Respiratory Flashcards
What is pneumonia?
Lung tissue infection causing inflammation and sputum filling the airways and alveoli.
What is seen on a chest XRAY in pneumonia?
consolidation of affected area
How does pneumonia present?
- cough - productive
- fever (>38.5)
- tachypnoea (ranges vary depending on age)
- tachycardia
- increased work of breathing
- lethargy / sleepiness
- delirium - acute confusion
What are the signs of pneumonia?
- tachypnoea
- tachycardia
- hypoxia
- hypotension (shock)
- fever
- confusion
- bronchial breath sounds (harsh sounds on both inspiration and expiration)
- focal coarse crackles (air passing through mucus)
- dullness to percussion
What are some of the common causes of pneumonia?
Bacterial
- streptococcus pneumonia
- Group A strep ( pyogenes )
- Group B strep (neonates from birth - pre vaccinations)
- staph aureus
- haemophilus influenza
Viral
- RSV - respiratory syncytial virus
- influenza / parainfluenza
What investigations are done for suspected pneumonia?
- chest XRAY
- sputum culture and throat swab
- initial SEPSIS six if indicated
- capillary blood gas can be useful
How is pneumonia managed?
Follow local abx guidelines. Amoxicillin - first line. A macrolide can be added to cover atypical organisms (e.g. clarithromycin).
Give oxygen if required.
Name some causes of recurrent lower respiratory tract infections
- reflux
- aspiration
- neurological disease
- heart disease
- asthma
- CF
- primary ciliary dyskinesia
- immune deficiency
What is croup?
Acute respiratory infection causing oedema in the larynx - typically between 6 months and 2 years.
What commonly causes croup?
- parainfluenza
- influenza
- adenovirus
- RSV - respiratory syncytial virus
(in undeveloped countries - diphtheria leading to epiglottitis)
How does croup present?
- increased work of breathing
- barking cough ( in clusters )
- hoarse voice
- stridor
- low grade fever
How is croup managed?
- mainly supportive - fluids and rest.
- avoid spread - stay off school, good hand washing
If more severe:
- oral dexamethasone - single dose 150mcg/kg (normally responds in <48hrs)
- oxygen
- nebulised budesonide (corticosteroid)
- nebulised adrenaline
- intubation and ventilation
What is bronchiolitis?
inflammation and infection in the bronchioles (small airways in the lungs) - usually caused by RSV (respiratory syncytial virus)
Who is most likely to have bronchiolitis?
Children under 1 (particularly <6 mnths or ex-premature babies)
How does bronchiolitis present?
- coryzal symptoms - viral URTI symptoms - sneezing, runny nose, mucus in throat, watery eyes
- signs of respiratory distress
- dyspnoea (heavy laboured breathing)
- tachypnoea (fast)
- poor feeding
- mild fever
- wheeze and crackles on auscultation
What are the signs of respiratory distress?
- tachypnoea (increased resp rate)
- use of accessory muscles
- intercostal and subcostal recessions
- nasal flaring
- tracheal tugging
- head bobbing
- cyanosis (low O2 sats)
- abnormal airway noises
How long do the symptoms of bronchiolitis last?
7-10 days with full recovery normally being in 2-3 weeks. Symptoms peak on day 3/4.
When are children with bronchiolitis admitted?
- pre-existing medical conditions such as prematurity, CF, Downs
- < 75% of their normal milk intake (poor feeding)
- clinical dehydration
- RR > 70
- O2 <92%
- moderate to severe resp. distress
- apnoeas (short periods where breathing stops)
How is bronchiolitis managed?
Supportive management
- ensuring adequate intake - may require NG tube or IV fluids
- saline nasal drops and nasal suctioning
- supplementary oxygen if sats <92%
- ventilatory support if required
What are the methods of ventilatory support for bronchiolitis?
- high flow humidified oxygen (prevents airways from collapsing)
- CPAP - continuous positive airway pressure
- intubation and ventilation - with endotracheal tube
How can ventilation be assessed in paeds?
Capillary blood gases
What does a capilliary blood gas show if there is poor ventilation?
- rising pCO2
- falling pH (respiratory acidosis)
What is palivizumab?
A monoclonal antibody that targets RSV. It is a monthly injection given to high risk babies - e.g. extremely premature or congenital heart disease. Gives passive protection (not long term).
What is epiglottitis?
Inflammation and swelling of the epiglottis due to infection (usually haemophilus influenza type B). This can lead to full obstruction of the airway.
Why is epiglottitis rare?
Routine vaccination against haemophilus
How does epiglottitis present?
- sore throat
- stridor
- drooling
- tripoding position
- fever
- difficulty or painful swallowing
- muffled voice
- septic features
How to investigate epiglottitis?
If acutely well - treat rather than do investigations. Do not examine to distress the patient and worsen any obstruction.
- can do lateral XRAY of the neck - showing the “thumb sign”. It can also help to exclude a foreign body.
How is epiglottitis managed?
- emergency - treat immediately
- avoid distressing the patient
- alert senior paediatricians and anaesthetist
- ensure adequate airway - may need intubation
- IV antibiotics - e.g. ceftriaxone
- steroids - e.g. dexamethasone
What is the most common life threatening complication of epiglottitis?
epiglottic abscess
What is laryngomalacia?
condition in infants where the supraglottic larynx causing partial airway obstruction due to a structural issue (the larynx flops across the airway with inspiration)
Describe the structural changes in laryngomalacia
There is shortening of the aryepiglottic folds, which pulls on the epiglottis - creating a ‘omega’ shape.
The supraglottic tissue has less tone, hence flops across the airway - particularly during inspiration.
How does laryngomalacia present?
In infants (peak = 6 mnths)
- inspiratory stridor (harsh inspiratory whistling) - intermittent - more prominent when upset or lying on their back
- can cause difficult with feeding
How is laryngomalacia managed?
Problem resolves itself - as the larynx matures and grows it can support itself better
- rarely tracheostomy or surgery may be needed
What is whooping cough?
URTI caused by bordetella pertussis.
Called whooping cough as the coughing fits are so severe that the child cant take in air in-between hence make a loud whooping sound
What gram stain is bordetella pertussis?
Gram negative (pink/red) - causes whooping cough
How does whooping cough present?
- mild coryzal symptoms
- low grade fever
- initially a mild dry cough followed by severe coughing fits - have free periods in between. loud inspiratory whoop
- hard coughing can causing - fainting, vomiting or even pneumothorax
- may have apnoeas
How is whooping cough diagnosed?
- nasal / nasopharyngeal swab - PCR and culture.
- if cough >2weeks patients can be tested for anti-pertussis toxin immunoglobulin G (normally in oral fluid - or in blood if >17)
How is whooping cough (pertussis) managed?
- notify public health
- generally supportive management
- prevent spreading - e.g. advise good hand hygiene
- antibiotics can be useful - macrolides e.g. azithromycin
(can also be given to any vunerable contacts - e.g. immunosupressed, pregnant)
Cough tends to last a while - typically 8 weeks but can be months.
What is a key complication of whooping cough?
Bronchiectasis
What is bronchiectasis?
Widening of the airways, leading to a build up of excess mucus
What is the pathophysiology behind a viral wheeze?
The virus causes inflammation and oedema of the airway. walls, narrowing the space for air to flow. This causes a wheeze (which leads to restricted ventilation and respiratory distress) This mainly affects children as their airways have a smaller diameter.
How does a viral wheeze present?
evidence of a viral illness (fever, cough, coryzal symptoms) for 1-2 days before
- SOB
- signs of resp distress
- expiratory wheeze throughout the chest
What is another name for chronic lung disease of prematurity?
Bronchopulmonary dysplasia
When does chronic lung disease of prematurity occur?
- premature babies - typically born under 28 wks
- suffer with respiratory distress syndrome and often require oxygen therapy or intubation and ventilation at birth.
What are the features of chronic lung disease of prematurity?
- low oxygen saturations
- increased work of breathing
- poor feeding and weight gain
- crackles and wheezes on chest auscultation
- increased susceptibility to infection
How is chronic lung disease of prematurity diagnosed?
- chest X-ray changes
- when the infant requires oxygen therapy after 36wks of gestation
How is chronic lung disease of prematurity prevented?
- giving corticosteroid (betamethasone) to mothers showing signs of premature labour less than 36 wks.
Once born
- CPAP rather than intubation and ventilation
- give caffiene to stimulate the respiratory effort
How is chronic lung disease of prematurity prevented?
- giving corticosteroid (betamethasone) to mothers showing signs of premature labour less than 36 wks.
Once born
- CPAP rather than intubation and ventilation
- give caffeine to stimulate the respiratory effort
- not over oxygenating
How is chronic lung disease of prematurity managed?
- sleep study assessing oxygen sats
- can be sent home on low dose oxygen
- require protection against RSV - respiratory syncytial virus (bronciolitis). Give monthly injections of a monoclonal antibody called palivizumab
What is cystic fibrosis?
Autosomal recessive genetic condition affecting the mucus glands. There is a mutation in the CFTR gene on chromosome 7. This affects chloride channels and transport across cells.
What are the key consequences of the cystic fibrosis mutation?
- thick pancreatic and biliary secretions - causing blockage of ducts and a lack of digestive enzymes such as pancreatic lipase in the digestive tract
- low volume thick airway secretions - reduce airway clearance = bacterial colonisations and susceptibility to airway infections
- sub or infertility. Congenital bilateral absence of the vas deferens in males. Thickened cervical mucus in females.
How is cystic fibrosis screen for?
Newborn bloodspot test ( heel prick)
What is often the first sign of cystic fibrosis and why?
Meconium ileus. If the meconium has not passed within 24 hours. It is more thick and sticky in CF, so can cause obstruction, abdominal distention and vomiting.
What are the symptoms of cystic fibrosis?
- chronic cough with thick sputum production
- recurrent respiratory tract infections
- loose, greasy stools (steatorrhea) due to a lack of fat digesting lipase enzymes
- abdominal pain and bloating
- salty taste to the child
- poor weight and height gain
What are the signs of cystic fibrosis?
- low weight or height on growth charts
- nasal polyps
- finger clubbing
- crackles and wheeze on auscultation
- abdominal distention
What can cause clubbing in children?
- hereditary clubbing (familial)
- cyanotic heart disease
- infective endocarditis
- cystic fibrosis
- tuberculosis
- inflammatory bowel disease IBD
- liver cirrhosis
How is cystic fibrosis diagnosed?
- newborn blood spot test
- sweat test (gold standard)
- genetic testing (amniocentesis or blood test after birth)
How is the sweat test for cystic fibrosis done?
- using pilocarpine and electrodes to stimulate sweating on a patch of skin
- measure chloride concentration from sweat
- diagnostic is >60mmol/l
What are common microbial colonisers in cystic fibrosis?
- staph aureus (should be given long term prophylactic flucloxacillin to prevent this)
- haem influenza
- pseudomonas aeruginosa (hard to treat)
- E.coli
- klebsiella pneumoniae
How is cystic fibrosis managed?
Managed by a specialist MDT
- chest physiotherapy (vibrator vests) several times a day to help clear mucus
- exercise to improve resp. function and help clear sputum
- high calorie diet (as have malabsorption)
- CREON tablets - replace missing lipase to allow digestion of fats
- prophylactic flucloxacillin
- treat chest infections
- bronchodilators
- nebulised DNase
- nebulised hypertonic saline
- vaccinations
Others:
- lung transplant
liver transplant
- fertility treatment (and genetic counselling)
What monitoring and screening do people with cystic fibrosis require?
- diabetes
- osteoporosis
- Vit D deficiency
- liver failure / function
What is another name for primary ciliary dyskinesia?
Kartagner’s syndrome
What is primary ciliary dyskinesia?
A autosomal recessive condition affecting the cilia of various cells in the body. This causes dysfunction of their motility, most notably in the respiratory tract. Also affects fertility (cilia of fallopian tubes and flagella or sperm)
Who is primary ciliary dyskinesia more common in?
People with parents who are related to each other (consanguinity)
What is Kartagner’s triad?
The three key features of primary ciliary dyskinesia
- paranasal sinusitis
- bronchiectasis
- associated with situs inversus
What is situs inversus?
Where all of the internal organs are mirrored inside the body (e.g. heart and stomach on right)
- dextrocardia is where only the heart is reversed
How is primary ciliary dyskinesia diagnosed?
- careful family hx assessing for any consanguinity in parents
- examination and imaging to diagnose situs inversus
- sample of ciliated epithelium from the upper airway - taken through nasal brushing or bronchoscopy
How is primary ciliary dyskinesia managed?
Similarly to cystic fibrosis + bronciectasis
- daily chest physiotherapy
-high calorie diet
- antibiotics when needed (or prophylactic)
