Respiratory Flashcards
What is bronchiolitis
Inflammation and infection of the bronchioles
Usually caused by a virus (RSV)
Very common in winter
Usually in children under 1
How might a patient with bronchiolitis present
Coryzal symptoms
Signs of respiratory distress
Dyspnoea
Tachypnoea
Poor feeding
Mild fever
Apnoea episodes
Wheeze
Crackles
What are the signs of respiratory distress
Raised respiratory rate
Use of accessory muscles
Intercostal recessions
Subcostal recessions
Nasal flaring
Head bobbing
Tracheal tug
Cyanosis
Wheeze
Grunting
Stridor
What is the pathophysiology of a wheeze
Airway narrowing
What is the pathophysiology of grunting
Exhalation with glottis partially closed
What is the pathophysiology of stridor
Upper airway obstruction
What are the indications for admitting a child with bronchiolitis
< 3 months
Pre-existing condition
< 50-75% normal milk intake
Clinical dehydration
Respiratory rate > 70
Saturations < 92%
Deep recessions
Head bobbing
Apnoea
Parents not able to manage at home
What is the management of bronchiolitis
Ensure adequate intake (consider NG, IV fluids)
Saline nasal drops
Nasal suctioning
Oxygen
Palivizumab (monoclonal antibody, targets RSV, given monthly to at risk babies)
What does RSV stand for
Respiratory syncytial virus
What is a viral-induced wheeze
Usually due to RSV or rhinovirus
Due to narrowing of small airways (inflammation, oedema, smooth muscle contractions, swelling)
How can viral-induced wheeze be differentiated from asthma
Before age 3
No atopic history
Only during viral illness
How might a patient with viral induced wheeze present
Symptoms of viral illness for 1-2 days, then:
Shortness of breath
Signs of respiratory distress
Expiratory wheeze throughout chest
What is the management of viral induced wheeze
Oxygen
Bronchodilators (salbutamol, ipratropium, IV magnesium sulphate, IV aminophylline)
Steroids (oral prednisolone, IV hydrocortisone)
Antibiotics (amoxicillin, erythromycin)
How are mild cases of viral induced wheeze managed
As outpatients
Regular salbutamol inhalers via spacer (4-6 puffs every 4 hours)
How are moderate/severe cases of viral induced wheeze managed
Stepwise approach
Salbutamol inhalers (10 puffs every 2 hours)
Nebulised salbutamol and ipratropium
Oral prednisolone
IV hydrocortisone
IV magnesium sulphate
IV salbutamol
IV aminophylline
How might a patient with acute asthma present
Progressively worsening shortness of breath
Signs of respiratory distress
Tachypnoea
Expiratory wheeze
Tight chest on auscultation (reduced air entry)
Look out for silent chest
How is moderate asthma classified
Peak flow > 50% predicted
Normal speech
How is severe asthma classified
Peak flow < 50% predicted
Saturations < 92%
Unable to complete sentences
Signs of respiratory distress
Respiratory rate (40+ in 1-5s, 30+ in over 5s)
Heart rate (>140 in 1-5s, >125 in over 5s)
How is life-threatening asthma classified
Peak flow < 33% predicted
Saturations < 92%
Exhaustion
Poor respiratory effort
Hypotension
Silent chest
Cyanosis
Altered consciousness/confusion
What is the management of acute asthma
Oxygen
Bronchodilators
Steroids
Antibiotics
How might a patient with chronic asthma present
Episodic symptoms with intermittent exacerbations
Diurnal variability (worse at night and early in morning)
Dry cough
Wheeze
Shortness of breath
History of atopy
Family history of asthma/atopy
Symptoms improve with bronchodilators
What are the typical triggers for chronic asthma
Dust
Animals
Cold air
Exercise
Smoke
Food allergens
What are the investigations for chronic asthma
Usually a clinical diagnosis in children (diagnosed around age 3)
If uncertain:
Spirometry with reversibility testing
Direct bronchial challenge test (histamines, methacholine)
Fractional exhaled nitric oxide (FeNO)
Peak flow variability
What is the management of chronic asthma in under 5s
Salbutamol inhaler PRN
Add low dose corticosteroid or leukotriene antagonist
Add other from step 2
Refer to specialist
What is the management of chronic asthma in 5-12s
Salbutamol inhaler PRN
Add low dose corticosteroid inhaler
Add LABA inhaler
Titrate up corticosteroid dose, consider adding leukotriene receptor antagonist
Increase corticosteroid to highest dose
Refer to specialist
What is the management of chronic asthma in over 12s
Salbutamol inhaler PRN
Add low dose corticosteroid inhaler
Add LABA inhaler
Titrate up corticosteroid dose, consider adding leukotriene receptor antagonist
Increased inhaled corticosteroid to highest dose, consider oral SABA, refer to specialist
Add oral steroids
What is pneumonia
Infection of lung tissue
Inflammation of lung
Sputum fills airways and alveoli
Seen as consolidation on X-ray
What are the common bacterial causes of pneumonia
Strep pneumoniae
Group A/B strep
Staph aureus
Haemophilus influenzae
Mycoplasma pneumonia
What are the common viral causes of pneumonia
RSV
Influenza
Parainfluenza
How might a patient with pneumonia present
Bronchial breath sounds
Focal coarse crackles
Dullness to percussion
Wet productive cough
Fever
Tachypnoea
Tachycardia
Increased work of breathing
Lethargy
Delirium
Low oxygen saturations
Hypotension
What investigations are needed for pneumonia
Chest X-ray
Sputum culture
Throat swab
Blood cultures (if septic)
What is the management for pneumonia
Antibiotics (amoxicillin, erythromycin)
Oxygen
What is croup
Acute infective respiratory disease
Affects young children (6 months - 2 years)
Upper respiratory tract infection
Leads to oedema of larynx
Usually improves within 48 hours
What are the common causes of croup
Parainfluenza
Influenza
Adenovirus
RSV
How might a patient with croup present
Increased work of breathing
Barking cough (clusters of episodes)
Hoarse voice
Stridor
Low grade fever
What is the management for mild/moderate croup
Mostly supportive (at home, sit child up, comfort them)
Oral dexamethasone (single dose, repeat at 12 hours if needed)
What is the management of severe croup
Stepwise approach
Oral dexamethasone
Oxygen
Nebulised budesonide
Nebulised adrenaline
Intubation and ventilation
What is epiglottitis
Inflammation and swelling of epiglottis
Can cause complete airway obstruction within hours
Usually due to haemophilus influenza type B
Now rare due to routine vaccination
How might a patient with epiglottitis present
Sore throat
Stridor
Drooling
Tripod position (sitting forward, one hand on each knee)
Fever
Difficulty swallowing
Painful swallowing
Muffled voice
Scared or quiet child
Septic and unwell
What are the investigations for epiglottitis
If unwell, do not attempt to investigate
Lateral X-ray neck (thumbprint sign)
What is the management for epiglottitis
Do not distress child
Alert most senior paediatrician and anaesthetist available
Prepare to intubate at any time
Tracheostomy
Once airway secured: IV antibiotics (ceftriaxone), steroids (dexamethasone)
What is the prognosis for epiglottitis
Most recover without need for intubation
Death if not diagnosed on time
Can develop epiglottic abscess (manage same as epiglottitis)
What is laryngomalacia
Larynx structured in a way that causes airway obstruction (aryepiglottic folds shortened)
Chronic stridor
Peak at 6 months
How might a patient with laryngomalacia present
Intermittent stridor (usually when feeding/upset/lying on back/ill)
Do not usually have respiratory distress
What is the management for laryngomalacia
Usually spontaneously resolves as larynx matures
If very severe, tracheostomy
What is whooping cough
URTI
Due to infection with bordetella pertussis
Children and pregnant women vaccinated (but immunity does not last)
Usually resolves in around 8 weeks
How might a patient with whooping cough present
Mild coryzal symptoms
Low grade fever
Mild dry cough
Severe coughing fits
Struggle to breathe during fits
Loud inspiratory whoop when cough ends
What are the investigations for whooping cough
Nasal swab
Anti-pertussis toxin IgG (if cough present for more than 2 weeks)
What is the management for whooping cough
Notify public health
Simple supportive care
Antibiotics (azithromycin, erythromycin)
Prophylactic antibiotics to vulnerable close contacts
What is the main complication of whooping cough
Bronchiectasis
What is chronic lung disease of prematurity
Respiratory distress syndrome in neonates
Usually those born before 28 weeks
Need oxygen or intubation and ventilation at birth
Diagnosis based on chest X-ray changes
How might a patient with chronic lung disease of prematurity present
Low oxygen saturations
Increased work of breathing
Poor feeding
Insufficient weight gain
Chest crackles
Wheeze
What are the preventative measures for chronic lung disease of prematurity
Corticosteroids to mothers showing signs of preterm labour
Once babies born, CPAP and caffeine (stimulate respiratory drive)
What is the management for chronic lung disease of prematurity
Monthly palivizumab injections (monoclonal antibodies against RSV)
What is cystic fibrosis
Autosomal recessive condition
Affects chloride channels in mucus glands
Screened for in newborn heel prick test
What are the key consequences of cystic fibrosis
Thickened pancreatic and biliary secretions (lack of digestive enzymes)
Thick airway secretions (increased susceptibility to infections)
Congenital bilateral absence of vas deferens
How might a patient with cystic fibrosis present
Meconium ileus
Recurrent LRTIs
Failure to thrive
Pancreatitis
Chronic cough
Thick sputum production
Steatorrhoea
Salty sweat
Nasal polyps
Clubbing
Crackles
Wheeze
What are the investigations for cystic fibrosis
Newborn heel prick test
Sweat test (gold standard, look for chloride concentration in sweat)
Genetic testing for CFTR gene
What are the common microbial colonisers of cystic fibrosis
Staph aureus
Haemophilus influenzae
Klebsiella pneumoniae
E coli
Pseudomonas aeruginosa
What is the management for cystic fibrosis
Chest physiotherapy
Exercise
High caloric diet
CREON tablets (replace lipase)
Prophylactic flucloxacillin
Treat any chest infections
Bronchodilators
Nebulised DNase (make secretions easier to clear)
Vaccines (pneumococcal, influenza, varicella)
Lung transplant
Liver transplant
Fertility treatment
Genetic counselling
What monitoring is needed for cystic fibrosis
Clinic every 6 months
Screen for: diabetes, osteoporosis, vitamin D deficiency, liver failure
What is the prognosis for cystic fibrosis
Median life expectancy 47
What is primary ciliary dyskinesia
Aka Kartanger’s syndrome
Triad of: paranasal sinusitis, bronchiectasis, sinus inversus
Autosomal recessive
Affects cilia of various cells
Strongly linked to consanguinity
Build up of mucus in lungs
Infertility in males
What are the investigations for primary ciliary dyskinesia
History of consanguinity in parents
Imaging for sinus inversus
Sample ciliated epithelium (nasal brushing, bronchoscopy)
What is the management for primary ciliary dyskinesia
Daily physiotherapy
High caloric diet
Prophylactic antibiotics
