Respiratory Flashcards
Name the 5 respiratory infection classifications
(according to level of resp tract most involved)
URTI, Tracheal infection, Bronchitis, Broncholitis, Pneumonia
Most important respiratory viruses
RSV, rhinovirus, parainfluenza, influenza, adenovirus
Most important bacterial viruses
Streptococcus pneumoniae, Haemophilus influenza, Moraxella, Bordetella pertussis
Types of URTI
common cold, sore throat (pharyngitis), acute otitis media, sinusitis
Common cold (coryza) causes and symptoms
Cx: rhinovirus, coronoaviruses, RSV
Sx: nasal discharge/blockage, pharyngitis, cough, mild fever, watery eyes
Treatment of coryza/common cold
self-limiting. No abx (viral infection). Rest + healthy food. Paracetamol or ibuprofen if fever and distressed.
What causes sore throat (pharyngitis)
pharynx and soft palate are inflamed and local lymph nodes enlarged and tender. Usually due to viral infection with respiratory viruses.
What is tonsilitis
Form of pharyngitis where there is intense inflammation of the tonsils, often with a purulent exudate. Commonly group A strep and EBV.
What is acute Otitis media?
Infection of the middle ear. Viral URTI often preceding bacteria entering from back of throat through eustachian tube.
Px of Otitis media
ear pain, reduced hearing, URTI symptoms. May cause balance issues and vertigo.
Dx of Otitis media
Otoscope - bulging, red/inflamed ear drum. If ear drum perforated will see discharge (normally pearly grey, translucent, slightly shiny)
Tx of Otitis media
Most self-resolving, try avoid abx. If abx (amoxicillin = 1st line) can prescribe immediate or delayed - 2-3D if not resolved.
What is Otitis media with effusion + why is there effusion.
Middle ear filled with fluid, loss of hearing in that ear. Blocked eustachian tube - secretions from middle ear not drained into throat.
Causes of glue ear
immature/malformation of Eustachian tube. Otitis media.
Dx + Mx of glue ear
dull, retracted eardrum. Fluid level visible.
Mx = self resolving within 3 mth.
When is active management needed for glue ear
If affecting learning and development, had severe hearing loss before glue ear, have downs or cleft
What is grommets
Used to treat glue ear. Small tubes implanted into ear drum under general anaesthesia.
What is sinusitis
May occur with viral URTI’s. Infection of paranasal sinuses. Pain, swelling around cheeks, eyes, forehead.
How can laryngeal and tracheal infections be life-threatening ?
Cause mucosal inflammation and swelling which can lead to obstruction of the airway
What is the most common laryngotracheal infection?
Croup
What feature of Croup can cause critical narrowing of the trachea
Oedema of the subglottic area
Common causes of Croup
parainfluenza most common cause, RSV, adenovirus
What age is Croup most common
6 months to 2 years but can be older
Typical features of Croup
barking cough, increased work of breathing, stridor, hoarseness usually preceded by fever
Mx of Croup
Usually managed at home and resolves within 48 hours. If severe use management pathway: oral dexamethosone (or pred) -> O2 -> budenoside -> adrenaline -> intubation + ventilation.
What must you avoid doing when examining obstruction of the upper airway
Avoid examining the throat using a spatula. Can precipitate total obstruction.
What type of layngotracheal infection is a life threatening emergency
Acute epiglottitis
What is the worry with acute epiglottitis
Can swell to complete obstruction of the airway within hours of symptoms developing - the thumb sign on xray
What causes acute epiglottitis and why is it now rare
Haemophilus influenza type B. Now a vaccination programme
How can you differentiate epiglottitis from Croup?
Epiglottitis: unvaccinated, high fever, intense painful throat, difficulty swallowing, sat forward and drooling, stridor and muffled voice, severe difficulty breathing.
Croup: mild fever, sore throat, barking cough, harsh stridor, hoarse voice, difficulty breathing.
Mx of epiglottits
intensive care unit. Be prepared to intubate.
IV antibiotics - cefuroxime. Tracheostomy may be required if intubation not possible
What is bronchitis in children?
inflammation of the bronchi (large breathing tubes). Cough and fever main symptoms unlike wheeze and coarse crackles in adults.
What is whooping cough?
A highly contagious form of bronchitis caused by bacteria Bordatella pertussis.
What is the presentation of whooping cough?
1 week of coryzal symptoms. Developing into a paroxysmal cough followed by a large, loud inspiratory whoop lasting 3-6week. Can cough so hard they vomit, go red/blue in face, faint.
Is whooping always present in infants with whooping cough
Can be absent, with apnoeas presenting instead. Can cause brain damage, death.
When should infants be vaccinated for whooping cough
4 months
How is whooping cough diagnosed and treated.
nasal swab with PCR testing or bacterial culture. Treated with macrolide in early stages.
What age is bronciolitis predominantly a concern?
Under 1 year old. Most common serious respiratory infection of infancy. Infant airways small, inflammation and mucus causes decrease in circulation.
What is the presentation of bronchiolitis
coryzal symptoms/ URTI precede dry cough with wheeze and crackles and increasing breathlessness (dyspnoea, tachypnoea, apnoea in <6m), signs of respiratory distress
What is the major cause of bronchiolitis
RSV
What is the prognosis of bronchiolitis
Most patients fully recover within 2-3weeks. Infants more likely to have viral induced wheeze throughout childhood
Investigations for bronchiolitis
pcr of nasal swab. CXR - hyperinflation of lungs
Signs of respiratory distress?
- Tachypnoea
- use of accessory muscles/intercostal recession,
- nasal flaring,
- head bobbing,
- tracheal tugging,
- cyanosis,
- abnormal airway noises
Management of bronchiolitis
supportive - O2 if needed. Fluids via NG tube or IV
What are 3 options for O2 support
humidified O2 via nasal cannula, continuous postiive airway pressure (CPAP), intubation and full control ventilation
Prevention of Bronchiolitis
Palivizumab monoclonal antibody that targets RSV. Given to high risk babies - ex premature or congenital heart disease
What is the definition of pneumonia
infection and inflammation of lung tissue. Sputum fills airways and alveoli.
What are the common causes of pneumonia?
- Newborns: group B strep bacteria biggest cause from mothers genital tract.
- Infants and young children: RSV virus and bacterial strep pneumoniae or haemophilus influenza.
- Older children: Strep pneumonia and atypical bacteria mycoplasma pneumoniae.
- Staph aureus is infrequent but serious cause.
Clinical features of pneumonia
High fever and cough (typically wet and productive). Tachypnoea and increased work of breathing. Lethargy.
Investigative signs of pneumnoia
Tachypnoea, nasal flaring, chest indrawing. Consolidation on XRAY + dullness on percussion. Decreased breath sounds and bronchial breathing over affected area.
What is consolidation of right upper lobe characteristic of?
Lobar consolidation is a feature of pneumococcal pneumonia.
A small proportion of pneumonias are associated with pleural effusion. What may these effusions develop into.
Build up of excess fluid inbetween pleural layers outside lungs. Fluid can collect and become infected forming empyema - collection of pus inbetween pleural layers.
What is bronchial breath sounds?
These are harsh breath sounds that are equally loud on inspiration and expiration. These are caused by consolidation of the lung tissue around the airway.
Mx of pneumonia
- Most cases can be managed at home, decreased sats, severe tachypnoea, apnoea require admission.
- O2 support + analgesia if pain
- Amoxicillin is often used first line. Adding a macrolide (erythromycin, clarithromycin or azithromycin) will cover atypical pneumonia.
What features of pleural irritation can be signs of pneumonia
abdominal or neck pain.
What is viral induced wheeze
Most wheezy under 3 year olds have viral induced wheeze. It is an acute wheezy illness caused by a viral infection.
What are the typical features of viral induced wheeze (differing from asthma)
< 3 years, no atopic history, episodic during viral infections. Asthma can also be triggered by viral infections, however also has other triggers.
Px of Viral induced wheeze
fever, cough, coryzal sympotms preceeding onset of SOB, resp distress, expiratory wheeze
Why does viral induced wheeze usually resolve by 5 years
It is a result of small airways being obstructed more easily from inflammation and immune responses to viral infection. Resolves with increase in airway size.
Risk factors for viral induced wheeze
parental smoking, prematurity, family history of VIW
Mx of viral induced wheeze
Same as acute asthma. Usually resolves by 5 years of age.
What is atopic asthma
Presence of IgE to common inhalant allergens. Leads to wheezing beyond pre school years
What are common allergens
house dust mite, pollens, pets
What conditions is asthma associated with
eczema, food allergies, hayfever, rhinoconjuctivitis.
What kind of wheeze is characterisitc of viral induced wheeze or asthma
Expiratory wheeze - neither cause a focal wheeze. Investigate focal airway obstruction e.g. from inhaled foreign body.
What does a wheeze sound like
whistling sound in chest. Expiratory wheeze = whistling when child breaths out.
What is chronic asthma
chronic inflammatory airway disease leading to variable airway obstruction. The smooth muscle in the airways is hypersensitive, and responds to stimuli by constricting and causing airflow obstruction.
Clinical features of chronic asthma
- Episodic symptoms with intermittent exacerbations
- Diurnal variability, typically worse at night and early morning
- Dry cough with expiratory wheeze and shortness of breath
- Typical triggers: allergens, infection, smoking, cold air, exercise, emotional
- A history of other atopic conditions such as eczema, hayfever and food allergies
- Family history of asthma or atopy
Dx of asthma
- There is no gold standard test or diagnostic criteria for asthma. A diagnosis is made clinically based on a typical history and examination. Children are usually not diagnosed with asthma until they are at least 2 to 3 years old.
- Spirometry with reversibility testing (in children aged over 5 years)
- Peak flow variability measured
Mx of asthma under 5 years old
- Start a short-acting beta-2 agonist inhaler (e.g. salbutamol) as required [reliever].
- Add a low dose corticosteroid inhaler [preventer] or a leukotriene antagonist (i.e. oral montelukast)
- Add the other option from step 2.
Mx of asthma 5-12 years
- Start a short-acting beta-2 agonist inhaler (e.g. salbutamol) as required
- Add a regular low dose corticosteroid inhaler
- Add a long-acting beta-2 agonist inhaler (e.g. salmeterol). Continue salmeterol only if the patient has a good response.
- Titrate up the corticosteroid inhaler. Consider adding:
Oral leukotriene receptor antagonist (e.g. montelukast)
What is an acute exacerbation of asthma
characterised by a rapid deterioration in the symptoms of asthma. This could be triggered by any of the typical asthma triggers, such as infection, exercise or cold weather.
Px of acute asthma
- Progressively worsening shortness of breath
- Signs of respiratory distress
- Fast respiratory rate (tachypnoea)
- Expiratory wheeze on auscultation heard throughout the chest
- The chest can sound “tight” on auscultation, with reduced air entry
What is a silent chest a sign of in acute asthma
-A silent chest is an ominous sign. This is where the airways are so tight it is not possible for the child to move enough air through the airways to create a wheeze.
What is criteria of moderate asthma
O2 sats >92%, peak flow >50% predicted, no clinical features of severe asthma
What is criteria of Severe asthma
O2 sats <92%, peak flow <50% predicted, signs of respiratory distress
What is criteria for life threatening asthma
O2 sats <92%, peak flow <33%, silent chest, cyanosis, altered consciousness
Mx of acute asthma
- Supplementary oxygen if required (i.e. oxygen saturations less than 94% or working hard)
- Bronchodilators (e.g. salbutamol, ipratropium and magnesium sulphate)
- Steroids to reduce airway inflammation: prednisone (orally) or hydrocortisone (intravenous)
- Antibiotics only if a bacterial cause is suspected (e.g. amoxicillin or erythromycin)
What symptoms can aspiration of feeds cause and what can be causes?
cough and wheeze. Can be caused by GORD or swallowing disorders e.g. cerebral palsy.
Differential diagnosis of recurrent/persistent cough in children
- URTI - series of infections
- Asthma (usu. wheeze, breathlesness, triggers)
- Cystic fibrosis (after an acute infection)
- TB (severe, persistent cough - CXR, Mantoux test)
- Aspiration of feeds
- Inhaled foreign body
What is cystic fibrosis
Cystic fibrosis (CF) is an autosomal recessive genetic condition affecting mucus glands. It is caused by a genetic mutation of the cystic fibrosis transmembrane conductance regulatory gene on chromosome 7.
What does the gene code for in cystic fibrosis
This gene codes for cellular channels, particularly a type of chloride channel.
What are the main consequences of gene mutation in CF
- Thick pancreatic and biliary secretions that cause blockage of the ducts, resulting in a lack of digestive enzymes such as pancreatic lipase in the digestive tract
- Low volume thick airway secretions that reduce airway clearance, resulting in bacterial colonisation and susceptibility to airway infections
- Congenital bilateral absence of the vas deferens in males. Patients generally have healthy sperm, but the sperm have no way of getting from the testes to the ejaculate, resulting in male infertility
Presentation of CF
- Chronic cough
- Thick sputum production
- Recurrent respiratory tract infections
- Loose, greasy stools (steatorrhoea) due to a lack of fat digesting lipase enzymes
- Abdominal pain and bloating
- Parents may report the child tastes particularly salty when they kiss them, due to the concentrated salt in the sweat
- Poor weight and height gain (failure to thrive)
- clubbing of fingers
What is often the first sign of CF
Meconium ileus - meconium usually passed 24 hours of birth. In about 20% of babies with CF, the meconium is thick and sticky, causing it to get stuck and obstruct the bowel. This presents as not passing meconium within 24 hours, abdominal distention and vomiting.
Dx of CF
- Newborn blood spot testing is performed on all children shortly after birth and picks up most cases
- The sweat test is the gold standard for diagnosis
- Genetic testing for CFTR gene can be performed during pregnancy by amniocentesis or chorionic villous sampling, or as a blood test after birth
Key colonisers of patients that have CF
Staph Aureus - take long term prophylactic flucloxacillin. Pseudomonas is hard to treat and makes CF worse. Chronic infection can lead to bronchiectasis and persistent cough
Mx of CF
- Chest physiotherapy several times a day is essential to clear mucus and reduce the risk of infection
- Prophylactic flucloxacillin tablets
- Treat chest infections when they occur
- enzymes to help digestion
Prognosis of CF
median life expectancy 47 years. pancreatic insufficiency and DM common. 1/3rd will have liver disease. Decreased lung function and damage.
