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*Medicine: Paediatrics > Respiratory (1s) > Flashcards

Respiratory (1s) Flashcards

1
Q

What are the respiratory differences between children and adults?

A
  • big heads, short necks
  • small faces, small airways - easily blocked
  • relatively large tongue
  • funnel-shaped airway - cricoid is narrowest part (larynx in adults) and can easily swell up
  • babies breathe through their noses
  • little respiratory “reserve”
  • horizontal ribs, compliant chest wall, diaphragmatic breathing
  • resp muscles more prone to fatigue
  • low FRC
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2
Q

What factors affect lung growth?

A
  • abnormal embryonic + foetal development
  • genetic and hormonal factors
  • maternal + foetal malnutrition
  • reduced foetal lung fluid
  • inadequate size of thoracic cage
  • preterm birth
  • maternal smoking
  • pre and post natal infections
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3
Q

How do you approach a history of coughing?

A
  • duration
  • age of onset
  • nature of cough
  • timing of cough
  • additional resp noises
  • improves/worsens
  • FHx
  • smoking
  • environmental factor(s)
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4
Q

What are the signs of increased respiratory effort in a child?

A
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5
Q

What are normal paediatric respiratory rates?

A
  • 0-1 year : 30-60
  • 1-3 years : 24-40
  • 3-6 years : 22-34
  • 6-12 years : 18-30
  • 12-18 years : 12-16
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6
Q

How can you tell a baby is in respiratory distress and similarly count the RR?

A
  • head bobbing
  • if they are using their accessory muscles to help them breathe
  • by each head bob you can count baby’s RR
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7
Q

What is expiratory grunting?

A
  • very common after birth but at any other time is a red flag
  • they are trying to maintain their end expiratory pressure by making this noise
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8
Q

What might cough in a child suggest?

A
  • ‘hacking’ or ‘dry’ -> bronchiolitis or asthma
  • ‘bark’ -> croup
  • ‘fruity’ -> bronchiectasis
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9
Q

What is wheezing and its causes in children?

A
  • whistling noise that comes from the chest normally on expiration but can be on inspiration
  • they are polyphonic (can be lots of different tones)
  • causes of recurrent wheeze:
    • asthma, CF, congenital abnormalities of lungs, airways or heart
    • recurrent aspiration of feeds in infants due to GORD, tracheo-oseophageal fistula or swallowing disorders
    • cow’s milk protein intolerance
    • inhaled foreign body
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10
Q

What is stridor?

A
  • inspiratory noise coming from upper airway
  • monotonic noise
  • due to upper airway obstruction, examples:
    • croup, epiglottitis, foreign body, trauma, allergic laryngeal oedema, infectious mononucleosis, measles + diptheria
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11
Q

What are other respiratory signs not mentioned?

A
  • hoarseness - caused by inflammation to vocal cords
  • dyspnoea - laboured or difficulty in breathing
  • pleuritic pain - ?acute lobar pneumonia
  • apnoea - bronchiolitis, whooping cough
  • crackles
  • snuffles
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12
Q

Asthma is a chronic condition characterised by airway hyper-responsiveness, bronchial inflammation and airflow limitation. It is generally characterised by classical helper T cell type 2 pathology w/ increased cytokines, driving symptoms.

What are the clinical features of asthma?

A
  • wheezing, cough - nocturnal, dyspnoea
  • specific triggers
  • chest tightness
  • poor exercise tolerance
  • nasal symptoms
  • atopic disease
  • altered sleep - night cough, awakening
  • exercise or activity avoidance
  • exacerbations in past year
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13
Q

What are the triggers of an asthma exacerbation?

A
  • viral respiratory infections
  • exercise
  • weather change - cold air
  • allergens - HDM, grass/tree pollen, animal dander, food
  • cig smoke
  • GORD
  • emotional factors
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14
Q

What are the risk factors in developing asthma?

A
  • family history
  • viral respiratory infections
  • atopic disease
  • allergies
  • passive or active tobacco smoking
  • abnormal lung function + airway hyper-responsiveness
  • air pollution
  • obesity
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15
Q

How does the presentation of asthma differ in children of different ages?

A
  • under-2s: difficult to distinguish from bronchiolitis
    • bronchodilators often not effective (dont have receptors yet)
  • under-5s: “viral wheeze”
    • episodic symptoms associated w/ URTI
    • most do not go on to have asthma in later childhood
      • therefore tend to avoid giving “asthma” label
      • progression more likely if atopic/many different triggers
  • 5+: typical childhood asthma
    • varied triggers
    • acute exacerbations
    • interval symptoms, variability
    • reversible (w/ medication)
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16
Q

What are key features that need to be established in a history when a child is presenting with suspected asthma attack(s)?

A
  • age of onset of symptoms
  • frequency of symptoms
  • severity of symptoms (school impact, PE, playing, night-time)
  • previous treatment tried
  • any hospital attendances (A+E or admissions, HDU/ITU, ventilated)
  • presence of food allergies
  • triggers for symptoms: exercise, cold air, smoke, allergens, pets, damp housing
  • disease history: viral infections, eczema, hay fever
  • family history of atopy

Always ask the question of compliance. Are the symptoms not controlled because the child is not taking the treatment?

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17
Q

What investigations can be done for asthma?

A
  • lung function tests -> obstructive pattern, showing a reduced FEV1, w/ relatively preserved FVC + reduced FEV1/FVC (<70%)
  • bronchodilator reversibility -> if child shows >12% improvement on lung function test, diagnostic of asthma (only useful in children older than 5 when can start using the test)
  • allergy test
  • chest x ray
  • PEFR (should increase 10-15% after bronchodilators)
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18
Q

What are the differences between viral-induced wheeze and asthma?

A
19
Q

All children require a written asthma plan. What is the treatment of chronic asthma in children?

A
  1. inhaled SABA eg. salbutamol PRN (“reliever”)
  2. + inhaled steroid eg. beclomethasone (“preventer”)
  3. + inhaled LABA eg. salmeterol
  • Different for under-5s: inhaled ipratropium; leukotriene antagonists
  • all children (+ adults) should use spacer, check technique
  • personal asthma plans
  • know about side-effects
  • allergent avoidance is controversial
  • definitely avoid exposure to smoke
20
Q

What are the clinical features of a mild, severe and life-threatening asthma attack?

A
21
Q

How are inhaled treatments administered?

A
  • <4 years : metered dose inhaler w/ spacer
  • 4-10 yrs: metered-dose inhaler w/ spacer or dry powder inhaler
  • nebulisers are only for severe or life-threatening asthma
22
Q

What is the immediate management of an acute asthma attack?

A
  • high flow oxygen in children w/ life threatening asthma or SpO2 < 94% via a tight fitting face mask or nasal cannula, aim for sats 94-98%
  • inhaled SABA - via nebs if severe
  • pMDI + spacer preferred option in children w/ mild-mod asthma
  • IF symptoms refractory to initial SABA, add ipratropium bromide (250mcg mixed w/ nebulised SABA)
  • consider adding 150mg magnesium sulphate to each nebulised salbutamol and ipratropium in the first hour in children w/ short duration of acute severe symptoms presenting w/ SpO2 <92%
  • 3-day oral steroids early in treatment:
    • use dose of 10mg prednisolone for kids < 2
    • 20mg for kids 2-5
    • 30-40mg kids >5
  • consider IV hydrocortisone in children vomiting or too unwell to tolerate oral meds
23
Q

When is it safe to discharge the child following an asthma attack and what is the follow up?

A
  • bronchodilators are taken as inhaler device w/ spacer intervals of 4-hrly or more (eg. 6 puffs salbutamol via spacer every 4 hrs)
  • SaO2 >94% in air
  • PEFR and/or FEV1 should be >75% of best/predicted
  • inhaler technique assessed/taught
  • written asthma management plan given + explained to parents
  • GP should review child 2 days after discharge
  • arrange follow up in paed asthma clinic within 1-2 months
  • arrange referral to a paeds resp specialist if there have been life-threatening features
24
Q

Croup, AKA acute laryngytracheobronchitis, is a common childhood illness. It is also the commonest cause of upper airway obstruction, causing 95% of laryngtracheal infection.

What is the clinical presentation?

A
  • typically presents in those between 6 months and 3 yrs of age
  • peak incidence is at 2 yrs of age
  • characterised by sudden onset of seal-like barky cough
  • often preceded by a fever or coryza (cold)
  • accompanied by stridor, voice hoarseness, resp distress, fever
  • if in resp distress: tachypnoea, intercostal recession
  • common in autumn, worse at night
  • red flag signs for respiratory failure: cyanosis, lethargic/decreased level of consciousness, laboured breathing, tachycardia
25
Q

What is the difference between mild, moderate and severe croup?

A
  • mild croup = occasional barking cough, no audible stridor at rest, no suprasternal or intercostal recession, child happy + will drink/eat/play
  • moderate croup = freq barking cough, audible stridor at rest, suprasternal + sternal wall retraction at rest, child is not distressed or agitated + will show interest in surroundings
  • severe croup = freq barking cough, prominent inspiratory stridor at rest, marked sternal wall retractions, child appears distressed/agitated or lethargic or restless, tachycardia may occur if more severe obstructive symptoms are present which can result in hypoxaemia
26
Q

Croup is a viral URTI, resulting in mucosal inflammation anywhere between the nose and trachea.

What are the common causative organisms for this?

A
  • parainfluenza virus (types I, II, III + IV) (most common)
  • respiratory syncytial virus
  • adenovirus
  • rhinovirus
  • enterovirus
  • measles
  • meta pneumovirus
  • influenza A + B
  • mycoplasma pneumoniae (rare)
27
Q

Croup is largely a clinical diagnosis based off of features on clinical exam.

Treatment is based on severity. What is the management?

A
  • MILD (no stridor at rest)
    • corticosteroids + supportive care
    • single dose of oral dexamethasone
    • care should be taken to avoid frightening child
    • parental assurance + education to self-limited nature of illness is important
  • MODERATE (stridor at rest)
    • corticosteroids + supportive care - nebulised budesonide preferable in severe hypoxia, persistent vomiting or resp distress preventing admin of oral dose
    • nebulised adrenaline for children presenting w/ stridor, sternal indrawing at rest + persistent or increasing agitation
  • SEVERE (stridor at rest + agitation/lethargy)
    • corticosteroids + supportive care
    • nebulised adrenaline
    • supplemental oxygen - humidified oxygen given to children demonstrating signifiant signs + symptoms of resp distress, preferably as blow-by oxygen via tubing held a few cm from child’s nose + mouth
    • intubation - indicated in children progressing to asynchronous chest wall + abdo movement, fatigue, signs of hypoxia + hypercarbia
28
Q

Bronchiolitis is a viral infection of the bronchioles. It is a common disease affecting children under age of 2. About 1/3 of children will develop clinical bronchiolitis in their first year of life, although up to 50% may ahve encountered RSV by this time. It mainly occurs in winter + spring months.

What agent is responsible for bronchiolitis, normally?

A
  • respiratory syncitial virus (RSV) infection
  • answer/hint given away in question
  • also adenovirus, hyman metapneumovirus + rhinovirus
29
Q

What are the clinical features of bronchiolitis?

A
  • cough → dry cough, episodic + often resulting in vomiting, may be preceding signs of URTI
  • resp distress → tachypnoea, head bobbing, tracheal tug, subcostal/intercostal recession, abdominal movements
  • pyrexia → low-grade fever common
  • poor-feeding → affecting predominantly infants
  • apnoea → breathing pauses particularly when sleeping
  • other exam findings → wheeze, reduced air entry, creps/crackles
30
Q

Bronchiolitis is a clinical diagnosis, but what important investigations can be done to support the diagnosis?

A
  • nasopharyngeal aspirate or throat swab → RSV rapid testing + viral cultures
  • blood + urine culture → if child pyrexic
  • FBC (WCC) + CRP
  • ABG → if severely unwell, may detect resp failure, assess ventilation
  • CXR → only if diagnostic uncertainty or atypical course, to show hyperinflation, focal atelectasis, air trapping, flattened diaphragm, peribronchial cuffing
31
Q

What is the management in children with bronchiolitis?

A

Main focus of management is supportive:

  • minimal handling → any distress can exacerbate respiratory distress, this is partly the reason why blood tests should be performed sparingly
  • oxygen + ventilation → usually main indicator of whether a chid needs admission is whether they can maintain their O2 sats in room air, some babies require more invasive support such as high-flow nasal cannula, CPAP or intubation
  • hydration support → once demand of ventilation is significant, feeding may become compromised, maintaining hydration is vital, support can be offered by either a NG tube or IV fluids
  • inhaled therapies → controversy remains over use of nebulised NaCl, salbutamol or ipratropium bromide as bronchodilators unlikely to benefit bc most children <6months do not possess ß2 receptors
32
Q

Pneumonia is an infection that causes inflammation of the lung tissue in which the alveoli becom e filled with inflammatory cells (consolidation).

What are the common causative organisms in neonates (<1m)?

A

Tend to be organisms from the mother’s genital tract

  • Group B Streptococcus
  • E.coli
  • Klebsiella
  • Staph Aureus
  • Chlamydia
  • Listeria
33
Q

For pneumonia, what are the common causative organisms in children <5yrs old?

A
  • RSV and other resp viruses (parainfluenza, adenovirus)
  • Steptococcus pneumoniae
  • Haemophilus Influenzae
  • Bordetella Pertussis
  • Chlamydia Trachomatis
  • Staphylococcal aureus
34
Q

For pneumonia, what are the common causative organisms in children >5yrs old?

A
  • mycoplasma pneumoniae
  • streptococcus pneumoniae
  • chlamydia pneumoniae
  • haemophilus influenzae (type B)
  • influenza viruses
  • legionella pneumophilia
35
Q

Which certain groups of children are at risk of pneumoniae?

A
  • congenital lung cysts
  • chronic lung disease
  • immunodeficiency
  • cystic fibrosis
  • sickle celld isease
  • tracheostomy in situ
36
Q

What are the clinical features of pneumonia in children?

A
  • cough → associated w/ vomiting in younger children + sputum production in older children
  • respiratory distress → blocked inflammed airways will result in resp compromise + a child who needs to use accessory muscles to achieve adequate gas exchange: look for tachypnoea, tracheal tug + use of subcostal + intercostal recession, infants may have apnoea due to poorer central resp control, grunting may also be heard
  • pyrexia → absence of an elevated temp on bg of significant consolidation on CXR is suspicious, both TB + malignancy should be considered
  • poor feeding → for v young child, symptom of ill health + taken seriously, inability to take feeds either due to coughing or general exhaustion is a common reason for hosp admission
  • abdominal pain → pleuritic pain can present as abdo pain in some children, often w/ v few signs of resp distress
37
Q

How do viral and bacterial pneumonias differ in presentation?

A
  • viral pneumonias associated more often w/ cough, wheezing or stridor; fever is less prominent than with bacterial
  • CXR in viral pneumonia shows diffuse, streaky infiltrates of bronchopneumonia + WBC count often is normal or mildly elevated w/ predominance of lymphocytes
  • bacterial pneumonias typically associated w/ higher fever, chills, cough, dyspnoea + auscultatory findings of lung consolidation
  • CXR often shows lobar consolidation (or round pneumonia) + pleural effusion, the WBC count is elevated w/ predominance of neutrophils
38
Q

How does afebrile pneumonia present in young infants?

A
  • characterised by tachypnoea, cough, crackles on auscultation, and often concomitant chlamydial conjunctivitis
  • WBC count typically shows mild eosinophilia
  • CXR shows hyperinflation
39
Q

What are the general examination findings for a child w/ pneumonia?

A
  • crepitations
  • asymmetrical chest wall movement
  • dull percussive note
  • bronchial breathing
  • reduced air entry
  • increased vocal fremitus
40
Q

How do ‘mild-moderate’ and ‘severe’ pneumonia differ between an infant and the older child?

A
41
Q

What are the investigations for pneumonia are needed in children?

A

In a well child w/ CAP and a clear diagnosis, no investigations (including CXR) are needed. However in mod-severe cases:

  • CXR → may show focal consolidation or bilateral changes
  • WCC → elevated + neutrophilia, particularly in bacterial
  • CRP → non-specific, will not peak until 24hrs into illness, in v severe infection the CRP may not rise as liver shuts down
  • sputum culture → best indication of pathogens causing infection
  • blood culture → important to obtain in an unwell febrile child, may be septicaemia if bacterial pathogen has crossed over the blood stream
  • chest ultrasound → if the CXR suggests an effusion
42
Q

What are indications for admission to hospital for infants and older children with pneumonia?

A
43
Q

Oral Abx are safe and effective in the treatment of CAP. IV Abx are used in children who cannot absorb or in those w/ severe symptoms.

What is the management for under 5 year olds?

A

Strep pneuomoniae is the most likely pathogen. Causes of atypical pneumoniae are mycoplasma pneumoniae + chlamydia trachomatis

  • 1st line = amoxicillin
  • alternatives
    • co-amoxiclav or cefaclor for typical pneumonia
    • macrolides (eg erythromycin, clarithromycin) for atypical
44
Q

For pneumonia, what is the management in over 5 year olds?

A

Mycoplasma pneumoniae is more common in this age group

  • 1st line = amoxicillin - effective against majority of pathogens, but consider macrolide abx if mycoplasma or chlamydia is suspected

*Medicine: Paediatrics (14 decks)

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