Respiratory Flashcards
1
Q
What is Bronchiolitis?
A
Condition characterised by acute bronchiolar inflammation
2
Q
What is the pathogen responsible for Bronchiolitis?
A
RSV- 80% of cases
Mycoplasma
Adenoviruses
3
Q
When does Bronchiolitis peak?
A
Winter
4
Q
What age do babies usually get bronchiolitis?
A
<1 year old
Peak incidence of 3-6 months
Can RARELY be diagnosed in ex-premature babies with chronic lung disease
5
Q
Symptoms of Bronchiolitis?
A
Coryzal symptoms
Dry cough
Increasing breathlessness
Parents may present baby with poor feeding
6
Q
Signs of bronchiolitis?
A
Wheezing, fine inspiratory crackles (not always present)
Dyspnoea - really heavy laboured breathing.
Tachypnoea
Poor feeding
Fever
Apnoeas - episode where child stops breathing
Signs of respiratory distress
7
Q
What are coryzal symptoms?
A
Snotty nose
Sneezing
Mucus in throat
Watery Eyes
8
Q
How does respiratory distress present in a child?
A
Raised RR
Use of accessory muscles
Intercostal recessions
Subcostal recessions
Nasal flaring
Head Bobbing
Tracheal tugging
Cyanosis
Abnormal airway noises
9
Q
What is a wheeze?
A
Whistling sound caused by narrowed airways, typically heard in expiration
10
Q
What is grunting?
A
caused by exhaling with the glottis partially closed to increase postive end-expiratory pressure
11
Q
What is Stridor?
A
High pitched inspiratory noise caused by obstruction of the upper airway e.g. croup
12
Q
When do you call 999 for a child with Bronchiolitis?
A
Apnoea
Child looks seriously unwell to a healthcare professional
Severe respiratory distress e.g. grunting, marked chest recession or RR over 70
Central cyanosis
Persistent O2 sats of less than 92% on air
13
Q
Investigations for bronchiolitis?
A
Immunofluorescence of nasopharyngeal secretions may show RSV
14
Q
Management of bronchiolitis?
A
Largely supportive
Humidified oxygen given via head box and typically recommended if sats are persistently less than 92%
NG feeding if children cannot take enough fluid/ feed by mouth
Suction sometimes used for excessive upper airway secretions
15
Q
What is the stepwise approach to ventilating a child?
A
To maintain breathing
1) High flow humidified oxygen via tight nasal cannula: air and oxygen continuously with some added pressure (positive end-expiratory pressure)
2) CPAP- using sealed nasal cannula, similar to above but can deliver much high and more controlled pressures
3) Intubation and ventilation. Involved inserting an endotracheal tube into trachea to fully control ventilation
16
Q
How do you assess ventilation in children with severe resp distress?
A
Capillary blood gases
Poor signs of ventilation:
Rising PCO2- showing airways have collapsed and can’t clear waste carbon dioxide
Falling pH, showing CO2 is building up an they are not able to buffer the acidosis- respiratory acidosis and if they are hypoxic: TYPE 2 RESP FAILURE
17
Q
What is Palivizumab?
A
Monoclonal antibody that target the RSV
Monthly injection is given as prevention against bronchiolitis caused by RSV
Given to high risk babies e.g. ex-premature or CHD
Gives passive protection
18
Q
Features of asthma in children?
A
Episodic symptoms with intermittent exacerbations
Diurnal variability- worse at night and better in the morning
Dry cough with wheeze and SOB
Hx of atopy
Bilateral widespread poylphonic wheeze
Symptoms improve with bronchodilators
19
Q
Differentials for wheeze in children?
A
Asthma
Viral wheeze- related to coughs and colds
Unilateal- suggesting focal lesion, inhaled foreign body or infection
20
Q
Triggers for asthma?
A
Dust
Animals
Cold air
Exercise
Smoke
Food allergens
21
Q
Investigations for asthma in children?
A
Usually diagnosed after the age of 2/3
Spirometry with reversibility testing (in kids over 5 years)
Direct bronchial challenge test with histamine or methacholine
FeNO
Peak flow variability- measure by a diary of several measurements a day, for 2-4 weeks
22
Q
Management for asthma in under 5s
A
Need to use clinical judgement in this scenario
1) SABA
2) Add ICS or Leukotriene antagonist. Potentially can trial 8 weeks of ICS and see if any improvements
3) Add the other option from step 2
4) refer to specialist
23
Q
Management of asthma is over 5’s
A
Very similar to adults
1) SABA
2) SABA + Pediatric low dose ICS
3) SABA + Pediatric low dose ICS + LTRA
4) SABA + Paediatric low dose ICS + LABA
(Stop LTRA if it hasn’t worked)
5) SABA + MART (combo of the paeds ICS and LABA)
6) SABA + moderate dose ICS MART
7) SABA + one of the following:
Increase ICS to paediatric high dose OR
Trial of an additional drug e.g. theophylline OR
Seek advice from a healthcare professional with expertise in asthma
24
Q
What may patients be anxious about RE ICS? How would you advise?
A
Slow growth- evidence that inhaled steroids can slightly reduce growth velocity and can cause a small reduction in final adult height of up to 1cm when used long term (for more than 12 months). DOSE DEPENDENT
Explain to parent that these are effective medicines and prevent poorly controlled asthma/ asthma attacks which can lead to a more significant impact on growth and development. Also regular asthma reviews to ensure child is growing well and on the minimal dose required for symptoms
25
Outline inhaler technique without a spacer
Remove the cap
Shake the inhaler (depending on the type)
Sit or stand up straight
Lift the chin slightly
Fully exhale
Make a tight seal around the inhaler between
the lips
Take a steady breath in whilst pressing the canister
Continue breathing for 3 – 4 seconds after pressing the canister
Hold the breath for 10 seconds or as long as comfortably possible
Wait 30 seconds before giving a further dose
Rinse the mouth after using a steroid inhaler
26
Inhaler technique with a spacer
Assemble the spacer
Shake the inhaler (depending on the type)
Attach the inhaler to the correct end
Sit or stand up straight
Lift the chin slightly
Make a seal around the spacer mouthpiece or
place the mask over the face
Spray the dose into the spacer
Take steady breaths in and out 5 times until the mist is fully inhaled
27
What is am acute asthma attack?
Characterized 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.
28
What are the parameters for a severe asthma attack?
Peak flow < 50% predicted
Saturations < 92%
Unable to complete sentences in one breath
Signs of respiratory distress
RR: > 40 in 1-5 years
> 30 in > 5 years
Heart Rate: >140 in 1-5 years
>125 in >5 years
Use of accessory neck muscles
29
What are the features of life threatening asthma?
Peak flow < 33% predicted
Saturations <92%
Exhaustion and poor respiratory effort
Hypotension
Silent chest
Cyanosis
Altered consciousness/confusion
30
Management of mild- moderate acute asthma?
Bronchodilator therapy:
Give a beta-2 agonist via a spacer (for child < 3 years use a close-fitting mask)
Give 1 puff every 30-60 seconds up to a mx of 10 puffs
If symptoms are not controlled repeat beta-2 agonist and refer to hospital
31
Management of acute asthma in hospital
Oxygen: SaO2 <94% should receive high flow oxygen to maintain sats between 94-98
Bronchodilators: Inhaled SABA- via nebuliser if severe
Steroids: all children with exacerbations should be started on oral prednisolone 3-5 days
Ipatropium bromide: add in if no/poor response to inhaled SABA
**2nd line**
IV salbutamol can be considered with specialist input if no response to inhaled bronchodilators
Magnesium sulphate can be considered, as has an effect as a bronchodilator
32
Prednisolone dose for asthma?
2-5 years old:
Dose as per BTS: 20mg od
Dose as per cBNF: 1-2mg/kg od (max 40mg)
>5 years
Dose as per BTS: 30-40mg od
Dose as per cBNF: 1-2mg/kg (max 40mg od)
33
Safe discharge criteria for acute asthma exacerbation?
Bronchodilators are taken as inhaler device with spacer at intervals of 4 hourly or more
SaO2> 94% in air
Inhaler technique reviewed
Written asthma management plan given and explained to parents
GP review 2 days after discharge
34
What is bronchiectasis?
Chronic irreversible inflammation of the bronchi and bronchioles leading to permanent dilatation and thinning of these airways.
These deformed bronchi has poor mucous clearance and there is predispostion to recurrent or chronic bacterial infection
35
Bronchiectasis symptoms?
Chronic cough
Daily mucopurulent sputum production
Breathlessness on exertion
Intermittent haemoptysis
Nasal symptoms
Chest pain
Fatigue
36
Signs in bronchiectasis?
Pulse ox: Hypoxaemia
Abnormal chest auscultation:
Coarse crackles + Wheeze ( CF pt with bronchiectasis)
Fine crackles (rales)
High pitched inspiratory squeaks
Rhonchi- on exertion
Fever- 50% of pts will have recurrent episodes of fever
Clubbing may be present
37
Diagnostic investigations for bronchiectasis?
Cxr: tram track sign
Gold standard: high resolution CT chest: signet ring appearance
38
Cause of bronchiectasis?
post-infective: tuberculosis, measles, pertussis, pneumonia
cystic fibrosis
bronchial obstruction e.g. lung cancer/foreign body
immune deficiency: selective IgA, hypogammaglobulinaemia
allergic bronchopulmonary aspergillosis (ABPA)
ciliary dyskinetic syndromes: Kartagener's syndrome, Young's syndrome
yellow nail syndrome
39
Management of Bronchiectasis?
physical training (e.g. inspiratory muscle training) - has a good evidence base for patients with non-cystic fibrosis bronchiectasis
postural drainage
antibiotics for exacerbations + long-term rotating antibiotics in severe cases
bronchodilators in selected cases
immunisations
surgery in selected cases (e.g. Localised disease)
40
Most common infective organisms in bronchiectasis?
Haemophilus influenzae (most common)
Pseudomonas aeruginosa
Klebsiella spp.
Streptococcus pneumoniae
41
What is a bronchiectasis exacerbation?
Deterioration in 3 or more key symptoms for at least 48 hours:
Cough
Sputum volume and/ or consistency
Sputum purulence
Breathlessness and/or exercise tolerance
Fatigue
Haemoptysis
42
What is cystic fibrosis?
* Most common recessive genetic disorder in populations of white europeans
* Causes molecular defect in cellular membrane chloride channel--> leads to excessively thick mucus in many body systems
43
Genetics of CF?
* Defect in the CF transmembrane regulator gene (CFTR) on chromosome 7
* Over 1000 different mutations have been indentified
* Recessive condition
* Children must inherit an abnormal CFTR gene from each parent- may be same mutation from each parent (homozygous) or 2 different CF-causing mutations (compound heterozygous)
44
What may be the history of a child with ?CF
## Footnote
From paeds at a glance
* May be a fhx, but not necessary
* failure to thrive with a ravenous appetite
* cough and wheeze
* recurrent chest infections
* recurrent sinusitis
* Bulky, pale, offensive stools, often difficult to flush away
* Fall in lung function and weight loss may indicate onset of CF-related diabetes
45
How may a child with CF present?
May be diagnosed by screening soon after birth, or antenatally in affected families
1/10 present with meconium ileus
Others may present in infancy with failure to thrive and malabsoprtion or recurrent chest infections
46
O/E how may a child with CF present?
* Finger clubbing
* evidence of malnutrition, poor weight gain and poor growth
* Delayed puberty
* Nasal polyps
* Chest deformity (e.g. chronic hyperexpansion)
* Crackles on auscultation
* Firm enlarged liver (rare) and splenomegally
* Subcutaneous vascular access devices may be present
* Gastrostomy tube may be present
47
Diagnosis of CF?
* Newborns: bloodspot screening: Immunoreactive trypsin levels are elevated in affected babies- tests for the most common mutations
* Gene testing: children presenting with typical hx or detected by screening should be diagnosed by mutation analysis of the CTFR gene. Only a panel of mutations are assessed- Non-white families may have unusual variantes that can be missed
* Sweat test: this is the diagnostic test for CF. Measuring sodium and chloride conce in sweat by passing small electric current across the skin
48
Common problems in CF?
* Chest infections
* Malabsorption
* DM
* Salt loss
* Liver disease
* Subfertility
49
What problems do people with CF have with chest infections?
* thick viscid mucus causes obstruction and predisposes to lung infection
* CHildren may develop chronic resp infection esp when colonized with Pseudomonas aeruginose or Burkholderia cepacia
* Can lead to rapid deterioration in lung function
50
Advice and treatment givent to patients with CF regarding chest infections?
* Mixing with other people with CF must be avoided
* Treatment may involve regular bronchodilators, antibiotics (oral, nebulized or IV)
* Steroid therapy
* Nebulized DNase enzymes can help break down mucus in the lungs
* Preventitive phsyiotherapy includes regular airway clearance by exercise, autogenic drainage, positive expiratory pressure, inhalation therapy and postural awareness
* Prophylatic immunization against influenza and pneumococcus is recommended
51
Why do children with CF get malabsorption?
* Pancreatic failure means that fatty food cannot be broken down easily and causes steatorrhoea
* Leads to malnutrition and deficiency of fat soluble vitamins (A,D,E,K)
52
How to manage CF induced malabsorption?
* Taking pancreatic enzyme capsules with food- should be started in babies
* High calorie diets may be required due to children having high metabolic demands
* Fat soluble vitamin supplements and advie froma specialist dietician are recommended
53
How to manage salt loss in CF?
Salt supplementation ma be required to replace sweat losses- must be carefully monitored
54
Why do children with CF get liver disease?
How can we manage it?
Sluggish bile flow may cause biliary disease and rarely cirrhosis
Ursodeoxycholic acid can help
55
How to manage 'pseudo-obstruction' of the bowel in children with CF
Be aware: can be mistaken for appendicitis
Usually responds to adjustment of pancreast enzyme replacement or osmotic laxatives
56
How is fertility affected in CF?
* Most men will have absence of vas deferens, leading to infertility.
* Women may be sub-fertile but most women with CF can achieve conception
* Carrier testing of partners should be considered
57
Common colonisers in CF?
* Staphylococcus aureus
* Haemophilus influenza
* Klebsiella pneumoniae
* Escherichia coli
* Burkhodheria cepacia
* Pseudomonas aeruginosa
58
Causes of clubbing in children?
Hereditary clubbing
Cyanotic heart disease
Infective endocarditis
Cystic fibrosis
Tuberculosis
Inflammatory bowel disease
Liver cirrhosis
59
Chesty child, what are your Ddx and think of specific factors regarding these
* Croup: barking cough and stridor
* Pneumonia: fever, cough, resp distress, IC recession, crackles
* Bronchiolitis < 1 year old, coryza, resp distress, wheezing
* HF: history of any left to right shunt e.g. ASD, VSD
* Acute asthma: are they a known asthmatic? hx of atopy, wheeze, cough
* TB: contact with TB patient, BCG vax? Haemoptysis, night sweats
* Viral induced wheeze: wheeze with URTI
* Whooping cough: paroxysmal cough, followed by vomiting, whoop or apnoea
* Inhaled foreign body: toddlers, history of choking, unilateral wheeze
* Cough without breathlessness: GORD, post nasal drip, tracheo-oesphageal fistula, passive smoking, CF
60
What causes pneuomnia in children?
* Viruses: RSV, influenza, parainfluenza, adenovirus, coxsackie virus
* Bacterial: Strep pneumoniae, haemophilus influenzae, staphylococcus, mycoplasma pneumoniae and in the newborn, group B beta haemolytic streptococcus
* Pseudomonas and straph aureua are more common in those with underlying resp disease
61
What are predisposing factors for pneumonia in a child?
Congenital anomaly of the bronchi, inhaled foreign body, immunosuppression, recurrent aspiration (e.g. with tracheo-oesophageal fistula) or CF
62
How does pneumonia usually present in children?
* Cough- typically wet and productive
* High fever (>38.5)
* grunting common in infants
* tachypnoea
* tachycardia
* increased work of breathing
* lethargy
* delirium
63
Signs in pneumonia?
* Dullness to percussion- due to lung tissue collapse and/or consolidation
* Bronchial breathing: due to consolidation
* Focal coarse Crackles
64
Investigations for pneumonia?
* CXR: consolidation- may show a lobar pneumonia or more widespread bronchopneumonia
* Sputum cultures
* throat swabs
* CBG in unwell patients to monitor if there is a resp or metabolic acidosis
* Blood cultures: if sepsis is suspected
65
Treatment of pneumonia?
Antibiotic therapy as per local guidelines
Amoxicillin is often used first line
Adding a macrolide will cover atypical pneumonia
Macrolides can be used as monotherpay in pts with penicillin allergy
IV abx are used when there is sepsis or problem iwith intestinal absorption
Oxygen is used to maintain saturations
66
Complications of pneumonia?
* Pleural effusion
* Septicaemia
* Bronchiectasis
* Empyema
* Lung abscess
67
What is acute epiglottitis?
Inflammation and swelling of the epiglottis caused by infection, typically with haemophilus influenza type B.
The epiglottis can swell to the point of completely obscuring the airway within hours of symptoms developing
68
Prevelance of Epiglottitis?
Rare due to the routine vaccination program, which vaccinates all children against haemophilus (Hib vaccine).
Be aware of children who have not have vaccines and have a high suspicison in an unvaccinated child presenting with fever, sore throat, difficulty swallowing that is sitting forward with drooling etc
69
Presentation of epiglottitis?
* sore throat and stridor
* Drooling
* Tripod position: sat forward with a hand on each knee
* High fever
* Diffiulty or pain swallowing
* Muffled voice
* Scared and quiet child
* Septic and unwell appearance
* USUALLY NORMAL RR
70
What to do if epiglottitis is suspected?
Transfer to operating theatre immediately for intubation by an experienced anaesthetist
Diagnosis is made by direct visualisation
XRAY only done if foreign body is suspected:
* a lateral view in acute epiglottis will show swelling of the epiglottis - the 'thumb sign'
i
Examination of the thrat can precipitate complete airway obstruction
71
Managment of acute epiglottitis?
* EMERGENCY- DO NO EXAMINE THE CHILD
* Alert the most senior paediatrician and anaesthetist available
* Ensure airway is secure
* Intubation may be required, but always need to be ready for it
* Additional treatments once airway is secure: IV antibiotics e.g. ceftriaxone, steroids i.e. dexamethasone
72
Complications of epiglottitis?
Epiglottic abscess- can also threaten airway, management is similar to epiglottitis
73
What is the definition of long-term ventilation?
Any child who, when medically stable, continues to require a mechanical aid for breathing, after an acknowledged failure to wean, or a slow wean, three months after the institution of ventilation
74
Goals of home mechanical ventilation?
* Enhance quality of life
* To sustain and extend life without compromising quality
* To improve or sustain phsyical and psychological function and to enhance growth and development
* To provide cost effective care
75
What criteria need to be met for a child to be considered for home ventilation?
(1) The medical condition is stable12: this would be a clinical decision and would generally imply:
* the presence of a stable airway;
* stable O2 requirements (if required), usually less than 40% (this should not exclude terminal care of home ventilated children);
* PCO2 levels that can be maintained within safe limits on ventilatory equipment that is operable by the family in their home;
* nutritional intake adequate to maintain expected growth and development;
* all other medical conditions are well controlled.
(2) Parents understand the long term prognosis and are willing and capable of meeting the special needs of their child in the home setting.
(3) It is practical to provide the level of support and intervention that the child requires at home.
76
What is viral induced wheeze?
Acute wheezy illness caused by a viral infection. This is due to small children (under 3) having smaller airways so the inflammation and oedema when ill causes a wheeze
77
Presentation of viral induced wheeze?
* Preceeding viral illness: fever, cough, coryzal symptoms for 1-2 preceding the onset
* SOB
* Signs of respiratory disterss
* Expiratory wheeze trhoughout the chest
78
What points towards viral induced wheeze rather than asthma?
* Presents before 3 years old
* No atopic history
* Only occurs during viral infections
79
Causes of sleep apnoea in children?
* Most common: enlarged tonsils and/or adenoids
* More commonly diagnosed in children with specific conditions e.g. obesity, sickle cell disease, down syndrome
80
How may sleep apnoea present in children?
* Snoring
* Sleeping in an unusual body position
* may have arousals during the night- leads to sleepiness during the day
* younger children with sleep deprivation: hyperactive or aggressive
* older children with sleep deprivation: tired
* difficulty concentrating
* Headache
* Poor growthy
* Weight gain
* Poor school performance
81
How is sleep apnoea diagnosed?
* An overnight sleep study main method of investigating OSA
* Involves a recording of various measurements, such as breathing rate, heart rate and oxygen levels while the child sleeps.
* Results are interpreted by a paediatric sleep medicine physician, who can make a diagnosis of OSA.
82
How is sleep apnoea treated?
* Case by case
* Most children will have tonsils/adenoids out
* If tonsil/adenoid removal is not indicated, positive airway pressure therapy may be used
* Other treatments incl nasopharyngeal airway: acts as a splint to maintain an open airway and keep the tongue from falling back- used mostly in less than 1 year of age
* Nasal steroids or montelukast to clear any inflammation of nasal passage
* Obese children: strongly encouraged to follow a weight management program incl nutrional advice, exercise regime
83
Causes of stridor? Briefly describe each one as well.
* Laryngeal abnormalities e.g.
Vocal cord palsy, may be associated with brain lesions of trauma
Papilloma: due to vertical transmission of wart virus: causes progressive stridor
* Laryngomalcia
Variable biphasic stridor from birth
Loudest when crying disappears when settled
Usually resolves within a few months
A well, thriving baby with characteristic mild stridor does not need investigations
* Upper airway obstruction
Pharyngeal cysts or haemangiona
* Tracheal abnormality
Subglottic stenosis- following prolonged intubation
Tracheomalacia
* Vascular ring
Congenital abnormality of great vessels
Worsens over time
* Croup
barking cough
coryzal illness
* Quinsy
* Epiglottitis
* Anaphylaxis
* Inhaled foreign body
Usually in toddlers
Sudden onset
History of choking
Unilateral signs
84
Name the causative organism for the following conditions:
1. croup
2. bronchiolitis
3. pseudomonas
4. pneumonia
5. whooping cough
| nice summary on passmed
85
Diagnostic criteria for whooping cough?
Whooping cough should be suspected if a person has an acute cough that has lasted for 14 days or more without another apparent cause, and has one or more of the following features:
* Paroxysmal cough.
* Inspiratory whoop.
* Post-tussive vomiting.
* Undiagnosed apnoeic attacks in young infants
86
How do you diagnose whooping cough?
per nasal swab culture for Bordetella pertussis - may take several days or weeks to come back
87
Management of whooping cough?
* infants under 6 months with suspect pertussis should be admitted
* in the UK pertussis is a notifiable disease
* an oral macrolide (e.g. clarithromycin, azithromycin or erythromycin) is indicated if the onset of the cough is within the previous 21 days to eradicate the organism and reduce the spread
* household contacts should be offered antibiotic prophylaxis
* antibiotic therapy has not been shown to alter the course of the illness
* school exclusion: 48 hours after commencing antibiotics (or 21 days from onset of symptoms if no antibiotics )
88
Complications of whooping cough?
subconjunctival haemorrhage
pneumonia
bronchiectasis
seizures
89
Phases of whooping cough?
* **catarrhal phase**
* symptoms are similar to a viral upper respiratory tract infection
* lasts around 1-2 weeks
**paroxysmal phase**
* the cough increases in severity
* coughing bouts are usually worse at night and after feeding, may be ended by vomiting & associated central cyanosis
* inspiratory whoop: not always present (caused by forced inspiration against a closed glottis)
* infants may have spells of apnoea
* persistent coughing may cause subconjunctival haemorrhages or even anoxia leading to syncope & seizures
* lasts between 2-8 weeks
**convalescent phase**
* the cough subsides over weeks to months
