Respiratory Flashcards
Upper respiratory tract infections (URTI)
Examples
- Common Cold (coryza)
- Sore throat (Pharyngitis, including tonsilitis)
- Acute otitis Media
- Sinusitis (Relatively uncommon) - Headache, Facial pain
Upper respiratory tract infections (URTI)
Commonest Presentation
- Nasal Discharge and blockage
- Fever
- Painful throat
- Earache
May cause -
* Difficulty in feeding in infants, as their noses are blocked and this obstructs breathing.
* FEbrile convulsions
* Acute exacerbations of asthma
Sore throat (Pharyngitis)
Causes
- Usually due to viral infections with respiratory viruses - Mostly adenovirus, enterovirus, rhinovirus. EBV, Corona
- In older children, group A beta-hemolytic streptococcus is a common pathogen.
Tonsilitis
Causes
A form of pharyngitis where there is intense inflammation of the tonsils, often with a purulent exudate.
Common Pathogens:
* Group A beta- hemolytic streptococci
* EBV
Often difficult to distinguish between the two.
If bacterial - High fever, exudates
Tonsilitis
Mx
- Antibiotics - Often prescribed for severe pharyngitis and tonsilitis
Penicillin - 6hrly, dose depends on weight for children, 500mg for adults.
Erythromycin if penicillin allergy. - In order to eradicate the organisms to prevent rheumatic fever, 10days of Rx is required.
- Amoxicillin is best avoided.
Tonsilitis
Why is Amoxicillin best avoided?
It may cause a widespread maculopapular rash if the tonsilitis is due to infectious mononucleiosis.
Infectious Mononucleiosis (IMN)
Cause and C/F
Caused by EBV. Also known as kissing disease.
C/F:
* Fever
* Tonsilitis (Pharyngitis + generalised lymphadenopathy)
* May be associated with splenomegaly and less commonly hepatomegaly.
* Palletal petechiae - red spots in mouth
Infectious Mononucleiosis (IMN)
Ix
- Increased Lymphocytes (atypical lymphocytes)
- Positive Monospot test - Antibodies against EBV
- Ab against EBV & heterophil Ab
- Bone marrow biopsy - Normal
Infectious Mononucleiosis (IMN)
What is often similar to IMN?
ALL
Infectious Mononucleiosis (IMN)
Similarities & Differences between IMN and ALL
Similarities -
* Atypical lymphocytes
* Generalised lymphadenopathy
* Tonsilitis
* Hepatomegaly
Differences -
* Bone marrow biopsy is normal in IMN, abnormal in ALL, Blast cells present.
* LN are tender and soft in IMN, LN are non-tender and firm/ hard in ALL.
* ESR is normal in IMN, ESR high in ALL
Infectious Mononucleiosis (IMN)
Indications for tonsillectomy
Children with recurrent tonsilitis are often refferred for removal of their tonsils, one of the commonest operations performed in children.
* Recurrent severe tonsilitis (as opposed to recurrent URTIs - atleast 4/year or >3times/year
* Peritonsilar abscess (quinsy)
* Obstructive sleep apnea (the adenoids will also normally be removed) - snoring
Generally tonsillectomy is avoided until 5yrs.
Many children have large tonsils but this in itself is not an indication for tonsillectomy, as they shrink spontaneously in childhood.
The adneoids increase in size until about the age of 8yrs and then gradually regress.
Infectious Mononucleiosis (IMN)
Indications for the removal of adenoids
- Recurrent otitis media with effusion and hearing loss
- Obstructive sleep apnea (an absolute indication)
Infectious Mononucleiosis (IMN)
Mx
Supportive care - PCM for pain, Salt H20 gargling.
Acute Otitis Media (OM)
Causes
Most common at 6-12M of age.
* Infants and young children are prone to acute OM because their eustachian tubes are short, horizontal and function poorly.
* Causative Organisms:
Viruses - Respiratory Syncytyl Virus (RSV), rhinovirus
Bacteria - pneumococcus (Strep. pneumoniae), H. influenza, Moraxella catarrhalis.
Acute Otitis Media (OM)
C/F
- Fever and Ear pain (Every child with fever should have their ear examined)
- Tympanic membrane is seen to be bright red and bulging with loss of the normal light reflection (Shiny appearance)
- Occasionally, there maybe acute perforation of the ear drum with pus visible in the external canal.
- There maybe ear discharge and even hearing loss due to conductive deafness.
Acute Otitis Media (OM)
Rx
- Most cases of acute OM resolve spontaneously (Commonly when viral)
- Pain should be treated with analgesics such as PCM or ibuprofen (NSAID, can cause peptic ulcers, Should be given with an antacid/PPI)
- Antibiotics - Amoxicillin, Co-amoxiclav - 8hrly for 7days.
Acute Otitis Media (OM)
Complications
- If recurrent, may result in otitis media with effusion (Glue ear), which may cause speech and learning difficulties from hearing loss.
- Recurrent OM can also lead to chronic OM.
- Serious complications are mastoiditis and meningitis (brain abcesses), but are now uncommon.
What is the most common chronic respiratory disorder in childhood?
Asthma
Childhood Asthma
Pathophysiology
A chronic condition caused by airway hyper-responsiveness to various stimuli, leading to reversible narrowing of the airway.
* Genetic predisposition, Atopy, enviormental triggers/ stimuli causes Bronchial inflammation.
* Bronchial inflammation leads to mucosal edema, excessive muscus production, infiltration with cells (eosinophils, mast cells, neutrophils, lymphocytes) and bronchial smooth muscle constriction.
* Results in bronchial hyper-responsiveness - Exaggerated ‘twitchiness’ to inhaled stimuli.
* Reversible airway narrowing leading to Sx:
Wheeze
Cough - Occurs in the morning or at night, non-productive cough.
Breathlessness
Chest tightness
Childhood Asthma
Enviormental triggers
- URTI - Simple cough and cold
- Allergens - house dust mite, grass pollen, pets
- Smoking - active or passive
- Cold air
- Exercise
- Emotional upset or anxiety
- Chemical irritants - paint, aerosols
Childhood Asthma
Atopic Asthma
Recurrent asthma associated with evidence of allergy to one or more inhaled allergens.
Skin rash + asthma
It is stronglt associated with other atopic diseases such as eczema, rhinoconjunctivitis and food allergy, and is more common in those with a FHx of such diseases.
Childhood Asthma
C/F
- Wheeze - Due to bronchoconstriction. A polyphonic (multiple pitch) noise coming from the airways believed to represent many airways of different dimensions vibrating from abnormal narrowing. It is an expiratory sound. It can be due to other causes other than asthma too.
- Chronic cough, SOB, chest tightness, Diurnal pattern.
- In long standing asthma there maybe hyperinflation of the chest, generalized polyphonic.
- Onset of the disease in early childhood may result in Harrison sulci.
Childhood Asthma
Harrison Sulci
- Due to early childhood onset of asthma
- Abnormality of chest
- Abdomen may invaginate into thorax.
Childhood Asthma
Features associated with a high probability of a child having asthma
- Sx worsen at night and in the early morning.
- Sx that have triggers - exercise, pets, dust, cold air, emotions, laughter
- Interval Sx - Sx between acute exacerbations
- Personal or FHx of an atopic disease
- Positive response to asthma therapy.
Childhood Asthma
Ix
A clinical Dx
Usually Ixs are not needed but Ix are done to exclude D/d or see the severity of Asthma.
* CXR - to rule out the presence of a pneumothorax or a Foreign body.
* PEFR - peak expiratory flow rate.
* FBC - may show eosinophilia
* Arterial Blood Gas (ABG) - Done in acute or severe asthma.
Childhood Asthma
How is PEFR carried out?
In standing position.
Take a deep breath, lips sealed on peak flowmeter and blow, Forcefully & Fast.
Done 3 times.
Highest value is taken.
Done for children >5yrs.
Normal value depends on age, weight, sex, height.
It is important to Dx asthma and check response to Rx.
Childhood Asthma
Mx
Aim of management is to allow the child to lead as normal a life as possible, by controlling Sx and preventing exacerbations, optimizing pulmonary function, while minimizing Rx and side-effects.
Mx of asthma involves mx of acute episodes and long term Mx.
Acute Mx:
* Identify whether it is acute severe asthma or life threatening asthma.
* Start O2 via face mask
* Start nebulisation with salbutamol (2.5mg if <2yrs. 5mg if 2-5yrs)
* If no response, add ipratropium bromide with salbutamol.
* Corticosteroids should be given
Prednisolone 1-2mg/kg if the child can swallow or
IV hydrocortisone 4mg/kg if not.
* If still no improvement - IV MgSO4 50mg/kg (+ monitor for S/E).
* If still no improvement,
Start IV bronchodilators - IV aminophylline/ IV salbutamol
Aminophylline 10mg/kg bolus over 1hr followed by 5mg/kg/hr infusion (bolus not given if the patient is already on theophylline)
* If the child is going in to respiratory arrest - Intubation
Long-term Mx:
* Depends on the severity
* Is with reliever medications and preventive medication.
Childhood Asthma
Acute Severe Asthma C/F
- Too breathless to talk or feed
- Can’t complete sentences in one breath
- Use of accessory neck muscles
- RR:
2-5yrs - >50/min, >5yrs - >30/min - Pulse:
2-5yrs - >130/min, >5yrs - 120/min - Peak flow <50% predicted or best value.
- Is type 1 respiratory failure.
