respiratory Flashcards
Presentation of URTI
coryza, sore throat, earache, sinusitis or stridor
presentation of LRTI
cough, wheeze and respiratory distress.
moderate of resp distress
tachypnoea, tachycardia, nasal flaring use of accessory respiratory muscles, intercostal & subcostal recession head retraction inability to feed cyanosis abnormla airway noises tracheal tugging
severe of resp distress
cyanosis, tiring because of increased work of breathing, reduced conscious level, oxygen saturation < 92% despite oxygen therapy.
children who are particularly susceptible to resp failure
ex-preterm infants with bronchopulmonary dysplasia, those with haemodynamically significant congenital heart disease or disorders causing muscle weakness, cystic fibrosis (CF) or immunodeficiency.
stridor
- High-pitched, harsh, high-intensity inspiratory sound.
- Produced as turbulent low passes through a narrow segment of UA.
- Suggests upper airway narrowing.
- Can be heard over the upper airways at a distance without a stethoscope.
- Usually inspiratory; can be biphasic.
Inspiration sound
extrathoracic airway obstruction in the trachea and larynx, is predominantly inspiratory
harsh, muscial sound due to partial obstruction of the lower portion of the upper airway including the upper trachea and the larynx
wheeze
- High-pitched; musical.
- Heard initially on expiration
- Indicates lower airway narrowing.
URTIs may cause
- difficulty in feeding in infants as their noses are blocked and this obstructs breathing
- febrile seizures
- acute exacerbations of asthma.
features of a common cold coryza
clear or mucopurulent nasal discharge and nasal blockage.
rhinoviruses
sore throat features
causes
pharyngitis the pharynx and soft palate are inflamed and local lymph nodes are enlarged and tender.
- viral infection (mostly adenoviruses, enteroviruses, as well as rhinoviruses).
In the older child, group A β-haemolytic streptococcus is a common pathogen.
tonsillitis features
assessment
Mx
form of pharyngitis
purulent exudate
group A β-haemolytic streptococci and the Epstein–Barr virus (infectious mononucleosis).
centor criteria
Mx
penicillin V for 10 days
scarlet fever
group A streptococcal infection diffuse erythematous eruption
fever, presence of headache
rash - sandpaper-like maculopapular rash w flushed cheeks and perioral sparing
strawberry tongue
Mx
penicillin V or erythromycin
complications
glomerulonephritis
rheumatic fever
sinusitis occur in which sinuses
maxillary not frontal s they dont develop til then
indications of tonsillectomy
recurrent severe tonsillitis peritonsillar abscess (quinsy) obstructive sleep apnoea
DDx of stridor
- CROUP Viral laryngotracheobronchitis
- Epiglotittis - haemophilus influenzae
inhaled foreign body
Rare causes Epiglottitis Bacterial tracheitis Laryngeal or oesophageal foreign body Allergic laryngeal angioedema (seen in anaphylaxis and recurrent croup) Inhalation of smoke and hot fumes in fires Trauma to the throat Retropharyngeal abscess Hypocalcaemia Severe lymph node swelling (tuberculosis, infectious mononucleosis, malignancy) Measles Diphtheria Psychological – vocal cord dysfunction
severe obstruction signs
increasing respiratory rate, heart rate, and agitation. Central cyanosis, drooling or reduced level of consciousness
hypoxaemia - oximetry
features of croup
6ms - 2yts
gradual onset - coryza
fever
• hoarseness due to inflammation of the vocal cords
• a barking cough, like a sea lion, due to tracheal oedema and collapse
• harsh stridor
• variable degree of difficulty breathing with chest retraction
• the symptoms often start, and are worse, at night.
categorise of severity Sx croup
Mild – seal-like barking cough but no stridor or sternal/intercostal recession at rest.
<4 - oral dexamethasone
<2 discharge otherwise observe for one hour
Moderate – seal-like barking cough with stridor and sternal recession at rest; no agitation or lethargy.
4-6
- Prompt senior review.
- oral dexamethasone.
Nebulised budesonide (if can’t take orally).
O2 is sats <92%.
- If improving observe for 2-3 hours and discharge is score <2.
- If ongoing respiratory concerns admit
Severe – seal-like barking cough with stridor and sternal/intercostal recession associated with agitation or lethargy. >6 - Urgent senior review - Nebulised adrenaline. - Nebulised budesonide. - Reassess diagnosis. - Notify CICU.
resp failure
Alert CICU.
Fast bleep senior SpR, ENT and anaesthetics.
Nebulised adrenaline.
Nebulised budesonide.
Do NOT attempt IV access unless airway secure or senior input
Mx of mild illness croup
single dose of oral dexamethasone (0.15 mg/kg) to be taken immediately.
Sx usually resolve within 48 hours
Mx if waiting hospital admission severe
O2 w nebulised epinephrine to all children with severe illness
Administer a dose of oral dexamethasone (0.15 mg/kg). If the child is too unwell to receive medication, inhaled budesonide (2 mg nebulised as a single dose) or intramuscular dexamethasone (0.6 mg/kg as a single dose) are possible alternatives.
acute epiglottitis
H influenza type B
1-6 yrs
- high fever in a very ill, toxic-looking child
- drooling
- soft inspiratory stridor
- rapidly increasing respiratory difficulty over hours
• the child sitting immobile, upright, with an open mouth to optimize the airway. - epigloitis cherry red, swollen, inflammed
Mx
- urgent hospital admission
- ABC
- anaesthetist, ENT surgeon -> intubation-> urgent tracheostomy
- only after airway is secured blood for cultures and ABx should be given CEFUROXIME
- consult senior and transfer to paeds ICU
complication
- acute airway obstruction
What is bacterial tracheitis
cause - staph aureus/strep
any age
gradual onset
T>38
Deterioration after viral URTI
Looks anxious
Brassy cough
Mx
IV ABx and intubation
other causes of stridor
apparent infection, consider anaphylaxis or inhaled foreign body.
subglottic stenosis, laryngomalacia (floppy larynx), or external compression (e.g. vascular ring, lymph nodes, tumours).
wheeze define
musical high-pitched respiratory sound heard predominantly on expiration
generated by narrowing of lower airways
partial obstruction of the intrathoracic airways mucosal inflammation and swelling - bronchiolitis - bronchoconstriction as in asthma - mechanical obstruction
bronchiololitis
occurs under 1 year and common under 6 months
Respiratory Syncytial Virus (RSV)
parainfluenza
adenovirus
rhinovirus
type 1 IgE mediated allergic type reaction
BRONCHIOCONSTRICTION
infiltration of lymphocytes oedema
infiltration of cytokines and chemokines
hyperinflation
increased airway resistant
atelectasis
increase mucus and increase goblet cells
features Coryzal symptoms precede a dry cough increasing breathlessness (dysnpnoea) tachypnoea poor feeding apnoeas
- dry wheezy cough
- tachypnoea and tachycardia
- subcostal and intercostal recession
- hyperinflation of the chest
- fine end-inspiratory crackles
- high-pitched wheezes – expiratory > inspiratory.
Ix for bronchiolitis
when to admit to hospital
pulse oximetry blood urine culture swab CXR shows hyperinflation blood gases and FBC only if diagnostic uncertainty or atypical course »Hyperinflation »Focal atelectasis »Air trapping »Flattened diaphragm »Peribronchial cuffing
hospital admission
- under 3 M
- pre-existing condition
• apnoea (observed or reported)
• persistent oxygen saturation of < 90% when breathing air
• inadequate oral fluid intake (50–75% of usual volume)
• severe respiratory distress – grunting, marked chest recession, or a respiratory rate over 70 breaths/minute.
Mx of bronchiolitis
primarily supportive with supplemental oxygen where
needed (SpO2 ≤ 93%) and help with feeds/fluids (NG feeds or IV fluids). Nebulised 3% saline
may improve symptoms of mild-to-moderate bronchiolitis and reduce hospital stay.
CPAP
the concentration required is determined by pulse oximetry
complications
fatigue
bronchiolitis obliterans - permanent damage to airways
lasts 7-10 days
self limiting
hospital admission upto 6 weeks
three patterns of wheezing
- viral episodic wheezing – wheeze only in response to viral infections
• multiple trigger wheeze – in response to multiple triggers and which is more likely to develop into asthma over time
• asthma.
causes if recurrent or persistent childhood wheeze
Viral episodic wheeze
Multiple trigger wheeze
Asthma
Recurrent anaphylaxis (e.g. in food allergy)
Chronic aspiration
Cystic fibrosis
Bronchopulmonary dysplasia
bronchiolitis
chronic lung disease of prematurity
Bronchiolitis obliterans - small airway RARE
Tracheo-bronchomalacia - abnormal cartilage, contractile not kept open by cartilage rings become floppy, if u use SABA and stuff it will make it worse
asthma symptoms
Symptoms worse at night and in the early morning
• Symptoms that have nonviral triggers
• Interval symptoms, i.e. symptoms between acute exacerbations
• Personal or family history of an atopic disease
• Positive response to asthma therapy.
Examination of asthma
long standing
onset of the disease in early childhood
hyperinflation of the chest, generalized polyphonic expiratory wheeze with a prolonged expiratory phase
harrison’s sulci
presence of a wet cough or sputum production, finger clubbing or poor growth suggests a condition characterized by chronic infection such as cystic fibrosis or bronchiectasis.
Ix of asthma
younger children -> histroy and examination alone
uncertainity - peak expiratory flow rate (FEV1/FVC <70%) - spirometry If FEV1/FVC <70% response to bronchodilator - helpful Ix
Still no answer
FeNO >35 ppb
BTS v NICE
asthma under 5 Mx
Step 1 – Diagnosis and assessment:
Consider monitored initiation of treatment with very low to low dose ICS.
Step 2 – Regular preventer: Very low (paediatric) dose inhaled corticosteroid (ICS).
Step 3 – Initial add-on therapy:
Very low (paediatric) dose ICS plus:
In children ³5 years old add inhaled LABA or LTRA
In children <5 years old add LTRA
Step 4 – Additional controller therapies:
Consider: Increasing ICS to low dose – or –
In children ³5 years old adding LRTA or LABA.
If no response to LABA, consider stopping LABA
Step 5 – Specialist therapies:
Refer patient for specialist care.
what happens if you give aminophylline as a rapid infusion
seizures
severe vomiting
fatal cardiac arrhythmias
