Respiratory (1s) Flashcards
What are the respiratory differences between children and adults?
- 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
What factors affect lung growth?
- 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
How do you approach a history of coughing?
- duration
- age of onset
- nature of cough
- timing of cough
- additional resp noises
- improves/worsens
- FHx
- smoking
- environmental factor(s)
What are the signs of increased respiratory effort in a child?
What are normal paediatric respiratory rates?
- 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
How can you tell a baby is in respiratory distress and similarly count the RR?
- head bobbing
- if they are using their accessory muscles to help them breathe
- by each head bob you can count baby’s RR
What is expiratory grunting?
- 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
What might cough in a child suggest?
- ‘hacking’ or ‘dry’ -> bronchiolitis or asthma
- ‘bark’ -> croup
- ‘fruity’ -> bronchiectasis
What is wheezing and its causes in children?
- 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
What is stridor?
- 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
What are other respiratory signs not mentioned?
- hoarseness - caused by inflammation to vocal cords
- dyspnoea - laboured or difficulty in breathing
- pleuritic pain - ?acute lobar pneumonia
- apnoea - bronchiolitis, whooping cough
- crackles
- snuffles
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?
- 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
What are the triggers of an asthma exacerbation?
- viral respiratory infections
- exercise
- weather change - cold air
- allergens - HDM, grass/tree pollen, animal dander, food
- cig smoke
- GORD
- emotional factors
What are the risk factors in developing asthma?
- family history
- viral respiratory infections
- atopic disease
- allergies
- passive or active tobacco smoking
- abnormal lung function + airway hyper-responsiveness
- air pollution
- obesity
How does the presentation of asthma differ in children of different ages?
-
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)
What are key features that need to be established in a history when a child is presenting with suspected asthma attack(s)?
- 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?
What investigations can be done for asthma?
- 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)
What are the differences between viral-induced wheeze and asthma?
All children require a written asthma plan. What is the treatment of chronic asthma in children?
- inhaled SABA eg. salbutamol PRN (“reliever”)
- + inhaled steroid eg. beclomethasone (“preventer”)
- + 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
What are the clinical features of a mild, severe and life-threatening asthma attack?
How are inhaled treatments administered?
- <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
What is the immediate management of an acute asthma attack?
- 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
When is it safe to discharge the child following an asthma attack and what is the follow up?
- 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
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?
- 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
What is the difference between mild, moderate and severe croup?
- 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
Croup is a viral URTI, resulting in mucosal inflammation anywhere between the nose and trachea.
What are the common causative organisms for this?
- parainfluenza virus (types I, II, III + IV) (most common)
- respiratory syncytial virus
- adenovirus
- rhinovirus
- enterovirus
- measles
- meta pneumovirus
- influenza A + B
- mycoplasma pneumoniae (rare)
Croup is largely a clinical diagnosis based off of features on clinical exam.
Treatment is based on severity. What is the management?
-
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
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?
- respiratory syncitial virus (RSV) infection
- answer/hint given away in question
- also adenovirus, hyman metapneumovirus + rhinovirus
What are the clinical features of bronchiolitis?
- 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
Bronchiolitis is a clinical diagnosis, but what important investigations can be done to support the diagnosis?
- 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
What is the management in children with bronchiolitis?
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
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)?
Tend to be organisms from the mother’s genital tract
- Group B Streptococcus
- E.coli
- Klebsiella
- Staph Aureus
- Chlamydia
- Listeria
For pneumonia, what are the common causative organisms in children <5yrs old?
- RSV and other resp viruses (parainfluenza, adenovirus)
- Steptococcus pneumoniae
- Haemophilus Influenzae
- Bordetella Pertussis
- Chlamydia Trachomatis
- Staphylococcal aureus
For pneumonia, what are the common causative organisms in children >5yrs old?
- mycoplasma pneumoniae
- streptococcus pneumoniae
- chlamydia pneumoniae
- haemophilus influenzae (type B)
- influenza viruses
- legionella pneumophilia
Which certain groups of children are at risk of pneumoniae?
- congenital lung cysts
- chronic lung disease
- immunodeficiency
- cystic fibrosis
- sickle celld isease
- tracheostomy in situ
What are the clinical features of pneumonia in children?
- 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
How do viral and bacterial pneumonias differ in presentation?
- 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
How does afebrile pneumonia present in young infants?
- characterised by tachypnoea, cough, crackles on auscultation, and often concomitant chlamydial conjunctivitis
- WBC count typically shows mild eosinophilia
- CXR shows hyperinflation
What are the general examination findings for a child w/ pneumonia?
- crepitations
- asymmetrical chest wall movement
- dull percussive note
- bronchial breathing
- reduced air entry
- increased vocal fremitus
How do ‘mild-moderate’ and ‘severe’ pneumonia differ between an infant and the older child?
What are the investigations for pneumonia are needed in children?
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
What are indications for admission to hospital for infants and older children with pneumonia?
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?
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
For pneumonia, what is the management in over 5 year olds?
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
