Respiratory Flashcards
What are the features and symptoms of bronchiolitis
Inflammation and infection of the bronchioles
Usually caused by RSV
Children under 1 yr during winter
Harsh breath sounds, wheeze and crackles
-Coryzal symptoms
-Signs of respiratory distress- high RR, accessory muscles, intercostal/subcostal recessions, nasal flaring, head bobbing, tracheal tugging, cyanosis, abnormal noises- grunting stridor, wheeze
-Dyspnoea
-Poor feeding
-Mild fever under 39
-Apnoeas
-Wheeze and crackles
How long does bronchiolitis last and when should a patient be admitted
Starts as URTI with cold symptoms
Chest symptoms over 1-2 days after
Chest symptoms worst on day 3-4
7-10 days total with full recovery in 2-3 weeks
Children who get bronchiolitis more likely to have viral induced wheeze as a child
Admission if
-Under 3 months or pre-exisit9ng condition (premature, downs, CF)
-50-75% less than their normal intake
-Clinical dehydration
-Resp rate over 70
-Sats below 92
-Moderate to severe resp distress
-Apnoeas
-Parents not confident to manage at home
What management is involved in bronchiolitis
Supportive
-Adequate intake- oral, NG or IV depending on severity - small frequent feeds
-Saline nasal drops and nasal suctioning
-Supplementary oxygen if sats still below 92%
-Ventilatory support if needed
-High flow humidified oxygen via nasal cannula
-Continuous positive airway pressure- sealed nasal cannula- higher pressure
-Intubation and ventilation
What are some signs of poor ventilation in children
Cap blood gases and useful in monitoring kids
-Rising PCO2- always have collapsed and can’t clear carbon dioxide
-Falling pH- CO2 is building up and not able to buffer acidosis- respiratory acidosis- if hypoxic- type 2 respiratory failure
When is palivizumab used in bronchiolitis
Targets RSV- monthly injection given as prevention to high risk babies- ex-premature or those with congenital heart disease
Gives passive protection until the body encounters the virus - antibody levels decrease over time- why it’s given monthly
What are the features and management of viral induced wheeze
Swelling and constriction of already small airways due to a virus (usually in under 3s) - greater restriction to airflow than in adults
Can tell it’s viral induced wheeze and not asthma if
-Present before 3 yrs
-No atopy
-Only occurs during viral infections not during exercise, cold weather, dust or emotions
Presentation- SOB, Resp distress, Expiratory wheeze throughout the chest
Management is the same as acute asthma in children
What does a focal wheeze indicate
Focal airway obstruction eg. inhaled foreign body or tumour
What is the presentation of acute asthma in children
Progressively worsening SOB
Resp distress
High RR
Expiratory wheeze heard on auscultation throughout chest
Tight chest on auscultation - reduced air entry
Silent chest- fatal
What are the severity guidelines for acute asthma in children
Moderate
Peak flow >50%
Normal speech
Severe
Peak flow <50%
Sats <92%
Can’t talk in sentences
Resp distress signs
RR >40 in under 5s and >30 in over 5s
HR >140 in under 5s and >125 in over 5s
Life threatening
Peak flow <33%
Sats <92%
Exhaustion/ no rest effort
Hypotension
Silent chest
Cyanosis
LOC/ Confusion
What is the management f acute asthma/ viral induced wheeze
- Supplementary oxygen if required (<94%)
- Bronchodilators (salbutamol, ipatropium, magnesium sulphate)
Stepped up as required
-Inhaled/ nebs salbutamol
-Inhaled/ nebst ipatropium bromide
-IV magnesium sulphate
-IV aminophylline
- Steroids- oral prednisone or hydrocortisone (IV)
- Abx- only if bacterial cause suspected
Mild cases managed as an outpatient- regular salbutamol inhalers with a spacer
What is the stepwise management of acute asthma in children in moderate to severe cases
- Salbutamol inhalers with a spacer- 10 puffs every 2 hours
- Nebulisers with salbutamol/ ipatropium bromide
- Oral Pred (1mg/ kg of bw once daily for 3 days)
- IV hydrocortisone
- IV magnesium sulphate
- IV sabutamol
- IV aminophylline
If not under control after this call Anesthetist and ICU
What is the typical step down regime of salbutamol/ discharge for a child
Salbutamol
10 puffs 2 hrly, 10 puffs 4hrly, 6 puffs 4hrly then 4 puffs 6 hrly
Monitor serum potassium ***
Discharge considered when the child is well on 6 puffs 4 hrly and have finished course of steroids if started
What presentations will indicate asthma
-Episodic symptoms
-Diurnal variation- worse at night
-Dry cough with wheeze and SOB
-Typical triggers - dust, animals, cold air, exercise, smoke
-Atopy
-Fam history
-Bilateral widespread polyphonic wheeze
-Symptoms improve with bronchodilators
No diagnosis until around 2-3
-Spirometry with reversibility can be done in over 5s
-Direct bronchial challenge test
-Fractional exhaled nitric oxide
-Peak flow variability 2-4 weeks
What is the medical therapy for asthma in under 5s
- Salbutamol inhaler as required
- Add low dose steroid or leukotriene antagonist (montelukast)
- Add other option from step 2
- Specialist referral
What is the medical therapy for asthmatics aged 5-12
- Salbutamol inhaler as required
- Regular low dose steroid inhaler
- Long acting beta 2 agonist- salmeterol - continue if patient has good response
- Titrate up corticosteroid inhaler to medium dose and consider adding
-Leukotriene antagonist (montelukast) or Oral theophylline - Increase dose of inhaled corticosteroid to a high dose
- Specialist referral
What is the medical therapy for asthma in children over 12 (same as adult)
- Salbutamol as required
- Regular low dose steroid
- Long acting beta-2 agonist - salmeterol
- Titrate up steroid to medium dose and viral montelukast, oral theophylline or an inhaled LAMA (tiotropium)
- Titrate up steroid to high dose and add additional treatments from step 4
- Oral salbutamol and refer to specialist
- Oral steroids at lowest dose
What chest sounds are characteristic of pneumonia
Bronchial breath sounds- harsh breath sounds equally loud on inspiration and expiration
Focal coarse crackles- air passing through sputum
Dullness to percussion
What are some of the bacterial and viral causes of pneumonia
Bacterial
Strep pneumonia (most common) Group A strep (strep pyrogenes)
Group B strep - pre vaccinated infants
Staph aureus- will show pneumatocoeles (round air cavaties) and consolidation on CXR
Haemophilus influenza (unvaccinated kids)
Mycoplasma pneumonia - atypical and will have other manifestations eg. erythema multiform
Viral
RSV
Parainfluenza virus
Influenza virus
What investigations and management are done in suspected pneumonia
CXR but not routinely required
Sputum cultures and throat swabs
Cap blood gas to assess respiratory/ metabolic acidosis
Management
Amoxicillin first line
Adding a macrolide (erythromycin, clarithromycin/ azithromycin) will cover atypical pneumonia - can be given first line in penicillin allergy
IV antibiotics when septic
What investigations should be done in recurrent lower respiratory tract infections
Underlying lung or immune system pathology
Fam history
Examination- reflux aspiration, near disease, heart disease, asthma, CF, immune deficiency
FBC - check WCC
CXR
Serum immunoglobulins- selective antibodies deficiency
Immunoglobulin G to previous vaccines (pneumococcus/ haemophilus) - some can’t convert IgM to IgG and won’t have long term immunity
-Sweat test for CF
-HIV test if mums status unknown
What are the features and management of croup
6mnths- 12 yrs
URTI- oedema in the larynx
Most common cause- parainfluenza virus - improves in less than 48 hrs and responds well to dexamethasone
Causes
Parainfluenza
Influenza
Adenovirus
RSV
Diptheria- this will cause epiglottis
Presentation
Harsh cough
Increased work of breathing
Barking cough
Hoarse voice
Stridor
Low grade fever
Management
Oral dexamethasone - single dose 150mcg/Kg- can be repeated after 12 hrs - if suspected give this asap
Oxygen
Nebs budensonide
Nebs adrenalin
Intubation and ventilation
What are the features and management of epiglossitis
Swelling of epiglottis due to haemophilus influenza type B - life threatening emergency
High suspicion in children who have not been vaccinated
Presentation
Sore throat, stridor
Drooling
Tripod position- sat forward with hands on knees
High fever
Difficulty or painful swallowing
Muffled voice
Scared and quiet
Septic and unwell
No investigations if suspected
Lateral x-ray of neck will show thumb sign- shadow
Management
Don’t upset patient
Ensure airway is secure - alert anaesthetics if intubation needed
IV antibiotics- ceftriaxone
Steroids- dexamethasone
Be aware of an epiglottic abscess- common complication
What are the features and management of laryngomalacia
The supraglottic larynx (above vocal cords) causes partial airway obstruction
Larynx tissue can flop across the airway when breathing in causing chronic stridor (harsh whistling)
Usually in infants around 6 months
Inspiratory stridor - intermittent
More prominent when feeding, upset, lying on back or URTI
Rarely causes complete airway obstruction
Resolves as the child grows so no intervention usually
Can do tracheostomy if needed or surgery
What are the features and management of whopping cough
URTI caused by bordetella pertussis (gram neg)
Coughing fits and loud whoop
Mild cold symptoms and low grade fever that progresses to more severe coughing fits after about a week
Loud inspiratory whoop
Can cough so hard they vomit, faint or get a pneumothroax
Infants may present with apnoeas instead of a whoop cough
Diagnosis
Nasopharyngeal/ nasal swab with PCR testing or bacterial culture within 2-3 weeks
If cough there for >2 weeks- test for anti-pertussis toxin IgG
Management
Notifiable disease- public health
Supportive and prevent spread
Macrolide antibiotics- azithromycin, erythromycin, clarity can be used in first 21 days
Co-trimoxazole is an alternative
Close contacts get prophylactic abx if they are vulberable- pregnancy, unvaccinated etc
Symptoms resolve in 8 weeks but can last months - 100 day cough
Key complication is bronchietasis
What are the features and management of chronic lung disease of prematurity
Premature babies before 28 weeks
Resp distress - oxygen and intubation at birth
Diagnosis made on CXR and when infant still needs 02 after 36 weeks
Features
Low 02, increased work breathing, poor feeding/ weight gain, crackles/ wheeze, increased infections
Management
Sleep study to assess 02 sats
Can be discharged on a low dose of 02 to have at home via nasal cannula and followed up
Protection against RSV- monthly injections with palivizumab
How is Chronic lung disease of prematurity prevented
Corticosteroids (betamethasone) to mothers during premature labour at less than 36 weeks
Once born
CPAP rather than intubation when possible
Caffeine to stimulate resp effort
What are the key features of cystic fibrosis
Autosomal recessive genetic condition
Delta-F508 mutation- chromosome 7
-Thick pancreatic and billiard secretions cause blockage of ducts- last of digestive enzymes
-Low volume thick airway secretions- reduce airway clearance - susceptible to infections
-Congential bilateral absence of vas defers in males- no sperm in ejaculation- infertility
What are the signs and symptoms of cystic fibrosis
Screened for in newborn bloodspot
Meconium ileus is usually the first sign - meconium (first bowel movement) gets stuck - no meconium passed in 24 hours, abdo distension and vomiting
Chronic cough, thick sputum production, recurrent respiratory tract infections, steatorrhoea (greasy stools), abdo pain/ bloating, tastes salty when kissing - concentrated salt in sweat, poor weight gain and height
Signs
Low weight/ height
Nasal polyps
Finger clubbing
Crackles and wheezing
Abdo distension
What are the 3 main ways to test for cystic fibrosis
-Newborn blood spot testing
-Sweat test- gold standard - pilocarpine applied to skin and current passed through by electrodes - sweat absorbed and chloride concentration tested- more than 60mmol/L chloride= CF
-Genetic testing- CFTR gene- amniocentesis or CVS
What are the most common colonies in CF
Staph aureus **
Haemophilus influenza
Klebsiella pneumonia
E.Coli
Burkodheria cepacia
Psuedomonas aeruginosa **
Patients will take long term prophylactic flucloxicillin to prevent staph aureus
Pseudomonas aeurginosa- hard to get rid of and resistant to many abx- nebuliser abx - tobramycin and oral ciprofloxacin
Avoid contact with other people who have CF
What is the management of cystic fibrosis
Chest pysio several times a day
Exercise
High cal diet
CREON tablets- to digest fats
Prophylactic fluclox
Treat chest infections
Bronchodilators- salbutamol
Nebulised DNase - enzyme to break down DNA in respiratory secretions
Nebulised hypertonic saline
Vaccinations- pneumococcal, influenza, varicella
Lung transplant, liver transplant, fertility treatment, genetic counselling
Other complications
Diabetes
Osteoporosis
Vit D dieficiency
Liver failure
Pancreatic insufficiency
What are the features and management of primary ciliary dyskinesia
Kartanger’s syndrome
Autosomal recessive- affects motility of cillia in body- build up of mucus in lungs
Affects cilia in fallopian tubes and flagella of sperm- infertility
Kartagner’s triad
Paranasal sinusitis
Bronchietasisi
Situs inversus (internal organs are mirror - heart on the right etc)
Diagnosis
Current respiratory tract infections
Check consanguinity of parents
Sintus inversus imaging
Semen analysis
Sample of ciliated epithelium- nasal brushing or bronchoscopy- key investigation
Management
Similar to CF and bronchiectasis
Daily physio, high cal diet, abx
What does bowel sounds in a respiratory exam signify
Neonate in resp distress + bowel sounds in respiratory exam- diaphragmatic hernia
What are the features of surfactant deficient lung disease (respiratory distress syndrome)
Premature babies
Risk factors
Male
Section
Diabetic mum
Second born twin
Features of resp distress\
Management
Maternal corticosteroids
Oxygen
Ventilation
