Respiratory Flashcards
Chronic cough causes
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
Cough hx
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
Airway obstruction causes of central cyanosis
Choanal atresia
Laryngomalacia
Macroglossia
Pierre-Robin Syn
Pulmonary causes of central cyanosis
Alveolar capillary dysplasia
Lobar emphysema
Pneumonia/PE/pneumothorax
Persistent pulmonary HTN of newborn
Pulmonary hypoplasia
RDS
Cardio-thoracic causes of central cyanosis
Congenital cyanotic heart disease
Congenital diaphragmatic hernia
CNS depression causes of central cyanosis
Apnoea of prematurity
Infection - meningitis, encephalitis
IVH
Seizure
Neuromuscular disorder causes of central cyanosis
Neonatal myasthenia gravis
Phrenic nerve injury
SMA type 1
Haematologic causes of central cyanosis
Haemaglobinopathies
Polycythaemia
Metabolic causes of central cyanosis
Severe hypoglycaemia
Inborn errors of metabolism
Stridor
harsh, musical sound due to partial obstruction of the lower portion of the upper airway including the upper trachea and the larynx
Stridor causes
- 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
Epiglottitis
- 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
Bacterial tracheitis
- high fever, toxic
- loud, harsh stridor
- management → IV antibiotics and intubation & ventilation if required
Viral episodic wheeze
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
Multi-trigger wheeze
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
Acute wheeze causes
Viral episodic wheeze
Multi-trigger wheeze
Bronchiolitis
Pneumonia
Foreign body inhalation
Anaphylaxis
Chronic wheeze causes
Bronchitis, bronchiectasis
CF
Tracheal/oesophageal foreign body
Recurrent aspiration
Structural - tracheo-bronchomalacia, vascular ring
Acute asthma
- characterised by a rapid deterioration in the symptoms of asthma
- could be triggered by any of the typical asthma triggers (infection, exercise, cold weather)
Acute asthma presentation
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
Asthma moderate severity
PF > 50% predicted
Normal speech
Asthma severe severity
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
Asthma life-threatening severity
PF < 33% predicted
Sats < 92%
Exhaustion and poor respiratory effort
Hypotension
Silent chest
Cyanosis
Altered consciousness/confusion
Acute asthma mx
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
Acute asthma discharge
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
Chronic asthma
- 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
Chronic asthma clinical features
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
Chronic asthma triggers
Dust
Animals
Cold air
Exercise
Smoke
Food allergens
Chronic asthma diagnosis
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
Chronic asthma long term mx
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
Bronchiectasis
Abnormal dilatation of the airways with associated destruction of bronchial tissue
Bronchiectasis aetiology
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
Bronchiectasis clinical features
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
Bronchiectasis ix
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
Bronchiectasis mx
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
Bronchiectasis complications
Recurrent infection
Life-threatening haemoptysis
Lung abscess
Pneumothorax
Poor growth and development
Croup
- acute infective respiratory disease affecting children mainly from 6 months to 2 years but can be older
- URTI causing oedema in the larynx
Croup causes
- parainfluenza
- influenza
- adenovirus
- RSV
Croup presentation
- 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
Croup mx
- 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
Bronchiolitis
Inflammation and infection in the bronchioles (small airways of the lungs)
Bronchiolitis epidemiology
- typically observed in the winter months
- approximately affects children aged between 1-9 months
Bronchiolitis aetiology
- respiratory syncytial virus (RSV)
- influenza
- COVID-19
Bronchiolitis clinical features
- 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
Bronchiolitis mx
- 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
Bronchiolitis palivizumab
- 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
CF
- 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
Key consequences of the CF mutation
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
CF presentation
Screened for at birth with newborn bloodspot test
Meconium ileus → meconium passed > 24 hours, abdominal distension & vomiting
Recurrent LRTIs
Failure to thrive
Pancreatitis
CF symptoms
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)
CF signs
Low weight/height growth charts
Nasal polyps
Finger clubbing
Crackles & wheezes on auscultation
Abdominal distension
CF diagnosis
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
CF mx
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
CF monitoring
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
LRTI
- infection of the lung tissue
- causes inflammation of the lung tissue & sputum filling the airways and alveoli
LRTI presentation
Cough (wet & productive)
High fever (>38.5 degrees)
Tachypnoea
Tachycardia
Increased work of breathing
Lethargy
Delirium
LRTI signs
Tachypnoea
Tachycardia
Hypoxia
Hypotension
Fever
Confusion
Chest signs - bronchial breath sounds, focal coarse crackles, dullness to percussion
LRTI causes
Bacterial - strep pneumonia, group A strep, group B strep, staph aureus, haemophilus influenza, mycoplasma pneumonia
Viral - RSV, parainfluenza virus, influenza virus
LRTI ix
CXR - useful in diagnostic doubt/severe or complicated cases
Sputum cultures & throat swabs for bacterial cultures and viral PCR
LRTI mx
Antibiotics - amoxicillin, adding a macrolide will cover atypical pneumonia
Oxygen to maintain saturations
OSA
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
OSA aetiology
Enlarged tonsils/adenoids
Obesity
More common is sickle cell disease, Down syndrome
OSA clinical features
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
OSA ix
Overnight sleep study
- test results interpreted by a paediatric sleep medicine physician → make a diagnosis of OSA
OSA mx
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
