Respiratory Flashcards
What is asthma?
Airway hyperresponsiveness - various triggers for bronchial smooth muscle contraction
Bronchial inflammation - immune cell infiltration causing oedema, smooth muscle hypertrophy, mucus plugging, epithelial damage
Airflow limitation - reversible
How can asthma present?
Symptoms induced by weather, exercise, and ill-health, and nocturnal symptoms
Wheeze - heard by bedside or on auscultation
An absent wheeze can suggest narrowed airways
Expiratory wheeze
Cough
Increased WOB
Atopy
What signs might suggest increased WOB?
Head bobbing Tripoding Nasal flaring Tracheal tug Use of abdominal muscles, sternocleidomastoid IC recession Grunting or gasping Chest expansion Cyanosis RR
What is the long term management of asthma?
Step 1 - SABA PRN Step 2 - regular low dose ICS Step 3 - < 5 leukotriene receptor antagonist - > 5 LABA Step 4 - increase ICS dose, add in LRA Step 5 - regular oral steroids
What suggests acute asthma?
33 92 CHEST
- < 33% PEFR
- < 92% sats
- Cyanosis
- Hypotension
- Exhaustion
- Silent chest
- Tachycardia
- Respiratory acidosis on ABG
How is acute asthma treated?
OH SHIT Me!
- Oxygen
- Hydrocortisone
- Salbutamol nebs or 10 puffs via INH or IV
- Ipratropium bromide
- Theophylline
- Magnesium sulphate
How does VIW tend to present?
Pre-school children Symptoms associated with chest infection Symptom free between infections Not worse at night Inhalers useful during symptoms No benefit for oral steroids during exacerbation
What is bronchiolitis?
Inflamed and mucus plugging of bronchioles
What is the most common cause of bronchiolitis?
RSV
Adenovirus
Rhinovirus
How does bronchiolitis present?
Dry cough followed by vomiting Increased WOB Low grade pyrexia Poor feeding Apnoea when sleeping
How is bronchiolitis investigated?
NPA - nasopharyngeal aspirate
Blood gas
CXR - if lung examination asymmetrical then might want to rule out superimposed pneumonia or pneumothorax or lobar collapse
U&E to look at hydration status
When should you use a SABA in bronchiolitis?
FHx or atopy
Co-existing eczema
Over 6 months - babies don’t have beta-2 receptors
What bacteria can cause pneumonia in children?
Strep pneumonia
Staph aureus
HiB
Mycoplasma
What viruses can cause pneumonia in children?
Adenovirus
Rhino virus
RSV
How does pneumonia present?
Cough Increased WOB Pyrexia Poor feeding and dehydration Auscultation - crepitations, reduced AE
What investigations should you do for pneumonia?
CXR - focal consolidations
Raised WCC and CRP
Sputum cultures
Blood cultures
How is pneumonia managed?
Oral antibiotics unless expecting sepsis
First line amoxicillin
Add macrolide if suspecting atypical infection or mycoplasma - clarithromycin
What are the complications of pneumonia?
Sepsis Parapneumonic effusions Lung abscess Empyema Dehydration
What bacteria can cause tonsilitis?
Group A strep
When might you suspect bacterial tonsilitis?
Fever
Tender swollen anterior cervical lymphadenopathy
Tonsillar exudate
Absent of cough
How do you manage bacterial tonsilitis?
10 days pen V
If stertor and dysphagia then IV antibitoics, IVI and corticosteroids
What is quinsy and how does it present?
Peritonsillar abscess Trismus Hot potato voice Drooling Odynophagia
How is quinsy managed?
I+D of abscess
IV antibiotics
What causes croup?
Most commonly influenza and parainfluenza virus in < 2
How does croup present?
Coryzal prodrome followed by barking cough
Mucosal inflammation of airway can result in inspiratory stridor, increased WOB, reduced AE, cyanosis, and LOC
How is croup managed?
Adrenaline nebs
Steroids
What does stridor sound like?
High-pitched, single tone
Caused by blockage in throat/larynx - upper airway obstruction
Often heard on inspiration
What does wheeze sound like?
Continuous, coarse, whistling sound produced in respiratory airways during breathing, musical
Caused by small airway narrowing
Often heard on expiration
What are the differentials for a child with stridor?
Croup Foreign body inhalation Epiglottitis Laryngitis Anaphylaxis Bacterial tracheitis Trauma to the throat Diphtheria Laryngomalacia
How might epiglottitis present?
Severe sore throat, pain when swallowing, drooling, looks very unwell, tripoding, acute onset
How might croup present?
Low-grade fever
Barking cough
Stridor
Why might you not examine a child with stridor?
May precipitate complete airway obstruction
What are the main causes of croup?
Parainfluenza virus
RSV
Other respiratory viruses
What time of year is croup most common?
Autumn
What age is croup most common?
3 months - 6 years
Peak at 2 years
What is the first line treatment of croup?
Oral dexamethasone 150mg/kg
What could be some differential diagnoses of bronchiolitis?
Asthma (depends on age) Pneumonia Croup Whooping cough Viral induced wheeze Covid Heart failure CF
What question can you ask to find out a child’s risk of whooping cough?
Did mother have whooping cough vaccine during pregnancy?
Child up to date with imms?
What can cause bronchiolitis?
RSV - most common
Adenovirus
Influenza virus
Parainfluenza virus
What factors can increase risk of bronchiolitis?
Premature Underlying heart/lung conditions Suppressed immune system Exposure to tobacco smoke Infant < 3 years Winter months Bronchopulmonary dysplasia Attending nursery Older sibling with infections
How is bronchiolitis treated?
Supportive treatment Fluids if dehydrated Anti-pyrexials if feverish O2 if low sats NG tube Nasal suction Don't give nebulisers - often doesn't help
How can bronchiolitis be prevented?
Vaccination
Antibody injection monthly for children with chronic lung disease/congenital heart disease/congenital muscular dystrophy
What investigations would you order to help confirm your diagnosis?
Throat swab and viral PCR Pulse oximetry Mucus sample test Blood gas CXR but only if suspect bacterial infection
Why would you do a throat swab for bronchiolitis?
Helps stop passing on different viruses, cohort areas of ward
What is the guthrie test?
Heel prick neonatal screening test
What conditions are picked up on the guthrie test?
CF Sickle cell disease Congenital hypothyroidism Galactosaemia Inherited metabolic diseases - Phenyloketonuria - Medium chain acyl-CoA dehydrogenase deficiency - Maple syrup urine disease - Isovaleric acidaemia - Glutaric aciduria type 1 - Homocystinuria
How is CF inherited?
Autosomal recessive
What is the pathophysiology of CF?
Mutation in CFTR gene (CF transmembrane conductance regulator) protein produced by gene regulates movement of chloride and sodium ions across epithelial membranes
What happens in the respiratory system due to CF?
Cells absorb too much Na and water so thick secretions
Reduced muco-ciliary clearance
Frequent infections
Scarring of lungs
What happens in the digestive system due to CF?
Sticky mucus blocks pancreatic ducts preventing pancreatic enzymes digesting food
Rectal prolapse
Meconium ileus (babies)
Diabetes
How does CF affect the reproductive system?
Vas deferens doesn’t develop, male infertility
How does CF present in newborns?
Bowel obstruction - failure to pass meconium
What is the definition of wheeze?
Wheezing/whistling sounds
Breathlessness
Persistent troublesome cough
Severely affecting the well-being of infant or child
Why might you get recurrently wheezing children?
Persistent infantile wheeze - small airways/smoking/viruses Viral episodic wheeze - no infantile symptoms/URI triggered Asthma - persistent symptoms/FH/atopy Other causes - CF - Chronic lung disease - Tracheo-bronchomalacia - Ciliary dykinesia - GORD - Chronic aspiration (potentially due to neurodisability) - Immune deficiency - Persistent bacterial bronchitis
What can cause transient early wheeze in children?
Small airways
Mother smoking
Early viruses
Preterm
What can cause viral episodic wheeze?
RSV/other LRTI
Airway hyper-reactivity
What can cause IgE associated asthma?
Atopy
Airway hyper-reactivity
What might the course of viral episodic wheeze look like?
No interval symptoms No excess of atopy Likely to improve with age No benefit from regular inhaled steroids Use bronchodilators May use oral steroids in severe exacerbations
How do you manage an acute asthma exacerbation?
ABC
O2 if needed
Beta agonist
Prednisolone 1mg/kg oral (or IV hydrocortisone)
IV salbutamol bolus
Aminophylline +/- MgSO4 +/- salbutamol infusion
What are the primary medications for asthma?
Preventers
Relievers
Add on therapies
What preventers are there for asthma?
Inhaled steroids - Beclomethasone - Budesonide - Fluticasone (Inhaled cromones) - Sodium cromoglycate - Nedocromil sodium
What relievers are there for asthma?
Beta agonists
- Salbutamol
- Terbutaline
Ipratropium bromide (muscarinic antagonist, atrovent)
What add on therapies are there for asthma?
Long acting beta-agonists - Salmeterol - Formeterol Leukotriene receptor antagonists - montelukast Theophyllines Omalizumab (anti-IgE) Protexo (high IgE)
What is important to consider when prescribing inhaled steroids?
Lowest effective dose
Minimise oral deposition
Minimise GI absorption
What is important to consider when prescribing relievers?
Age-appropriate device
Easy to use
Portable
Dosage not critical
What is step 1 of asthma management in children aged 5-12?
Mild intermittent asthma
- Inhaled short acting beta-agonist PRN
What is step 2 of asthma management in children aged 5-12?
Regular preventer therapy
- Add inhaled steroid 200-400mcg/day
What is step 3 of asthma management in children aged 5-12?
Add on therapy
- Add inhaled long-acting beta-agonist
- Assess asthma control
- Good response from LABA
- Benefit from LABA but control still inadequate so increase steroid
- No response to LABA - stop LABA and increase steroid dose
What is step 4 of asthma management in children aged 5-12?
Persistent poor control
- Increase inhaled steroid up to 800mcg/day
What is step 5 of asthma management in children aged 5-12?
Continuous or frequent use of oral steroids
- Refer to resp paediatrician
- Use daily steroid tablet to lower dose providing adequate control
- Maintain high dose inhaled steroid at 800mcg/day
What could be causes of failure to respond to medication in asthma?
Adherence Bad disease Choice of drugs/devices Diagnosis Environment - parent still smoking, sensitised to animal that child won't keep away from
What are the possible risks of inhaled corticosteroids?
Adrenal suppression
Growth suppression - brief
How can you minimise risk of inhaled corticosteroids?
Discuss issues with parent/patient
Minimise dose and maximise targeting
Monitor growth in children
Name 3 types of URTI
Rhinitis Otitis media Pharyngitis Tonsilitis Laryngitis
Name 3 types of LRTI
Bronchitis Croup Epiglottitis Tracheitis Bronchiolitis Pneumonia
What respiratory tract infections are generally caused by viral infection?
Rhinitis Pharyngitis Laryngitis Croup Bronchiolitis
What respiratory tract infection are generally caused by bacterial infection?
Epiglottitis
How common is RSV?
Annual epidemics 60%+ of infants 20-30% LRTI 0.5-2% infants hospitalised Mean admission 3 days UK Mortality v low Long term morbidity
What acute URTI can RSV cause?
Rhinitis
Otitis media
Pharyngitis
What acute LRTI can RSV cause?
Bronchitis Acute bronchiolitis Pneumonia Viral associated wheeze Exacerbation of asthma Croup
What is the difference between URTI and LRTI caused by RSV?
Increased viral load
What are the two main causes of acute stridor?
Croup
Acute epiglottitis
What are the S&S of croup?
Viral - usually parainfluenza More common in spring/autumn Self-limiting Worse at night Barking seal-like cough Stridor Recessions Steroids
What causes acute epiglottitis?
HiB
Severe acute illness
What RTI can pneumococcus cause?
Otitis media - acute/chronic
Sinusitis
Bacterial bronchitis
Pneumonia - acute/chronic
What is pneumonia?
Respiratory disease characterised by inflammation of the lung parenchyma (excluding bronchi) with congestion caused by viruses or bacteria or irritants
WHO - history of cough and/or difficulty breathing < 14 days with increased RR
What do the cells look like in pneumonia?
Congestion
Red hepatisiation
Grey hepatisation
Resolution
What is an increased RR for children aged under 2 months?
> 60/min
What is an increased RR for children aged 2-11 months?
> 50/min
What is an increased RR for children aged over 11 months?
> 40/min
What does a pneumonia CXR look like?
Dense/fluffy opacity that occupies portion or whole of a lobe or lung that may or may not contain an air bronchgram
Consolidation
How is pneumonia diagnosed?
Consider in children aged up to 3 years when fever > 38.5 together with chest recession and RR > 50/min
For older children history of difficulty in breathing more helpful than clinical signs
Chest radiography not performed routinely in children with mild and uncomplicated acute LRTI
Radiographic findings poor indicators of aetiology
What bacteria can cause pneumonia?
Pneumococcus 30-50% HiB 10-30% S aureus K pneumoniae TB
What viruses can cause pneumonia?
RSV 15-40% Influenza A and B Parainfluenza Human metapneumovirus Adenovirus
What can cause pneumonia in immunosuppression eg HIV?
Bacterial infection
Pneumocysitis jiroveci
TB
What other organisms can cause pneumonia?
Mycoplasma pneumoniae Chlamydia spp Pseudomonas spp E coli Measles Varicella Histoplasmosis Toxoplasmosis
What is the difference between bacterial bronchitis and pneumonia?
Pneumonia affects lung parenchyma and alveoli
Bronchitis 3 specific organisms, form biofilms, chronic cough
