Respiratory Flashcards
What are the signs of respiratory distress seen in a child?
Accessory muscles Tachypnoea Grunting Nasal flaring Recession Head bobbing Tripoding - optimise use of accessory muscles Cyanosis
What is grunting caused by?
Exhaling against a partially closed glottis to keep airway open
What is the difference between a wheeze and stridor?
Wheeze is an expiratory sound caused by lower airway obstruction. Intrathoracic airway collapse
Stridor is a high pitched inspiratory sound caused by upper airway obstruction. Extra thoracic airways collapse
Name some causes of wheeze
Asthma
Bronchiolitis
Viral wheeze
Foreign body
Name some causes of stridor
Croup Foreign body Epiglottitis Laryngomalacia Vocal cord dysfunction Abscess - peritonsillar or retropharyngeal Anaphylaxis
What causes of respiratory distress should you consider? (broadly speaking)
Cardiac problems?
Structural issues?
Infective cause?
Gas exchange problem?
What duration of cough corresponds to being acute, subacute and chronic respectively?
Acute <3 weeks
Subacute 3-8 weeks
Chronic >8 weeks
What about a cough could indicate it is due to asthma?
Night time
Wheeze
Has a trigger
What features of a cough could indicate it is due to a recurrent infection?
Start with additional respiratory signs
What feature of a cough would indicate a post nasal drip or GORD
Worse on lying down
What would suggest a cough is one of habit?
Won’t cough at night
Otherwise well
What would suggest a cough has an environmental cause?
History of smoking/parental smoking
Live in polluted area
How would a cough present in a child with Cystic Fibrosis?
Begin at young age
Systemically unwell
What are the red flag signs for a cough?
Sudden onset Haemoptysis Dysphagia Moist productive cough Night sweats Weight loss Worsening cough Failure to thrive
What investigations would you consider if a child had a chronic cough?
CXR
Lung function
Skin prick
Sputum sample for culture and microscopy
How is a diagnosis of obstructive sleep apnoea made?
Generally clinical
Can do overnight polysomnography
How is obstructive sleep apnoea managed?
Remove tonsils/adenoids
CPAP
Weight loss
Orthodontic/maxillary surgery
What should you not give to help treat obstructive sleep apnoea and why?
DONT GIVE CODEINE
Causes respiratory depression
What is cystic fibrosis?
Autosomal recessive disease leading to mutation in CFTR gene which leads to defective Cl- secretion and increased Na+ absorption
What systems can cystic fibrosis affect?
Respiratory system Pancreas Sweat Liver Intestines Bones Male fertility
How does Cystic Fibrosis present in a newborn?
Meconium ileus
Failure to thrive
Prolonged jaundice
How does meconium ileum happen in a newborn with Cystic Fibrosis?
Bowel blocked by sticky secretions leading to signs of intestinal blockage:
Bilious vomit
Abdo distention
Delay in passing meconium
Why do children with Cystic Fibrosis fail to thrive?
Malnutrition due to poor gut absorption
What is the pathophysiology behind Distal Intestinal Obstruction Syndrome in children with Cystic Fibrosis?
Insufficient pancreatic enzymes and thick mucus –> thick dehydrated contents –> Faecal obstruction in ileocaecum
What signs of Distal Intestinal Obstruction Syndrome would you find on examination/imaging?
Palpable RIF mass
AXR show faecal loading and junction between small and large bowel
How does Cystic Fibrosis affect the respiratory system?
Abnormal ion transport leads to thickening of mucus
Inadequate mucociliary clearance
Chronic bacterial colonization
Lung injury
What respiratory problems can be seen in Cystic Fibrosis?
Recurrent chest infections
Chronic sinusitis
Nasal polyps
Bronchiectasis
What pattern of breathing would you see on a lung function test in cystic fibrosis?
Obstructive pattern
What changes would you see on CXR in children with Cystic Fibrosis?
Hyperinflation - flat diaphragm Bronchial dilation Bronchiectasis Pulmonary artery dilation RV hypertrophy
How is Cystic Fibrosis diagnosed?
Positive history in sibling OR positive newborn screen result
AND
> 60mmol/L Cl- on sweat test OR 2 CF genetic mutations OR abnormal nasal epithelium ion transport
2 positive sweat tests confirm the diagnosis
What bacteria are children with Cystic Fibrosis particularly susceptible to?
Staph Aureus H Influenzae Pseudomonas aeruginosa Burkholderia cepacia Aspergillus
What signs would you see on examination of a child with Cystic Fibrosis?
Hyperinflation
Wheeze
Crackles
Clubbing
Why do children with Cystic Fibrosis get steatorrhea?
Deficiency in pancreatic enzymes –> pale greasy offensive stools
How are the chest symptoms of Cystic Fibrosis managed?
Physio - postural drainage and airway clearance 2x per day
Prophylactic antibiotics
Mucolytics - DNase or hypertonic saline
What physiotherapy devices are used in Cystic Fibrosis?
PEP masks
Flutter devices
Acapella device
How are gastro symptoms managed in Cystic Fibrosis?
Creon - pancreatic enzyme replacement
High calorie diet
Fat soluble vitamines - ADEK
What do you screen for in children with Cystic Fibrosis?
Diabetes - annually
Osteoporosis
What lifestyle changes are suggested for children with Cystic Fibrosis?
No smoking Avoid other patients with CF Avoid people with colds No Jacuzzi (pseudomonas) Annual flu vaccine Clean and dry nebulisers fully NaCl tablets in hot weather Exercise!
What screening methods are used to find if children have Cystic Fibrosis?
IRT - immunoreactive trypsin
Sweat test
CFTR gene
What are nasal polyps in a child indicative of?
Cystic Fibrosis or Primary ciliary dyskinesia
When do chest problems start to affect children with CF?
Generally seen once they get a little bit older
What can cause false positive and false negative sweat tests
False positive
Malnutrition, G6PD, hypothyroidism, adrenal insufficiency
False negative
Skin oedema due to hypoalbuminaemia due to pancreatic exocrine insufficiency
Outline five management strategies for Cystic fibrosis
MDT with CF specialist tertiary care
Respiratory
Chest physio BD
Encourage exercuse
Regular sputum cultures
Prophylactic ABX and treat any active infections
Bronchodilators
Nasal polyps: Nasal steroids; Polypectomy
Pancreas: Creon
Monitor and maintain weight
High calorie (130%) and protein diet
Liver transplantation in progressive failure or complications of portal hypertension
Diabetes screening
Reproduction and genetic counselling
Bone protection: Ca2+; Vit D; Bisphosphonates
Name 3 risk factors of paediatric obstructive sleep apnoea syndrome
Obesity
Down’s syndrome
Achondroplasia (dwarfism)
Small maxilla and/or mandible
What is the aetiology of paediatric obstructive sleep apnoea syndrome?
Adenotonsillar hypertrophy
Obesity - 4-5x greater risk
Neck-to-waist ratio - index of body fat
Neuromuscular disease - e.g. craniofacial abnormalities
Describe the presentation of paediatric obstructive sleep apnoea syndrome
Snoring - can resolve spontaneously overtime
esp loud snoring 3+ times a week
Mouth breathing
Witnessed apnoeic episodes - pauses in breathing, may be followed by gasp/snort
Poor concentration and school difficulties
Failure to thrive
Behavioural problems
Frequent nightmares
Daytime hyperactivity
Enuresis
In what situations should paediatric obstructive sleep apnoea syndrome be considered?
Symptoms of recurrent blocked nose Recurrent nasal or throat infections Recurrent ear infections Any risk factors Any child whose parents are concerned about snoring
Where should children be referred if they have adenotonsillar hypertrophy and symptoms of persistant snoring?
Paediatric ENT specialist
What is the gold-standard investigation for paediatric obstructive sleep apnoea syndrome?
Polysomnography sleep studies
Describe the management of paediatric obstructive sleep apneoa syndrome
Medical: CPAP and weight loss
Surgical: adenotonsillectomy, uvulopalatopharyngoplasty
Orthodontic: mandibular advancement devices
Watchful waiting - may improve overtime by its own
What are the potential complications of untreated paediatric obstructie sleep apnoea?
Adverse effects on growth and development
Cardiovascular risk: HTN, LVH, pulmonary HTN
Daytime hyperactivity
Cognitive deficits
Failure to thrive
Associated with insulin resistance
Increased risk of obesity in school-aged children
Define apnoea
Cessation of respiratory airflow
Differentiate the types of paediatric apnoea
Central apnoea: lack of respiratory effort reduced response to hypercapnia head trauma toxin-mediated apnoea arrhythmias Obstructive apnoea: occluded airway obstructed sleep apnoea inhaled foreign body vocal cord paralysis Mixed apnoea
List 3 differential diagnoses for paediatric apnoea
Aspiration syndrome Sepsis Bronchiolitis Paediatric asthma Opioid toxicity Paediatric status epilepticus Prematurity Physical child abuse
Name 5 causes of paediatric apnoea
Idiopathic: most common
Seizure
Head injury: central apnoea
Drugs: opiates, benzodiazepines, barbiturates
Upper/lower resp infeciton: second commonest
Laryngomalacia/tracheomalacia
Cardiac: arrythemia, congenital heart disease
Sepsis
GORD
Define infant apnoea
An unexplained episode of cessation of breathing for 20 seconds or longer, or
A shorter respiratory pause associated with bradycardia, cynanosis, pallor, and/or marked hypotonia.
Commoner in preterm infants.
Define infant apnoea
An unexplained episode of cessation of breathing for 20 seconds or longer, or
A shorter respiratory pause associated with bradycardia, cynanosis, pallor, and/or marked hypotonia.
Commoner in preterm infants.
What is the pathophysiology of central apnoea?
Medullary responsiveness is not adequate for proper respiration so muscle contraction is poor or absent
What is the pathophysiology of obstructive apnoea?
An airway obstruction causes poor or no air exchange
A child present with multiple episodes of “stopping breathing”.
What questions do you want to ask?
- HPC - how long are the episodes, how long have they been going on for, any other symptoms at the time of episodes, when do they happen (day/night/during activity). Get accurate picture of an episode, parents mnay have filmed it. Any specific triggers noticed. Any recent or current infections? Any snoring at night?
- PMH - Any pre-existing medical conditions? Congenital or genetic are most common, but also neuro/cardiac/GORD/metabolic. Do they have any touble with eating/swallowing?
- Paedss Hx - were pregnancy, delivery, and neonatal period ok? Were they premature? Is the child well-behaved?
In an episode of apnoea where the child has some unusual movements, what important differential do you want to investigate/rule out?
Seizures
Why is it important to ask about recent or current infections with a child presenting with apnoea
It may be a symptom of sepsis in the child
Define bronchiolitis.
An acute viral infection of the lower airways that affects infants under 2 years of age.
Tell me about who bronchiolitis affects.
Infants under the age of 2.
Peaks between 3 and 6 months of age.
Most common in under 1s.
What is the most common pathogen causing bronchiolitis?
What other organisms can cause bronchiolitis?
Respiratory syncytial virus (RSV)
Adenovirus/rhinovirus/parainfluenza/influenza
What are the social and environmental risk factors for bronchiolitis?
- Older siblings
- Nursery attendance
- Passive smoking
- Overcrowding
How does bronchiolitis typically present?
1-3 day hx of coryzal symptoms with:
- persistent cough
- respiratory distress/increaded effort
- wheeze +/or crackles
A child comes in with 3 days of coryzal symptoms, a cough, tachypnoeaic, and with a wheeze.
What are your differentials?
- Bronchiolitis
- Viral induced wheeze
- Pneumonia
- Asthma
- Pulmonary oedema
- Forgein body asp
- Pneumothorax
How should bronchiolitis be managed in primary care?
Supportively:
- Good fluid intake
- Good nutrition
- Temperature control (paracetamol)
- May need supplementary O2 if referring on to hospital
How should bronchiolitis be managed in secondary care?
Still supportively mainly! (Fluids, O2, temperature control, nutrition) NG feeding may be necessary. Upper airway suction can help. CPAP if in respiratory failure
How long does bronchiolitis tend to last?
3-7 days, with the cough settling after ~3 weeks.
What is the prognosis with bronchiolitis?
Good - majority make a full recovery.
Death is very uncommon and tends to be in those children with pre-existing cardiac or pulmonary disease.
What can we give to those at risk of contracting bronchiolitis due to RSV?
Palivizumab - first dose given before the start of the RSV season.
What is asthma?
A respiratory condition characterised by paroxysmal and reversible airway obstruction.
What are the 2 elements of an acute asthma attack?
- Bronchospasm
- Excessive production of secretions in airways
What are the typical symptoms of asthma?
- Wheeze
- Shortness of breath
- Tight chest
- Cough
What can happen if a child has undertreated asthma for a long time?
Ongoing inflammation -> airway remodelling -> fixed airway disease
What other conditions are commonly associated with asthma, either in the personal hx or family hx?
Other people with asthma
Eczema
Allergies
What are the risk factors to look out for in a history of asthma?
- Inner city environment
- Obesity
- Prematurity/low birth weight
- Smoking
- Viral infections in early childhood
A child comes to the GP because wheeze on exercise and a cough has been bothering him for some time.
What do we want to know from the HPC?
- What does it take to become breathless?
- Any specific triggers noticed? (Ask then go through options)
- When are the symptoms at their worst?
- Does it happen apart from colds?
- How does it change over time/between exacerbations
You examine a child with suspected asthma.
What signs might you elicit?
- Bilateral wheeze
- Increased work of breathing
- High pulse and resp rate
- Recessions (subcostal, intercostal, tracheal tug)
- Hyperexpansion
Talk me through the stepwise approach to asthma management in a 5-16 year old.
- PRN bronchodilators for occasional symptoms
- Add low dose inhaled corticosteroid daily for symptoms >3x a week.
- Add a leukotriene receptor antagonist
- Swap LTRA for a LABA if LTRA unhelpful
- SABA + change LABA/ICS for maintenance and reliever therapy inc. low dose ICS
- SABA + moderate dose ICS MART
- SABA + one of a) high dose ICS MART, b) additional drug e.g. theophylline, or c) refer to expert asthma specialist.
How is asthma management different in a child under 5 years old?
Its not technically asthma under 5 years old, but pre-school wheeze.
- SABA
- SABA + 8 wk trial of moderate dose ICS
- SABA + low dose ICS + LTRA
- Refer to specialist
What is classed as a moderate asthma attack in an under 5?
SpO2 under 92%
No clinical features of severe asthma
What is classed as a severe asthma attack in an under 5?
SpO2 under 92% + Too breathless to talk/feed HR over 140 RR over 40 Use of accessory muscles
What is classed as a life-threatening asthma attack in an under 5?
SpO2 under 92% Silent chest Poor respiratory effort Agitation Altered consciousness Cyanosis Normal CO2 on abg
When should PEF be measured in an asthma attack?
In all children over 5
What is classed as a moderate asthma attack in a child over 5?
SpO2 under 92%
PEF under 50% of best/predicted
No clinical features of severe asthma
What is classed as a severe asthma attack in a child aged over 5?
SpO2 under 92% PEF 33-50% best/predicted Too breathless to complete sentences/talk/eat HR over 125 RR over 30 Use of accessory muscles
What is classed as a life threatening asthma attack in a child over 5?
SpO2 under 92% PEF less than 33% best/predicted Silent chest Poor respiratory effort Altered consciousness Cyanosis
How should mild/moderate acute asthma be managed?
Acutely - bronchodilator (B2 agonist)
Steroid therapy for 3-5 days
How should severe asthma be managed in hospital?
ABCDE assessment Do an ABG High flow O2 via non-rebreath mask Salbutamol nebs with ipratropium bromide IV hydrocortisone/Oral prednisolone CXR
What dose of salbutamol and ipatropium bromide should we give kids?
5mg salbutamol
0.5mg IB
How should life threatening asthma be managed in hospital?
Inform ITU and senoirs ABCDE Magnesium sulphate IV over 20 minutes Repeat salbutamol nebs every 15 minutes or 10 mg continuously per hour. Repeat PEF every 15-30 minutes Corticosteroids
What dose of magnesium sulphate should be given in a life threatening asthma attack?
1.2-2g IV over 20 minutes
What organism causes whooping cough?
Bordetella pertussis - gram neg coccobacillus
Considering the 2012 outbreak of whooping cough was most serious to the under 3 months, what has been introduced?
28-32 week gestation vaccination for pregnant mothers.
How long do the symptoms of whooping cough last?
6-8 weeks even when treated with abx
What does whooping cough sound like?
Hacking cough followed by characteristic “whoop” where the child gasps and flails
What often follows chronic coughing in whooping cough?
Post-cough vomiting
How is whooping cough spread?
Respiratory droplets
How long is a person infective for when they have whooping cough?
For at leats 3 weeks after symptoms start
When should someone stay home with whooping cough?
If they are a child in school or a HCP until at least 21 days after symptoms start, or 48 hours after starting to take antibiotics
Which abx are first line for whooping cough?
Macrolides e.g. clarythromicin/azithromycin/erythromycin
What suggests an inhaled foreign body?
- Witnessed episode
- Sudden onset coughing or choking
- Recent hx of playing with or eating small objects/new foods
What suggests an ineffective cough in a child who has inhaled a foreign body?
Inability to vocalise Quiet or silent cough Inability to breath Cyanosis Decreasing LoC
How should an inhaled foreign body be managed?
ABCDE
According to level of severity
Send to A+E if severe respiratory distress
What viruses commonly cause pneumonia in children?
- Influenza A
- RSV
- Human metapneumovirus
- VZV
What bacteria commonly cause pneumonia in children?
Strep. pneumonia (vast majority of bacterial pneumonias)
H. influenzae
Staph. aureus
K. pneumoniae
What is the most common atypical that causes children with pneumonia to be hospitalised?
Mycoplasma pneumonia
How does pneumonia typically present in an older child?
Not usually with wheeze/stridor, but respiratory symptoms (chest recession, tachypnoea) with persistent fever.
Cough, sputum, chest pain
How does pneumonia typically present in an infant?
- Cough
- Raised RR
- Grunting
- Chest recessions
- Feeding difficulties
- Irritability
- Poor sleep
- Fever
How does pneumonia typically present in a neonate?
- Grunting
- Poor feeding
- Irritability/lethargy
- Fever
- Cyanosis
- Cough
In younger children, what kind of pain does a LRTI cause?
Apparent abdominal pain, especially if lower lobe
What are the signs of respiratory distress in a child?
- Cyanosis
- Grunting
- Nasal flaring
- Tripodding
- Tachpnoea
- Chest recessions
- Abdominal breathing
- O2 sats under 95%
What differentials are there for a LRTI in a child?
- Exacerbation of asthma
- Ihaled foreign body
- Pneumothorax
- Cardiac dyspnoea
- Other causes of pneumonitis
What are the common causes of pneumonitis in children, other than infective?
- Extrinsic allergic alveolitis
- Smoke inhalation
- Gastro-oesophageal reflux
Do all children with LRTIs need admitting?
No - many can be managed as outpatients with oral antibiotics.
When is admission for a LRTI advised?
O2 sats under 92%
- RR >70
- Tachycardia significantly higher than fever
- Cap refil .2
- Signs of respiratory distress
- Comorbidities
- Child under 6 months
How should LRTI in children be managed in hospital?
- Anitpyretics (not aspirin)
- Antibiotics (amoxicillin unless pen allergic)
What is the prognosis like for LRTIs in children?
Great - vast majority have complete resolution.
If a very unlucky child was to develop a complication of an LRTI, what might happen?
- Pneumonic consolidation
- Sepsis
- Empyema
- Lung abscess
- Pleural effusion
When is wheezing in a child very very unusual?
What might this suggest?
In the immediate neonatal period.
If a neonate is wheezing, there is probably a structural abnormality in the airway.
How does the Westley clinical scoring system classify croup?
0-3 = mild 4-6 = moderate 6+ = severe
Points for degree of stridor, intercostal recessions, air entry decrease, cyanosis, and LoC.
How is croup investiagted?
It isn’t really, diagnosis is clinical, but O2 sats might be checked, and CXR or bloods may be done if it is felt this will be significantly beneficial.
How should croup be managed?
Supportively - keep child happy/calm, and comfortable e.g. control fever, ensure adequate fluid intake, and use of oxygen therapy if necessary.
Single dose oral or neubilsed steroids given in hospital.
Nebulised adrenaline can also be beneficial.
What dose of oral steroids is given for croup?
150 micrograms/kg dexamethasone PO OR
1-2 mg/kg prednisolone PO OR
2mg nebulised budesonide
What dose of oral steroids is given for croup?
150 micrograms/kg dexamethasone PO OR
1-2 mg/kg prednisolone PO OR
2mg nebulised budesonide
How can you distinguish between viral induced wheeze and asthma?
Viral induced wheeze presents before 3 years of age
No atopic history
Only occurs during viral infections
What is the presentation of viral induced wheeze?
SOB
Signs of respiratory distress
Expiratory wheeze throughout the chest
What is a focal wheeze?
Be very cautious
Investigate further for a focal airway obstruction such as an inhaled foreign body or tumour
What causes viral induced wheeze?
Inflammation and oedema from virus commonly RSV/rhinovirus leads to swelling and restriction of the space for air to flow.
What are the characteristic chest signs of pneumonia?
Bronchial breath sounds - harsh
Focal coarse crackles - air passing through sputum
Dullness to percussion
What are the investigations for pneumonia?
CXR not routinely required Sputum cultures Throat swabs, viral PCR Sepsis? Blood cultures Capillary blood gas
What is the management of pneumonia?
In accordance to local guidelines
Amoxicillin first line
Add macrolide for atypical pneumonia
IV antibiotics when there is sepsis or problem with intestinal absorption
Oxygen to maintain saturations
What are the investigations for recurrent LRTIs?
History and examination
Screen for CF, primary ciliary dyskinesia
FBC CXR Serum immunoglobulins Immunoglobulin G to prev vaccines Sweat test for CF HIV test
What are the investigations for recurrent LRTIs?
History and examination
Screen for CF, primary ciliary dyskinesia
FBC CXR Serum immunoglobulins Immunoglobulin G to prev vaccines Sweat test for CF HIV test
What is bronchiectasis?
Abnormal dilatation of the airways with associated destruction of bronchial tissue
Can be reversible in kids
Commonly due to CF
What is the pathophysiology of non-CF bronchiectasis?
Infection leads to structural damage, scarring leads to reduced number of cilia
Post infection e.g. staph, strep, measles, TB
Immunodeficiency
Primary ciliary dyskinesia - autosomal recessive defect, causes problems with mucociliary clearance
What are the clinical features of bronchiectasis?
HPC chronic productive cough
Breathlessness, wheeze, haemoptysis, recurrent infection, chest pain
Finger clubbing
Inspiratory crackles
Wheezing
What are the investigations for bronchiectasis?
Imaging
CXR - bronchial wall thickening, airway dilatation
High resolution CT - signet ring
(Bronchoscopy not routine)
Chloride sweat test to exclude CF
FBC, immunoglobulin panel
Antibody levels, HIV
Spirometry
What is the management of bronchiectasis?
Chest physio
Antibiotics for exacerbations
Bronchodilators for wheeze
Regular follow up
What are the complications of bronchiectasis?
Recurrent infection Life threatening haemoptysis Lung abscess Pneumothorax Poor growth and development
What are breath holding spells and how are they managed?
When an infant cries and they hold their breath, it can lead them to become pale/ blue and even faint.
They are benign and self limiting and the parent just needs reassurance that theyll grow out of them
Describe the clinical features of a child with asthma
- recurrent symptoms (wheeze, cough, SOB) which occur between exacerbations (differentiates from viral induced wheeze)
- variable symptoms (worse at night, with certain triggers, at different times of year)
- history of atopy (eczema, hay fever, allergy)
- variable PEF
- Age >2 (generally >5)
Name 2 long acting beta agonists and 3 corticosteroids used to treat asthma?
LABA: salmeterol (MDI, accuhaler), fometerol (turbohaler)
ICS: beclomethasone (MDI, clickhaler, easibreathe, easihaler), fluticasone (MDI, accuhaler), budesonide (MDI, easihaler, turbohaler)
What is the first line therapy for asthma if >5 and <5yrs
if >5yrs very low dose ICS
if <5yrs can use leukotriene receptor antagonists (monteleukast)
+ SABA for symptom relief
What are the 2nd, 3rd and 4th line therapies for asthma in children
2nd= add LABA if >5 and LRTA if <5yrs 3rd= increase ICS dose, consider adding LTRA. stop LABA if no help, continue if some help 4th= increase ICS again, consider adding 4th agent eg theophyline and refer to specialist 5th= specialist use of oral steroids, monoclonal antibodies etc
Why may a childs asthma be poorly controlled?
- poor inhaler technique
- parental smoking
- unidentified triggers/ lack of avoidance
- poor adherence with steroid therapy
- inadequate dose of ICS
- damp/ mould
- developed allergic rhinitis
- chest infection
- wrong diagnosis
give 5 features of well controlled asthma
- SABA use <3 times per week (<1 inhaler per month)
- no daytime symptoms
- no night time wakening
- no rescue med use
- no attacks
- no limits on physical activity
- normal lung function tests
- minimal side effects
- on lowest possible dose of ICS
Describe the features of a moderate and severe asthma attack
Moderate: sats>92%, able to talk, PEFR >50% best/ predicted. HR <25 (or 140 if <5yrs), RR < 30 (<40 if <5yrs)
Severe: <92%, cant talk, accessory muscle use, PERF 33-50%, HR >125//140 RR>30//40
Describe the features of a life threatening asthma attack
Sats <92% + any of:
- poor resp effort
- exhaustion
- agitation
- altered consciousness
- cyanosis
- silent chest
- PEFR <33% best/ predicted
how is a moderate- severe asthma attack managed initially and what do you do if good and poor response?
Salbutamol 6 puffs via inhaler + pred 1-2mg/kg up to 40mg. Give 8L O2 and consider salbutamol as neb (2.5-5mg)if severe.
If good response (PEFR >75%) after 15 mins, continue spacer as needed but if needs >4hrly manage as poor response. continue pred for 3 days and arrange F/U
Poor response: repeat salbutamol 1-2 times. If still poor, send to hospital if not already and manage as life threatening
How is a life threatening asthma attack managed?
Oxygen Salbutamol neb 2.5-5 mg back to back PO Prednisolone (1-2mg up to 40mg) / IV hydrocortisone (4mg/kg up to 100mg) Ipratropium bromide neb (0.25mg) Consider Theophylline IV Consider anaphylaxis dose adrenaline ITU support
Describe the 7 safe discharge criteria for asthma attacks
- PEFR >75%
- stopped nebs for 24hrs
- inpt asthma nurse r/v
- PEFR meter and written asthma action plan given
- 5 days oral pred given
- GP follow up in 2 working days
- resp clinic follow up within 4 weeks
What age does bronchiolitis affect? Give 3 risk factors
- children <2yrs, generally <1 yr
RFs: breast feeding for <2 months, parental smoking, siblings are nursery, chronic lung disease due to prematurity
How should bronchiolitis be investigated? and what are cxr signs (4)
- nasopharyngeal aspirate/ throat swabs for RVS rapid testing and viral cultures to confirm diagnosis
- blood and urine sample if pyrexic for sepsis screen
- fbc, crp and cap blood gas to check not in resp failure
- CXR if diagnostic uncertainty or atypical course (findings: hyperinflation, focal atelectasis, air trapping, flattened diaphragm)
give 4 complications of bronchiolitis?
- hypoxia
- dehydration
- fatigue
- resp failure
- persistent cough or wheeze for several weeks
- bronchiolitis obliterates- permanent damage due to inflammation and fibrosis (rare)
How is cystic fibrosis diagnosed?
- one or more characteristic phenotypical features AND
- a history of CF in a sibling
- or +ve newborn screening rest AND increase sweat chloride concentration
- or two CF mutations identified on genotyping
- or demonstration of abnormal nasal epithelial ion transport (nasal potential difference)
Give 4 differentials for LRTI in children
- asthma attack
- inhaled foreign body (usually stridor but may be small and gone lower)
- pneumothorax
- cardiac failure (think congenital defects and check liver size)
- pneumonitis from other causes (smoke, aspiration of reflux, extrinsic allergic alveolitis)
- URTI (no tachypnoea)
Give 3 differentials for croup? (stridor)
- epiglottitis
- inhaled foreign body
- acute anyphalxis
- peritonsilar abscess
When does a child with croup need to be admitted?
- <6 months old
- Immunocompromised
- Inadequate fluid intake
- Poor response to initial treatment
- Uncertain diagnosis
- Significant parental anxiety
- Moderate- severe croup or resp failure signs need urgent admission
Describe the common aetiology of pleural effusion in children
- usually secondary to acute bacterial pneumonia (parapneumonic)
- less likely bacterial causes: TB, abscess, bronchiectasis)
- malignancy (rare)
- CHD, renal disease, CT disorders (bilateral, transudative)
- trauma
How should pleural effusions be investigated?
- CXR
- USS chest
- blood and sputum culture
- FBC, u&E, serum albumin, CRP, dipstick
- small volume diagnostic tap for cytology if suggestion that it may not be infective
- biochemical analysis of aspirated effusion rarely needed as most are parapneumonic
how should a parapneumonic pleural effusion be managed?
- O2, fluid, IV abx, analgesia, antipyretics, refer to resp paediatrician
- most will get chest drain initially, if loculated or empyema on USS then intrapleural fibrinolytics (urokinase) can be given
- If this fails then they may get surgery- minithoracotomy or VATS procedure
- abx continued for 1-4 weeks after chest drain removed
- follow up after 4 weeks
How may TB manifest in a child?
- pleural effusion
- lymphadenopathy
- progressive primary TB(presents similar to pneumonia)
- reactivation TB (weightloss, night sweats, cough, fever)
- TB meningitis (younger kids, 3-6 months after exposure, meningism develops over a couple of weeks)
- milliary TB (fever, weightloss, malaise, cough)
- bone/ joint TB
How is TB investigated and managed in children?
- TST +/- interferon gamma test
- specimen collection via sputum, gastric, bronchoalveolar levage, lung tissue, CSF, urine, stool, lymph node FNA for ZN stain and cultures
- treatment is same as adult: 6 months I and R, 2 months P and E
How does chronic lung disease of prematurity/ bronchopulmonary dysplasia develop?
In infants who need ventilation in the early days of life. It is thought to be due to irritation and scarring of airways due to high pressures of ventilation and high concentration of oxygen
How is risk of bronchopulmonary dysplasia reduced?
- gentle ventilation
- permissive hypercapnia
- budesonide and surfactant inhalation
- caffeine
- vit a
- nitric oxide
How can asthma be confirmed?
FeNo - 35 parts per bill
Spirometry before and after bronchodilators
How can a foreign body inhalation be confirmed?
CXR, inspiratory and expiratory film
