Respiratory Flashcards
What should do if think its asthma and QoL is affected?
QoL affected confirm diagnosis with a trial of ICS
QoL not affected, watch and see
What is asthma?
Chronic
Wheeze, Cough, SOB
Multiple triggers-although in children the predominant trigger is an URTI
Variable/reverisble
RESPONDS TO ASTHMA TX
Is asthma a diagnosis of exclusion?
NOOOOO
Key words:
- Wheeze
- Variability
- Respond to treatment
What causes asthma?
- Host response to environment
- Infection
- Physiology abnormal before symptoms
- It is a syndrome
- Genetics (ADAM33, ORMDL3 (not all people with these genes have asthma))- interact with environment
What are some asthma syndromes (multiple hits)?
All go into a final common pathway
- Infant onset
- Childhood onset
- Adult onset
- Exertional asthma
- Occupational asthma
Does allergy cause asthma?
Thats a nope (not directly related)
Primary epithelial (skin, airway, gut) abnormality results in:
1) Eczema/asthma etc
2) Allergy
Allergy then fuels (sensitisation) eczema/asthma etc
Early environment causes childhood asthma: what are some of these interventions to change environments to reduce exposure?
- Feeding (breast, late weaning
- Allergen (ante- and post natal)
- Smoking
Is there a diagnostic test for asthma in children?
NO
Tests can be useful (excluding>diagnosing)
What makes spirometery useful?
Bronchodilator response to measure the lung function
Asthma diagnosis tests (more for exclusion of other things?
- Spirometry
- BDR
- FeNO
- Peak flow
Asthma diagnosis tests (more for exclusion of other things?
- Spirometry
- BDR
- FeNO
- Peak flow
Why is it hard to diagnose asthma in <5s?
Uncertainty greatest in <5s
Tests not reliable in <5s
Tests not great anyway
Does a cough variant asthma exist in children?
NOOOOOO
Rattle of … & the whistle of …
Rattle of bronchitis and the whistle of asthma
Do you get a Hx of SOB in asthma?
YES DUH
- Sig resp difficult (<30% lung function)
- Airway obstruction
- ‘Sooking’ in of ribs with wheeze
What kind of cough is associated with asthma?
- Dry
- Nocturnal (just after falling asleep)
- Exertional
What is the treatment/diagnosis of asthma?
ICS for 2 months
Remember false positive responses-inhaler holiday
What Hx do you ideally need to diagnose asthma (hindsight diagnosis)
Wheeze (with & w/o URTI)
SOB @ rest
Parental asthma
Responds to Tx
What are the harms of a trial of treatment for asthma and what are the benefits?
Harm=0.5-1cm loss in height, oral thrush
Benefit=helps diagnosis and if symptoms respond it improves QoL & reduces risk of attacks
What are the harms of a trial of treatment for asthma and what are the benefits?
Harm=0.5-1cm loss in height, oral thrush
Benefit=helps diagnosis and if symptoms respond it improves QoL & reduces risk of attacks
Under 18 months respiratory symptoms are most likely infection and >5 most likely asthma but…?
If it sounds like asthma & responds to asthma Tx it is asthma regardless of age!
Are asthma & VIW treated the same?
Yes-they are the same condition
- Preschool children
- Different shades of the same colour
- Should be treated
Is there a cure for asthma?
No, only palliation or spontaneous resolution
How is control measured (what criteria)?
SANE
Short acting beta agonist/week
Absence school/nursery
Nocturnal symptoms/week
Exertional symptoms/week
If patient has been symptom free for 3 months what might you consider in asthma?
Stepping down the treatment
What is the starting treatment for asthma?
Low dose ICS (severe may respond to minimal treatment)
Review after 2 months (inhaler hol-easter)
ICS is the standard preventer so what is SABA?
Blue relieving medication
What is the max dose of ICS in <12 yo?
800microg
What is the first line preventer in <5s?
LTRA
What are the contrasts between child and adult asthma meds?
- No oral B2 tablet
- No LAMAs
- Only 2 biologics
When should a regular preventer of asthma be used?
- Diagnostic test
- B2 agonists >2 days a week
- Symptomatic 2 x a week or more or waking one night a week
What can oral steroids cause?
HT & Cataracts
Higher dose steroids (fluticasone in particular) can cause what?
Adrenocortical suppression
How are LABAs given?
Not used without ICS
Used as a fixed dose inhaler
What leukotriene receptor agonist is given?
Montelukast only in children
- Rule of thirds
- Granules for reluctant todlers
- Oral - better adherance
What should be added to an ICS if a patient is poorly controlled?
Add on a LABA but keep an open mind
Additional add on therapies include increase ICS and LTRA
What are the 2 types of delivery system?
MDI/Spacer
Dry powder device-licensed in over 5s-under 8s cant use them
How is a spacer of benefit?
<5% lung deposition w/o spacer
<20% lung deposition with spacer
MDI/spacer=4xMDI
Shake=2x no shake
Wash to reduce static charge=2x no wash
Shake, wash and use spacer
Are nebulisers indicated for day to day use?
NO
What is some other management for asthma that are not meds?
- Stop tobacco smoke exposure
- Remove environmental triggers
What can air ionisers do?
Increase cough
How in an acute setting is it worked out what meds to give?
Look at RR, work of breathing and O2 saturations
- Confusion
- Air entry
- Ability to complete sentences
The level of treatment is determined by symptoms and sats (be guided by sats/oxygen requirement)
What should you do in acute asthma after you have started treatment?
Reassess in 1 hr
Step up or down as appropriate
What is the difference in the use of steroids for chronic and acute asthma?
Chronic/maintenance= inhaled steroids (NOT oral)
Acute= oral steroids
What are some side effects of Abx?
- Diarrhoea
- Oral thrush
- Nappy rash
- Allergic reaction
- Multi-resistance
What are some examples of anti-pyretics?
Paracetamol and ibuprofen for fever
Rhinitis is usually a self limiting condition but what could it be a predrome to?
- Pneumonia, bronchiolitis
- Meningitis
- Septicaemia
What is ottitis media?
Infection in the middle ear
- Erythema
- Bulging drum
- Common and self limiting
- Spontaneous rupture of drum
- Abx Tx doesn’t usually help
What is the secondary infection of otitis media?
Pneumococcus/H’flu
How is otitis managed?
- ANALGESIA
- Abx may work >24hrs
With tonsilitis/pharyngitis how is it managed?
Throat swab-bacterial or viral
Viral=nothing
Bacterial=10 days penicillin
(Don’t use amoxycillin-EBV get rash)
What is characteristics of strep throat?
- Scarlet fever-faint pink rash - sandpaper like feel
- Pallor around the mouth
- Temp & poor energy
What is the treatment for croup (LTB)?
Oral dexamethasone
Duration of croup 1-2 days
What are the signs and treatment of epiglottits?
- Stridor, drooling
- Intubation & Abx
What is tracheitis, what is it caused by and how is it managed?
Fever, sick child-‘croup which doesn’t get better’
Staph or strep invasive infection
Augmentin
Bronchitis is an endobronchial infection where the child is very well but the parent is worried. How does it present?
- Loose rattly cough with URTI
- Post tussive vomit-‘glut’
- Chest free of wheeze/creps
- Haemophilus/pneumococcus
- Mostly self limiting
What is the mechanism of bacterial bronchitis?
- Disturbed mucocilliary clearance-mild airway malacia, RSV/adenovirus
Bacterial infection is secondary
What is the natural Hx of bacterial bronchitis?
- Lasts 4 weeks following an URTI
- Third winter fine
- Pneumococcus/H flu
How to manage persistent bacterial bronchitis?
Make the diagnosis-reassure-do not treat
What causes bronchiolitis (LRTI of infants) & how does it present?
Usually RSV-others incl. paraflu III, HMPV
- Nasal stuffiness, tachypnoea, poor feeding
- Crackles +/- wheeze
Bronchiolitis is very predictable
RSV for XMAS!!
- <12 months old
- One off (NOT recurrent)
- Typical Hx
How do we investigate Bronchiolitis?
- NPA
- Oxygen sats (severity)
No routine need for CXR, Bloods & bacterial cultures
What are the main characteristics of a LRTI?
48 hrs, fever (>38.5), SOB, cough, grunting
- Wheeze makes bacterial cause unlikely
- Reduced or bronchial breath sounds
Only call pneumonia instead of LRTI if have…?
- Signs are focal (ie in one area (LLZ))
- Creps
- High fever
Is CRX indicated in CAP?
NO, CXR & inflam markers are NOT ‘routine’
What is the management for CAP?
- Nothing if symptoms are mild
- Oral Amoxycillin 1st line
- 2nd line=Oral macrolide
- Only for IV if vomiting
When should oral Abx be used and not IV?
- Abx are indicated (48 hrs etc)
- In non severe LRTI
- When child is not vomiting
What is the difference between LRTI & Bronchiolitis?
LRTI= In all ages, more rapid onset of symptoms, fever
Bronchiolitis=<12 months, 3 days before reach peak, fever rarely >38 degrees
Is pertussis common?
YES
Vax reduces risk and severity
What are the symptoms of Pertussis?
- Coughing fits
- Vomiting & colour change
What is empyema and what is it a complication of?
Complication of pneumonia
Extension of infection into pleural space
How does empyema present and how is it treated?
Chest pain & very unwell
Abx +/- drainage
Good prognosis (in contrast with adults)
