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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
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
26
What are some RSV induced LRTIS in early childhood?
Wheezy bronchitis Viral exacerbation of asthma Bronchiolitis Pneumonia Croup
27
What are some rhinovirus induced LRTIS in early childhood?
Wheezy bronchitis Viral exacerbation of asthma Bronchiolitis Pneumonia Croup
28
What causes acute stridor in children?
Croup Acute epiglottitis
29
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
30
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
31
Examination of croup
Keep the child calm Barking cough Stridor Respiratory distress Do not examine the throat or cause unnecessary upset
32
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
33
Features of croup?
Viral – usually para flu Spring/autumn Self limiting Worse at night Barking seal like cough Stidor Recession Steroids
34
Acute epiglottitis features
Haemophilus influenza type B Severe acute illness
35
What can meningococcus cause in children?
Septicaemia Meningitis v occ chronic forms
36
What can Haemophilus influenzae B cause?
Epiglotitis Meningitis Pneumonia
37
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
38
What is pneumonia?
respiratory disease characterized by inflammation of the lung parenchyma (excluding the bronchi) with congestion caused by viruses or bacteria or irritants
39
What are the key features of pneumonia?
Congestion Red hepatization Gray hepatization Resolution
40
Background for Pneumonia
Caused by: Bacteria Strep pneumoniae Mycoplasma Viruses (most common in pre-school) Aspiration
41
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
42
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
43
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
44
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
45
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
46
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
47
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.
48
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.
49
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
50
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
51
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
52
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
53
What is the vicious circle hypothesis for bronchiectasis?
Inflammation > Airways damage > Impaired mucocillary clearance (Physiotherapy) > Infection (Antibiotics) > Inflammation
54
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
55
Egs of presenting complaint
Cough - onset, quality, time SOB - when, exercise tolerance, impact Noisy breathing - Wheeze, stridor, Ruttle, Grunt
56
DDs of cough
URTI Pneumonia Viral LRTI Asthma or viral-induced wheeze Bronchiolitis Foreign body Croup
57
DDs of SOB
Asthma or viral-induced wheeze Bronchiolitis Croup Pneumonia (less so)
58
DDs of noisy breathing
Asthma or viral induced wheeze Croup URTI (transmitted sounds) Inhaled foreign body
59
Remember – non-respiratory symptoms as presentations of respiratory disease - Fever and abdominal pain
Fever - non resp focus Abdominal pain - Pneumonia
60
Tachypnoea - resp presentation but what else could it be?
Cardiac Metabolic
61

3A Paediatrics (19 decks)

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