Respiratory Flashcards
What is Croup also known as
Acute laryngotracheobronchitis
Describe the epidemiology of croup
- Typically affects children: 6 months - 3 years
- Peaks incidence at 2 years old
- Mc in boys
- mc in autumn
What causes croup
Viral infection
* parainfluenza virus
* adenovirus
* enterovirus
Give some presenting features of croup
- seal-like barky cough that may be worse at night
- stridor
- fever
- increased work of breathing
- coryzal symptoms
Give 5 features of severe croup
- Frequent barking cough
- Prominent stridor at rest
- persistent agitation
- marked sternal recession
- tachycardia
How is croup diagnosed
- Clinical diagnosis
- CXR anteroposterior and lateral neck
What sign may show in anteroposterior CXR view in croup
Steeple sign - narrowed trachea
When should children with croup be admitted
- moderate or severe croup
- < 3 months of age
- known upper airway abnormalities
- uncertainty about diagnosis
What is the first line treatment for croup
- Dexamethasone 0.15mg/kg orally as a single dose (prednisolone if unavailable)
What should be administered alongside the first line treatment of croup when children present with stridor or sternal indrawing at rest
Nebulised adrenaline
Describe the management for severe croup
- Oral dexamethasone
- Nebulised budesonide
- Nebulised adrenaline
- blow-by Oxygen - 8-10L/min
- Intubation if impending resp failure
When is nebulised budesonide preferred over oral dexamethasone in children with croup
- Severe hypoxia
- Persistent vomiting
- Respiratory distress
What is bronchiolitis
Viral infection of the bronchioles
What is the leading cause of hospital admission in infants under 1 years old
Bronchiolitis
What is the most common cause of bronchiolitis
Respiratory syncytial virus
Give 4 RFs of bronchiolitis
- < 3 years
- Prematurity
- Passive tobacco smoke exposure and air pollution
- Winter months
Give 5 features of bronchiolitis
- Variable cough increasing in severity over several days
- Wheezing
- Tachypnoea and dyspnoea
- Low grade fever
- Rhinitis
5 signs of respiratory distress in paeds
- Nasal flaring
- Head bobbing
- Tracheal tugging
- Grunting
- Intercostal and subcostal recessions
What is stridor
high pitched inspiratory noise caused by upper airway obstruction
How is bronchiolitis investigated
- immunofluorescence of nasopharyngeal secretions may show RSV
- Reverse transcriptase PCR
- CXR: not required for diagnosis - may show hyperinflation and interstitial inflammation
How is bronchiolitis managed
Largely supportive:
* Ensure adequate intake - Oral/ NG/ IV fluids
* humidified Oxygen if sats below 92%
* Ventilation support if required
* Ribavirin in severe disease
What prophylaxis is used for bronchiolitis
IM palivizumab once monthly during RSV season
When is prophylaxis considered in bronchiolitis
- Preterm infants with chronic lung disease of prematurity
- Children less than 24m who will be profoundly immunocompromised during RSV season
Give 5 indications for hospital admission in children with bronchiolitis
- Resp rate >70
- SpO2 < 92%
- Apnoea
- severe resp distress, e.g. grunting, marked chest recession
- central cyanosis
Does whooping cough affect the upper or low respiratory tract
Upper respiratory tract
What causes whooping cough
Bordetella pertussis
What is the classification of the microorganism that causes whooping cough
Gram negative bacteria
Describe the presentation of whooping cough (4)
- persistent Cough that is usually worse at night
- Coryzal symptoms
- Inspiratory whooping
- Paroxysms of coughing ending in vomiting or gagging
What are the 3 identifiable stages in whooping cough
- Catarrhal: 1-2w - coryzal symptoms
- Paroxysmal: 1-6w - severe paroxysmal coughing , infants may present with apnoeas
- Convalescent: w-m - gradual recovery, non-paroxysmal cough
How is whooping cough investigated (3)
- Culture of nasal swab - high specificity
- PCR - high sensitivity
- FBC - elevated WBC
What test can be conducted for patients with a whooping cough persisting for more than 2 weeks
Detection of anti-pertussis immunoglobulin G in oral fluid
How is whooping cough managed
- Notify public health
- Macrolides: Azithromycin (5 days) or clarithromycin (7d)
- CI Macrolides: Trimethoprim/sulfamethoxazole (14d)
- Abx should be offered if the onset of the cough is within the previous 21 days
What is the guidance on school exclusion for whooping cough
- 48 hours after commencing antibiotics
- or 21 days from onset of symptoms if no antibiotics
What is the preferred treatment for pregnant women with whooping cough
Erythromycin
Close contacts with a patient infected with whooping cough are given prophylactic Abx if they are in a high risk health group. Give 3 examples of these high risk groups
- Pregnant women
- Infants <1 years old
- Healthcare workers in contact with above 2 groups
What is pneumonia
Infection of the lower resp tract and lung parenchyma
Which age group is more likely to develop viral pneumonia
Young infants
When does the likelihood of bacterial pneumonia increase in children
Becomes more common in older children (over 5)
Common bacterial causes of pneumonia in children
- Streptococcus pneumonia
- Staphylococcus aureus
- Haemophilus influenza
- Group B strep - pre-vaccinated infants
- Mycoplasma pneumonia
common viral causes of pneumonia in children
- Respiratory syncytial virus (RSV)
- Parainfluenza virus
- Influenza virus
Give 5 ways pneumonia may present in children
- Fever
- Rapid breathing
- Productive cough
- Lethargy
- Usually precede a upper resp infection
4 signs of pneumonia in children
- Tachypnoea
- Nasal flaring
- Chest indrawing
- Oxygen saturation may be decreased
Give 3 auscultation signs of pneumonia in children
- dullness to percuss
- End-inspiratory coarse crackles
- decreased breath sounds and
bronchial breathing over affected area
How is pneumonia diagnosed in children
- CXR - consolidation
- Sputum cultures and throat swabs for cultures and PCR
Most children with pneumonia can be managed at home. What are 3 indications for admission
- O2 Sats below 92%
- Recurrent apnoea
- Grunting and/or an inability to maintain adequate fluid/ feed intake
What is the general supportive management for children with pneumonia (3)
- Oxygen for hypoxia
- Analgesia for pain
- IV fluids to correct dehydration and for sodium balance
Management of pneumonia in children
- Amoxicillin is first-line for all children with pneumonia
- add Macrolide if no response
- Macrolides should be used if mycoplasma or chlamydia is suspected
- In pneumonia associated with influenza, co-amoxiclav is recommended
What is asthma
chronic inflammatory airway disease leading to variable airway obstruction.
Explain the pathophysiology of asthma
The smooth muscle in the airways is hypersensitive, and responds to inhaled stimuli by constricting and causing reversible airflow obstruction.
Give 4 RFs of asthma in children
- Genetic predisposition
- Prematurity
- FHx Atopy
- Viral bronchiolitis in early life
Give 6 key features associated with a high probability of a child having asthma
- Episodic bilateral polyphonic wheeze
- Dry cough and SOB
- Diurnal variability of symptoms
- Symptoms that have non-viral triggers
- Sx improve with bronchodilators
- FHx of atopic conditions
State 4 environmental triggers of asthma
- Allergens (house dust mites, pollen, pets)
- Cold air
- Exercise
- Active/ passive smoking
How is asthma diagnosed
- Usually diagnosed from Hx and exam alone
- Spirometry with reversible testing in kids over 5
What percentage improvement confirms bronchodilator reversibility and is characteristic of asthma
12%
What is the medical therapy for children under 5 with asthma
- Short acting B2 agonists (relievers)
- Low dose ICS - 8 week trial
- Oral Leukotriene receptor antagonist (LTRA)
- If still uncontrolled, refer to asthma specialist
What is the medical therapy for children aged 5-16 with asthma
- SABA
- ICS preventor therapy
- Add LTRA
- Stop LTRA and add LABA
- SABA + switch ICS/LABA for a maintenance and reliever therapy (MART), that includes a paediatric low-dose ICS
Give 4 side effects of theophylline in children
- Vomiting
- Insomnia
- Headaches
- Poor concentration
What is important to monitor in children with asthma, specifically those take regular steroids
Growth
Give 2 exampes of a long acting B2 agonist (LABA)
- Salmeterol (purple)
- Formeterol
Give 2 examples of a short acting B2 agonist (SABA)
- Salbutamol (blue)
- Terbutaline
Give an example of an LTRA
Montelukast
Give 4 ways an acute asthma attack may present
- Progressively worsening wheeze/ SOB
- Becoming exhausted
- Tachypnoea
- Signs of respiratory distress
Give some features of a moderate asthma attack in children
- Able to talk
- SpO2 >92%
- Peak expiratory flow (PEF) >50% best/predicted
- no clinical features of severe asthma
Give the features of a severe asthma attack in children
- Too breathless to talk
- O2 sats <92%
- PEF 33-50% (best/predicted)
- use of accessory neck muscles
RR: - 2-5yrs: >40
- > 5yrs: >30
HR: - 2-5yrs: >140
- > 5yrs: >125
Give 6 features of a life-threatening asthma attack in children
- silent chest
- cyanosis
- Exhaustion, altered consciousness
- peak flow <33% (best)
- poor respiratory effort
- O2 sats <92%
What is a silent chest
- airways are so tight that the child isn’t able to move enough air through airways to create a wheeze
- associated with poor expiratory effort or exhaustion
How are moderate asthma attacks in children managed
- salbutamol via spacer - 2-4 puffs, increasing by 2 puffs (max 10 puffs)
- Oral prednisolone (1mg/kg OD for 3d)
- Monitor response for 15-30mins
- if symptoms not controlled, seek urgent medical attention
How are severe-life threatening asthma attacks in children managed
- immediate referral to hospital
- Salbutamol via spacer - 10 puffs or nebulised (assess response and repeat as required)
- oral prednisolone or IV hydrocortisone
- > 6yrs: Nebulised ipratropium bromide (SAMA)
- High flow O2
If a child having a life-threatening asthma attack is not responding to initial treatment what should be done
- Transfer to PICU
- Consider intubation/ ventilation
- Consider CXR and blood glasses - infection? pneumothorax?
- IV Magnesium sulphate, salbutamol or aminophylline
Define complete control of asthma (5)
- Absence of day/night time symptoms
- No limit on activities
- No need for reliever use
- Normal lung function
- no exacerbations in last 6 months
What is the inheritance pattern of cystic fibrosis
Autosomal recessive
Explain the pathophysiology of cystic fibrosis
- Occurs due to mutations in the CF transmembrane conductance regulator gene
- CFTR is a channel protein that pumps chloride into secretions making them thin and watery
- Defective gene = thick secretions
Describe the epidemiology of cystic fibrosis
- most life-limiting condition in caucasians
- incidence of 1 in 2500 live births
- 1 in 25 are carriers
What is the most common genetic variant of cystic fibrosis in the UK
delta-F508
How does CF present in newborns
- All newborns are screened at birth
- meconium ileus: too thick and sticky to pass and causes obstruction
- Vomiting, abdo distention and failure to pass meconiumin first 24h
What will be raised in newborn infants with CF during screening
Immunoreactive trypsinogen (IRT)
Give 5 features of cystic fibrosis
- Failure to thrive
- Steatorrhoea
- short stature and delayed puberty
- Chronic cough with thick sputum
- Recurrent chest infections
Give 4 signs of cystic fibrosis
- finger clubbing
- coarse crackles and/or expiratory wheeze on auscultation
- nasal polyps
- Bilateral absence of vas deferens (male infertility)
How is cystic fibrosis diagnosed
- GS: sweat test
- Genetic testing - 2 mutations
- Newborn blood spot testing
Describe the sweat test and state what would confirm a positive diagnosis of cystic fibrosis
- Sweating is stimulated by applying a low-voltage current to pilocarpine on the skin
- Sweat is collected and [Cl-] tested
- Confirmation: [Cl-] >60 mmol/L
How is cystic fibrosis managed
MDT
* Resp: chest physio at least twice daily, salbutamol, mucolytics (neb dornase alfa)
* Infection: prophylactic Abx
- s.aureus: flucloxacillin
- pseudonomas: neb tobramycin or oral ciprofloxacin
* GI: Pancreatin, omeprazole, fat-soluble vitamin supps
* high calorie, high fat diet
* Lung/liver transplant if failure
Give 3 common colonisers in cystic fibrosis
- Staph aureus
- H.influenzae
- P. aeruginosa
- Burkholderia cepacia
Give 5 complications of cystic fibrosis
- Pancreatic insufficiency
- CF-related diabetes mellitus
- Nasal polyps
- Cirrhosis and portal hypertension
- respiratory failure
- delayed puberty, short stature
What is epiglottitis
Inflammation and intense swelling of the epiglottis and surrounding tissues
What organism causes epiglottitis
H. influenzae type b
Why is epiglottitis an emergency
- Life-threatening as there is a high risk of complete respiratory obstruction within hours
At what age is epiglottitis most common
aged 1 - 6 years
Describe the presentation of epiglottitis
- rapid onset
- high fever in a toxic looking child
- Severe sore throat
- Drooling of saliva
- inspiratory stridor and rapidly increasing resp difficulty
- Tripod position: leaning forward with extended neck to optimise airway
How is epiglottitis diagnosed
Clinical diagnosis - direct visulation by senior/ airway trained staff
What investigations are omitted if epiglottitis is suspected
- Laying child down
- Examining throat with spatula
What would a lateral neck XR show in epiglottitis
Thumb sign - oedematous and swollen epiglottis
How is epiglottitis managed
- Alert most senior anaesthetist, paediatrician and ENT surgeon
- Secure airways - endotracheal intubation
- IV Abx: Ceftriaxone
- Prophylactic rifampicin for close contacts
Give 5 contrasting features of croup and epiglottitis
Croup: onset over days, barking cough, able to drink, harsh stridor, hoarse voice
Epiglottitis: onset over hours, fever over 38.5, drooling saliva, soft stridor, muffled/ reluctant to speak
