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Y4 paediatrics > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Chronic cough causes

A

Minor persistent problems - recurrent URTIs, post-nasal drip, post-infectious

‘Asthma syndrome’

Chronic pneumonia

Chronic endobronchial suppurative disease - CF, immunodeficiency, PCD, post-infectious

Aspiration - swallowing problem/laryngeal disorder, GORD

Mechanical - inhaled retained foreign body, inefficiency, SOL

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2
Q

Cough hx

A

Preceding sx - fever, runny nose, choking ep

Onset - rapid, prodromal symptoms - present in viral illness

Duration - acute < 3 weeks, chronic > 6 weeks

Nature - wet or dry

Quality - barking, honking, paroxysmal

Associated symptoms - dyspnoea, wheeze, feeding difficulties, vomiting

Diurnal variation

Response to mx

PMHx

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3
Q

Airway obstruction causes of central cyanosis

A

Choanal atresia

Laryngomalacia

Macroglossia

Pierre-Robin Syn

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4
Q

Pulmonary causes of central cyanosis

A

Alveolar capillary dysplasia

Lobar emphysema

Pneumonia/PE/pneumothorax

Persistent pulmonary HTN of newborn

Pulmonary hypoplasia

RDS

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5
Q

Cardio-thoracic causes of central cyanosis

A

Congenital cyanotic heart disease

Congenital diaphragmatic hernia

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6
Q

CNS depression causes of central cyanosis

A

Apnoea of prematurity

Infection - meningitis, encephalitis

IVH

Seizure

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7
Q

Neuromuscular disorder causes of central cyanosis

A

Neonatal myasthenia gravis

Phrenic nerve injury

SMA type 1

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8
Q

Haematologic causes of central cyanosis

A

Haemaglobinopathies

Polycythaemia

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9
Q

Metabolic causes of central cyanosis

A

Severe hypoglycaemia

Inborn errors of metabolism

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10
Q

Stridor

A

harsh, musical sound due to partial obstruction of the lower portion of the upper airway including the upper trachea and the larynx

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11
Q

Stridor causes

A
  • croup
  • epiglottitis
  • bacterial tracheitis
  • laryngeal/oesophageal foreign body
  • allergic laryngeal angioedema
  • inhalation of smoke and hot fumes in fires
  • trauma to the throat
  • retropharyngeal abscess
  • hypocalcaemia
  • severe lymph node swelling - TB, infectious mononucleosis, malignancy
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12
Q

Epiglottitis

A
  • caused by H. influenzae type b
  • mostly 1-6 years
  • acute, life-threatening illness
  • high fever, ill, toxic-looking
  • painful throat, unable to swallow saliva → drools down chin
  • management → ensure airway is secure, IV abx & steroids
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13
Q

Bacterial tracheitis

A
  • high fever, toxic
  • loud, harsh stridor
  • management → IV antibiotics and intubation & ventilation if required
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14
Q

Viral episodic wheeze

A

Cause - narrow small airways, aberrant immune response

Symptomatic only with viral infections

RFs - maternal smoking, prematurity, male gender

Resolves by age 5 as airways enlarge

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15
Q

Multi-trigger wheeze

A

Wheeze triggered by many stimuli eg. cold air, dust, exercise

Used where formal asthma diagnosis not justified

Recurrent may benefit from asthma treatment

Many go on to develop asthma

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16
Q

Acute wheeze causes

A

Viral episodic wheeze

Multi-trigger wheeze

Bronchiolitis

Pneumonia

Foreign body inhalation

Anaphylaxis

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17
Q

Chronic wheeze causes

A

Bronchitis, bronchiectasis

CF

Tracheal/oesophageal foreign body

Recurrent aspiration

Structural - tracheo-bronchomalacia, vascular ring

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18
Q

Acute asthma

A
  • characterised by a rapid deterioration in the symptoms of asthma
  • could be triggered by any of the typical asthma triggers (infection, exercise, cold weather)
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19
Q

Acute asthma presentation

A

Progressively worsening shortness of breath

Signs of respiratory distress

Fast RR

Expiratory wheeze on auscultation heard throughout the chest

Chest can sound ‘tight’ on auscultation with reduced air entry

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20
Q

Asthma moderate severity

A

PF > 50% predicted
Normal speech

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21
Q

Asthma severe severity

A

PF < 50% predicted
Sats < 92%
Unable to complete sentences in one breath
Signs of respiratory distress
RR:
> 40 in 1-5 years
> 30 in > 5 years
HR:
>140 in 1-5 years
> 125 in > 5 years

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22
Q

Asthma life-threatening severity

A

PF < 33% predicted
Sats < 92%
Exhaustion and poor respiratory effort
Hypotension
Silent chest
Cyanosis
Altered consciousness/confusion

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23
Q

Acute asthma mx

A

Supplementary O2 if required

Bronchodilators

  • stepped up at required:
    • inhaled or nebulised salbutamol (monitor K+ as causes hypokalaemia, tachycardia, tremor)
    • inhaled or nebulised ipratropium bromide
    • IV magnesium sulphate (CCB - can aid in the relaxation of constricted bronchioles during an exacerbation)
    • IV aminophylline

Steroids

Antibiotics - only if bacterial cause is suspected

Mild cases - can be managed as an outpatient with regular salbutamol inhalers via a spacer (4-6 puffs every 4 hours)

Moderate to severe cases:

  • salbutamol inhalers via a spacer device starting with 10 puffs every 2 hours
  • nebulisers with salbutamol/ipratropium bromide
  • oral prednisolone
  • IV meds - hydrocortisone, magnesium sulphate, salbutamol, aminophylline
  • if still not controlled → anaesthetist & ICU → intubation and ventilation

Typical step down regime of salbutamol - 10 puffs 2 hourly, 10 puffs 4 hourly, 6 puffs 4 hourly, 4 puffs 6 hourly

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24
Q

Acute asthma discharge

A

Considered when the child is well on 6 puffs 4 hourly of salbutamol

Can be prescribed a reducing regime of salbutamol to continue at home

Finish the course of steroids

Provide safety-net information

Individualised written asthma action plan

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25
Q

Chronic asthma

A
  • asthma is a chronic inflammatory airway disease leading to variable airway obstruction
  • smooth muscle in the airways is hypersensitive & responds to stimuli by constricting & causing airflow obstruction
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26
Q

Chronic asthma clinical features

A

Episodic symptoms with intermittent exacerbations

Diurnal variability, typically worse at night and early morning

Dry cough with wheeze & SoB

Typical triggers

PHx/FHx of atopy

Bilateral widespread ‘polyphonic’ wheeze

Symptoms improve with bronchodilators

27
Q

Chronic asthma triggers

A

Dust

Animals

Cold air

Exercise

Smoke

Food allergens

28
Q

Chronic asthma diagnosis

A

Trial of treatment can be implemented and if treatment improves symptoms → diagnosis can be made based on clinical suspicion

Spirometry with reversibility testing (children > 5 years)

Direct bronchial challenge test with histamine/methacholine

Fractional exhaled nitric oxide (FeNO)

Peak flow variability measured by keeping a diary of peak flow measurements several times a day for 2 to 4 weeks

29
Q

Chronic asthma long term mx

A

Medical therapy in < 5 years

  • start a SABA
  • add a low dose ICS or LTRA
  • add the other option from step 2
  • refer to a specialist

Medical therapy in 5-12 years

  • start a SABA
  • add a low dose ICS
  • add a LABA, continue only if patient has a good response
  • titrate up the corticosteroid inhaler to a medium dose, consider adding: LTRA/theophylline
  • increase ICS to high dose
  • referral to a specialist

Medical therapy > 12 years

  • start a SABA
  • add a regular low dose ICS
  • add a LABA, continue only if patient has a good response
  • titrate up the ICS to medium dose, consider LRTA/theophylline/inhaled LAMA
  • titrate the ICS to high dose, combine additional treatments from step 4, including option of oral beta-2 agonist, refer to a specialist
  • add oral steroids at lowest dose possible
30
Q

Bronchiectasis

A

Abnormal dilatation of the airways with associated destruction of bronchial tissue

31
Q

Bronchiectasis aetiology

A

Cystic fibrosis

Post-infectious - severe infection of the LRT can lead to bronchial damage & bronchiectasis eg. Strep pneumonia, staph aureus, adenovirus, measles

Immunodeficiency - antibody defects, HIV infection, ataxia telangiectasia

Primary ciliary dyskinesia - autosomal recessive genetic defect → the reduced efficacy/complete inaction of bronchial cilia

Post-obstructive: foreign body aspiration

Congenital syndromes - Young’s syndrome, Yellow-nail syndrome

32
Q

Bronchiectasis clinical features

A

Presence of chronic, productive cough

Purulent sputum expectoration

Chest pain

Wheeze

Breathlessness on exertion

Haemoptysis

Recurrent/persistent infections of LRT

O/E: may be entirely normal, finger clubbing and/or inspiratory crackles, wheezing

33
Q

Bronchiectasis ix

A

CXR - bronchial wall thickening/airway dilatation

HRCT - gold standard ix

  • bilateral upper lobe bronchiectasis = CF
  • unilateral upper lobe bronchiectasis = post-TB infection
  • focal bronchiectasis can be seen after foreign body inhalation

Bronchoscopy - not routinely performed in all children with the disease

Ix for underlying cause - chloride sweat test, FBC, immunoglobulin panel, specific antibody levels to vaccinations, biopsy, HIV

Microbiological assessment

Lung function

34
Q

Bronchiectasis mx

A

Symptomatic relief, prevent progression of lung disease & ensure normal growth & development

Chest physiotherapy

Abx for exacerbations

Bronchodilators for wheeze

Follow-up regularly & continual monitoring of their symptoms and lung function

35
Q

Bronchiectasis complications

A

Recurrent infection

Life-threatening haemoptysis

Lung abscess

Pneumothorax

Poor growth and development

36
Q

Croup

A
  • acute infective respiratory disease affecting children mainly from 6 months to 2 years but can be older
  • URTI causing oedema in the larynx
37
Q

Croup causes

A
  • parainfluenza
  • influenza
  • adenovirus
  • RSV
38
Q

Croup presentation

A
  • increased work of breathing
  • ‘barking’ cough due to tracheal oedema and collapse
  • harsh stridor
  • hoarseness due to inflammation of the vocal cords
  • symptoms often start & are worse at night
39
Q

Croup mx

A
  • most cases can be managed at home with simple supportive treatment (fluids and rest)
  • during attacks can help to sit the child up and comfort them
  • single dose of oral dexamethasone
  • stepwise options in severe croup to get control of symptoms:
    • oral dexamethasone
    • oxygen
    • nebulised budesonide
    • nebulised adrenalin
    • intubation and ventilation
40
Q

Bronchiolitis

A

Inflammation and infection in the bronchioles (small airways of the lungs)

41
Q

Bronchiolitis epidemiology

A
  • typically observed in the winter months
  • approximately affects children aged between 1-9 months
42
Q

Bronchiolitis aetiology

A
  • respiratory syncytial virus (RSV)
  • influenza
  • COVID-19
43
Q

Bronchiolitis clinical features

A
  • coryzal symptoms
  • signs of respiratory distress
    • raised RR
    • use of accessory muscles of breathing
    • intercostal and subcostal recessions
    • nasal flaring
    • head bobbing
    • tracheal tugging
    • cyanosis
    • abnormal airway noises
  • dyspnoea
  • tachypnoea
  • poor feeding
  • mild fever
  • apnoeas - episodes where child stops breathing
  • wheeze and crackles
44
Q

Bronchiolitis mx

A
  • supportive management
  • ensuring adequate intake - orally, NGT or IV fluids
  • saline nasal drops and nasal suctioning → can help clear nasal secretions
  • supplementary oxygen if sats remain < 92%
  • ventilatory support if required
45
Q

Bronchiolitis palivizumab

A
  • monoclonal antibody that targets RSV
  • monthly injection given as prevention against bronchiolitis
  • given to high risk babies → ex-premature and those with congenital heart disease
  • provides passive protection by circulating the body until virus is encountered → activates immune system to fight it
    • circulating antibodies decrease over time = monthly injection is required
46
Q

CF

A
  • autosomal recessive genetic condition affecting mucus glands → caused by a genetic mutation of the cystic fibrosis transmembrane conductance regulatory gene on chromosome 7
  • most common mutation → delta-F508 → codes for cellular channels, particularly a type of chloride channel
47
Q

Key consequences of the CF mutation

A

Thick pancreatic & biliary secretions that cause blockage of the ducts → lack of digestive enzymes eg. pancreatic lipasein the GI tract

Low volume thick airway secretions that reduce airway clearance → bacterial colonisation & airway infections

Congenital bilateral absence of the vas deferens in male → sperm have no way of getting from testes to ejaculate → male infertility

48
Q

CF presentation

A

Screened for at birth with newborn bloodspot test

Meconium ileus → meconium passed > 24 hours, abdominal distension & vomiting

Recurrent LRTIs

Failure to thrive

Pancreatitis

49
Q

CF symptoms

A

Chronic cough

Thick sputum production

Recurrent LRTIs

Steatorrhoea → lack of fat digesting lipase enzymes

Abdominal pain & bloating

Child tastes salty → concentrated salt in sweat

Poor weight & height gain (failure to thrive)

50
Q

CF signs

A

Low weight/height growth charts

Nasal polyps

Finger clubbing

Crackles & wheezes on auscultation

Abdominal distension

51
Q

CF diagnosis

A

Newborn blood spot test

Sweat test - gold standard for diagnosis (Cl- > 60mmol/L)

Genetic testing for CFTR gene can be performed during pregnancy by amniocentesis or chorionic villous sampling

52
Q

CF mx

A

Managed by the specialist MDT

Chest physiotherapy several times a day

Exercise

High calorie diet

CREON tablets - digest fats in patients with pancreatic insufficiency

Prophylactic flucloxacillin tablets to reduce the risk of bacterial infections

Treat chest infections when they occur

Bronchodilators

Nebulised DNase → enzyme that can break down DNA material in respiratory secretions, making secretions less viscous & easier to clear

Nebulised hypertonic saline

Vaccinations

Others - lung transplantation is an option in end stage respiratory failure, liver transplant, fertility treatment, genetic counselling

53
Q

CF monitoring

A

Managed and followed up in a specialist clinic, typically every 6 months

Require regular monitoring of their sputum for colonisation of bacteria

Monitoring & screening for diabetes, osteoporosis, vitamin D & liver failure

54
Q

LRTI

A
  • infection of the lung tissue
  • causes inflammation of the lung tissue & sputum filling the airways and alveoli
55
Q

LRTI presentation

A

Cough (wet & productive)

High fever (>38.5 degrees)

Tachypnoea

Tachycardia

Increased work of breathing

Lethargy

Delirium

56
Q

LRTI signs

A

Tachypnoea

Tachycardia

Hypoxia

Hypotension

Fever

Confusion

Chest signs - bronchial breath sounds, focal coarse crackles, dullness to percussion

57
Q

LRTI causes

A

Bacterial - strep pneumonia, group A strep, group B strep, staph aureus, haemophilus influenza, mycoplasma pneumonia

Viral - RSV, parainfluenza virus, influenza virus

58
Q

LRTI ix

A

CXR - useful in diagnostic doubt/severe or complicated cases

Sputum cultures & throat swabs for bacterial cultures and viral PCR

59
Q

LRTI mx

A

Antibiotics - amoxicillin, adding a macrolide will cover atypical pneumonia

Oxygen to maintain saturations

60
Q

OSA

A

Condition that affects the airway and how we breathe

Obstruction of the airway in the nose, throat or upper airway & happens when your child is asleep & apnoea

61
Q

OSA aetiology

A

Enlarged tonsils/adenoids

Obesity

More common is sickle cell disease, Down syndrome

62
Q

OSA clinical features

A

Snoring

Sleeping in unusual body position

Younger children - hyperactive, aggressive whereas older children may feel tired

Difficulty concentrating or behavioural change

Wake up tired, unhappy, with a headache

Poor growth and weight gain

Poor school performance

63
Q

OSA ix

A

Overnight sleep study

  • test results interpreted by a paediatric sleep medicine physician → make a diagnosis of OSA
64
Q

OSA mx

A

Surgery to remove adenoids and/or tonsils

CPAP/BiPAP if surgery not indicated/doesn’t fully resolve with surgery

Nasopharyngeal airway

Nasal steroids or montelukast - clear any inflammation

Weight reduction if appropriate

Y4 paediatrics (8 decks)

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