Resp Flashcards
Wheeze V Stridor
Wheeze = polyphonic, expiratory noise, mainly from lower airway. Stridor = Inspiratory, harsh noise, from larger upper airways.
Signs of acute upper airway obstruction
Stridor
Hoarseness
Barking cough
Variable dyspnoea
Differential diagnosis for a child with STRIDOR 🤷♀️🤷♀️🤷♀️
Croup/laryngotracheobronchitis Pseudomembranous croup/Bacterial tracheitis Rhinitis Epiglottitis Anaphylactic reaction Inhaled foreign body Whooping cough/Pertussis Retropharyngeal abscess
Croup epidemiology and pathogenesis
Upper airway obstruction and inflammation
Mostly due to viral infection
Commonly 6months-6years
Mostly due to parainfluenza virus
Classic symptoms of croup
Coryzal of several days
Barking cough, strider hoarse voice, respiratory distress.
Low grade fever
Can have respiratory distress with signs such as intercostal and sternal indrawing/recessions.
Symptoms worse at night and on agitation.
Management of croup
Most mild cases can be managed at home with appropriate safety-net advise and basic analgesia. Oral dexamethasone (0.15mg/kg), oral prednisolone or nebulised steroids can be prescribed to reduce severity and duration. If severe = nebulised adrenaline with oxygen facemask. but beware of rebound effect.
Pseudomembranous croup
Bacterial tracheitis
More acute onset
Bacterial cause (croup mostly viral) S.aureus.
VERY HIGH FEVER, airway obstruction, increased secretions creating mucopurulent exudate.
Loud harsh stridor.
Treat with IV flucloxacillin.
Epiglottitis causative organism
H.influenza type B
Clinical features of epiglottis
ACUTE ONSET - EMERGENCY! Drooling saliva Very ill child/toxic Very high temp over 38.5 Soft stridor Very sore throat preventing child from speech and swallowing. Difficulty in breathing/resp distress No cough No coryza prodrome
Management of epiglottitis
DO NOT EXAMINE THROAT! SECURE AIRWAY! IV access Cefuroxime Rifampicin for close contact prophylaxis.
Bronchiolitis main causative organism and peak age of onset
Respiratory syncytial virus
Affects children less than 12months old.
Clinical features of bronchiolitis
Apnoea in under 4months Coryza prodrome Sharp dry cough Tachypnoea Low grade temp Hyperinflation Pallor and cyanosis Sub and inter-coastal recessions
Differentials for bronchiolitis
Pneumonia Infective exacerbation of asthma Viral induced wheeze Whooping cough GORD Cystic fibrosis
Risk factors for developing bronchiolitis
Preterm (<32weeks) Cystic fibrosis Congenital heats defect babies Very young babies Neuromuscular disorder babies
Diagnosing bronchiolitis
CLINICAL DIAGNOSIS
PCR of nasopharyngeal secretions for causative organisms (msc)
Treating bronchiolitis
No cure, supportive care.
High flow O2/CPAP
Isolation treatment/barrier nursing.
Good feeding and fluid intake.
Prophylaxis of bronchiolitis
Monoclonal antibody for RSV. Given to high risk babies (e.g.premature) via IM injection in winter months. expensive so limited use!
Types of respiratory infections in children
Upper airway = coryza, otitis media, pharyngitis, tonsillitis.
Laryngeal/tracheal = croup, epiglottitis, bacterial tracheitis.
Bronchitis
Bronchiolitis = RSV
Pneumonia
Aetiology of community acquired pneumonia in children
Most are viral - respiratory syncytial virus.
Neonate bacterial = group B strep (from mother’s tract), E.coli.
Infant bacteria = Strep pneuoniae, H.influenza, S.aureus.
Children over 5 bacteria = Mycoplasma pneumoniae, S.pneumoniae, Chlamydia pneumoniae.
Always consider mycoplasma tuberculosis.
Clinical features of pneumonia
High fever Cyanosis Tachypnoea Cough Lethargy Increased work of breathing = chest in-drawing, nasal flaring, grunting. Poor feeding. End expiratory coarse, focal crackles in auscultation. Low Oxygen sats (No hyperinflation)
Symptoms and signs suggestive of a bacterial pneumonia
Localised chest, abdo or neck pain = pleural irritation.
Pleural effusion (absent breathes sounds, dull percussion)
Lobar consolidation
Leukocytosis.
Investigations for pneumonia
SpO2 CXR - localised consolidation FBC Sputum and blood cultures Do not require investigations if child is being treat with CAP at home (safety-net)
Treatment of pneumonia
As viral and bacteria can not be easily differentiated, always give ABx -amoxicillin.
Signs of a child with pneumonia needing hospital admittance
SpO2 less than 92%
Grunting, recessions, resp rate over 60breaths/min
Cyanosis
Signs of pneumonia complicated by effusion.
Unrousable and unresponsive to cues.
Temp over 38 if 3months or less
Differentials for wheeze/cough/pneumonia
Viral induced wheeze.
Acute exacerbation of asthma - Hx of asthma or atopy, worsened by asthma triggers.
Bronchiolitis - sharp dry cough, prodrome.
CAP - acute, localised consolidation.
Bronchiectasis - copiious sptum, frequent RTI.
CF - productive cough, GI symptoms, failure to thrive, chronic symptoms from birth.
Pertussis - paroxysms coughing followed by inspiratory whoop.
Asthma pathophys
Triggers e.g. pollen, dust mites cause IgE production via Th2 cells.
Airway oedema, excess mucus production and plugging, white cell infiltration into epithelium.
Bronchial hyper-responsiveness.
Bronchoconstriction.
Airway narrowing and obstruction.
Reversible changes.
INFLAMMATION + AIRWAY HYPERSENSITIVITY
Risk factors for asthma
Low birth weight
FHx/genetic atopy
Pollution and exposure to tobacco smoke
Hx of lung disease
Clinical features of asthma
COUGH, WHEEZE, SOB.
Recurrent, episodic polyphonic wheeze - worse at night and in early morning (diurnal variation).
Wheeze is triggered by exercise, mites, emotions, laughter, dust etc
Chest tightness, breathlessness, cough
Symptoms worsened on infection (exacerbation)
Details of the wheeze in asthma
Polyphonic
Episodic
Triggered by laughter, emotions, dust, pets, cold, allergens.
Worse in early morning and night.
Investigations for asthma
Fractional exhaled nitric oxide test = +ve if result over 40ppb
Spirometry = FEV1/FVC < 70%
Bronchodilator reversibility = bronchodilator will improve FEV1/FVC by 12%
Variable peak expiratory flow = more than 20% variability in twice daily testing for 2-4weeks.
Chronic asthma drug treatment
1) Short acting beta-2-agonist as reliever e.g. PRN salbutamol
2) Add inhaled corticosteroid as preventer e.g. OD beclometasone.
3) Add leukotriene receptor antagonist e.g. pd Montelukast.
4) Stop LRTA and add long-acting beta-2-agonist .e.g salmeterol.
5) MART regime = maintenance and deliver therapy e.g. ICS and LABA in 1 inhaler.
6) Increase ICS dose
7) Specialist assessment.
How does treatment of asthma change if child under 5
If asthma not controlled on ICS and LRRA for to specialist
General advise and education for asthma and review topics
Self-management education. Up to date on routine vaccines. Advise on avoiding triggers. Explain how to use inhalers. In review - ask about days off school, oral steroid use, inhaler technique and adherence.
Signs in a moderately severe asthma exacerbation
peak expiratory flow rate is between 50-75%. Normal speech. No features of acute or life-threatening asthma
Signs in an acute severe asthma exacerbation
PEFR between 33-50% tachypnoea tachycardia inability to complete sentences in a single breath use of accessory muscles inability to feed SpO2 less than 92%
Signs of a life-threatening asthma exacerbation
PEFR less than 33% SpO2 less than 92% Altered consciousness exhaustion or arrhythmia hypotensive cyanosis silent chest confused. Poor resp effort
Management of acute asthma exacerbation
1) High flow 100% oxygen
2) SABA + ipratropium bromide nebulised
3) Prednisolone or hydrocortisone
4) Consider Magnesium Sulphate
5) Aminophylline
6) Consider CPAP get some more help!
Genetics of cystic fibrosis
Autosomal recessive.
Chromosome 7 mutation at cystic fibrosis transmembrane conductance regulator gene (CFTR), dysfunctional cyclic AMP-regulated sodium/chloride channel.
Diagnosis of cystic fibrosis
Guthrie test in postnatal period = raised immunoreactive trypsinogen.
Sweat test = greater than 60mmol/L of chloride.
Genetic counselling.
Infancy clinical features of cystic fibrosis
Meconium ileus
Prolonged neonatal jaundice
Failure to thrive
Recurrent chest infections with atypical organisms
Steatorrheoa and malabsorption due to pancreatic insufficiency,
Clinical features of a child with cystic fibrosis
Recurrent chest infections with atypical organisms (Bronchiectasis) Rectal prolapse Nasal polyp Sinusitis Distal intestinal obstruction syndrome
Clinical features in an adolescent with cystic fibrosis
Diabets mellitus Cirrhosis and portal HTN Pneumothorax Allergic bronchopulomary aspergillosis Sterility/infertility
Atypical organisms seen in cystic fibrosis RTI
S.aureus
H.influenza
P.aeruginosa
Resp clinical features of cystic fibrosis
Persistent cough which produces purulent sputum. Hyperinflation of chest. Expiratory wheeze Coarse inspiratory creptations. Clubbing Haemoptysis Neutrophilic airway inflammation.
Meconium ileus
Presents in first days of life.
Thick meconium causes bowel obstruction = vomiting, abdo distension and poor defection.
Steatorrhoea
Oily, loose, pale fatty stools
Pathophys of cystic fibrosis
Low chloride secretion High sodium reabsorption More viscous mucus Worse muco-cilary clearance. Increased bile concentration. Stagnation of pancreatic enzymes (DM)
MDT for cystic fibrosis
Paediatrician Nures Physio Dietician Pharmacist Psychologist Social worker
Annual review of cystic fibrosis
Pulmonary assessment. Nutrition assessment. DM testing Psych review exercise programme.
Treatment for pulmonary symptoms of cystic fibrosis
Airway clearance techniques and exercises. Teach percussion and postural drainage. 2-3/day
Immunomodulatory agent e.g. azithromycin or corticosteroid.
Mucoactive agent e.g. rhDNase, hypertonic saline or mannitol dry powder.
Treatment for GI symptoms of cystic fibrosis
Replace pancreatic enzymes e.g. Pancrex V
High calorie diet
Fat soluble vitamin supplements.
Complications of cystic fibrosis
Diabetes mellitus Cirrhosis Distal intestinal obstruction syndrome Low bone density Pancreatic insufficiency.
Type of immune response seen in asthma
Hypersensitivity type 1
Contents of sputum from asthma
Curschmann’s spirals
Charcot-Leyden crystals
4 signs on auscultation of pneumonia
Crackles
Pleural rub
Increase vocal resonance
Bronchial breathing
