Respiratory Flashcards
What is bronchiolitis?
How does it present?
Inflammation of the bronchioles with increased mucus secretions, due to a viral infection; most commonly RSV (respiratory syncytial virus). Adult bronchioles are a lot larger so would be unaffected by his level of inflammation and hypersecretion.
Commonly affects under 1yr old, typically under 6 months.
Baby’s who had bronchiolitis are more likely to get viral induced wheeze.
Starts off as an URTI for a few days, where some baby’s will recover, others will go on to develop a chest infection.
Children present with; Coryzal symptoms (since starts off as URTI)- runny nose, sneezing, mucus throat and watery eyes. Symptoms of respiratory distress Mild fever Poor feeding Poor wt gain Wheeze and crackles Apnoea Dyspnoea Increased RR
What are the features of respiratory distress?
Cyanosis Accessory muscles for breathing i.e. abdominal, SCM, intercostal Subcostal recess Intercostal recess Head bobbing Tracheal tug (pulled downward) Nasal flaring Abnormal Airway noise. Increased RR
NB- Wheeze - small airway narrowing, high pitched heard on expiration.
Stridor- high pitch heard on expiration; large airway obstruction.
Grunt- Exhaling with partially closed glottis.
How is bronchiolitis managed?
Can manage at home with symptomatic relief. Only admit when: Under 3 months old Has prematurity, Down's, CF etc Parents can't manage at home Clinically dehydrated Reduced feeds by 50-75% O2 sat <92% RR>70 Apnoea Moderate-severe respiratory distress
Hospital management is also supportive; Ensure adequate intake; IV, NG Nasal saline drips/nasal suctioning to clear nasal airways Supplementary O2 if remains <92% Ventilation if required
Ventilation is escalated to the next step if the previous is not sufficient:
1) High flow humidified O2- tight nasal cannula used to allow O2 intake and also pressure prevents airways collapsing.
2) CPAP- Similar to 1 but more pressure
3) Intubation and ventilation
To assess the effectiveness of ventilation take capillary blood gas. Increasing CO2 suggesting collapsing airways, as does a low pH where there has not been any compensation- leading to respiratory acidosis.
What is a viral induced wheeze?
How does it present?
How is it managed?
Essentially is an asthma caused by a virus.
Get inflammation and oedema of small airways, where inflammation leads to SM constriction (as with asthma).
Has a strong FHx and patients are more likely to develop asthma.
Children present with a viral prodrome (fever, cough coryzal symptoms) followed by SOB, expiratory wheeze throughout the chest and signs of respiratory distress.
Manage the same as acute asthma.
How does acute asthma present? RECAP
SOB
Cyanosis
Respiratory distress
Expiratory wheeze throughout the chest.
NB- Silent chest- suggests not enough air to create a wheeze- could be as a result of exhaustion leading to reduced respiratory effort.
How is acute asthma managed? RECAP
Also same for viral induced wheeze
Give O2 if sats <94%
If mild can discharge home with 2-6 puffs of salbutamol 4 hourly via a spacer.
If moderate to severe then requires stepping up the management ladder until control is gained:
1) Salbutamol inhaler with spacer 10 puffs 4hrly
2) Nebulised salbutamol/ipratropium bromide
3) Oral prednisolone (typically a 3 day course)
4) IV hydrocortisone
5) IV Magnesium Sulphate
6) IV Salbutamol
7) IV theophylline
If not gained control whilst approaching the end need to call anaesthetist to intubate and ventilate.
Once control is gained can wean pt down the ladder. Monitor K+ levels with salbutamol. Also salbutamol can cause tremors and tachycardia.
Discharge the child when they are well on 6 puffs 4hrly (prescribe a reducing regime alongside this for when they are at home i.e. after 48hrs 4 puffs 6hrly, after 48hrs 2-4 puffs PRN)
Ensure to finish course of oral prednisolone, safety net the family and discharge with an asthma action plan.
How is chronic asthma diagnosed in children?
Most children are not diagnosed until 5 yrs old.
Tests to use are:
Spirometry with bronchodilator reversibility.
FeNO test.
Peak flow variability- Keep a diary of peak flow test results for 2 weeks.
How is chronic asthma managed in children?
FInd out which guidelines we follow!!!
What is pneumonia?
How does it present?
Inflammation of the airway and alveoli, with sputum filling them. LRTI- common bacterial cause is strep.pneumonia, common viral cause is RSV, followed by influenza.
Presentation: SOB Increased RR Increased HR Fever Cough (wet) Lethargy Increased worked breathing
Think sepsis if hypoxia, tachypnoea, tachycardia, hypotension, fever, confusion etc.
Characteristic signs of pneumonia:
Bronchial breathing (on inspiration and expiration)
Dull percussion
Focal coarse crackles
How is pneumonia diagnosed?
How is pneumonia managed?
CXR will indicate pneumonia (consolidation), although is not always needed for a diagnosis.
Sputum culture to find the organism and then guide treatment.
Management:
O2 if saturation below 92%
Mild- Amoxicillin +/- clarithromycin
Severe- Co-amoxiclav +/- clarithromycin
Penicillin allergy- use macrolide alone.
How is a patient with recurrent admissions of RTI requiring Abx treatment managed?
Need to test for underlying pathology. Take thorough family history Sweat test for CF FBC- WBC anomalies HIV CXR- Any structural abnormality Test immunoglobulins
What is croup?
How does it present?
How is it managed?
URTI- Oedema of the larynx, common in 6 months-2yrs old. Will resolve within 48hrs.
Presentation: Barking cough Increased work of breathing Stridor Low grade fever Hoarse voice
Management:
Can manage at home with symptomatic relief.
If more severe then single dose of dexamethasone (can be repeated after 12hrs).
If not responding can escalate further.
What is epiglottitis?
How does it present?
Inflammation and swelling of the epiglottis which can obscure the airway, within hrs of symptoms- therefore life threatening.
Due to H.influenza, now seen mainly in unvaccinated children.
Presents: Fever Sore throat Drooling Tripod position (hands on both knees and head leaned forward) Difficulty/painful swallowing Upset/quiet child Unwell/septic looking Muffed voice
How is epiglottitis investigated?
How is it managed?
Don’t investigate- can aggravate the child and encourage airway closing. On lateral X-Ray of the neck, will see thumb print sign- epiglottis swollen pressing on the trachea.
Management is focused on securing the airway. Call a senior paediatrician and anaesthetist. Ensure also ENT surgeons present if airway closes and need to tracheostomy. If intubated need ICU admission.
Don’t bother the child, keep them comfortable.
Once airway secure- give IV ceftriaxone and dexamethasone.
Most children recover w/o intubation, those who are extubated recover well also. Few may die.
Complication includes epiglottis abscess; puss filled which can potentially compromise the airway- manage same as epiglottitis.
What is Laryngomalacia?
How is it managed?
Poorly developed supraglottic larynx; aryepiglottic folds (important for constricting the airway ot prevent food and fluid enering the larynx/trachea) are shortened and softer. So when the child breathes in the folds are pulled downwards, creating an upper respiratory tract obstruction.
Usually presents at 6 months old
Chronic inspiratory stridor- can be intermittent- worse on crying, lying on back, feeding etc.
Can cause poor feeding
Will self resolve as the larynx matures. However options for corrective surgery or tracheostomy are available.
