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
What drug is useful for exercise-induced asthma?
Monteleukast sodium
(other indications = frequent intermittent, mild persistent or aspirin-sensitive asthma)
What are the side effects of long term inhaled steroids?
initial slowing of growth velocity, which picks up with ongoing steroid therapy (MILD growth issues)
monitor for immunosuppression, HPA axis suppression
RF for asthma
RISK FACTORS FOR ASTHMA
- FHx (parent or other sibling) or personal Hx of asthma OR other atopic conditions
- eczema
- allergic rhinitis
- food or drug allergy
- Maternal smoking (esp in utero)
- Early infection (colonisation w strep etc)
protective factors
- non-asthmatic parents
- large family 3+ siblings
- live on farm w livestock
- length of breastfeeding
- indigenous
Define: bronchiolitis
+ pathogenesis
CLINICAL Dx based on Hx + exam
clinical features
acute URTI (nasal congestion +/- discharge, mild ocugh, fever) followed by onset of respiratory distress + fever + 1 or more of:
- cough
- tachypnoea
- chest wall retractions/WOB
- widespread crackles or wheeze
Other:
- difficulty feeding
- dehydration
- cyanosis
- apnoea
AKA:
URTI, peak severity day 2-3 but may extend to day 5 w resolution over 10 days.
median duration 12 days, 9% infants not completely well at 28 days
cough may persist for weeks
peak in winter months
Causes
mostly RSV (75%)
rhinovirus, parainfluenza, human metapneumovirus, influenza, adenovirus, coronovirus
Pathogenesis
virus causes direct damage to lungs
pneumonitis → small airway obstruction (from inflammation + excessive mucous + sloughed epithelial cells) → atelectasis
Severity of bronchiolitis
MILD
- normal ability to feed
- little or no respiratory distress
- no need for supplemental O2 (SpO2 >92% RA)
- often febrile
MODERATE
- appear SOB when feeding
- mod resp distress + retractions
- brief apnoeic episodes
- mild hypoxaemia (easily corrected w O2)
SEVERE
- reluctant or unable to feed
- severe resp distress, nasal flaring, grunting
- hypoxic, not easily corrected by O2
- may have frequent or prolonged apnoeic episodes
- looking exhausted
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
Mx bronchiolitis
- prevent/treat dehydration
- satisfactory oxygenation ( O2 if sats <92%)
- LFNP/face mask
- HFNP - 2L/kg/min
- CPAP
- intubation
medication/suctioning/chest physio not indicated
Mild
- no Ix
- Rx at home if possible
- medical review in 2-3 days
Moderate
- admit hispital
- O2 as needed to maintain SpO2 >92%
- frequent small feeds or NG (if <50% of normal intake)
- observe closely for deterioration
Severe
- admit hospital → PICU
- O2 therapy
- IV fluids preferred (correct for extra WOB, fever, maintenance therapy)
INDICATIONS FOR TRANSFER
- progression to severe disase
- serious apnoeic episodes (esp if need resus)
- uncorrectable hypoxia
- blood gas → T1RF/T2RF
- “at risk” group
Ix bronchiolitis
not generally needed
BUT
- CXR if Dx uncertainty or atypical course
- NPA/PCR - if cohorting pt, unclear Dx
- septic screen - if toxic
- UEC/BSL if IV fluid given
- BSL if sick
Discharge criteria bronchiolitis
- minimal distress, feeding well
- SpO2 >92% (except high risk needs to be higher)
- parents happy, well informed
Consequences bronchiolitis
increased risk of VIW, but not increased risk of asthma
bronchiolitis prevention
- avoid smoking
- breast feed
- immunoprophylaxis (pavilizumab) - human MAb agains RSV → consider
- handwashing
Chronic supperative lung disease
chronic productive cough
- begins at infancy or childhood
- lots of causes (acquired or congenital)
- usually associated w radiographic evidence of bronchial dilatation (bronchiectasis)
Pathophys
ineffective or impaired mucous clearance due to obstruction/poor drainage/infection
→ chronic recurrent infection/inflammation
→ airway damage + progressive lung disease
- dilated cylindrical airways (reversible!)
- varicosity → cystic (irreversible)
CAUSES
AFFLUENT countries
- CF
- impaired immune fx - esp IgG + subclass deficiency
- PCD
- aspiration syndromes eg: tracheo-esophageal fistula. swallowing dysfunction, GORD
- congenitally abnormal airways eg: tracheo/broncheomalacia
- Post infectious (<10%) - pneumonia
- obstructed airway eg: due to FB or mass (esp if localised)
- bronchiolitis obliterans
- toxic fumes, smoke inhalation
- idiopathic
NB: Non-affluent
- post infectious 40 -60% eg: measles, pertussis, adenovirus, recurrent pneumonia, TB
CSLD presentation
- chronic, recurrent or persistent MOIST cough
- wheezing (60%)
- SOB esp on exercise
- sputum production
- haemoptysis
- weight loss
- fever
- chest pain
Examination
- persistent insp crackles, typically localised in >75%
- wheeze 33%
- clubbing <10% (CSLD even if FB)
- poor growth
- ear infections, sinus disease
- severe cases → cyanosis, cor pulmonale, COPD
When to Ix for CSLD in children
- Chronic productive cough
- some response to Abx but relapses when ceased
- poorly responsive asthma
- recurrent pneumonia
- +ve sputum culture for:
- S.aureus
- H.influenzae
- P.aeruginosa
- atypical mycobacterium
- pneumonia with incomplete resolution of Sx, physical signs OR radiographic changes eg: persistent atelectasis
- unexplained haemoptysis
- pertussis like illness failing to resolve
investigating CSLD in children
- CXR
- sputum MCS
- immune fx
- FBC (lymphocyte count),
- IgG total (esp for CVID)
- Ab responses to vaccination
- Sweat test/CF genetic testing
- barium swallow/24hr pH study - for aspiration
- airway screening with barium
- bronchoscopy/BAL
- ciliary biopsy (nasal brushing)
- confirm severity + distribution w HRCT
- spirometry (obstructive picture early)
Mx principles CSLD
accurate Dx
Abx directed by sputum MCS + sensitivities (PO or
chest physio + clearance
- PEP masks (positive expiratory pressure)
- mycolytics eg: hypertonic saline (3 - 6%), mannitol
bronchodilators, ICS
immunisation - influenza, pneumococcal
Mx co-morbidities (nutritioin, asthma etc)
regular r/v (2 months for 1st 6 months, then 3 monthly)
consider surgery in localised disease
team approach
CF definition
genetic abnormality in CFTR gene
→ abnormal mucous secretion
→ exocrine duct obstruction, infection + inflamamtion
→ resulting in complex multi-system involvement
→ esp respiratory, GIT
leads to death from respiratory failure
Infections
s.aureus
pseudomonas
burkholdaria cepacia, MRSA
viruses etc
CF diagnostic criteria
95% Dx on newborn screening
mean age of Fx 2 months
diagnostic criteria
HALLMARK
- sweat chloride >60mg NaCl/L
- chronic pulmonary disease
- pancreatic insufficiency
- meconium ileus
SUGGESTIVE
- +ve FHx
- nasal polyps
- rectal prolapse
- p.aeruginosa in sputum
- aspermia in males
- focal biliary cirrhosis
CF Mx
MDT ++++++
immunisation + additional flu/pneumococcal
Resp
- antibiotics (PO, inh, IV)
- in 1st year of lifeinfants: prophylactic fluclox i
- anti-inflams
- mucolytics
- DNAses (pulmozyme)
- hypertonic saline
- mannitol
- physiotherapy
CFTR correctors - Kalydeco G551D (5-7%), Delta508
GIT
- diet: high fat, calorie, protein diet
- CREON
- vitamin ADEK
- Mx Cx
O2 therapy, bridge to transplant
90% 1 yr survival, 60 - 70% 5yrs
