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
other causes of acute wheezing
atypical pneumonia - mycoplasma, chlamydia, adenovirus
foreign body inhalation
anaphylaxis
whooping cough
bordtella pertussis
week of coryza (catarrhal phase)
characteristic paroxysmal or spasmodic cough followed by a characteristic inspiratory whoop (paroxysmal phase)
cough worse at night and may culminate in vomiting
paroxysm, the child goes red or blue in the face, and mucus flows from the nose and mouth. The whoop may be absent in infants, but apnoea is common at this age
spells of apnoea
complications
- pneumonia, seizures, bronchiectasis
Ix of whooping cough
Mx
culture of a pernasal swab, although PCR (polymerase chain reaction) is more sensitive. Characteristically, there is a marked lymphocytosis (>15 × 10 9 /L) on a blood count.
Mx
< 6 ms child admit to hospital
azithromycin or clarothromycin if the onset of cough is within the previous 21 days
beyond 21 days it is advise only
NOTIFIABLE DISEASE
family close contacts ABx prophylaxis
school exclusion: 48 hours after commencing antibiotics (or 21 days from onset of symptoms if no antibiotics )
Complications subconjunctival haemorrhage pneumonia bronchiectasis seizures
persistent cough define
cough more than 8 weeks in the absence of recurrent URTI
causes of persistent cough
Recurrent respiratory infections
• Following specific respiratory infections (e.g. pertussis, respiratory syncytial virus, Mycoplasma )
• Asthma
• Persistent lobar collapse following pneumonia
• Suppurative lung diseases (e.g. cystic fibrosis, ciliary dyskinesia or immune deficiency)
• Recurrent aspiration (±gastro-oesophageal reflux)
• Persistent bacterial bronchitis
• Inhaled foreign body
• Cigarette smoking (active or passive)
• Tuberculosis
• Habit cough
• Airway anomalies (e.g. tracheo-bronchomalacia, tracheo-oesophageal fistula)
Pathogens seen in
newborn
infants
children over 5
- Newborn – organisms from the mother’s genital tract, particularly group B streptococcus, but also Gram-negative enterococci and bacilli.
- Infants and young children – respiratory viruses, particularly RSV, are most common, but bacterial infections include Streptococcus pneumoniae or H. influenzae . Bordetella pertussis and Chlamydia trachomatis can also cause pneumonia at this age. An infrequent but serious cause is Staphylococcus aureus.
- Children over 5 years – Mycoplasma pneumoniae, Streptococcus pneumoniae , and Chlamydia pneumoniae are the main causes.
- At all ages Mycobacterium tuberculosis should be considered.
common organisms of chronic lung infection
Ix
Mx
Haemophilus influenzae and Moraxella catarrhalis
Ix
Bacterial growth from sputum or bronchial lavage is consistent with the diagnosis.
Mx
Treatment is with a high dose of antibiotic such as co-amoxiclav, coupled with physiotherapy.
bronchiectasis
causes
permanent dilatation of the bronchi
cystic fibrosis, primary ciliary dyskinesia, immunodeficiency, or chronic aspiration.
Aspiration or inhalation injury.
Chronic obstructive pulmonary disease, asthma.
Disorders of mucociliary clearance.
Immunodeficiency.
Endobronchial tumours.
Allergic bronchopulmonary aspergillosis (ABPA).
Connective tissue disorder
Ix
HRCT scan
complications of bronchiectasis
haemoptysis Pneumothorax. Respiratory failure. Cor pulmonale. Chest pain. Coronary heart disease, ischaemic stroke. Anxiety and depression. Urinary incontinence. Fatigue and reduced exercise tolerance. Nutritional deficiency. Reduced quality of life
Sx of bronchiectasis
examination
A chronic moist or productive cough unresponsive to 4 weeks of antibiotics, especially between viral colds, or with positive sputum cultures for Staphylococcus aureus, Haemophilus influenza, P. aeruginosa, non-tuberculosis mycobacteria, or Burkholderia cepacia complex.
A recurrent or persistent wet cough (over 6 weeks’ duration).
Asthma that does not respond to treatment.
An episode of severe pneumonia, especially if symptoms, physical signs, or radiological changes do not completely resolve.
Recurrent pneumonia.
Persistent and unexplained physical signs or chest radiographic abnormalities.
Localized chronic bronchial obstruction.
Respiratory symptoms and structural or functional disorders of the oesophagus and upper respiratory tract.
Unexplained haemoptysis.
Exertional breathlessness.
examination Finger clubbing. Cyanosis. Chest deformity and hyperinflation. Persistent inspiratory crackles and wheeze (these are much less common).
pathophysiology of CF
defective protein called the CF transmembrane conductance regulator (CFTR). This is a cyclic AMP-dependent chloride channel found in the membrane of cells -> chromosome 7
eduction in the airway surface liquid layer and consequent impaired ciliary function and retention of mucopurulent secretions. Chronic endobronchial infection with specific organisms such as Pseudomonas aeruginosa ensues.
meconium ileus
pancreatic duct blocked -> pancreatic enzyme deficiency and malabsorption.
caucasian > afro-carribean > asian
clinical features of CF
Immunoreactive trypsinogen (IRT) is raised in newborn infants with CF and is measured in routine heel-prick blood taken for biochemical screening. -> CF gene mutations -> sweat test
Newborn • Diagnosed through newborn screening • Meconium ileus Infancy • Prolonged neonatal jaundice • Growth faltering • Recurrent chest infections • Malabsorption, steatorrhoea Young child • Bronchiectasis • Rectal prolapse • Nasal polyp • Sinusitis Older child and adolescent • Allergic bronchopulmonary aspergillosis • Diabetes mellitus • Cirrhosis and portal hypertension • Distal intestinal obstruction (meconium ileus equivalent) • Pneumothorax or recurrent haemoptysis • Sterility in males
Ix
features of xray
organisms found in CF pts
Mx of CF
sweat test
diagnosis of CF
- Typical pulmonary and/or gastrointestinal tract manifestations
- A family history
- A positive result on ‘sweat-test’ (based on Cl-ion concentration).
hyperinflation
bronchiectasis
lobar atelectasis
larger hila
- staph aureus
- klebsiella pneumoniae
- pseudomonas aeruginosa
burkholderia cepacia
reviewed anually in a specialist centre
resp
physio 2x a day
- airway clearance - chest percussion and postural drainage
- continuous prophy ABx w additional rescue oral ABx
- Persisting symptoms or signs require prompt and vigorous intravenous therapy to limit lung damage, usually administered for 14 days via a PIC (peripherally inserted central) line
primary ciliary dyskinesia
congenital abnormality in the structure or function of cilia lining the respiratory tract. This leads to impaired mucociliary clearance.
lead to severe bronchiectasis. They characteristically have a recurrent productive cough, purulent nasal discharge, and chronic ear infections.
Mx
daily physiotherapy to clear secretions, proactive treatment of infections with antibiotics, and appropriate ENT follow-up.
define asthma
symptoms of wheeze, cough and breathing difficulty together w reversible airways obstruction, airway inflammation and bronchial hyper-responsiveness
bronchiolitis v virla induced ewheeze
inflammation airways narrowing bronchiolitis big secretory response narrows airways further, sweelling due to oedema and muscous obstruction
cant breathe
wheeze and creps sign of LRTI
do not respond to asthma medications
not irreversible airway t
viral induced rhinovirus respond to asthma meds no crepitations
features of obstructive sleep apnoea
excessive daytime sleepiness or hyperactivity, learning and behaviour problems, faltering growth, and in severe cases, pulmonary hypertension.
predisposing causes of sleep disordered breathing
- neuromuscular disease (e.g. Duchenne muscular dystrophy)
- craniofacial abnormalities (e.g. Pierre Robin sequence, achondroplasia), - dystonia of upper airway muscles (e.g. cerebral palsy)
- severe obesity.
Ix for sleep disordered breathing
overnight pulse oximetry
complex cases polysomnoraphy
Mx of sleep disordered breathing
adenotonsillectomy
Before surgery for obstructive sleep apnoea, overnight oximetry should be performed to identify severe hypoxaemia, which may increase the risk of perioperative complications
CPAP, BiPAP
what is chronic lung disease of prematurity
Ix
bronchopulmonary dysplasia
premature babies
prior 28 weeks
respiratory distress syndrome
- oxygen therapy
- intubation and ventilation
Ix
chest xray changes and when the infant requires oxygen therapy after they reach 36 weeks gestational age.
features of bronchopulmonary dysplasia
Low oxygen saturations Increased work of breathing Poor feeding and weight gain Crackles and wheezes on chest auscultation Increased susceptibility to infection
prevention of bronchopulmonary dysplasia
give steroids if suspecting premature labour <36 weeks
Once the neonate is born the risk of CLDP can be reduced by:
Using CPAP rather than intubation and ventilation when possible
Using caffeine to stimulate the respiratory effort
Not over-oxygenating with supplementary oxygen
Mx of bronchopulmonary dysplasia
sleep study to assess their oxygen saturations during sleep
Babies may be discharged from the neonatal unit on a low dose of oxygen to continue at home, for example 0.01 litres per minute via nasal cannula. They are followed up to wean the oxygen level over the first year of life.
protection against respiratory syncytial virus (RSV) to reduce the risk and severity of bronchiolitis. This involves monthly injections of a monoclonal antibody against the virus called palivizumab
types of ventilatory support
high flow humidified oxygen
CPAP
intubation and ventilation
- endotracheal tube
assessing ventilation
signs of poor ventilation
- rising pCO2
- airways have collapsed
- failing to clear waste CO2 - falling pH
- CO2 building up
acidosis -> excessive CO2
- respiratory acidosis
- type 2 resp failure
RFs of bronchiolitis
Breast fed for <2 months
Smoke exposure ie. from parental smoking
Siblings who attend nursery or school – risk of exposure to viruses
Chronic lung disease due to prematurity
DDx fro bronchiolitis
Pneumonia – consider if temp >39˚C and persistent focal crackles
Croup
Cystic fibrosis
Heart failurevery important to rule out
Bronchitis
Viral induced wheeze – if wheeze but no crackles, history of episodic wheeze and/or a family history of atopy
Pulmonary oedema
Foreign body inhalation
Aspiration
Bronchomalacia/tracheomalacia
presenting symptoms of CAP include
- acute onset
• Cough – may be associated with vomiting in young children. Can be episodic or constant.
• Fever.
• Tachypnoea.
• Breathlessness or difficulty breathing. Grunting may be heard.
• Localised neck, chest or abdominal pain is a feature of pleuritic irritation and suggests a
bacterial infection.
Signs
- Bronchial breathing
- Soft non-musical sounds heard in both phases of respiratory cycle.
- Mimics tracheal sounds (although not as loud).
- Indicates parent airway surrounded by consolidated lung tissue.
- Reduced expansion on inspiration.
- Increased vocal fremitus.
Increased vocal resonance.
(Patient’s voice heard -more clearly over area affected) - Diminished air entry on auscultation.
- Possible crackles.
(Usually fine crackles) - Pleural rub may be present.
Decreased air entry, crackles ± wheeze
bacterial v viral pneumonia
viral
- Age < 2 years
- onset - gradual (over 24-48 hours)
- coryzal (runny nose, cough) prodrome.
Clinical findings:
- Myalgia, rash, mucous membrane signs.
- rhinorrhoea
- Temperature <38.5⁰C.
- Cough usually dry.
- Bilateral diffuse chest signs.
- Associated wheeze.
- No pleuritic pain.
- Other family members unwell
Yes, with concurrent RTI, rash, conjunctivitis.
Bacterial
1. >2yrs
2. Onset: Abrupt (often appearing toxic).
No prodrome; no runny nose.
- Clinical findings:
- Appears toxic.
- Temperature ≳38.5⁰C.
- Cough can be wet and productive.
- Pleuritic pain: chest, abdomen or neck.
- Unilateral clinical signs.
- No wheeze on auscultation.
- Absence of rhinorrhoea
The most common pathogens causing pneumonia vary with age:
newborns
infants and young children
children over 5 years
- Newborns: organisms from mother’s genital tract
- group B streptococcus
- gram negative enterococci and bacilli. - Infants and young children: respiratory viruses
- RSV
- bacteria - Streptococcus pneumonia or Haemophilus influenzae
- pertusis
- chlamydia - Children over 5 years: - - Streptococcus pneumonia
- Mycoplasma pneumonia and Chlamydia
pneumonia are the main causes
Staphylococcus aureus is a rare but serious pathogen.
Mycobacterium tuberculosis should be considered at all ages.
normal resp rate neonate infant young children older children
Neonate 30-50 >60
Infant 25-40 >50
Young children 25-35 >40
Older children 20-25 >30
mx of mild CAP
RR < 5/min
CRT < 2 sec
Mild recessions
Taking full feeds
older children RR < 35/min CRT < 2 sec Mild breathlessness Taking full feeds
Infant and child not needing supplemental oxygen and able to tolerate oral feeds
and medications.
• Managed safely in community provided parents are well supported and informed
with clear guidance what to do if their child becomes unwell.
• Oral amoxicillin + clarithromycin
5-7 days
mx of moderate CAP
RR 50-70/min
CRT ~ 2 sec
Moderate recessions
Reduced feeds
older children RR 35-50/min CRT ~ 2 sec Moderate recessions Reduced feeds
Usually require hospital admission – may need supplemental oxygen (if oxygen
saturation <93% in air) or support with feeds.
- IV co-amoxiclav +/- PO clarithromycin
mx of severe CAP
RR > 70/min CRT > 2 sec Nasal flaring Intermittent apnoea Grunting Unable to feed
older children RR >50/min CRT > 2 sec Unable to complete sentences Severe recessions Nasal flaring Signs of dehydration
Admission.
• Blood tests (FBC, CRP, blood cultures).
• Chest x-ray.
• IV fluids – bolus (if necessary) and maintenance.
• IV Cefuroxime ± PO Clarithromycin
or consider
additional antibiotics
bronchiolitis immediate referral
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.
how will you monitor the efficacy of the new treatment
symptom diary
review at 6-8 weeks
if Mx for asthma not working well what qs should u ask
Check concordance
Check inhaler technique
Exclude other concomitant cause of cough
Increase asthma preventer treatment
first line Mx of acute exacerbation of asthma
Nebulised salbutamol
neb ipratropium bromide -> used in addition to SABA for the first 2hrs of severe asthma attack
BOTH ABOVE every 20 mins
oral prednisolone - 3-5 days
RFs of severe/life-threatening asthma
- Previous near-fatal asthma e.g. previous ventilation or respiratory acidosis.
- Previous admissions for asthma, especially in the last year.
- Requiring three or more classes of asthma medication.
- Heavy use of SABA.
- Repeated attendances at ED for asthma care, especially in the past year.
- Brittle asthma.
complications of whooping cough
subconjunctival haemorrhage
pneumonia
bronchiectasis
seizures
what is laryngomalacia
Commonest cause of stridor in infants. Typically presents in
the neonatal period and progresses during infancy but resolves by 12-18 months.
Hoarseness
cause of respiratory distress syndrome
RFs
CFs
Ix
Mx
insufficient surfactant production and structural immaturity of the lungs
RFs male sex diabetic mothers Caesarean section second born of premature twins
CFs
tachypnoea, intercostal recession, expiratory grunting and cyanosis
Ix - Chest x-ray characteristically shows ‘ground-glass’ appearance with an indistinct heart border
Mx
prevention during pregnancy: maternal corticosteroids to induce fetal lung maturation
oxygen
assisted ventilation
exogenous surfactant given via endotracheal tube
Mx of pneumonia in children
amoxicillin
mycoplasma/chlamydia pneumonia - erythromycin
pneumonia w influenza - co-amoxiclav
Life threatening asthma attack
SpO2 <92% PEF <33% best or predicted Silent chest Poor respiratory effort Agitation Altered consciousness Cyanosis
pulmonary hypoplasia
oligohydramnios
congenital diaphragmatic hernia
Mx of CF
- regular (at least twice daily) chest physiotherapy and postural drainage. Parents are usually taught to do this. Deep breathing exercises are also useful
- high calorie diet, including high fat intake*
- patients with CF should try to minimise contact with each other to prevent cross infection with Burkholderia cepacia complex and Pseudomonas aeruginosa
- vitamin supplementation
- pancreatic enzyme supplements taken with meals
- lung transplantion
- –> chronic infection with Burkholderia cepacia is an important CF-specific contraindication to lung transplantation
acute viral wheeze
Pre-school aged children; preceding coryzal symptoms.
Wheeze responding to inhaled salbutamol.
May be personal/family history of atopy.
RFs
maternal smoking during and/or after pregnancy.
prematurity, male gender (boys have narrower airways
rhonchus
low pitched musical
lower than wheeze
heard mainly on expiration
- Associated with airway mucus or oedema in large airways.
- Can clear with coughing.
fine crackle
- Short explosive sound.
- Heard on mid-to late-inspiration.
- Not affected by cough.
- Gravity dependent.
pneumonia hf pf
coarse crackle
- Short explosive sound.
- Heard on early inspiration and throughout expiration.
- Affected by cough.
related to secretions
stretor
Low-pitched snoring or gasping.
Caused by partial obstruction of the airway above the level of the larynx.
Produced by vibrations of the naso-pharynx, pharynx and soft palate.
factors suggesting severe asthma
SpO2 <92% PEF <33% best or predicted Silent chest Poor respiratory effort Agitation Altered consciousness Cyanosis
