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.
Childhood Asthma
Life threatening Asthma C/F
- Silent chest
- Cyanosis
- Poor respiratory effort
- Decreased RR
- Bradycardia and hypotension
- Peak flow <33% predicted or best value
- Altered conciousness
- Oxygen saturation <92%
- Is type 2 respiratory failure
Childhood Asthma
Reliever Medication types
Relieve Sx (bronchodialators)
* Short acting beta 2 agonists (SABA) - salbutamol, terbulaline
* Anti-cholinergics - ipratropium bromide
* Corticosteroids - hydrocortisone
Childhood Asthma
Preventive Medication types
Prevents attacks
* Inhaled steroids - budesonide, beclomethasone, fluticasone
* Long acting b2 agonists - salmeterol
* Methylxanthines - theophylline
* Leukotriene inhibitors/ receptor modulaor- Montelukast, Sodium chromoglycate
Childhood Asthma
Mild intermittent asthma, C/F and Mx
Frequency of signs and Sx during day <=2 per week
Frequency of signs and Sx at night: <=2 per month
Mx:
Inhaled SABA (salbutamol) as and when needed - Blue color inhaler
Childhood Asthma
Mild persistent asthma, C/F and Mx
Frequency of Sx and signs during day: >2 per week but not every day
Frequency of Sx and signs at night: >2 per month
Mx:
Inhaled SABA (salbutamol) as and when needed - Blue color inhaler
+
Low dose inhaled steroids for prevention - Brown color inhaler (Eg: Beclomethasone)
Childhood Asthma
Moderate Persistent Astma, C/F and MX
Frequency of Sx and signs during day: Once a day
Frequency of Sx and signs at night: >1 per week
Mx:
Inhaled SABA (salbutamol) as and when needed - Blue color inhaler
+
Medium dose inhaled steroids
or
Low dose inhaled steroids & LABA (salmeterol) - Eg: Salmeterol and Fluticasone - Purple color inhaler
Childhood Asthma
Severe persistent asthma, C/F and Mx
Frequency of Sx and signs during day: Continual
Frequency of Sx and signs at night: Frequent
Mx:
Inhaled SABA (salbutamol) as and when needed - Blue color inhaler
+
High dose inhaled steroids and LABA (salmeterol)
Childhood Asthma
Complications
Medical Complications:
*Acute - *
* Respiratory Distress, which lead to respiratoy arrest
* Pneumothorax
* Respiratory alkalosis
Long term -
* Growth Failure, due to chronic disease
* Reduced capacity to withstand respiratory tract infections
* Adverse effects of medication (steroid inhalation) - Oral candidiasis - Wash mouth thoroghly after using.
Social complications:
* Social stigma and stress of having a chronic disease
* Cost of medication, hospital visits
* Psychological
Childhood Asthma
Types of inhaler devices and care
- <2yrs - Metered dose inhaler (MDI) + baby haler
- 2-5yrs - MDI + Spacer device (with face mask until 3yrs)
- 5-8yrs - MDI alone
- > 8yrs - Dry powder inhaler (DPI)
In MDI, mother should keep count of doses, cannot wait until there is no more spray from inhaler. Because there is another chemical that facilitates delivery of the medication which may remain even after medication is over, which itself can trigger asthma.
Spacers are replaced - generally 6monthly, maximum 1yearly
Washing is done under running water and air dried - No scrubbing
What is the most common serious respiratory infection of infancy (<1yr)?
Bronchiolitis
Rare after 1yr of age, but can occur upto 2yrs.
Bronchiolitis
Causes
- Respiratory syncytial virus (RSV) - 80% of cases.
- Others - Human metapneumovirus, parainfluenza virus, rhinovirus, adenovirus, influenza virus, Mycoplasma pneumoniae
Bronchiolitis
C/F
- Sharp, dry cough, No sputum
- Tachypnea
- Subcoastal and intercostal recessions - features of difficulty in breathing
- Hyperinflation of chest - due to air trapping
Prominent sternum
Liver displaced downwards - Fine end-inspiratory crackles (crepitations)
- High-pitched wheezes (Rhonchi) - expiratory>inspiratory
- Tachycardia
- Cyanosis or pallor
- Apnea in infants <4M
- Coryzal Sx (URTI) may precede bronchiolitis - Cough, cold, runny nose.
Bronchiolitis
Risk fators for severe bronchiolitis
- Prematurity - Bronchopulmonary dysplasia
- Underlying lung diseases (Eg: Cystic fibrosis)
- Congenital heart disease
Differences on auscultation between pneumonia, asthma and bronchiolitis
Pneumonia - Crepitations only
Asthma - Rhonchi only
Bronchiolitis - Both
Bronchiolitis
Dx
Clinical
Xray changes:
* Hyperlucent blackish lung fields
* Horizontal ribs
* Flat diaphragm
Bronchiolitis
Mx
Supportive
* Humidified O2
* Monitor for apnea
* Fluids - IV or via NG tube
* Antibiotics - given if child has gotten secondary bacterial infection.
* Steroids and nebulized bronchodilators such as salbutamol or ipratropium - Not proven to be effective, can be given, May work for some, may not for others.
* There is a place for hypertonic (3%) saline nebulization.
Bronchiolitis
Prognosis
Most recover from the acute infection within 2W. However, as many as half will have recurrent episodes of cough and wheeze.
Bronchiolitis
Prevention
A monoclonal antibody to RSV for high risk infants, but is costly - IM palivizumab.
Not given in SL
Croup
Pathophysiology of Croup
- mucosal inflammation
- increased secretions affecting the airway
- edema of the subglottis area
Croup
MOs causing Croup
- Viruses- parainfluenza, RSV, influenza, human metapneumovirus
Croup
Most common MO causing croup
Parainfluenza virus
Croup
Age group
6 months to 6 years.
Most common in the second year of life
Croup
Clinical features
- Barking cough
- harsh stridor
- mild fever
- followed by coryza
Croup
Croup Sx may worsen during…..
night time
Croup
Mx
- Usually managed at home but monitored for acute severity
- Steam inhalation
- PO dexa, nebulized budesonide
- severe croup- nebulized epinephrine w oxygen facemask
- croup complicated w secondary bacterial infections- antibiotics
Croup
what measures can reduce the need for hospitalization
- PO dexa
- nebulized budesonide (Pulmicort)
Giving steroids can reduce the need for hospitalization
Croup
how is adrenaline given during severe croup
nebulized w oxygen facemask in hospital
Croup
What needs to be done while giving nebulized adrenaline during severe croup
monitor for adverse effects
Pseudomembranous croup
Pseudomembranous croup is also known as
bacterial tracheitis
Bacterial tracheitis
Sx
- high fever
- appears toxic/ very ill
- copious thick airway secretions
- rapidly progressive airway obstruction
Bacterial tracheitis
MO
Staph aureus
Bacterial tracheitis
Mx
- IV ABx- flucloxacillin, cloxacillin, vancomycin
- If needed intubate and ventilate
Epiglottitis
MO
Haemophilus influenzae type B
Epiglottitis
major reason for >99% reduction in epiglottitis
Universal Hib immunization in infancy
Epiglottitis
Pathophysiology
intense swelling of the epiglottis and sorrounding tissues w septicemia
Epiglottitis
age group
1-6 years commonly but can affect any age group
Epiglottitis
Sx
- acute onset very high fever
- ill, toxic- looking child
- very painful throat that prevents the child from speaking or swallowing-** drooling of saliva**
- **soft **inspiratory stridor
- rapidly increasing respi difficulty
- child in tripod possition to optimize the airway
Epiglottitis
Mx
Pediatric emergency
* urgent hospital admission
* do not examine the throat
* call ENT surgeon, anesthetist, pediatrician
* transfer child immediately to the ICU or anesthetist room
* intubate or if it fails urgent tracheostomy
* once the airway is secured, take a blood culture,iv ABx (cefuroxime)
Epiglottitis
Prophylaxis to family members
Rifampicin
Difference between epiglottitis and croup
Croup
* Onset - over days
* Preceding coryza- yes
* cough- severe, barking
* able to drink- yes
* Drooling of saliva - no
* appearance- unwell
* fever- <38.5
* Stridor- harsh, rasping
* voice cry- hoarse
Epiglottitis
* Onset- over hours
* Preceding coryza- no
* Cough- absent/ slight
* able to drink- no
* Drooling of saliva- yes
* appearance- toxic/ very ill
* fever- >38.5
* stridor- soft, whsipering
* voice cry- muffled, reluctant to speak
