resp Flashcards
increased risk of severe resp illness: risk factors
parental smoking, poor nutrition, underlying lung disease (CF, asthma, chronic lung disease), cyanotic heart disease, immunodeficiency infants
URTI presentation
coryza, nasal discharge/ blockage fever painful throat earache cough Screen in all: feeding difficulties, breathing difficulties, drinking enough? urine output (dehydration) apnoea/ blue
congenital softening of cartilage of larynx, collapse during inspiration
laryngomalacia
laryngomalacia features
can present at birth, usually worsens in first few wks of life. otherwise well infant w stridor noisy breathing can be severe- w reps distress signs + FTT (need surgery)
most common cause of tonsillitis
group A B-haemolytic strep and EBV (viral)
viral vs bacterial tonsillitis
both have fever, throat pain, pain on swallowing. but white tonsillar exudate and cervical lymphadenopathy more common w bacterial
Bacterial tonsillitis Mx
10 days Penicillin (erythromycin if penicillin allergy) Analgesia (NSAIDs, paracetamol)
Recurrent tonsillitis
Indicated for tonsillectomy
Complications of Group A strep
Rheumatic fever, erythema nodosum, post strep glomerulonephritis
Tonsillitis Ix
Look in mouth at tonsils. Feel for cervical LN General obs- temp etc If severely unwell, FBC, WCC, CRP, Blood cultures. Culture of throat swab
Acute Otitis Media risk factors
if eustachian tubes are short, horizontal or function poorly assoc w Downs, cleft palate, primary ciliary dyskinesia, allergic rhinitis. Freq URTI household smoking
acute otitis media
pain in ear + fever
Acute otitis media Ix
Examine tympanic membrane - bright red and bulging with loss of normal light reflection occasionally - perforation of eardrum w pus visible in ear canal
Acute otitis media complications
mastoiditis meningitis
Acute otitis media mx
analgesia (paracetamol or ibuprofen) antibiotics if still unwell after 2-3 days. Amoxicillin
Otitis media with effusion
children asymptomatic apart from decreased hearing. most common cause of conductive hearing loss in children -> can lead to interference w normal speech development and learning difficulties in sch
otitis media with effusion ix
examine tympanic membrane- ear drum dull and retracted, often w fluid level visible Tympanometry: flat trace Audiometry: evidence of conductive loss Distraction hearing test in younger children: reduced hearing
Otitis media w effusion Mx
usually resolves spontaneously. if severe interference, grommet insertion
pain swelling and tenderness over the cheek
sinusitis
sinusitis mx
antibiotics if bacterial infection (symptoms >10 days) [1st line Phenoxymethylpenicillin] analgesia (paracetamol, ibuprofen) topical decongestants Admit if severe systemic infection, or serious complication involving orbital region (periorbital oedema, double vision, ophthalmoplegia) or intracranial region (severe frontal headache, swelling over frontal bone, meningitis, focal neuro signs) If recurrent (req >3 abx per yr) -> routine referral to ENT specialist
Croup aka laryngotracheobronchitis what is it?
viral infection cause inflammation and oedema of the upper airways + increased secretions *oedema of the subglottic area potentially dangerous as it may cause critical narrowing of the trachea
What is contraindicated in croup?
throat exam
Croup features
barking cough harsh stridor (ask about noisy breathing) hoarseness preceded by fever and coryza symptoms often worse at night
Croup mx
if mild- manage at home low threshold of admission for <12 yo due to narrow airway calibre. *** Oral dexamethasone to all nebulised steroids (budesonide) if severe: nebulised adrenaline w oxygen If still not improving: tracheal intubation w anaethetist
Croup mx for all severities
Oral dexamethasone
Croup mx for severe
oral dexamethasone nebulised steroids nebulised adrenaline w oxygen admit!!
most common pathogen cause of croup
parainfluenza virus
Pseudomembranous croup
bacterial tracheitis similar to severe viral croup but child has HIGH fever, appears toxic and has rapidly progressive airway obstruction w thick airway secretions (loud, harsh stridor)
Psuedomembranous croup pathogen
Staph Aureus -> tx w IV Abx and intubation and ventilation if required
Acute epiglottitis cause
Haemophilus influenza type B
Acute epiglottitis what is it
life-threatening EMERGENCY Intense swelling of epiglottis and surrounding tissues, assoc w septicaemia
Acute epiglottitis features
acute onset (over hours compared to croup- days) High fever unwell toxic looking child no preceding coryza intensely painful throat drooling soft inspiratory stridor w rapidly increasing resp difficulty Child sitting immobile, upright, w open mouth to optimise airway
What is contraindicated in acute epiglottitis
Throat exam
Acute epiglottitis mx
urgent hospital admission and tx senior anaesthetist, paediatrician and ENT surgeon. ITU, intubation w GA otherwise, urgent tracheostomy after securing airway, blood cultures and IV ABx (cefuroxime) started
Acute epiglottitis abx
cefuroxime IV
acute epiglottitis prophylaxis to close contacts
rifampicin
whooping cough aka Pertussis pathogen
Bordatella pertussis
Pertussis presentation
Preceding coryza characteristic paroxysmal cough followed by inspiratory whoop (due to airway obstruction from airway swelling and increased mucus) Violent bouts of coughing may lead to vomiting, child going blue
Pertussis complications of vigorous coughing
vomiting cyanosis apnoea epistaxis subconjunctival haemorrhage broken ribs seizures
How long do symptoms of pertussis last
may persist for months due to damage by bacteria
Pertussis Ix
Always examine child, full obs, assess dehydration, resp exam for resp distress Pernasal swab for PCR/ culture (diagnostic) Antibody serology FBC - WCC/CRP - shows marked lymphocytosis
Pertussis Mx
Erythromycin/ Azithromycin within 21 days of onset of illness close contacts esp immunocomp given prophylaxis erythromycin School exclusion until ABX/ after d21
When are immunisations for pertussis?
2, 3, 4 months, preschool booster
bronchiolitis most common cause
RSV
severe bronchiolitis dual infection
RSV and Humanmetapneumovirus
Bronchiolitis features
Coryza feeding difficulty dry cough Resp difficulty - subcostal/ intercostal recessions, fine end inspiratory crackles
Severe bronchiolitis risk factors
Chronic lung disease, congenital heart disease, CF
bronchiolitis ix
NPA PCR O2 sats Blood venous gas in severe when considering additional ventilatory support
Bronchiolitis Mx
Supportive. Admit if <50% normal feeding, parental concern, resp difficulties (esp if blue, apnoeic) Optiflow (humidified oxygen via nasal cannulae) NG feeding if necessary Fluids via NG tube or IV Suction of excessive upper airway secretions Assisted ventilation (CPAP) may be required
Bronchiolitis complications
permanent damage to airways - bronchiolitis obliterans
bronchiolitis prevention
Pavilizumab (monoclonal Ab to RSV) for high risk premies
bronchiolitis what is it?
infection, most often viral, of the small airways
Pneumonia most common pathogens in newborn
GBS E coli Listeria
Pneumonia most common in children > 5
mycoplasma pneumoniae strep pneumonia chlamydia pneumoniae
pneumonia most common in infants
strep pneumoniae or h influenzae
CF chronic endobronchial infection
Pseudomonas aeruginosa
CF signs in newborn
meconium ileus prolonged jaundice
CF in infant features
FTT recurrent chest infections malabsorption steatorrhoea
CF complications in young child
bronchiectasis due to chronic infection nasal polyp sinusitis rectal prolapse
CF future complications
DM infertility (99% have congenital bilateral absence of vas deferens) cirrhosis
CF signs on examination
chest hyperinflation coarse inspiratory creps and or expiratory wheeze finger clubbing
CF Ix
faecal elastase test (pancreatic insufficiency) sweat test diagnostic (Cl is 60-120 mmol/L) Genetic testing: CFTR mutation CXR to monitor disease progression
CF MX
MDT Approach- Paediatrician, GP, physiotherapist, dietician, specialist nurse, teachers rv annually at specialist centre Aim is to prevent progression, maintian adequate nutrition and growth Resp- physio incl chest percussion and postural drainage to clear mucus Hypertonic saline may help decrease sputum viscosity Prophylactic ABx and vaccinations Pancreas: oral pancreatic replacement therapy w all meals High calorie intake + high fat intake essential Vitamin supplements
CF end stage treatment
Lung transplant
Guthrie screening test for CF
Immune reactive trypsin increased
examination findings in bronchiolitis? (resp)
signs of resp distress e.g. intercostal, subcostal recessions, tachypnoea, tracheal tug, nasal flaring, grunting widespread fine inspiratory crackles wheeze
When to refer to emergency hospital care?
if apnoea, looks seriously unwell, central cyanosis severe resp distress e.g. grunting, marked chest recession, RR > 70, persistent SaO2 <92% on RA
apnoea + central cyanosis - emergency?
yes
RR>70 or RR>60 - emergency?
70
emergency signs of resp distress?
grunting marked chest recession
risk factors for more severe bronchiolitis?
immunodeficiency Chronic lung disease congenital heart disease age <3 mth premie
red flags of bronchiolitis?
fluid intake 50-75% of normal no wet nappy for 12 h apnoea cyanosis exhaustion worsening work of breathing
life threatening asthma attack - PEFR?
PEFR <33%
life threatening asthma features?
PEFR<33% silent chest too breathless to speak altered consciousness cyanosis confusion
Viral induced wheeze Mx?
give oxygen via face mask/ nasal cannula treat w SABA with spacer (salbutamol) Puff every 30-60 s up to 10 puffs.
Asthma acute exacerbation MX?
O2 SABA via spacer (salbutamol) or if severe/life threatening - nebulised salbutamol oral prednisolone
Pneumonia features?
high fever >39 cyanosis increased work of breathing focal crackles low saO2 dull percussion note haemoptysis
Pneumonia Ix?
obs- temp, RR, HR, SaO2, BP, clinical hydration status (CRT, skin turgor, mucous membranes, UO) examination of resp system- chest
pneumonia Mx?
rAntibiotics. amoxicillin 1st line if no response add Macrolide to cover mycoplasma pneumoniae. for 7-14 d
Ix for suspected inhaled foreign body?
bronchoscopy
barking cough
croup
examination findings of chronic resp disorder?
FTT finger clubbing hyperinflated chest
fever, progressive cough, Haemoptysis, weight loss
TB
chronic cough >8 wks DDx
asthma post nasal drip/ allergic rhinitis chronic lung infection: CF, primary ciliary dyskinesia interstitial lung disease TB habitual pertussis
whooping cough
pertussis
wet productive cough
CF bronchiectasis infection
Viral induced wheeze 2nd line mx if SABA not effective?
oral montelukast/ ICS
asthma history?
wheeze, cough, SOB, any daily/ seasonal variation? any triggers? FH/Hx of atopy?
asthma features on examination?
expiratory polyphonic wheeze
asthma investigations?
- spirometry 2. bronchodilator reversibility test (offer if obstructive spirometry) 3. peak flow variability
findings of an asthmatic with spirometry?
FEV1/FVC ratio <70%
findings of an asthmatic with bronchodilator reversibility test?
improvement of FEV1 of 12% or more
findings of an asthmatic with fractional exhaled nitric oxide?
> 35 ppb
findings of an asthmatic with peak flow variability?
>20%
what can you do to identify triggers after diagnosis of asthma made?
skin prick tests to aeroallergens or specific IgE tests
mx of asthma if not controlled on SABA + low dose ICS?
add leukotriene receptor antagonist Montelukast so reliever: SABA Maintenance tx: low dose ICS + LTRA
mx of asthma if not controlled on SABA + low dose ICS + not responsive to LTRA?
start LABA, stop LTRA so reliever: SABA Maintenance tx: low dose ICS + LABA
mx of asthma if not controlled on SABA + low dose ICS + LABA?
change ICS + LABA maintenance therapy to MART regimen w paediatric low maintenance ICS dose MART e.g. formoterol. 2 in 1 inhaler used daily
mx of asthma if not controlled on MART with low maintenance ICS dose?
Increase ICS to a paediatric moderate maintenance dose
mx of asthma if not controlled on MART w moderate maintenance ICS dose?
seek advice from healthcare professional w expertise in asthma increase ICS dose to high maintenance or trial of additional drug e.g. theophylline
mx of asthma if <5 yo?
SABA then add low dose ICS then add LTRA then refer to paediatric asthma specialist
e.g. of LABA?
salmeterol
e.g. of MART?
formoterol
What is low dose ICS?
<200 micrograms budesonide
what is moderate dose ICS?
200-400 micrograms budesonide
what is high dose ICS?
>400 micrograms budesonide
Bronchiolitis NICE recommends immediate referral usually by 999 ambulance if any of the following:
apnoea (observed or reported) child looks seriously unwell to a healthcare professional severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute central cyanosis persistent oxygen saturation of less than 92% when breathing air.
Bronchiolitis consider referring to hospital if?
respiratory rate of over 60 breaths/minute difficulty with breastfeeding or inadequate oral fluid intake (50-75% of usual volume ‘taking account of risk factors and using clinical judgement’) clinical dehydration.
what is the most common cause of stridor in neonates?
laryngomalacia.
congenital abnormality of the larynx infants typically present at 4 wks of age with stridor.
laryngomalacia can be exacerbated by intercurrent respiratory infections.
laryngomalacia - what is it?
laryngeal cartilage is soft and floppy. causing it to collapse and narrow during inspiration, resulting in inspiratory stridor. It is usually a benign condition with noisy breathing but no major problems w feeding or significant respiratory distress. Most cases resolve spontaneously within a year as the larynx grows and the cartilagninous rings stiffen.
when you see a strawberry haemangioma on the skin, what do you have to consider?
a haemangioma is a collection of small blood vessels that form a lump under the skin. most children only have one, but occasionally a child has multiple haemangiomas in various parts of the body. Haemangiomas can occur in various parts of the body. e.g. liver, airway, heart and brain. potentially life threatening e.g. in the upper airway -> assessment by ENT
DDx of stridor in infant
laryngomalacia laryngeal cyst/ haemangioma laryngeal stenosis
Dx of laryngomalacia?
visualization of the larynx using flexible laryngoscopy. Can be done by ENT surgeon as an outpatient procedure. This demonstrates prolapes over the airway of an omega-shaped epiglottis or arytenoid cartilages.
O/E with inhaled foreign body
unilateral wheeze and decreased air entry on one side
DDx of sudden/ acute onset stridor in child
Croup: usually URTI followed by barking cough, hoarse voice, stridor and low grade fever
Foreign body: sudden coughing and or choking, accompanying cyanosis
Anaphylaxis: exposure to allergen and usually w associated urticarial rash, facial swelling, vomiting, wheeze or hypotension
Epiglottitis: unimmunized child? drooling
Severe tonsilitis w v large tonsils
Bacterial tracheitis
Mx of Croup/ acute stridor
ABC
Oral dexamethasone
(nebulised budesonide)
If 2-3 h later and child has improved, SaO2>95% on air, child can be discharged.
If not, further dose of steroids can be administered 12-24 h later.
If the child deteriorates, then nebulized adrenaline can be administered. If adrenaline is requied then senior help and an anaesthetist should be summoned urgently.
If further deterioration, then intubation and ventilation to secure airway. If intubation unsuccessful, an ENT surgeon will be required to perform an emergency tracheostomy.
Dx for RSV
Nasopharyngeal aspirate for viral immunofluorescence and Polymerase chain reaction or culture.
Largely for infection control and epidemiology and does not affect acute management.
Prevention of RSV bronchiolitis?
Pavilizimub
monoclonal RSV Ig
reserved for high risk infants, e.g. premies, CHD, CLD
Indications for hospital referral with bronchiolitis
apnoeic episodes
intake <50% of normal in last 24h
cyanosis
severe resp distress- grunting, nasal falring, severe recession, RR>70/min
Congenital heart disease, pre-existing lung disease or immunodeficiency.
Significant hypotonia e.g. trisomy 21 - less likely to cope with resp compromise
survivor of extreme prematurity
social factors
v low threshold for admitting any baby <2 months of age on day 1 -2 of their illness as they may deteriorate and become exhausted and apnoeic.
If infant in hospital with bronchiolitis and deteriorating?
capillary blood gas checked
CXR IF clinical course unusual
Blood tests if diagnostic uncertainty e.g. if temp>39 or a superadded bacterial infection is suspected.
Small proportion of infants need high dependency or intensive care- most respond well to continous positive airways pressure (CPAP)
*exposure to tobacco smoke must be avoided.
DDX of recurrent or persistent cough in childhood
recurrent viral URTIs
ashtma - usually w wheeze / SOB
allergic rhinitis- often nocturnal due to post nasal drip
chronic non specific cough- probably post viral w increased cough receptor sensitivity
pertussis - can continue for months
recurrent aspiration- GOR
envt - smoking,
suppurative lung disease- CF/ primary ciliary dyskinesia
TB
Habit
erythema multiforme with resp symptoms- crackles, fever, coryza etc
suggestive of mycoplasma pneumoniae
presentations of CF in neonate
meconium ileus
intestinal atresia
hepatitis/ prolonged jaundice
presentation of CF in an infant
FTT
Malabsorption and Vit A, D, E, K deficiciency-> steatorrhoea
rectal prolapse
presentation of CF in older child
recurrent chest infections
haemoptysis
nasal polyps
diabetes mellitus (exocrine pancreatic insufficiency)
liver disease
distal intestinal obstruction syndrome
National newborn screening of CF: what does it look for?
immunoreactive trypsinogen
(a pancreatic enzyme precursor found in the blood that is raised in most of those w CF at birth)
IRT raised since pancreatic ducts are partially blocked leading to abnormal enzyme drainage.
most common cause of finger clubbing in children
Cystic fibrosis
in Asthma, signs of impending resp failure
exhaustion
unable to speak/ complete sentences
colour - pallor/ cyanosis
hypoxia despite high flow humidified oxygen
restless and agitation are signs of hypoxia, esp in small children
silent chest
tachycardia
drowsiness
PEFR persistently <30%
mx of acute asthma attack
acute mx goals are to correct hypoxia, reverse airway obstruction and prevent progression.
Give high flow oxygen via mask and monitor saturations.
Start regular inhaled B agonist (salbutamol) via a nebulizer. B agonists can be given continuously- but cardiac monitoring is needed.
Inhaled Ipratropium Bromide.
Give oral prednisolone or IV hydrocortisone.
Capillary or venous blood gas and a CXR may be required.
if child continues to deteriorate,
IV salbutamol, IV MgSo4 (Smooth muscle relaxant) and IV aminophylline
Review in a child whose asthma is not well controlled
- review compliance
is there parental supervision?
- review technique
Children rarely use MDIs effectively and need a spacer, esp during acute episodes.
- consider stepping up tx
- smoking in the household? education about allergen avoidance e.g. daily vacuuming to reduce house dust mites.
- all asthmatics should have a written home mx plan.
- asthma symptom diary
In SIADH, what is the urine and serum osmolality?
serum osmolality is low
urine osmolality is high
normally, a fall in serum osmolality would suppress ADH secretion to allow excretion of excess water as dilute urine. In SIADH, urine osmolality is inappropriately high (>320) and urine sodium is usually high (>40mmol/L) unlike in hypovolaemic states where it is <20mmol/L
pneumonia in a child + hypoNa
SIADH
diarrhoea/ excessive vomiting -> hypovolaemic hypoNa
Mx of pneumonia
oxygen to maintain SaO2 >92%
adequate pain relief for pleuritic pain (may be tummy pain esp if lower lobe pneumonia)
IV Abx according to local guidelines e.g. co-amoxiclav
Fluid balance, U&Es monitoring- adjust fluids accordingly.
Physiotherapy e.g. bubble blowing, encourage mobility
Monitor for development of a pleural effusion. if present- longer course of abx needed. or even a chest drain
Ensure adequate nutrition - low threshold for supplementary feeds via ng tube
arrange for follow up CXR in 6-8 wks in those w lobar collapse and/ or effusion.
What are the side effects of continuous B agonist e.g. salbutamol?
irritability, tremor, tachycardia, hypokalaemia
so must have cardiac monitoring
DDx of chest pain in children
w lack of any resp/ chest signs
Idiopathic/ psychological chest pain - due to stresses e.g. family death, bullying, anxiety
Costochondritis - tenderness on palpation of cartilage in the anterior chest wall and pain may be worse on movement or coughing.
trauma e.g. fractured rib
exercise e.g. overuse injury
reflux oesophagitis
sickle cell disease with chest crisis
w resp signs:
pneumonia w pleural involvement
asthma
severe cough
pneumothorax
chest signs:
pericarditis, angina eg from severe aortic stenosis
what is costochondritis?
inflammation of the cartilage that connects the inner end of each rib to the sternum
tenderness on palpation and pain may be worse on movement or coughing.
usually self limiting. consider NSAIDs for pain relief.
assessment of a child w multiple congenital abnormalities
characteristic pattern of abnormalities?
karyotyping/ other specific genetic tests
clinical geneticist should assess child
making a diagnosis allows future problems to be anticipated and allows genetic counselling about recurrence risk in future pregnancies
what is apnoea
cessation of breathing >20s
or shorter if there is color change/ bradycardia
causes of apnoea in newborn
apnoea of prematurity
lung disease
congenital heart disease
sepsis
hypoglycaemia
hypothermia
sedative drugs
neuro insults
gastro-oesophageal reflux
sudden desaturation in ventilated neonate?
chest movement decreased/ asymmetrical
pneumothorax
worsening resp disease
sudden desaturation in ventilated neonate
no chest movement
ventilator not working/ disconnected
endotracheal tube blocked/ dislocated
sudden desaturation in ventilated neonate
chest movement normal
right to left shunt e.g. PDA
large periventricular haemorrhage
severe sepsis
mx of pneumothorax
chest drain
- should be inserted into the 3/4/5th intercostal space in the mid axillary line
then CXR should be done to ensure that the lung has re-inflated and to check the position of the drain
diagnosis of pneumothorax
cold light transillumination (one side lights up)
and/or CXR
duodenal atresia is also assoc w?
Downs
malrotation
oesophageal atresia
congenital heart disease
what is the concerning complication with eyelid swelling/ orbital cellulitis?
meningitis
as infection spreads to the CSF around the optic nerve
neonatal jaundice in first 24h of life
mother is O+ baby is A+
ABO incompatibility
it can occur w first pregnancy and does not get worse w successive pregnancies.
anti-A and anti-B is naturally found
causes of a floppy infant
central vs peripheral causes
central causes more common.
central- deep tendon reflexes are present
peripheral (neuromuscular cause)- absent
causes of floppy infant
peripheral (neuromuscular) causes
infantile spinal muscular atrophy
congenital myasthenia
congenital myotonic dystrophy
congenital muscular dystrophy
causes of floppy infant
central causes
chromosomal disorder e.g. Downs, Prader-Willi
Brain injury e.g. HIE
brain infection/ sepsis
metabolic disturbance e.g. hypoglycemia
drug exposure e.g. pethidine
what would a baby whose delivery was complicated by shoulder dystocia look like?
apnoeic
bradycardia
asystolic
pale
floppy
-> acute asphyxial insult as a result of cord compression
resuscitation of newborn
baby dried, covered and assessed for color, tone, breathing, heart rate
if the baby is not breathing, airway should be opened by placing head in neutral position
+ five inflation breaths
effectiveness of inflation breaths should be assessed by checking for increase in HR
chest compressions may be required
baby may also require adrenaline/ sodium bicarb to be administered
transfer to neonatal unit immediately for supportive and neuroprotective care
Causes of congenital malformations
congenital:
- chromosomal abnormalities
= gene defects
environmental:
- maternal factors e.g. diabetes
- prescribed drugs e.g. phenytoin
- recreational drugs e.g. alcohol
envt toxins
- infections e.g. CMV/ rubella
sporadic
CHARGE syndrome
coloboma, heart defects, atresia (choanal), retardation of growth and development, genital and ear abnormalities
Microdeletions e.g. Digeorges
Diagnosis via?
FISH
a severe resp infection in early children may lead to?
bronchiectasis
caused by dilatation and poor mucociliary clearance, predisposing to further infection.
primary ciliary dyskinesia
affects?
resp tract and reproductive organs - which are lined by cilia.
+ assoc w dextrocardia/ situs inversus
what lobe is a foreign body most likely to end up in
right middle lobe
