Respiratory Flashcards
What is VIW +why is it important in young kids? Who does it affect?
Viral infections can cause respiratory symptoms and difficulty breathing in some children due to narrowing of smaller airways due to aberrant immune response to infection
May be multi-trigger or acute intermittent (former associated with increased risk of asthma). Episodic nature which resolves by 5yo
Thought to be on the spectrum of:
Bronchiolitis (<1y) –> VIW (1-5yo) –> Asthma
May have Hx of atopy, food allergies etc also
RF: prematurity, maternal smoking, FHx of VIW/Asthma
What is asthma and its pathophysiology?
Asthma is a chronic respiratory disease of the airways characterised by hyper-responsvieness of the airways, inflammation and obstruction.
IgE production to inhaled allergens; may have other atopic diseases
What signs and symptoms would a child with asthma present with?
- wheeze (end expiratory polyphonic)
- SOB
- chest tightness
- cough
- Sx worst in morning and at night
- Personal or FHx of atopy/asthma
- Positive response to bronchodilator therapy
signs:
- hyper inflated chest (+accessory muscle use)
- harrisons sulci (depressions at base of thorax where the diaphragm has become more muscular)
How would you investigate a child with suspected asthma?
if <5yo, then clinical diagnosis
if >5yo, then consider spirometry (FEV1:FVC<70%), bronchodilator use (>12% difference) and PEFR variability
Obs - SpO2, BP, HR, RR (acute especially)
FeNO levels (higher in some asthma phenotypes)
How can asthma be categorised into moderate, severe and life threatening?
Moderate:
- PEFR >50-75%
- normal speech
Severe:
- PEFR 33-50%
- SpO2 >95%
- RR >40 (2-5y)/>30 (5-12y)/>25 (>12y)
- HR >110 (12y)/ >125 (5-12y)/ >140 (2-5y)
- can’t complete sentences
- inability to feed
- accessory muscle use
Life-threatening:
- PEFR <33%
- normal/elevated CO2
- SpO2 <92%
- altered consciousness
- severe features plus cyanosis, poor respiratory effort, silent chest, hypotension, exhaustion
How would you manage a hospital case/ED Asthma patient?
What should patients/parents be educated on?
What drugs are CI in asthma?
- Admit if severe/life threatening (moderate = 4h salbutamol and oral prednisolone for 3d; f/u in 48h)
- Burst step:
- 3x Salbutamol nebs/pumps within 1h
- 2x Ipratropium nebs
- +O2 if sats <92%
- Oral prednisone (works after 4-6h)
involve seniors if burst therapy fails to work
- IV Bolus of MgSO4 [+/or Salbutamol if <2*]
- monitor ECG for hypokalaemia - Give one of either
- IV Salbutamol
- IV Aminophylline - Intubate and ventilate if life-threatening and transfer to ICU
After the patient has stabilised, give salbutamol 1h/ly then 2h -> 3h -> 4hly and then home discharge when stable on 4hly treatment (can wean further once home) and PEF >75% predicted and SpO2 >94%
- f/u within 2 days of discharge
Patient education on:
- when drugs should be used (PRN vs regular)
- What each drug does (relief vs prevention)
- how they are used (proper inhaler technique)
- what to do if asthma worsens (features of poorly controlled asthma - wheeze, SOB, decreasing relief from therapy)
- measuring PEF to help identify worsening asthma
CI whilst on salbutamol:
- ACEi
- NSAIDs
- Adenosine
- B-blockers
What is the management for a paediatric asthma patient in an outpatient/community setting?
- SABA PRN (Salbutamol)
- consider stepping up when using inhaler 3/+x a week
- can use a spacer if younger
- acute dose = 1 puff per 30-60s w 5 tidal breaths per puff, max 10 puffs
- normal dose shouldn’t exceed 4h/ly puffs i.e. 4 puffs daily - +ICS e.g Becotide (beclometasone)
- LTRA [2-16yo]
- review after 4-8 weeks
- if fail on review and <5y, then stop LTRA and refer to specialist
- if fail on review and 5-16yo, switch LTRA to LABA - Increase ICS dose
- consider reducing once asthma better controlled
- e.g. Fixotide (fluticasone) - Oral steroid
- lowest dose to maintain control
- Prednisolone
- managed b specialist
- Also used in any severity exacerbation of asthma for 3-5 days
What is acute otitis media and why does it occur more commonly in children?
Infection of the middle ear, commonly a complication of viral respiratory illnesses
V common (most 6-12months) –> young Eustachian tubes are short, horizontal and function poorly.
What are some risk factors for acute OM and common causative organisms?
RFs - FHx, males, cleft palate, Down’s syndrome
Causative organisms:
- H. influenza
- S. pneumonia
- RSV
How may a child with acute otitis media present? How would you investigate them?
Sx:
- Fever
- Pain in the ear
- May have preceeding/coexisting respiratory illness
- Irritability
- Vomiting
- Difficulty hearing
Ix:
- Observations (inc temperature)
- Otoscopy –> shows bright red, bulging tympanic membranes, loss of normal light reaction, perforation and pus
How would you manage a child with: i) acute otitis media, ii) AOM with perforation and iii) AOM with effusion/’glue ear’?
What are some complications of AOM?
Mx:
Admission if:
- Severe systemic infection
- Complications e.g. meningitis, mastoiditis, facial nerve palsy
- Children <3mo with fever>38
i) AOM Mx:
- Advice (lasts ~3d, up to 1w and most recover without Abx, use ibuprofen/paracetamol for symptoms
- Abx given [5d Amoxicillin/Clarithromycin if allergic] if symptoms not improved after 3d
OR
Worsened symptoms
OR
Systemically unwell
OR
<2y old
ii) AOM with perforation
- Oral amoxicillin 5d
- Review in 6months to check healing
iii) OM with effusion
- Can present as asymptomatic except for reduced hearing (conductive)
- May interfere with normal speech development
- Otoscopy shows dull and retracted eardrum with possible fluid level visible
- Ix = tympanometry, audiometry
- Mx = if have co-existing cleft palate/Down’s then refer to ENT. If no comorbidities then active observation for 6-12 weeks, 2 hearing tests (pure tone audiometry), 3 months apart; if persistent past 6-12w then refer to ENT for non surgical measures (hearing aids/autoinflation or surgical (myringomy/gromets - have SE such as otorrhoea, reinsertion etc)
Complications:
- perforation
- mastoiditis
- meningitis
- facial nerve palsies
- febrile convulsions
What is otitis external? What are some types of these infections and how may they present?
Inflammation of the outer ear (auricle, external auditory canal and outer surface of eardrum)
Acute diffuse OE [‘Swimmer’s ear’]:
- moderate temperature and lymphadenopathy
- diffuse swelling
- variable pain and itching
- moving ear/jaw is painful
- impaired hearing
- often bacterial
Chronic OE:
- fungal, associated with underlying skin conditions, DM, immunosuppression
- less acute
- discharge and itch are less common
Necrotising OE:
- LIFE-THREATENING extension into mastoid and temporal bones
- more seen in elderly/immunocompromised/DM
- primarily due to P.aeroginosa or S.aureus
- pain, oedema, exudate, micro-abscess, granulation tissue, pseudomonas culture
- if suspected, requires urgent ENT referral
What are some risk factors for otitis externa?
RFs:
- Hot + humid climate
- Immunocompromised, DM
- Swimming
- Older age
- Wax build up or insufficient wax
- Narrow external canal
How would you Ix and Mx a patient with acute otitis externa?
Ix:
- Otoscopy
- Swabs and culture
- Tympanometry?
Mx:
- Topical drops of Acetic acid (effective for 1w)
- Topical drops of Abx i.e. neomycin or clioquinol
- Wicking and removal of debris
- If cellulitis or cervical lymphadenopathy present then give oral Abx
DAPSICAMP - Croup
See written notes
