usually lower fever (less than 39 °C)
Chest signs usually bilateral
Antibiotics:
PO Amoxicillin
IV Benzylpenicillin
+/- Oxygen/respiratory support
Antipyretics
How is pneumonia diagnosed based on WHO guidelines?
history of cough and/or difficulty breathing (<14 days duration) with increased respiratory rate (defined for age)
> 2 months > 60/min
2-11 months > 50/min
> 11 months > 40/min
What will a CXR show for the diagnosis of pneumonia?
A dense or fluffy opacity that occupies a portion or whole of a lobe or lung that may or may not contain an air bronchograms
How is pneumonia diagnosed in the UK?
Bacterial pneumonia should be considered in children aged up to 3 years when there is fever of >38.5°C together with chest recession and a respiratory rate of >50/min.
For older children a history of difficulty in breathing is more helpful than clinical signs.
Chest radiography should not be performed routinely in children with mild uncomplicated acute lower respiratory tract infection
Radiographic findings are poor indicators of aetiology.
What is the bacterial aetiology of Pneumonia?
Worldwide prospective, microbiology-based studies show
leading bacterial cause is pneumococcus, being identified in 30–50% of pneumonia cases.
The second most common organism isolated in most studies is H. influenzae type b (Hib) (10–30% of cases)
S. aureus and K. pneumoniae also important.
Lung aspirate studies have identified a significant fraction of acute pneumonia cases to be due to Mycobacterium tuberculosis, which is notoriously difficult to identify in children.
What is the viral aetiology of pneumonia?
Pneumonia etiology studies that incorporate viral studies show that respiratory syncytial virus is the leading viral cause, being identified in 15–40% of pneumonia or bronchiolitis cases admitted to hospital in children in developing countries, followed by influenza A and B, parainfluenza, human metapneumovirus and adenovirus
What is the aetiology of HIV?
In recent years, the HIV epidemic has also contributed substantially to increases in incidence and mortality from childhood pneumonia. In children with HIV, bacterial infection remains a major cause of pneumonia mortality, but additional pathogens (e.g. Pneumocystis jiroveci) are also found in HIV-infected children while M. tuberculosis remains an important cause of pneumonia in children with HIV
Mycoplasma pneumoniae
Chlamydia spp.
Pseudomonas spp.
Escherichia coli
Measles
Varicella
Histoplasmosis and toxoplasmosis
HIV and children
Available vaccines have lower efficacy in children infected with HIV, but still protect a significant proportion against disease.67 Antiretroviral programmes can reduce the incidence and severity of HIV-associated pneumonia in children
through the prevention of HIV infection, use of co-trimoxazole prophylaxis and treatment with antiretrovirals
Most common aetiology of pneumonia
Streptococcus pneumoniae 35.7% 7.3% 7.8%
Haemophilus influenzae 26.1% 0.6%
Mycoplasma pneumoniae 17.8% 3.7% 15.7%
Group A Streptococcus
What is the vicious circle hypothesis for bronchiectasis?
Inflammation > Airways damage > Impaired mucocillary clearance (Physiotherapy) > Infection (Antibiotics) > Inflammation
Whats involved in a paediatric history?
PC
HPC
PMH
Perinatal history (feeding)
Growth and developmental history
Drug + allergies
Immunisation
Fhx
Psychosocial history
Safeguarding/ support systems enquiry
Egs of presenting complaint
Cough - onset, quality, time
SOB - when, exercise tolerance, impact
Noisy breathing - Wheeze, stridor, Ruttle, Grunt
DDs of cough
URTI
Pneumonia
Viral LRTI
Asthma or viral-induced
wheeze
Bronchiolitis
Foreign body
Croup
DDs of SOB
Asthma or viral-induced wheeze
Bronchiolitis
Croup
Pneumonia (less so)
DDs of noisy breathing
Asthma or viral induced wheeze
Croup
URTI (transmitted sounds)
Inhaled foreign body
Remember –
non-respiratory symptoms as presentations of respiratory disease - Fever and abdominal pain
Fever - non resp focus
Abdominal pain - Pneumonia
Tachypnoea - resp presentation but what else could it be?
Cardiac
Metabolic
