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MODULE 1: NEONATES + INFANCY > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Pneumonia - bg + RF + micro

A

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)
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2
Q

Pneumonia clinical features + Ix

A

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

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3
Q

Determining severity of pneumonia

A

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

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4
Q

Mx of pneumonia

A

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)

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5
Q

complications of pneumonia

A

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

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6
Q

Acute asthma paediatric guidelines (NAC)

  • salbut
A
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7
Q

Acute asthma guidelines
ipratrop/steroids/mg/amino

A
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8
Q

Doses meds in acute asthma for kids

A
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9
Q
A

CO2 retention or rise (even if in normal parameters) is an OMINOUS sign of SEVERE or lifethreateneing asthma

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10
Q

Discharge criteria for acute asthma +

A

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
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11
Q

Definition/diagnosis of asthma

A

heterogenous disease, characterised by chronic airway inflammation/hyperactivity w variable airflow limitation and intensity

BTS 2016. GINA 2018 criteria

  1. wheeze, SOB, chest tightness +/- cough
  • >1 symptom
  • vary over time (worse @ night or on waking)
  • vary in intensity
  1. Variable expiratory airflow limitation
  2. specific +allergenic triggers (exercise, laughter/emotion, allergens, cold air, infection)
  3. 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)

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12
Q

RF for asthma exacerbation within the next few months

A
  • 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
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13
Q

How to Mx asthma

A

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)

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14
Q

Asthma differentials in children (conditions that can be confused w asthma)

A

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
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15
Q
A
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16
Q
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17
Q

What drug is useful for exercise-induced asthma?

A

Monteleukast sodium

(other indications = frequent intermittent, mild persistent or aspirin-sensitive asthma)

18
Q

What are the side effects of long term inhaled steroids?

A

initial slowing of growth velocity, which picks up with ongoing steroid therapy (MILD growth issues)

monitor for immunosuppression, HPA axis suppression

20
Q

RF for asthma

A

RISK FACTORS FOR ASTHMA

  1. FHx (parent or other sibling) or personal Hx of asthma OR other atopic conditions
    • eczema
    • allergic rhinitis
    • food or drug allergy
  2. Maternal smoking (esp in utero)
  3. Early infection (colonisation w strep etc)

protective factors

  • non-asthmatic parents
  • large family 3+ siblings
  • live on farm w livestock
  • length of breastfeeding
  • indigenous
22
Q

Define: bronchiolitis

+ pathogenesis

A

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

24
Q

Severity of bronchiolitis

A

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
25
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
26
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
27
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
28
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
29
Discharge criteria bronchiolitis
* minimal distress, feeding well * SpO2 \>92% (except high risk needs to be higher) * parents happy, well informed
30
31
Consequences bronchiolitis
increased risk of VIW, but not increased risk of asthma
32
bronchiolitis prevention
* avoid smoking * breast feed * immunoprophylaxis (**pavilizumab**) - human MAb agains RSV → consider * handwashing
33
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
34
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
35
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
36
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)
37
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
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39
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
40
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
41
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
42

MODULE 1: NEONATES + INFANCY (8 decks)

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