Resp 2 Flashcards
What is a wheeze due to?
obstruction of the intrathoracic airways
What are causes for wheeze
bronchiolitis
asthma
foreign body
What is bronchiolitis
inflammation of the bronchioles (smallest airways) due to RSV
What are symptoms of bronchiolitis
Dry cough
SOB
Wheeze
Recurrent apnoea
What is investigations for bronchiolitis
Clinical (pulse oximetry)
Who is at especially high risk for bronchiolitis
children born prematurely
What are examination findings in bronchiolitis
dry wheezy cough tachypnoea, tachycardia Subcostal, intercostal recession Chest hyperinflation Fine end-inspiratory crackles Cyanosis Pallo
What is management for bronchiolitis^?
Oxygen supplementation if SaO2 <92 Consider CPAP consider upper airway sunction if increased secretions Fluids by NG/OG tube Supportive
What medication can you give as prevention from bronchiolitis?
Palivizumab
Who do you give Pavililzumab to
High risk pre term infants
Give three patterns of wheezing which are similar to asthma
Viral episodic wheeze
Multiple trigger wheeze
Asthma
Explain why Viral episodic wheeze occurs
in response to viral infection
How do you manage Viral episodic wheeze
Salbutamol inhaler (using spacer)
What is the max dose of salbutamol a child can receive if wheezy?
10 puffs every 4 hours
What causes multiple trigger wheeze
multiple triggers:
- infection
- dust
- cold air
What is the definition of atopic astham
Recurrent wheezing associated with
- interval symptoms (symptoms between viral infections)
- allergy to one or more inhaled allergens
What are key features of asthma
Wheezing
Worse at night and in early morning
Non-viral triggers
Interval symptoms (between acute exacerbations)
What is wheezing described as
a whistling in the chest when the child breathes out
What is a visible sign of early onset asthma on the chest?
Harrison sulk (depressions at the base of thorax)
What are investigations for asthma in a child under 5
NONE- clinical
What are investigations for asthma in a child over 5
Spirometry
Bronchodilator reversibility
Peak expiratory flow variability
FeNo test
What is PEFR in life threatening asthma?
PEFR<33%
What is Sp02 in life threatening asthma?
<92%
What are other features in life threatening asthma
altered consciousness exhaustion hypotension cyanosis poor respiratory effort silent chest
What should PaCO2 be like in someone with life threatening asthma? What will REALLY WORRY you?
PaCO2 should be LOW - because patient is hyperventilating
If normal - means patient is no longer compensating - you need to WORRY
Who do you admit in acute asthma?
anyone with moderate or severe asthma
How do you manage acute asthma?
+ what do you give on discharge
Supplemental oxygen
Nebulised SABA
— if SABA ineffective:
Nebuilised TIOTROPIUM BROMIDE
– if ineffective try: (bolus then infusion)
IV Magnesium sulphate
IV Aminophylline
IV Salbutamol
PO prednisolone 3-5 days on discharge
What is the dose of salbutamol you give in acute asthma
2.5 mg if under 5
5mg if over 5
What is the dose of Nebuilised TIOTROPIUM BROMIDE you give in acute asthma
under 2: 10mg
2-5yrs: 20mg
>5yrs: 30-40mg
How do you manage acute asthma if hospital admission is not required
SABA with large volume spacer Oral prednisolone (short course of 3-7 days)
For chronic asthma, when should you escalate treatment
SABA use >3 times weekly
Symptoms > 3 times weekly
Waking up from sleep > 1 time weekly
Hospital admission requiring corticosteroids
What is the typical presentation of foreign body inhalatuion
abrupt onset cough
followed by wheeze
in previously well child
What investigation should you get in suspected foreign body inhalation
CXR
What will a CXR in foreign body inhalation show
Ipsilateral volume loss
contralateral hyper expansion from air trapping
How do you manage foreign body inhalation
If conscious: encourage coughing, external maneuvres (back blows, chest thrust, abdominal thrust)
If unconscious: secure airway immediately
Removal of foreign body: flexible / rigid bronchoscopy
What pathogen causes whooping cough
bordatella pertussis
What is the presentation of whooping cough
A week of coryza (catarrhal phase) +
Development of paroxysmal / spasmodic cough
Characteristic inspiratory whoop - lasts up to 3 months
Bouts of coughing last worse at night, after eating
May cause vomiting
During spasm, child goes blue > mucous shoots from nose/mouth
What investigations for whooping cough
Perinasal swab > culture / PCR
Serology
How do you treat whooping cough
NOTIFY HEALTH PROTECTION UNIT
Prescibe antibiotic within 1 month from cough onset
- <1 month: clarythromycin
- > 1 month: azithromycin
- pregnant: erythromycin
how do you manage pneumonia in children
Amoxicillin 7-14 days
What is bronchitis
Persistent inflammation of lower airways due to chronic infection
What are key causes of persistent bronchitis
h influenza
Moraxella catarrhal is
What are differentials for wet cough in a c child
Pneumonia
Persistent bacterial bronchitis
Bronchiectasis
Explain CF mutation
Defective CF Transmembrane Conductance Regulator
On Chr 7
Chloride dependent channel
Results in thickened mucous and retention of mucopurulent secretions
How do you investigate CF
IRT in newborn (<6 weeks)
Sweat test after first 6 weeks
What are presentation of CF in the body=?
Lung: thickened secretions
Intestine: thick meconium, causing meconium ileum (where meconium causes obstruction)
Pancreas: blockage of pancreatic ducts due to secretions > pancreatic enzyme deficiency and malabsorption
How do you manage CF
MDT approach
What is the resp management of CF
Pulmonary monitoring (review children) Airway clearance (physiotherapists, repeat techniques x2 daily) Mucoactive agents (RhDNase, hypertonic saline, mannitol dry power inhalation) New agents e.g. Lumacaftor, Ivacaftor
What is infection management in CF
Continuous prophylactic antibiotics
Rescue oral Abx
What is nutritional management in CF
pancreatic replacement therapy
High calorie diet (150% normal)
Fat soluble vitamins
What kind of management should you consider for CF in adults / teens=
Ursodeoxycholic acid (improves bile flow)
liver transplant
laxatives
Fertility counselling
what is bronchiectasis
Irreversible DILATATION and DISTORTION of the bronchial tree > chronic obstructing lung disease
what are symptoms of bronchiectasis
chronic cough
sputum
recurrent chest infections
what changes to the airways occur in bronchiectasis
chronic inflammtion and infection
impaired mucociliary function
mucous plugging
what are causes of bronchiectasis
GENERALISED BRONCHIECTASIS:
- Cystic fibrosis
- Primary ciliary dyskinesia
- Immunodefiiency
- Chronic aspitration
FOCAL BRONCHIECTASIS
- prior severe pneumonia
- congenital lung abnormality
- foreign body obstruction
How do you manage bronchiectasis
exercise, improve nutrition
airway clearance therapy
inhalied broncholilator + inhaled hyperosmolar agent + long term oral macrolide
REFER TO SECONDAY CARE
What investigations must you get for bronchiectasis in secondary care
- bronchiectaasis severity index
- sweat chloride test / CF genetic testing
- antibody deficiency scrrenign
- test for primary ciliary dyskinesia
what antibiotics can you give for a non-CF bronchiectasis acute exacerbation?
start empirical, then guide by sputum sensitivisites
- ORAL: 1m to 11 years: amox/clarythromycin > co-amoxiclav
- ORAL: 12y-17y: doxy > co-amoxiclav
How do you manage latent TB
Isoniazid for 6m
OR
Rifampicin + isoniazid 3m
what must you do for TB treatment other than give medications
Assign a key worker to monitor patient’s adherence to treatment, treatment response, and any adverse effects
Do contact tracing
What spirometry result do you expect for asthma?
FEV1/FVC <70%
How do you follow up acute asthma episode after discharge3?
follow up 2 days later (regardless of whether they were admitted / sent home from A&E)
What is bronchiectasis
Abnormal irreversible dilatation and distortion of the bronchial tree
Causes Chronic Obstructive lung disease
What are causes of bronchieectasis
CF
Primary ciliary diskinesia
Immunodeficiecy
Chronic aspiration
OR
Prior severe pneumonia
Congenital lung abnormality
How do you diagnose bronchiectasis
Chest CT
Broncoscopy if focal bronchiectasis
How do you manage bronchiectasis
Exercise, improve nutrition Airway clearance therapy (postural draainage, percussion, vibration, oscillatory devices) Inhaled broncodiltor INhaled hypersomolar agent Long term macrolide
What result on sweat test indicates CF
> 60
What is fertility like in CF in men vs women
men - always inferttile, use intracytoplasmic sperm injection
women - normal fertility, tolerate opreg ancy
What is the mode of inheritance of CF
Autosomal RECESSIVE
Most common genetic disease causing lifelong impariment in caucasians
Explain primary ciliary dyskinesia
Congenital abnormality iin ciliary structure / function
Causes impaired mucociliary clearance
What are sx of PCD
recurrent productive cough
purulent nasal discharge
chronic ear infections
What is PCD associarted with
Kartagener syndrome
What is Kartagenetr syndorme
Dextrocardia + situs invertus
How do you manage PCD
Daily physio
Treat infections with antibiotics
ENT follow up
What is the key cause of OSA in chidlren
adenotonsillar hypertrophy
How do you manage OSA in children
CPAP/BiPAP
OR
adenotonsillectomy
