Respiratory Flashcards
Most common cause of bronchiolitis?
RSV
Presentation of bronchiolitis?
<1yr
coryzal symptoms
signs of respiratory distress
dyspnoea
tachypnoea
poor feeding
mild fever
apnoea
wheeze and crackles
Signs of respiratory distress?
tachypnoea
use of accessory muscles
intercostal and subcostal recessions
nasal flaring
head bobbing
tracheal tugging
cyanosis
abnormal airway noises (wheeze, grunting, stridor)
When to admit in bronchiolitis?
< 3 months
pre-existing condition (prematurity, CF, DS)
50-75% less than normal milk intake
dehydration
RR > 70
O2 sats <92%
signs of resp distress
apnoeas
parents concerned
Management of bronchiolitis?
supportive management
adequate intake (NG)
saline nasal drops and suctioning
supplementary O2
ventilator if required
What is palivizumab used for?
monoclonal antibody that targets RSV
given monthly to high-risk babies (CHD, premature)
Viral-induced wheeze vs asthma?
presenting before 3yrs
no atopic history
only occurs during viral infections
Presentation of acute asthma?
progressively worsening dyspnoea
signs of resp distress
tachypnoea
expiratory wheeze globally
‘tight’ chest
silent chest (severe)
Moderate asthma attack?
peak flow >50%
normal speech
no signs of resp distress
Severe asthma attack?
peak flow 33%>x>50%
sats <92 %
unable to complete sentences
signs of resp distress
RR >40 (1-5) or >30 (>5)
HR >140 (1-5) or >125 (>5)
Life-threatening asthma attack?
peak flow <33%
sats <92%
exhaustion and poor resp effort
hypotension
silent chest
cyanosis
altered consciousness/ confusion
normal PaCO2
Mx of acute asthma?
O2
bronchodilators (salbutamol, ipratropium, magnesium sulphate, aminophylline)
steroids (prednisolone, hydrocortisone)
antibiotics if bacterial infection suspected
What is chronic asthma?
chronic inflammatory airway disease leading to variable airway constriction and obstruction
Atopic conditions?
asthma
hay fever
eczema
food allergies
Features suggestive of asthma?
episodic symptoms
diurnal variability (worse at night and early morning)
dry cough
triggers
hx of atopy
FHx of atopy
bilateral widespread wheeze
symptoms improve with bronchodilators
Features suggestive of alternative diagnosis to asthma?
wheeze only related to colds
isolated or productive cough
normal investigations
no response to treatment
unilateral wheeze
Typical asthma triggers?
dust
animals
cold
exercise
smoke
food allergens
Investigations for asthma?
spirometry with reversibility testing (>5)
direct bronchial challenge test with histamine or methacholine
fractional exhaled NO
peak flow variability diary
Asthma mx in <5yrs?
1) SABA as required
2) add low-dose ICS or leukotriene antagonist
3) add the other
4) refer to specialist
Asthma mx in 5-12yrs?
1) start a SABA
2) add low dose ICS
3) add LABA
4) titrate steroid to medium dose + consider leukotriene receptor antagonist or oral theophylline
5) titrate steroid to high dose
6) refer to specialist
Asthma mx in >12yrs?
(same as adults)
1) SABA
2) add low-dose ICS
3) add LABA
4) titrate steroid to medium dose + consider leukotriene receptor antagonist, oral theophylline or
Presentation of pneumonia?
productive cough
high fever
tachypnoea
tachycardia
incr. work of breathing
lethargy
delirium (late)
bronchial breath sounds
focal coarse crackles
dullness to percussion
Causes of pneumonia?
Bacterial:
strep pneumoniae
Group A strep
Group B strep
staph aureus
haemophilus influenzae
mycoplasma pneumoniae
Viral:
RSV
parainfluenza
influenza
Investigations in pneumonia?
CXR (consolidation)
sputum culture
throat swabs
viral PCR
blood cultures (sepsis)
blood gas analysis
Mx of pneumonia?
amoxicillin
+ macrolide to cover for mycoplasma pneumoniae
(macrolide as monotherapy in penicillin allergy)
O2
What is croup?
upper respiratory tract infection that causes oedema of the larynx, typically affecting children between 6m - 2yrs
Who gets croup?
children between 6 months and 2 years
Causes of croup?
parainfluenza
influenza
adenovirus
RSV
Presentation of croup?
incr. work of breathing
‘barking’ cough
hoarse voice
stridor
low-grade fever
Mx of croup?
supportive treatment
oral dexamethasone (150mcg/kg)
rarely -> nebulised budesonide, nebulised adrenaline, intubation and ventilation
What is epiglottitis?
inflammation and swelling of the epiglottis
life-threatening emergency
Cause of epiglottitis?
haemophilus influenza type B
(now rare due to vaccines)
Presentation of epiglottitis?
sore throat
stridor
drooling
tripod position
high fever
difficult or painful swallow
muffled voice
scared and quiet child
septic or unwell
Mx of epiglottitis?
DON’T DISTRESS PATIENT
secure airway
IV ceftriaxone
dexamethasone
treat abscess if occurs
What is laryngomalacia?
condition affecting infants, where the part of the larynx above the vocal cords is structured to cause partial airway obstruction
chronic stridor
Presentation of laryngomalacia?
infants - peak 6 months
inspiratory stridor
more prominent when feeding, upset, or laying on back
Management of laryngomalacia?
usually no interventions and the child grows out of the condition as the larynx matures
rarely - tracheostomy or surgery
What is whooping cough?
URTI caused by Bordetella pertussis
Presentation of whooping cough?
starts with mild coryzal symptoms, low grade fever and dry cough
severe paroxysmal coughs with loud inspiratory ‘whoop’
can present as apnoeas in infants
Diagnosis of whooping cough?
nasopharyngeal swab with PCR or bacterial culture within 2-3wks of onset
>2wks of onset -> anti-pertussis toxin immunoglobulin G
Mx of whooping cough?
notifiable disease
supportive care
macrolides in early stages or vulnerable patients
prophylactic antibiotics to vulnerable close contacts
Key complication of whooping cough?
bronchiectasis
What is Chronic Lung Disease of Prematurity?
aka bronchopulmonary dysplasia
occurs in very premature babies (typically <28wks) and they suffer with resp distress syndrome
Diagnosis of CLDP?
when they require oxygen after 36 wks
or on CXR
Features of CLDP?
low o2 sats
incr. work of breathing
poor feeding and weight gain
crackles and wheezes on chest auscultation
incr. susceptibility to infection
Prevention of CLDP?
maternal steroids
using CPAP > ventilation
caffeine
not over-oxygenating
Mx of CLDP?
oxygen (even at home depending on needs)
palivizumab (monthly injections against RSV)
What is cystic fibrosis?
autosomal recessive condition affecting the mucus glands
caused by mutation of the CF gene on chromosome 7
characterised by pancreatic and biliary secretions, airway secretions and male infertility
Inheritance pattern of cystic fibrosis?
autosomal recessive
Presentation of cystic fibrosis?
heel prick test
meconium ileus
recurrent LRTIs
failure to thrive
pancreatitis
chronic cough
thick sputum
steatorrhea (no lipase)
abdo pain and bloating
salty sweat
nasal polyps
clubbing
infertility in males (absent vas deferens)
Causes of clubbing in children?
hereditary clubbing
cyanotic heart disease
infective endocarditis
cystic fibrosis
TB
IBD
liver cirrhosis
Diagnosis of CF?
new born heel prick test
sweat test is gold standard (chloride conc. >60mmol/L)
genetic testing for CFTR gene
Common colonisers in CF?
staph aureus (prophylactic flucloxacillin)
haemophilus influenza
klebsiella pneumoniae
E coli
bulkholderia
pseudomonas aeruginosa
Dangers of pseudomonas in CF?
very hard to get rid of
often resistant
significant increase in morbidity and mortality
for this reason, children with CF are discouraged from meeting other children with CF
Tx for pseudomonas in CF?
long-term nebulised antibiotics tobramycin
ciprofloxacin
Mx of CF?
MDT
chest physio
exercise
high calorie high fat diet
Creon tablets
prophylactic flucloxacillin
treat chest infections
bronchodilators
nebulised DNase
nebulised hypertonic saline
vaccines (pneumococcal, influenza, varicella)
lung transplant
liver transplant
fertility treatment in males
genetic counselling
Monitoring in CF?
monitor sputum for colonisation, particularly pseudomonas
diabetes
osteoporosis
vit D deficiency
liver failure
Prognosis of CF?
median life expectancy 47yrs
90% get pancreatic insufficiency
50% get diabetes
30% get liver disease
most males are infertile
What is primary ciliary dyskiniesia?
aka Kartagener’s
autosomal recessive condition resulting in dysfunction of the motile cilia in the body, most notably in the respiratory tract
leads to a build-up of mucus -> RTIs, infertility, sinusitis
What is Kartagener’s triad?
paranasal sinusitis
bronchiectasis
situs inversus
What is situs inversus?
where all the internal viscera are on the opposite side
(dextrocardia -> only the heart is reversed)
25% of patients with situs inversus have PCD
50% of patients with PCD have situs inversus
Diagnosis of PCD?
recurrent RTIs
Hx -> consanguinity
imaging for situs inversus
semen analysis for male infertility
sample of the ciliated epithelium
