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3A Paediatrics > Resp > Flashcards

Resp Flashcards

1
Q

What is the definition of a wheeze?

A

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

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2
Q

What could be the causes for recurrently wheezing children?

A

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

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3
Q

What are the characteristics of a viral episodic wheeze?

A

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

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4
Q

What could be the other causes of a viral episodic wheeze?

A

Cystic Fibrosis
CLDN
Tracheo-bronchomalacia
Ciliary dyskinesia
Gastro-oesophageal reflux
Chronic aspiration
Immune deficiency
Persistent bacterial bronchitis

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5
Q

Background for asthma

A

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

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6
Q

History of asthma

A

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

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7
Q

Examination of asthma

A

Cough
Respiratory distress
Bilateral wheeze
+/- Decreased air entry

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8
Q

Investigation of asthma

A

Acute presentation:
Peak flow if able

Chronic asthma:
Peak flow diary
Spirometry
Exhaled nitric oxide
?Skin prick tests for air allergens

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9
Q

What is the management for acute asthma in children?

A

Oxygen if needed
B-agonist ++
Prednisolone 1 mg/kg (IV hydrocortisone) (?benefit in preschool viral wheeze)

IV salbutamol bolus
Aminophylline / MgSO4 / Salbulatmol Infusion

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10
Q

What are the primary preventer medications for asthma in children

A

Inhaled steroids
- Beclomethasone
- Budesonide
- Fluticasone
- (Ciclesonide)
- (Mometasone)

(Inhaled Cromones)
- Sodium Cromoglycate
- Nedocromil Sodium

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11
Q

What are the primary relivers of asthma in children?

A

B2-agonists
- Salbutamol
- Terbutaline

Ipratropium bromide

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12
Q

What are some add- on therapies for asthma?

A

Long acting B2-agonists
- Salmeterol
- Formoterol
Leukotriene receptor antagonists
- Montelukast

Theophyllines

Omalizumab (Anti IgE)

Protexo (High IGE)

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13
Q

Examples of inhaled steroids

A

Beclomethasone dipropionate
≈
Budesonide
≈
0.5 x Fluticasone propionate

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14
Q

What are the principles of steroid usage in asthma for children?

A

Lowest effective dose
Minimise oral deposition
Minimise G-I absorption

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15
Q

What are the principles of reliever usage in children?

A

Age-appropriate device
Easy to use
Portable
Dosage not critical

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16
Q

What is always used in all ages for children?

A

Spacers and MDI de rigeur for steroids in all ages.

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17
Q

When should turbohalers be used?

A

Turbohaler probably useful in older children, but ?point in under 5s

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18
Q

When should relievers in DPI form be used?

A

Relievers in DPI form are probably not important until age 6-8 years and independent.
Nebulisers are not often (if ever) needed.

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19
Q

Stepwise mgmt in asthma in children aged 5-12 years

A
  1. Mild intermittent asthma - inhaled short acting B2 agonist as required
  2. Regular preventer therapy -add inhaled steroid 200-400mcg/day - other preventer drug is steroid inappropriate
  3. 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
  4. Persisten poor control - increase steroid to 800mcg a day
  5. 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
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20
Q

What if the patient fails to respond to asthma treatment? (In order of importance)

A

Adherence (Compliance)
Diagnosis
Environment
Choice of drugs/devices
Bad disease

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21
Q

What is the rule of thirds in adherence?

A

Adequate
Not at all
Partial

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22
Q

SE of inhaled steroids

A

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

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23
Q

Examples of upper respiratory infections in children

A

Rhinitis - viral
otitis media - both
pharyngitis - viral
tonsilitis - both
laryngitis - viral

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24
Q

Lower resp infections

A

Bronchitis - both
croup - viral
epiglottitis - bacterial
tracheitis - both
bronchiolitis - viral
pneumonia - both

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25
Q

Features of Respiratory Syncytial Virus

A

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

26
Q

What are some RSV induced LRTIS in early childhood?

A

Wheezy bronchitis
Viral exacerbation of asthma
Bronchiolitis
Pneumonia
Croup

27
Q

What are some rhinovirus induced LRTIS in early childhood?

A

Wheezy bronchitis
Viral exacerbation of asthma
Bronchiolitis
Pneumonia
Croup

28
Q

What causes acute stridor in children?

A

Croup
Acute epiglottitis

29
Q

Background of croup

A

Common ages 6m – 6 yrs
Viral cause:
Most commonly parainfluenza
Inflammation of upper airway
Oedema in subglottic area causing narrowing of trachea

30
Q

History of croup

A

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

31
Q

Examination of croup

A

Keep the child calm
Barking cough
Stridor
Respiratory distress

Do not examine the throat or cause unnecessary upset

32
Q

Management of croup

A

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

33
Q

Features of croup?

A

Viral – usually para flu
Spring/autumn
Self limiting
Worse at night
Barking seal like cough
Stidor
Recession
Steroids

34
Q

Acute epiglottitis features

A

Haemophilus influenza type B
Severe acute illness

35
Q

What can meningococcus cause in children?

A

Septicaemia
Meningitis
v occ chronic forms

36
Q

What can Haemophilus influenzae B cause?

A

Epiglotitis
Meningitis
Pneumonia

37
Q

What can pneumococcus cause?

A

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

38
Q

What is pneumonia?

A

respiratory disease characterized by inflammation of the lung parenchyma (excluding the bronchi) with congestion caused by viruses or bacteria or irritants

39
Q

What are the key features of pneumonia?

A

Congestion
Red hepatization
Gray hepatization

Resolution

40
Q

Background for Pneumonia

A

Caused by:
Bacteria
Strep pneumoniae
Mycoplasma
Viruses (most common in pre-school)
Aspiration

41
Q

History for Pneumonia

A

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

42
Q

General examination of pneumonia

A

Flushed, moderately unwell and mildly dehydrated.
Fever 39.8°C
SaO2 89% in air, heart rate 124/min

Growth 25th centile
Not clubbed

43
Q

Chest examination of pneumonia

A

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

44
Q

Management of pneumonia

A

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

45
Q

How is pneumonia diagnosed based on WHO guidelines?

A

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

46
Q

What will a CXR show for the diagnosis of pneumonia?

A

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

47
Q

How is pneumonia diagnosed in the UK?

A

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.

48
Q

What is the bacterial aetiology of Pneumonia?

A

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.

49
Q

What is the viral aetiology of pneumonia?

A

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

50
Q

What is the aetiology of HIV?

A

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

51
Q

HIV and children

A

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

52
Q

Most common aetiology of pneumonia

A

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

53
Q

What is the vicious circle hypothesis for bronchiectasis?

A

Inflammation > Airways damage > Impaired mucocillary clearance (Physiotherapy) > Infection (Antibiotics) > Inflammation

54
Q

Whats involved in a paediatric history?

A

PC
HPC
PMH
Perinatal history (feeding)
Growth and developmental history
Drug + allergies
Immunisation
Fhx
Psychosocial history
Safeguarding/ support systems enquiry

55
Q

Egs of presenting complaint

A

Cough - onset, quality, time
SOB - when, exercise tolerance, impact
Noisy breathing - Wheeze, stridor, Ruttle, Grunt

56
Q

DDs of cough

A

URTI
Pneumonia
Viral LRTI
Asthma or viral-induced
wheeze
Bronchiolitis
Foreign body
Croup

57
Q

DDs of SOB

A

Asthma or viral-induced wheeze
Bronchiolitis
Croup
Pneumonia (less so)

58
Q

DDs of noisy breathing

A

Asthma or viral induced wheeze
Croup
URTI (transmitted sounds)
Inhaled foreign body

59
Q

Remember –
non-respiratory symptoms as presentations of respiratory disease - Fever and abdominal pain

A

Fever - non resp focus
Abdominal pain - Pneumonia

60
Q

Tachypnoea - resp presentation but what else could it be?

A

Cardiac
Metabolic

61
Q
A

3A Paediatrics (19 decks)

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