Respiratory Flashcards
Pneumonia - bg + RF + micro
BG
leading cause of hospitalisation in developed countries, one of the most common causes of death in developing country (19% in children <5)
pneumonia kills more children than ANY other illness ( more than AIDS, malaria + measles combined)
RF
- Age: highest risk for disease, and increased severity <5yo (higher the younger you are)
- malnutrition
- prematurity (24 - 28wks OR 4)
- CLD - bronchopulmonary dysplasia/CF/bronchiectasis/ primary ciliary dyskinesia
- immunodeficiency
- neurodisability
- co-morbid infections (measles, varicella, diarrhoeal illness)
- not breastfeeding (5x risk of pneumonia death)
- not immunised Microbiology( viral more common than bacterial earlier on) VIRAL: RSV (predominantly), parainfluenza, human metapneumovirus, influenza, adenovirus, coronavirus, measles, varicella BACTERIAL: streptococcus pneumonia (most common ~90 serotypes), HiB strep pyogenes (rapid onset illness, higher severity), s.aureus (more common in ATSI + infants, post viral, higher rates necrotising) atypicals: chlamydia, mycoplasma, **bordetella pertussis (**important DDx infants/preschool age)
Pneumonia clinical features + Ix
Fever - abrupt onset +/- rigors +/- cough (may have rusty sputum) chest pain abdominal pain** lower lobe pneumonia (pleurisy) tachypnoea hypoxia headache arthralgia (wheeze and normal O2 sats decreased likelihood of pneumonia) O/E increased WOB ↑ RR ↑ HR ↓ O2 sats fever tactile fremitus (↑ in consolidation, ↓ in pleural effusion/PTx) percussione cyanosis Ix: CXR -should NOT be routinely done (esp not if OP Mx) - if hospitalised, if suspected complicated pneumonia. - round pneumonia ( a thing in children, but needs follo-up imaging cuz could have lots of other DDx) can consider lung USS NPA/Sputum/aspirate MCS +/- PCR Bloods +VBG, cultures, esp UEC
Determining severity of pneumonia
No validated scores in paeds, but severe if: - O2 sats <90% - RR >70 in infants, >50 in older children - nasal flaring - tachycardia - signs of dehydration - central cyanosis -severe respiratory distress -unable to drink/feed (vomiting everything) - altered conscious state - seizures multilobar ilfiltrates, co-morbidities, shock, ventilatory Rx, apnoea need I/P Mx w Abx - benpen or amp + gent, add trimethroprim in all infants exposeMxd/infected w HIV
Mx of pneumonia
ABx Rx MILD amoxicillin 1st line (superior to augmentin) - 25mg/kg TDS add macrolide eg: azithromycin @ 48hr mark if no improvement (macrolides 1st line in penicillin allergy) or benpen 60mg/kg QID if cant tolerate PO duration 7 - 10 days for penicillin, 5 days for azith MOD - SEVERE - 3rd gen cephalosporin (if penicillin allergy, cipro or moxiflox) - cefotaxime or ceftriaxone -AND anti-staph → flucloxacillin – clinda** preferred as anti-toxic shock/lincomycin/vanc consider tamiflu (oseltamivir)
complications of pneumonia
Empyema - prolonged ABx (IV) - drain or VATS pleural effusion necrotising pneumonia - abscess +cavitation formation - strep most common, staph also common causes DDx pseduomonas – need HRCT, prolonged abx (14-21 days IV), consider image guided drainage bronchopleural fistulae - pneumonia + PTx lung abscess bronchiectasis respiraory failure extra-pulmonary Cx sepsis SIADH HUS - strep pneumo common cause - cause of AKI + bleeding + HTN, MAHA, anaemia, thrombocytopenia 0 RRT, antiHTNsives
Acute asthma paediatric guidelines (NAC)
- salbut
Acute asthma guidelines
ipratrop/steroids/mg/amino
Doses meds in acute asthma for kids
CO2 retention or rise (even if in normal parameters) is an OMINOUS sign of SEVERE or lifethreateneing asthma
Discharge criteria for acute asthma +
clinically stable on 3rd hrly bronchodilators
(DONT use oximetry as primary criteria as remains unclear what satisfactory lvl)
All patients on d/c need
- d/c sum + triggers (compliance/infection/allergy/exercise) + whatwas done during admission, what meds child responded to
- asthma Mx plan
- D/C meds
- F/U
- education/revise on inhaler technique
Definition/diagnosis of asthma
heterogenous disease, characterised by chronic airway inflammation/hyperactivity w variable airflow limitation and intensity
BTS 2016. GINA 2018 criteria
- wheeze, SOB, chest tightness +/- cough
- >1 symptom
- vary over time (worse @ night or on waking)
- vary in intensity
- Variable expiratory airflow limitation
- specific +allergenic triggers (exercise, laughter/emotion, allergens, cold air, infection)
- a/w airway hyperresponsiveness + chronic airway inflammation (dont always see this objectively)
NB: just cough without other symptoms is RARELY asthma (applies to children and adult)
RF for asthma exacerbation within the next few months
- uncontrolled asthma symptoms
- 1+ severe exacerbation in previous year
- start of child’s usual flare up season (esp autumn/spring)
- exposures - tobacco, air pollution, indoor allergens esp in combo w viral infection
- major psychological or socio-economic issues
- poor med adherence or incorrect inhaler technique
How to Mx asthma
3 main patterns of asthma
infrequent intermittent
frequent intermittent (frequent = < than 6 weeks btw episodes)
persistent asthma
95% intermittent, 5% persistent
GINA classification guidelines for Mx
Step 1: SABA PRN
Step 2: SABA PRN + daily low dose ICS (persistent asthma)
+/- LRTA (better for exercise-induced asthma), low dose theophylline
Step 3: SABA PRN +
- double low dose ICS ( 5 and under)
- mod dose ICS alone (6 - 11yrs)
- low dose ICS/LABA >12yo
+/- LRTA (better for exercise-induced asthma), low dose theophylline
Step 4: med - high dose ICS/LABA
- under 5 refer to specialis here
Step 5: refer (add on ?tiotropium, anti-IgE, anti-IL5)
Asthma differentials in children (conditions that can be confused w asthma)
Specific bronchitis
- pertussis
- mycoplasma
- TB
- 2’ bacterial bronchitis
- infantile bronchiolitis
Suppurative lung disease
- CF
- immunodeficiency
- PCD (primary ciliary dyskinesia)
- retained FB
- post viral
- idiopathic
Pulmonary aspiration
- GORD
- swallowing
- ToF
Focal lesions
- FB
- congenital airway abnormalities
- tumours
Upper airway obstruction
- allergic rhinitis
- OSA
Smoking
Habit/psychogenic coughing
conditions characterised by:
COUGH:
- Pertussis (whooping cough)
- CF
- most cases picked up by newborn screening
- may present as difficult to control asthma
- Airway abnormalities (eg: tracheomalacia/bronchomalacia)
- protracted bacterial bronchitis - in young children
- chronic secretions → wheeze
- Habit-cough syndrome
WHEEZING:
- upper airway dysfunction
- inhaled FB - partial obstruction
- esp if localised wheeze
- tracheomalacia
DYSPNOEA
- hyperventilation
- anxiety
- cardiopulmonary issues + poor fitness
DDx of bronchiolitis
- Heart failure (check for murmur, liver size, femorals)
- pneumonia (could be complication)
- bronchial FB
- pertussis
- PTx
- chlamydia/ atypical pneumonia
- aspiration (esp if neurological condition)
- asthma assoc w viral infeciton
High risk infants for bronchiolitis
All of the above
- premature ( <37 week)
- chronological age at presentation <10 wks
- immunodeficiency
- exposure to cigarette smoke
- breast fed <2 months
- CLD
- CHD
- FFT
- chronic neurological condition
- indigenous ethnicity
- immunodeficiency
- congenital/anatomic defect of airway
