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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
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
26
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
27
Chronic asthma triggers
Dust Animals Cold air Exercise Smoke Food allergens
28
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
29
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
30
Bronchiectasis
Abnormal dilatation of the airways with associated destruction of bronchial tissue
31
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
32
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
33
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
34
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
35
Bronchiectasis complications
Recurrent infection Life-threatening haemoptysis Lung abscess Pneumothorax Poor growth and development
36
Croup
- acute infective respiratory disease affecting children mainly from 6 months to 2 years but can be older - URTI causing oedema in the larynx
37
Croup causes
- parainfluenza - influenza - adenovirus - RSV
38
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
39
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
40
Bronchiolitis
Inflammation and infection in the bronchioles (small airways of the lungs)
41
Bronchiolitis epidemiology
- typically observed in the winter months - approximately affects children aged between 1-9 months
42
Bronchiolitis aetiology
- respiratory syncytial virus (RSV) - influenza - COVID-19
43
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
44
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
45
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
46
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
47
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
48
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
49
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)
50
CF signs
Low weight/height growth charts Nasal polyps Finger clubbing Crackles & wheezes on auscultation Abdominal distension
51
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
52
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
53
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
54
LRTI
- infection of the lung tissue - causes inflammation of the lung tissue & sputum filling the airways and alveoli
55
LRTI presentation
Cough (wet & productive) High fever (>38.5 degrees) Tachypnoea Tachycardia Increased work of breathing Lethargy Delirium
56
LRTI signs
Tachypnoea Tachycardia Hypoxia Hypotension Fever Confusion Chest signs - bronchial breath sounds, focal coarse crackles, dullness to percussion
57
LRTI causes
Bacterial - strep pneumonia, group A strep, group B strep, staph aureus, haemophilus influenza, mycoplasma pneumonia Viral - RSV, parainfluenza virus, influenza virus
58
LRTI ix
CXR - useful in diagnostic doubt/severe or complicated cases Sputum cultures & throat swabs for bacterial cultures and viral PCR
59
LRTI mx
Antibiotics - amoxicillin, adding a macrolide will cover atypical pneumonia Oxygen to maintain saturations
60
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
61
OSA aetiology
Enlarged tonsils/adenoids Obesity More common is sickle cell disease, Down syndrome
62
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
63
OSA ix
Overnight sleep study - test results interpreted by a paediatric sleep medicine physician → make a diagnosis of OSA
64
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

Y4 paediatrics (8 decks)

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