Respiratory Flashcards
Croup epidemiology and features
Croup is a form of upper respiratory tract infection seen in infants and toddlers. It is characterised by stridor which is caused by a combination of laryngeal oedema and secretions. Parainfluenza viruses account for the majority of cases.
Epidemiology
- peak incidence at 6 months - 3 years
- more common in autumn
Features
- stridor
- barking cough (worse at night)
- fever
- coryzal symptoms
Croup classification and reasons for admission
Admit with moderate/severe croup and other admission factors:
- <6 months of age
- known UA abnormalities (e.g. laryngomalacia, Down’s syndrome)
- uncertainty about diagnosis (e.g. epiglottitis, bacterial tracheitis, peritonsillar abscess and foreign body inhalation)
- pallor, cyanosis, decreased consciousness, RR>70, fatigue, asyncrhonous chest well and abdominal movement, sternal/intercostal recession
- increasing UA obstruction
- *Mild croup**: barking cough
- *Moderate**: + stridor/sternal recession at rest
- *Severe:** + agitation/lethargy, sternal/intercostal recession
Westley croup severity score (in image)
Croup Ix
clinical Dx
if CXR done:
- PA view = subglottic narrowing aka ‘steeple sign’
- Lateral view = swelling of epiglottis aka ‘thumb sign’
ix:
- Basic obs
- Examination
- Urine catch (hard to get)
- CXR = not usually done, steeple sign
tripod stance
NEVER examine a child’s throat (unsettles child)
Croup Mx
All severities croup:
- Oral dexamethasone (0.15 mg/kg)
- if not possible = inhaled beclomethasone (2mg) or IM dexamethasone (0.6/kg)
- can give while transported to hospital for admission
- incorporate paediatrician, nurses, anaesthetist → airway support STAT,
- provide analgesics
Hospital
- A to E, reduce temperature, start steroids, supportive care (fluids)
- then talk about community care
Mild croup:
- admission NOT required
- Advise to take child to hospital if continuous stridor heard or skin between ribs pulling in with every breath
- call ambulance if = pale/blue/grey for more than few seconds, unusually sleep or not responding, having a lot of trouble breathing, upset (agitated/restless) while struggling to breathe and cannot be calmed down quickly, unable to talk/drooling/trouble swallowing
Moderate croup:
- oxygen
Severe croup:
- oxygen (high flow via non-rebreathe mask)
- nebuliser adrenaline (1 in 1000 (1mg/ml)) = RISK OF REBOUND 2h later so needs close monitoring, observe on day unit until respiratory distress settles
Causes of stridor in children
What is laryngomalacia? features and ix, complications
Congenital abnormality of the larynx cartilage which predisposes to dynamic supraglottic collapse during inspiration of respiration → results in upper airway obstruction and stridor.
Most frequent congenital stridor in infants and cause ‘noisy breathing’ in infancy.
- 2-6 weeks old with noisy respiration and inspiratory stridor – worse supine, when feeding or if agitated
- ± association with GORD
- ± feeding difficulties, slow, ↑ cough/choking, ↑ respiratory noise
- Normal cry → no abnormality with vocal cords
- Not present at birth
- Baby is otherwise comfortable despite thenoise
Ix:
- monitor sats + laryngoscopy if diagnostic difficulty to assess anatomy and comorbidities
Complications = respiratory distress, failure to thrive, cyanosis
Laryngomalacia mx
- Manage conservatively with close observation
- Regular review and monitoring of growth
- Tend to resolve by 18-24 months (although
- may initially worsen with age, max at 6-8 months) – 70% resolve by 1 year old
Endoscopic supraglottoplasty if airway compromise or feeding disrupted sufficiently to prevent normal growth.
Asthma medical management for children aged 5 to 16
What is bronchiolitis, causes and epidemiology, more serious with…
Bronchiolitis is a condition characterised by acute bronchiolar inflammation. Respiratory syncytial virus (RSV) is the pathogen in 75-80% of cases.
OTHER CAUSES = mycoplasma, adenoviruses, 2o to bacterial infection
More serious if bronchopulmonary dysplasia (e.g. premature), congenital heart disease or CF
Epidemiology
- most common cause of a serious lower respiratory tract infection in < 1yr olds (90% are 1-9 months, with a peak incidence of 3-6 months). Maternal IgG provides protection to newborns against RSV
- higher incidence in winter
Features of bronchiolitis
coryzal symptoms (including mild fever) precede:
- dry cough
- increasing breathlessness
- wheezing, fine inspiratory crackles (not always present)
- feeding difficulties associated with increasing dyspnoea are often the reason for hospital admission
Bronchiolitis: when to make immediate referral and consider referring to hospital
‘consider’ referring to hospital if any of the following apply:
- a respiratory rate of over 60 breaths/minute
- difficulty with breastfeeding or inadequate oral fluid intake (50-75% of usual volume ‘taking account of risk factors and using clinical judgement’)
- clinical dehydration.
immediate referral (usually by 999 ambulance) if they have any of the following:
- apnoea (observed or reported)
- child looks seriously unwell to a healthcare professional
- severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute
- central cyanosis
- persistent oxygen saturation of less than 92% when breathing air.
How do we investigate bronchiolitis
clinical
immunofluorescence of nasopharyngeal secretions may show RSV
Bronchiolitis management and prevention
Infection control measures are required in the ward the patient is placed as RSV is highly infectious
Palivizumab (monoclonal antibody against RSV) reduces the number of hospital admissions in high-risk preterm infants
Nephrotic
Bronchiolitis vs Viral Episodic Wheeze
Bronchiolitis = crackles
VEW = wheeze
2 types of pre-school wheeze in children
- episodic viral wheeze: only wheezes when has a viral upper respiratory tract infection (URTI) and is symptom free inbetween episodes (not associated with asthma in later life)
- multiple trigger wheeze: as well as viral URTIs, other factors appear to trigger the wheeze such as exercise, allergens and cigarette smoke (a lot fo children with this end up with asthma)
Management of pre-school wheeze in children
Parents who are smokers should be strongly encouraged to stop.
Episodic viral wheeze
- treatment is symptomatic only
- first-line is treatment with short acting beta 2 agonists (e.g. salbutamol) or anticholinergic via a spacer
- next step is intermittent leukotriene receptor antagonist (montelukast), intermittent inhaled corticosteroids, or both
- there is now thought to be little role for oral prednisolone in children who do not require hospital treatment
Multiple trigger wheeze
- trial of either inhaled corticosteroids or a leukotriene receptor antagonist (montelukast), typically for 4-8 weeks
How do we diagnose Cystic Fibrosis?
On day 5 of life, newborns have the heel prick test. They are tested for cystic fibrosis (CF), congenital hypothyroidism, sickle cell disease, and a number of other metabolic diseases. For CF, the levels of IRT (immune reactive trypsinogen) are tested, and if they are raised that can indicate CF. The baby should then undergo the sweat test, and if this is raised, this confirms a diagnosis of CF.
Sweat test
- patient’s with CF have abnormally high sweat chloride
- normal value < 40 mEq/l, CF indicated by > 60 mEq/l
Causes of a false positive sweat test (and also false negative)
Causes of false positive sweat test
- malnutrition
- adrenal insufficiency
- glycogen storage diseases
- nephrogenic diabetes insipidus
- hypothyroidism, hypoparathyroidism
- G6PD
- ectodermal dysplasia
The most common reason for false negative tests is skin oedema, often due to hypoalbuminaemia/ hypoproteinaemia secondary to pancreatic exocrine insufficiency.
What causes whooping cough? (pertussis) when infants vaccinated?
G-ve Bordetella pertussis
Imms at 2,3,4 months and 3-5 years (infection/imms does not result in lifelong protection)
Features of whooping cough (pertussis)
Diagnosis criteria:
Acute cough >14 days w/o another apparent cause, and one or more of the following:
- paroxysmal cough (CATARRHAL PHASE)
- inspiratory whoop
- post-tussive vomiting
- undiagnosed apnoea attacks in young infants
2-3 days coryza precede onset of:
- coughing bouts = worse at night/after feeding, ended by vomiting, associated central cyanosis
- inspiratory whoop = forced inspiration against closed glottis
- apnoea spells
- persistent coughing → subconjunctival haemorrhages or anoxia → syncope/seizures
- sx’s 10 - 14 weeks and more severe in infants (→ CONVALESCENT PHASE)
- marked lymphocytosis
Whooping cough diagnostic ix
Per nasal swab culture for Bordetella pertussis = takes several days/weeks to come back
PCR + serology increasingly used as more available
Complications of pertussis
subconjunctival haemorrhage
pneumonia
bronchiectasis
seizures
Management of whooping cough
Notify HPU
Admit if:
- <6m or acutely unwell
- significant breathing difficulties (apnoea, severe paroxysms, cyanosis)
- complications (seizures, pneumonia)
Pharm = if NOT admitted, onset within 21 days (as does not shorten course but affects infectivity)
- <1m = clarithromycin
- >1m and not pregnant = azithromycin
- if pregnant = erythromycin (from 36 wk GA w/o vaccination to reduce risk of transmission to newborn)
- if macrolides CI → co-trimoxazole (do NOT use in pregnant/infants <6wks of age)
Advice:
- rest, adequate fluid intake, paracetamol/ibuprofen for sx relief
- inform parents, despite abx tx, disease likely to cause protracted non-infectious cough that may take weeks to resolve
- children avoid nursery until 48 hours of abx tx has been completed, or until 21 days after onset of cough if not treated with abx
- once acute illness dealt with, advise parents to complete any outstanding imms
Assessment of acute asthma attacks
Management of life-threatening/severe asthma attack
salbutamol x3 = 10 puffs, 10 minute break, 10 puffs, 10 minutes break, 10 puffs
nebulised
IV salbutamol, IV aminophylline, IV magnesium sulfate second line
Moderate exacerbation of asthma requiring admission mx
inhaler with space
no magnesium sulfate
Mild exacerbation or moderate exacerbation not requiring admission
no hospital admission
inhaler with spacer
no ipratropium bromide, no magnesium sulfate
return to SABA up to 4x a day
consider initiating montelukast in children >2 years old
Follow up of asthma exacerbation
Prenisolone doses in mild/moderate asthma attack
When can you give pertussis vaccine in pregnant women?
16 - 32 weeks of pregnancy
o provide maternal antibodies to the foetus when it is delivered and to prevent the spreading of pertussis which can cause severe illness and death in a newborn.
What is cow’s milk protein intolerance/allergy and what are it’s features and two types
Cow’s milk protein intolerance/allergy (CMPI/CMPA) occurs in around 3-6% of all children and typically presents in the first 3 months of life in formula-fed infants, although rarely it is seen in exclusively breastfed infants.
Both immediate up to 2 hours (IgE mediated) and delayed 2-72 hours (non-IgE mediated) reactions are seen. The term CMPA is usually used for immediate reactions and CMPI for mild-moderate delayed reactions.
Features
- regurgitation and vomiting
- diarrhoea (has a lot of mucus in it)
- urticaria, atopic eczema
- ‘colic’ symptoms: irritability, crying
- wheeze, chronic cough
- rarely angioedema and anaphylaxis may occur
Ix of CMPI/A
Diagnosis is often clinical (e.g. improvement with cow’s milk protein elimination). Investigations include:
- skin prick/patch testing
- total IgE and specific IgE (RAST) for cow’s milk protein
CMPI/A mx
formula fed/mixed feeding = eHF (extensively hydrolysed formula) → eAAF (elementary amino acid formula)
breastfed =
- exclusion of all cow’s milk protein from mother’s diet
- mother to take calcium and vitamin D supplements
Milk Ladder
CMPI/A prognosis
CMPI usually resolves in most children
- in children with IgE mediated intolerance around 55% will be milk tolerant by the age of 5 years
- in children with non-IgE mediated intolerance most children will be milk tolerant by the age of 3 years
- a challenge is often performed in the hospital setting as anaphylaxis can occur.
stridor condition timelines
laryngomalacia = commonest cause of stridor in neonate
bronchiolitis = stridor 3-6 months
epiglottitis = 2-4 years
What causes acute epiglottitis
features of acute epiglottis
HiB → airway obstruction
2-4 years old
Features:
- rapid onset
- high temperature, generally unwell
- stridor
- drooling of saliva
- ‘tripod’ position
How do we diagnose acute epiglottitis?
direct visualisation (only by senior/aitway trained staff)
XR if concern about foreign body = ‘THUMB’ sign
How do we manage acute epiglottitis?
urgent hospital admission to ICU for tx → involve seniors esp. for away support (e.g. anaesthetics, ENT)
secure airway → endotracheal intubation and give oxygen
IV ceftriaxone for 7-10 days
Oral co-amoxiclav once stable and extubated
Rifampicin to close contacts
- steroids + adrenaline (in some patients to reduce inflammation)
most children recover within 2-3 days
Causes of stridor in children
Features of sudden onset inhaled foreign body
where does it go if aspirated
- coughing
- choking
- vomiting
- stridor
If aspirated, foreign bodies are most likely to be found in the right main bronchus as it is wider, shorter and more vertical than the left.
How do we manage foreign body inhalation?
Conscious
encourage coughing
external manoeuvres (back blows x5, Heimlich x5) = do NOT do Heimlich on infants and very young children (chest thrusts x5 instead)
removal of foreign body = flexible/rigid bronchoscopy
- rigid → stridor, asphyxia, radio-opaque object on CXR, foreign body aspiration hx associated with unilateral decreased breath sounds, localising wheeze, obstructive hyper-inflation, or atelectasis
- flexible → all other cases
- done under conscious sedation or GA
- 2nd line = surgery, thoracotomy
Unconscious
Secure airway immediately (endotracheal intubation)
- unless foreign body can be seen and removed from upper airway
- may need to do a cricothyroidectomy
Removal of foreign body
Asthma mx in children less than 5 years
- SABA
- SABA + 8wk trial MODERATE ICS
Sx do not resolve → consider alternative diagnosis
Sx resolved then reoccured within 4 weeks of stopping ICS tx → restart ICS at LOW-DOSE as 1st line maintenance therapy
Sx resolved but reoccured beyond 4 weeks of stopping ICS tx → repeat 8wk trial
- SABA + low-dose ICS + LTRA
- stop LTRA and refer to a paediatric asthma specialist
Non-pharamacological asthma management
- assess baseline asthma status (Asthma Control Questionnaire or Lung Function Test aka spirometry)
- provide self-mx education and personalised asthma action plan (from Asthma UK)
- ensure child is UTD with imms
- provide source of support (Asthma UK)
- Advise trigger avoidance (allergens, smoke, b-blockers, NSAIDs)
- assess for presence of anxiety and depression
- give patient town peak flow meter
- explain how to use inhalers
At review:
- confirm adherence with medication
- review inhaler technique
- review if tx needs to be changed
- ask about occupational asthma and triggers
Non-pharamacological asthma management
- assess baseline asthma status (Asthma Control Questionnaire or Lung Function Test aka spirometry)
- provide self-mx education and personalised asthma action plan (from Asthma UK)
- ensure child is UTD with imms
- provide source of support (Asthma UK)
- Advise trigger avoidance (allergens, smoke, b-blockers, NSAIDs)
- assess for presence of anxiety and depression
- give patient town peak flow meter
- explain how to use inhalers
At review:
- confirm adherence with medication
- review inhaler technique
- review if tx needs to be changed
- ask about occupational asthma and triggers
When do we go straight to step on asthma ladder (SABA PLUS ICS)
Newly-diagnosed asthma with symptoms ≥3/week or night-time waking
Causes of snoring children
Causes
- obesity
- nasal problems: polyps, deviated septum, hypertrophic nasal turbinates
- recurrent tonsillitis
- Down’s syndrome
- hypothyroidism
Give an example of a low dose ICS
beclometasone diproprionate
acute otitis media causes
URTI precedes otitis media, mostly 2o to bacteria (Step pneumoniae, Hib, Moraxella cararrhalis, RSV, rhinovirus), 6-12 months
Viral URTI disturbs nasopharyngeal microbiome → allows bacteria infect middle ear via Eustachian tube (tube short and function poorly)
Acute otitis media features
Features
- Otalgia (rub/tug ear)
- Fever (50%)
- Hearing loss
- Recent viral URTI sx common (e.g. coryza)
- Ear discharge may occur if tympanic membrane perforates (+effusions = glue ear)
Criteria (3) =
- acute onset symptoms, (otalgia)
- presence of middle ear effusion
- inflammation of tympanic membrane
Investigation findings for acute otitis media
Otoscopy =
- bulging tympanic membrane → loss of light reflex
- opacification
- erythema of tympanic membrane
- perforation with purulent otorrhoea
Mx of acute otitis media
Mx:
- Analgesia (paracetamol/NSAID)
- Seek help if sx don’t resolve after 3 days/deterioration
- Admit = complications, systemically unwell, children <3m with temperature >38dc, ENT referral/advice, hearing test, developmental assessment
Abx → + <2y bilateral, perforation/discharge, immcomp
- None = most cases resolve
- Back-up = abx NOT needed immediately, but should be used if sx’s have not improved after 3 days/worsened
- Immediate = sx worsen rapidly, systemically unwell, seek medical help
- Amoxicillin 5-7d → allergy then clarithromycin, erythromycin, 2nd line co-amoxiclav
Allergic rhinitis features
- Intermittent vs persistence
- Mild vs severe
- Seasonal vs perennial
Features
- Coryza, conjunctivitis, chronically blocked nose, sleep disturbance, impaired daytime behaviour/concentration
- Sleep disturbance, impaired daytime behaviour/concentration
Investigations for allergic rhinitis
- Identify causative allergen
- Assess for atopy, asthma, allergic conjunctivitis, eczema
- Look for signs of nasal congestion (mouth breathing, cough, halitosis)
- Examine nose = nasal polyps, deviated septum, mucosal swelling/depressed, wide nasal bridge
Mx of allergic rhinitis
- Mild-mod = allergen avoidance, nasal irrigation, intranasal antihistamines/PO non-sedating antihistamines (e.g. loratadine/cetirizine). 2nd line intranasal chromone
- Mod-severe = as above, + intranasal corticosteroid, short course PO corticosteroids
- Add-ons for ineffective therapy= intranasal decongestants (ephedrine/xylometazoline), intranasal anticholinergic, SL/SC immunotherapy
f/u 2-4 weeks
Food allergy features
Primary and secondary “oral allergy syndrome”
Ask for personal/FHx of atopy, details of food avoidance, feeding history *age of weaning, breast/formula)
Similar features to CMPA
With rash, erythema, urticaria, angioedema, colicky abdominal pain, sneezing, rhinorrhoea, congestion, cough, tightness, wheeze
- Anaphylaxis in 10-15 minutes
Food allergy investigations
Ix:
- Skin prick allergy testing and RAST
- Trial elimination of suspected allergen then reintroduce
- Consider endoscopy, intestinal biopsy
Food allergy mx
Diet
- Exclusion of offeding food from diet
- Paed dietician referral
- Dietary exclusion in mother if breastfeeding
Drug
- Mild (no cardioresp sx) = non-sedating anti-histamine (diphenhydramine)
- Severe (cardio, laryngeal, bronchial) = IM adrenaline/EpiPEN, salbutamol for bronchospasm
Education = allergy action plan
- Training and self-management
- Epi-Pen use (2 doses at all times)
Food challenge
- After 6-12m sx free
- If previous reaction severe (do in hospital)
Principles of upper airway mx (REMEMBER THIS ORDER)
- step away from the child = do NOT examine the throat
- give oxygen
- Get people you need in the room (anaesthetics, ENT, paediatrics)
- reduce the inflammation = adrenaline nebulisers (repeat as necessary), dexamethasone orally, budesonide nebuliser
Bacterial tracheitis summary
3 years old, presents with stridor and spreading rash after returning from a plane
salbutamol toxicity signs
nausea + vomiting
low potassium
lactic acidosis
tremors
Causes of snoring in children
- Obesity
- Nasal problems (polyps, deviated septum, hypertrophic nasal turbinates)
- Recurrent tonsillitis
- Down’s syndrome
- Hypothyroidism
Scarlet fever: pathogen, epidemiology, physiology and features
Scarlet fever is a reaction to erythrogenic toxins produced by Group A haemolytic streptococci (usually Streptococcus pyogenes). It is more common in children aged 2 - 6 years with the peak incidence being at 4 years.
Scarlet fever is spread via the respiratory route by inhaling or ingesting respiratory droplets or by direct contact with nose and throat discharges, (especially during sneezing and coughing).
Scarlet fever has an incubation period of 2-4 days and typically presents with:
- fever: typically lasts 24 to 48 hours
- malaise, headache, nausea/vomiting
- sore throat
- ‘strawberry’ tongue
-
rash
- fine punctate erythema (‘pinhead’) which generally appears first on the torso and spares the palms and soles
- children often have a flushed appearance with circumoral pallor. The rash is often more obvious in the flexures
- it is often described as having a rough ‘sandpaper’ texture
- desquamination occurs later in the course of the illness, particularly around the fingers and toes
Scarlet fever diagnosis and management
Diagnosis = throat swab, BUT abx commenced immediately rather than waiting for the results
Management:
- notify HPU
- Abx = penicillin V (QDS 10 days) OR azithromycin (if penicillin allergy)
- 10 days to prevent complications such s acute glomerulonephritis and rheumatic fever
- stay away from nursery/school for 24 hours after starting abx
- paracetamol/ibuprofen given for symptomatic relief
- symptoms should settle down after 1 week
Scarlet fever complications
- otitis media: the most common complication
- rheumatic fever: typically occurs 20 days after infection
- acute glomerulonephritis: typically occurs 10 days after infection
- invasive complications (e.g. bacteraemia, meningitis, necrotizing fasciitis) are rare but may present acutely with life-threatening illness
Inhaled corticosteroid doses
- <200 is low dose
- 200 - 400 is moderate dose
- >400 is high dose
Cystic fibrosis features
Main features
- Neonatal = meconium ileus, less commonly prolonged jaundice
- Recurrent chest infections
- Malabsorption = steatorrhea, FTT
- Liver disease
Other features = Short stature, DM, delayed puberty, rectal prolapse (from bulky stools), nasal polyps, male infertility, female subfertility, USI, muscle pains, arthralgia
Pulmonary = pneumonia, nasal polyps, sinusitis
GI = underweight, malnutrition, intussusception, meconium ileus
Cystic fibrosis epidemiology and aetiology
AR, defect in CFTR, delta F508 on Chr7, mutation mainly, increased viscosity of secretions (e.g. lungs, pancreas), 1 in 25 carrier rate, 1 in 2500 births, 5% diagnosed after 18 years old
Organisms:
S. AUREUS, P.AERUGINOSA, BURHOLDERIA CEPACIA, ASPERGILLUS
CXR in cystic fibrosis
CXR =hyperinflation, peribronchial shadowing, bronchial wall thickening, ring shadows
Cystic fibrosis Management
MDT = paeds, physio, GP, dieticians, specialist nurses, primary care team, teachers, psychologists, social workers, annual review in specialist centre, psych and educational support, routine reviews
DF508 mutation = lumacaftor/ivacaftor
Pulmonary, infection, nutrition, psychosocial
Pulmonary:
- airway clearance techniques + mucoactive agents 1) rhDNase 2) hypertonic NaCl +/- rhDNase 3) mannitol dry powder for inhalation
- S. aureus pneumonia flucloxacillin (prophylaxis)
- P. aeruginosa pneumonia Acute = PO/inhaled abx, chronic/persistent = 1) colistimethate sodium + PO/IV abx 2) tobramycin DPI
- Immunomodulatory agents for deteriorating lung function: azithromycin, oral corticosteroids
GI: high calorie diet, Creon, H2 receptor antagonist/PI, UDA (only for abnormal LFTs, stop when recovers) for liver disease, distal intestinal obstruction syndrome diatrizoate meglumine + diatrizoate sodium solution (Gastrografin)
