Resp Flashcards
Signs of respiratory distress
Tachypnoea Increased WOB Cyanosis Recessions Nasal flaring Tracheal tug Grunting See-saw abdomen
Commonest cause of child death worldwide
Resp
What is stridor
Narrowing/obstruction of upper airways
4 causes of stridor
Croup
Epiglottitis
Foreign body
Larngomalacia
Commonest causative organism of epiglottitis
Hib
Epiglottitis age of presentation
1-6 years
Epiglottitis clinical features
Sudden onset Quiter/whispering stridor High fever Sore throat Drooling - unable to swallow secretions (Absence of a preceding coryza - unlike croup)
What must you not do in a child with epiglottitis?
Examine their throat or lie the child down
Allow them to position themselves
Management of epiglottitis
Blood cultures Urgent admission (?PICU) IV ceftriaxone Steroids \+/- adrenaline nebs Prolonged intubation if severe
Recovery of epiglottitis
Usually 2-3 days
Clinical features of croup
Onset over days Barking stridor (seal) Preceding coryza Hoarseness Fever (Symptoms worse at night)
Age of presentation croup
6mos - 6 yrs
Percentage of croup with viral cause
95%
What is croup
Laryngotracheal bronchitis with mucosal inflammation and increased secretions
Management of mild croup
Single dose oral dex 0.15mg/kg
Three severities of croup and defining features
Mild - symptoms disappear at rest
Moderate - symptoms persist at rest
Severe -
Management moderate croup
ADMISSION
Oral/nebulised dex/budenoside
+/- nebulised adrenaline
Management severe croup
ADMISSION
IV dex, nebulised adrenaline
100% O2
Intubation
Prognosis croup
Usually resolves over 48 hours
Where is a foreign body more commonly found
R main bronchus
CXR features of foreign body
Hyperlucent on one days, mediastinal shift to the other side
Management of foreign body in conscious child
Encourage coughing
5 back blows
5 heimlich’s (not on infants/very young children)
Flexible/rigid bronch (w/ conscious sedation/GA)
Surgery/thoracotomy
Management of a foreign body in unconscius child
Secure airway (ET tube)
Remove FB from upper airway
Cricothyroidotomy
Inspiratory stridor in otherwise well child
Laryngomalacia
What is laryngomalacia
Cartilage rings not yet strong enough to hole patent airway
Complications of foreign body
Bronchiectasis if diagnosis delayed
Ix for laryngomalacia
Flexible laryngoscopy showing omega shaped epiglottis
Monitor SATs
Mx of laryngomalacia (mild/mod/severe)
Mild: observation looking for resp distress/FTT. GORD therapy (thickened fluids, baby gaviscon, Nissen fundoplication. Patient fed upright)
Moderate: observation. Surgery - supraglottoplasty relieving obstruction. BiPAP. GORD therapy.
Severe: surgical therapy - supreaglottoplasty. BiPAP. GORD therapy.
Causes of cough in child
Asthma URTI/LRTI (viral/bacterial) Pertussis CF Smoking parents GORD Bronchiectasis TB
Commonest cause of cough
URTI
Age of presentation pertussis
3 years
Causative agent pertussis
Bordatella pertussis
Pertussis presentation
1 week of coryza
Paroxysmal cough with expiratory “whoop” (+/- cyanosis)
Vomiting
Worse at night and after feeding
Epistaxis and conjunctival haemorrhage (from increased pressure)
How long does pertussis persist for?
3-6 weeks
Investigations and results for pertussis
Nasal swab
Blood film shows marked lympocytosis
Three phases of pertussis
Catarrhal
Paroxysmal
Convalescent
Management of pertussis
NOTIFY HPU
Admission(isolation) if <6 months old, significant breathing difficulties, complications (e.g. seizure,pneumonia)
Azithromycin if still in catarrhal phase (within 21 days of cough starting)
School exclusion until 48 hours after starting abx
When can Azithromycin be given in pertussis?
Within 21 days of cough starting (catarrhal phase)
When can a child with pertussis return to school?
48h after starting abx
Causes of bronchiectasis
CF Kartagener's (ciliary dyskinesia) Delayed foreign body Chronic aspiration Immunodeficiency
Presentation of bronchiectasis
Recurrent URTI/LRTI infections Purulent cough (green sputum)
Chronically dilated bronchi
Investigations and results bronchiectasis
CT - permanent dilatation of bronchi
Management of bronchiectasis
Improved nutrition
Exercise
Airway clearance therapy (physiotherapists)
Inhaled SABA/hypertonic saline
Tobramycin if common P.aeuroginosa infections
Long term macrolide PO (e.g. azithro)
Surgical lung resection/transplantation
Which abx is appropriate in a patient with recurrent P.aeuruginosa infections?
Tobramycin
Which patients often get P.aeuruginosa infections?
CF
Bronchiectasis
Kartagener’s
Pathophysiology of GORD
Inappropriate relaxation of LES
Management of GORD
Physical - position during feeding, winding
Feed - smaller, more frequent feeds. Consider thickener.
Baby gaviscon
PPI
Complications of GORD
Oesophagitis
FTT
What must be considered (feeding) in patients with resp illness?
Ensuring they have enough feed.
Also cutting down feed to 2/3 because thorax working hard, more likely to precipitate GORD/vomit
Causes of wheeze in child
Asthma (acute/chronic) Viral episodic wheeze Bronchiolitis Pneumonia Allergy CF
Age of presentation viral episodic wheeze
<3 years
Presentation of viral wheeze
Resp distress
Wheeze
Coryzal symptoms (+preceding)
Reduced feeding
Risk factors for viral wheeze
Smokers in household Mother smoking during pregnancy Pets Damp/mould Other ill contacts
Management viral wheeze
Burst therapy (3x salbutamol nebs, ? 1x ipratroprium). If inhaled -- SPACER
Inhaled glucocorticoids
“Stretching” - once they can last 4 hours without symptoms, can be discharged.
(At home can be given 10 puffs every 4 hours (via space))
Viral episodic wheeze (parent explanation)
Narrowing of airways due to viral chest infection causes whistling sound
Paent information on discharge: viral wheeze
Salbutamol - 10 puffs every 4 hours via spacer.
If requiring more than every 4 hours, or requiring more than 10 puffs, come back.
Any other resp distress, come back - recessions, nasal flaring, tracheal tug, etc.
Two types of asthma
Atopic/non-atopic
Features of asthma
Child > 3 years Wheeze on more than one occasion Worse at night/morning Worse in cold/on exercise Interval symptoms (Response to SABA) DRY COUGH
Asthma signs
Prolonged expiratory phase
Polyphonic widespread wheeze
Hyperinflated chest
Harrison Sulci - COPD of childhood
Investigations in suspected asthma
Examination
CXR - hyperinflated chest, Harrison sulci
PEFR
Skin prick to gauge atopy
Features of moderate asthma attack
PEFR >50%
SPO2 >92
Features of severe asthma attack
PEFR 33-50% SPO2 <92 Difficulty talking Tachycardia/pnoea Use of accessory muscles
Features of life threatening asthma attach
PEFR <33% SPO2 <92 Silent chest Reduced consciosness "Normal" CO2 Reduced BP
Acute asthma attack treatment (escalation ladder)
ABCDE
O2 if hypoxic
Burst therapy (3x back to back SABA nebs)
Ipratroprium nebs
Oral pred
IV bronchodilators - aminophylline, theophylline, MgSO4
IM adrenaline
TRANSFER TO ICU
Appropriate salbutamol dose in <5 yr child
2.5mg
Appropriate salbutamol dose in >5 yr child
5mg
What factors does chronic asthma management depend on? And what is it trying to achieve?
Frequency of attacks Severity of attacks Interference with school Sleep disturbance Exercise tolerance Growth/nutrition
Chronic asthma management in child <5 years
Inhaled SABA (10 puffs 4x/day) \+ low dose ICS/LTRA \+ med dose ICS \+ high dose ICS and specialisr r/f \+ PO steroids
Chronic asthma management in child >5 years
Inhaled SABA (10 puffs 4x/day) \+ low dose ICS/LTRA \+ med dose ICS + LABA \+ high dose ICS and specialisr r/f and omalizumab \+ PO steroids
What is omalizumab?
Monoclonal antibody used in asthma therapy (>5 years). Used in allergy therapy
What is asthma?
Bronchial hyperresponsiveness and airway narrowing
Commonest serious resp condition in <2 years
Bronchiolitis
Commonest causative organism in bronchiolitis
RSV
What % of patients with bronchiolitis are admitted?
2-3
Presentation of bronchiolitis
Preceding coryzal features, then dry distinctive cough, increased SOB/WOB
- Feeding difficulty
- Recurrent apnoea
- Fever
- Pallor
- Tachy
Bronchiolitis signs
- Fine end inspiratory crackles
- Prolonged expiration
- Hyperinflation
Ix bronchiolitis
NPA (viral PCR)
Monitor O2 SATs
CXR
Blood gas
Mx bronchiolitis
Humidified O2 if SATs <92% (optiflow/airvo)
CPAP
Suction
IVI (maintenance/recovery fluids - consider 2/3 if breathing affecting feeding)
Pavulizumab - monoclonal antibody against RSV
What is pavulizumab?
Monoclonal antibody against RSV
Reduced incidence of bronchiolitis when given to preterm infants
What causative organism is commonly associated with lobar consolidation?
S.pneumoniae
Features of pneumonia
Preceding URTI Fever DIB Poor feeding Generally unwell
Mx penumonia
Admission if: SATs <92 on air Resps >60/min T > 38 (if <3 mos) Cyanosis Clinically dehydrated
Amoxicillin 7-14/7
Controlled O2
Commonest life long AR conditions in caucasians
CF
Common presentation of CF
Persistent purulent cough after acute infection Meconium ileus Pale, greasy stools (Clubbing) POOR GROWTH
Pathophysiology of CF
Mutation in Cl- ion transporters. Blocks flow of H2O - thick, viscous secretions
Three commonly affected organs in CF
Lungs
Bowel
Pancreas
Resp effects of CF
Thick, viscous secretions
Recurrent endobronchial chest infections (P.aeruginosa)
Bowel effects of CF
Thick, viscid meconium
Meconium ileus in 10-20% patients
When is CF detected?
Guthrie
Pancreatic effects of CF
Thick, viscid pancreatic secretions = reduced enzymes into bowel.
Reduced elastae
Enzyme deficiency
Malabsorption
Resp treatment for CF
Chest physio (with SABA first to help open up airways)
Mucolytics (rhDnase and inhaled hypertonic saline)
Inhaled tobramycin
Ibuprofen/steroids (anti-inflammatories)
CFTR modulators (e.g. ivacaftor)
How often should CF patients be reviewed?
Annual review of their condition AND at least one other review per year by specialist CF MDT
What is ivacaftor?
CFTR modulator used in CF management - helps thin the thickened mucous
Which conditions are classes as “URTI”?
Common cold
Sinusitis
Pharyngitis/tonsilitis
Acute otitis media
Why does frontal sinusitis rarely present in children under 10 years?
Frontal sinuses only develop in late childhood
Sinusitis presentation
Coryza/cough
Bad breath
General feeling unwell
Painful cheeks/eyes
Yellow-green nasal/post-nasal drip
Commonest cause of sinusitis <10 days
Viral
When should pt with sinusitis be admitted?
If severe systemic infection
Intracranial symptoms - meningitis
Intra-periorbital symptoms
Treatment for sinusitis lasting <10 days
NO abx
Consider nasal decongestant/nasal steroid spray
Paracetamol/ibuprofen for fever
Return if lasts longer than 3/52
Commonest cause of sinusitis >10 days <4 weeks
Bacterial
Treatment for sinusitis lasting >10 days
Abx (delayed - if persists beyond 10 days) AMOXICILLIN
Paracetamol/ibuprofen for fever
High dose nasal steroids if >12 years (mometasone)
Seek advice if symptoms worse
Persistent cough after acute infection
CF
Unresolved lobar collapse
Persistent cough
CF TB Unresolved lobar collapse (Asthma) GORD
Kartagener’s syndrome
Primary ciliary dyskinesia
Situs inversus
Dextrocardia
Predisposing factors for sleep disordered breathing
Hypotonia Obesity Muscle weakness Anatomical problems Enlarged tonsils/adenoids
Ix sleep disordered breathing
Overnight O2 saturations: frequency/severity of periods of desaturation
Mx sleep disordered breathing
Adenotonsillectomy (if hypertrophy)
CPAP/BiPAP to maintain upper airway
Montelukast +/- intranasal budesonide if surgical intervention does not help
