Respiratory Flashcards
What pathogen causes most resp infections in childhood?
Viruses
Which are the important viruses in resp infections? X6
RSV (respiratory syncytial virus), rhino viruses, parainfluenza, influenza, metapneumovirus and adenoviruses
Most important bacterial pathogens in resp infections x5
Streptococcus pneumoniae (pneumococcus), haemophilus influenzae, moraxella catarrhalis, bordetella pertussis (whooping cough), mycoplasma pneumoniae
Environmental risk factors for resp infection x3
Parental smoking - especially maternal, poor socio-economic status (overcrowding, large family, damp), poor nutrition
Host risk factors for resp infections x4
Underlying lung disease, male gender, haemodynamically significant congenital heart disease, immunodeficiency
Underlying lung disease which increase risk for resp infection x3
Bronchopulmonary dysplasia (preterm infants), cystic fibrosis or asthma
What is encompassed by URTI? X4
Common cold (coryza), sore throat (pharyngitis including tonsillitis), sinusitis
What can URTI cause in infants?
Poor feeding as blocked nose obstructs breathing
Febrile convulsions
Acute exacerbations of asthma
Classic features of common cold
Blocked nose and clear/mucopurulent nasal discharge
Commonest pathogenic causes of common cold
Viruses - rhinoviruses, corona viruses, RSV
Treatment of common cold
Self-limiting and no curative treatment
Fever and pain - treat with paracetamol and ibuprofen
What is pharyngitis?
Inflammation of pharynx and soft palate
Local lymph nodes enlarged and tender
What usually causes sore throat/pharyngitis? And in older children
Viruses - adenoviruses, enteroviruses and rhinoviruses
In older children group a b-haemolytic streptococcus
Common pathogens for tonsillitis?
Group a b-haemolytic strep and EBV
How do you tell between viral and bacterial tonsillitis
Clinically you can’t!
EBV exudate meant to be more membranous
Bacterial may have more constitutional disturbance (headache, apathy and abdominal pain, white exudate and cervical lymphadenopathy)
What is treatment for pharyngitis and tonsillitis - how long?
If severe often antibiotics even though only 1/3 are bacterial
To eradicate organism (b-haem strep) and prevent rheumatic fever need 10days of treatment
What antibiotic should be used in pharyngitis/tonsillitis and what should be avoided?
Penicillin and erythromycin (if penicillin allergy) usually used
Avoid amoxicillin because can cause maculopapular rash if due to EBV
When is acute otitis media most common?
6-12months
Symptoms and signs of acute otitis media?
Pain in ear and fever
Tympanic membrane bright red and bulging - loss of normal light reflection
May be visible pus if perforation of eardrum
Pathogens of acute otitis media
Viruses especially RSV and rhinovirus
Bacterial include pneumococcus, h.influenzae and moraxella catarrhalis
Serious complications of acute otitis media
Mastoiditis and meningitis
Treatment of acute otitis media
Paracetamol or ibuprofen for pain - constant rather than as required - more effective - may be needed for up to a week
Significance of antibiotics in acute otitis media
Shown to reduce the duration of pain but not affect risk of hearing loss - if no improvement after 4 days - give 5days of amoxicillin (erytho/clarithro if pen allergic)
Don’t wait for 4days if bilateral AOM or perforation in children
What can recurrent ear infections lead to?
Otitis media with effusion
Symptoms and signs of otitis media with effusion
Children asymptomatic apart from possible decreased hearing
Eardrum is retracted and dull and can often see a fluid level
Diagnosis of otitis media with effusion
Flat trace on tympanometry
Conductive hearing loss on pure tone audiometry (if >4) or reduced hearing on distraction hearing test in younger children
When is otitis media with effusion common
Age 2-7
Peak incidence 2.5-5
Treatment of otitis media with effusion
No evidence for benefit of long term antibiotics, steroids or decongestants
Condition usually resolves spontaneously
If affecting hearing - grommet insertion
What surgery can be useful for otitis media with effusion
Adenoidectomy because believed adenoids can harbour organisms contributing to infection spreading up Eustachian tubes
Also hypertrophied adenoids can obstruct and affect function of Eustachian tubes - poor ventilation of Middle ear
Another name for otitis media with effusion
Glue ear
When does sinusitis occur
Infection of para nasal sinuses with viral URTIs
What can occur with sinusitis and symptoms?
Secondary bacterial infection
Pain, swelling and tenderness over cheek from infection of maxillary sinus
What sinuses not usually affected in childhood sinusitis
Frontal sinuses because they do not develop until late childhood
Treatment for sinusitis
Reassure that >95% are viruses and can take 2.5 weeks to get better
Analgesia, intranasal steroids and decongestants, saline irrigation, warm face packs
but if bacterial suspected then antibiotics
Treatment for bacterial sinusitis
But if bacterial suspected (purulent discharge, severe pain, temp >38, worsening after initial being okay) then give antibiotics
Amox 7 days, or phenoxymethylpenicillin 7 days (pen allergic doxy (not children) erythro or clarithro)
Growth of tonsils and adenoids in childhood
Large in childhood and then gradually regress
If too large can cause trouble such as obstruction of airways (adenoids) and therefore be indication for removal
Number of resp infections in preschool children per year
6-8
Most common laryngeal/tracheal infection (acute upper airway obstruction)
Croup - viral laryngotracheobronchitis
What are symptoms and signs of acute upper airway obstruction x6
Stridor (rasping sound heard on inspiration)
Hoarseness (inflammation of vocal cords)
Barking cough
Dyspnoea
Tachypnoea (severe)
Tachycardia (severe)
How can you assess severity of upper airway obstruction
Degree of chest retraction (none, only on crying, at rest)
Degree of stridor (none, only on crying, at rest or biphasic)
What is pathology of croup x3
Mucosal inflammation and increased secretions
Oedema of subglottic area - most dangerous factor as causes critical tracheal narrowing
Pathogenic cause of croup
Viruses 95% including metapneumovirus, RSV, influenza
Most common is parainfluenza virus
Peak incidence of croup
Occurs from 6months-6 years but peak is in 2nd year of life
What season is croup most common
Autumn
Typical features of croup x6
Barking cough, harsh stridor and hoarseness
Usually preceded by fever and coryza
Symptoms often start and are worse at night
Treatment of croup
Oral Dexamethasone, prednisolone or neb budesonide
one dose - repeat next day if not better
Treatment of severe upper airway obstruction
Neb adrenaline - needs careful monitoring because risk of rebound symptoms 2hours after adrenaline when effects wear off
What is bacterial tracheitis?
Pseudomembranous croup
Rare but dangerous
Similar to viral croup but high fever, toxic and rapidly progressive obstruction with thick airway secretions
What causes bacterial tracheitis?
Staph aureus - treated with IV antibiotics
What is epiglottis and incidence?
Life threatening emergency caused by h.influenza type b - now massively reduced due to immunisation in infancy
Swelling of epiglottis and surrounding tissues
What complicates epiglottis?
Septicaemia
What age group is epiglottis common in?
Children 1-6
But can occur in all ages
Differences of presentation between croup and epiglottis
Epiglottis onset over hours without preceding coryza - no cough, can’t drink or swallow so drooling saliva. They appear very toxic and ill with high fever. Have soft whispering stridor not harsh and muffled voice rather than hoarse
Appearance of child with epiglottis
Sitting upright with open mouth to optimise airway
Treatment of epiglottis
Intubated with general anaesthetic (24hours)
Blood for culture
IV antibiotics such as cefuroxime (3-5days)
What should be done for contacts of epiglottis patients
As with all serious h.influenzae infections - prophylaxis with rifampicin
Presentation of bronchitis in childhood
Cough and fever are main symptoms (not usually wheeze presentation)
Cough may persist for 2 weeks
What is whooping cough
Highly contagious infection caused by bordetella pertussis
Incidence of whooping cough
Epidemic - occurring every 3-4 years
Presentation of whooping cough
1) catarrhal phase - week of coryza
2) paroxysmal phase - spasmodic cough followed by inspiratory whoop (3-6weeks)
What can occur as a result of the cough in whooping cough
Often worse at night - may lead to vomiting
May also get epistaxis and subconjunctival haemorrhages if vigorous coughing
Red/blue in face during coughing and mucus flows from nose and mouth
Uncommon complications of whooping cough x3
Pneumonia
Convulsions
Bronchiectasis
Blood count in whooping cough
Typically lymphocytosis >15 x 10(9)
Treatment of whooping cough and its effect
Started within 21days of cough onset
under 1m clarithro
>1m azithro or clarithro
Contact treatment with whooping cough
Prophylaxis in close contact and vaccination of any unvaccinated infant contacts
same unless pregnant in which case erythro
Most common age for bronchiolitis
90% are 1-9months
Rare after age 1
Pathogen in bronchiolitis
RSV in 80%
Also other viruses and mycoplasma pneumoniae
Symptoms of bronchiolitis
Coryzal symptoms precede:
Dry cough, increasing dyspnoea and difficulty feeding
Cyanosis, pallor, hyperinflation, SDL
Auscultation in bronchiolitis x2
Fine end-inspiratory crackles
High pitched wheeze (exp>insp)
Chest X-ray in bronchiolitis
Hyperinflation due to air trapping following small airway obstruction
Management of bronchiolitis
Humidified oxygen
Antibiotics, steroids and bronchodilators not shown to reduce severity or duration of illness
Prognosis of bronchiolitis
Most recover within 2 weeks
Adenovirus can have permanent damage to airways - bronchiolitis obliterans
What is palivizumab?
Monoclonal antibody to RSV given to high risk preterm infants
Pathogenic cause of pneumonia
50% cause not found
Can be viral or bacteria (viral more common in younger children and bacterial in older)
Most common pathogen in newborn pneumonia
Group b strep
Clinical features of pneumonia - most common presentation
Fever and difficulty breathing
Usually preceded by URTI
Other symptoms of pneumonia - including indication of bacterial infection
Cough, lethargy, poor feeding
Localised pain may suggest pleural irritation and therefore bacterial infection
Signs of pneumonia
SDL - tachypnoea, nasal flaring, chest indrawing
Auscultation in pneumonia
End inspiratory resp coarse crackles over affected area
Classical signs of consolidation (dullness on percussion, reduced air entry and bronchial breathing) not usually present
Management of pneumonia x4
Oxygen for hypoxia
Analgesia if pain
IV fluids if dehydrated
Antibiotics depending on age
Antibiotics in newborn with pneumonia
Broad spectrum - amox
Antibiotics in older infants with pneumonia
Oral amoxicillin
Broad spectrum eg co-amoxiclav for complicated or unresponsive
Can add in macrolides (azithro etc) if not responding
%of children affected by asthma
15-20
Two patterns of wheezing in children- indications of asthma
Transient early wheezing
Persistent and recurrent wheezing
What is transient early wheezing?
Virus associated wheeze or episodic viral wheeze
Due to small airways being more likely to narrow and obstruction due to inflammation from viral infection
Hence episodically triggered by viral infections
Risk factors for transient early wheezing x5
Decreased lung function from birth due to small airway diameter
Maternal smoking during and or after pregnancy
Preterm
Family hx of atopy not a risk factor
More common in males
When does transient early wheezing resolve
Age 5
What is persistent and recurrent wheezing
Wheezing due to IgE hypersensitivity - aka asthma
3 main pathological features of asthma
Bronchial inflammation, bronchial hyperresponsiveness and airway narrowing
What triggers most asthma exacerbations
Rhinovirus infection
Signs of long standing asthma x3
Hyperinflation
Generalised polyphonic wheeze
Prolonged expiratory phase
Indications of another cause of wheeze (not asthma) x3 and what do they indicate?
Wet cough or sputum production
Finger clubbing
Poor growth
Indicate chronic infection such as cystic fibrosis or bronchiectasis
Ladder of treatment of asthma in infant >5
Short acting inhaled bronchodilator Inhaled steroids ( 3 or more b2 needed per week) Long acting b2 Increase steroid dose Oral steroids
Other than b2 and steroids for asthma what can be added and when?
Leukotriene receptor antagonist or theophyllines - if no response to LABA
Asthma ladder in less than 5 years old
Ipratropium bromide + SABA
Inhaled steroids or oral leukotriene r-antagonist (montelukast, zafirlukast) if inhalers not tolerated
LABA
refer to resp paediatrician
What is good for exercise induced asthma
LABA + inhaled steroid
Signs of severity in acute asthma attack
If less than 5 - RR > 50 (not as good as HR) or HR >130
If older than 5 RR >30 or HR >120
Accessory muscle use and chest recession
Pulsus paradoxus
Can’t talk
Signs of life threatening asthma
Cyanosis fatigue, drowsiness and silent chest
What is good in treating acute asthma
Ipratropium bromide
Steroids - IV if severe
Most common cause of recurrent cough in children
1) URTI - common cold
2) Asthma
3) Wet - cystic fibrosis
4) GORD
5) Parents smoking
Chronic wet cough is indicative of…
Chronic lung infection eg. Bronchiectasis due to cystic fibrosis, primary ciliary dyskinesia, immunodeficiency or chronic aspiration
What is Kartagener syndrome?
Situs inversus
Dextrocardia
Primary ciliary dyskinesia (recurrent productive cough, purulent nasal discharge, chronic ear infections)
Who has chronic aspiration
Children with neurodisability
Incidence of cystic fibrosis
1 in 2500 live births
Carrier rate 1 in 25
Correlation between genotype and phenotype in CF
Weak for lung disease but stronger for GI disease
Indicates that environmental factors influence lung disease (passive smoking, social deprivation, microbial pathogens)
Pathogen usually causing infection in CF
Pseudomonas aeruginosa
Incidence of meconium ileus in infants with CF
10-20%
Other organ affected in CF
Pancreas - pancreatic enzyme deficiency leads to malabsorption
Also sweat glands - increased sodium and chloride in sweat
Presentation of CF if not picked up at heel-prick screening x3
Recurrent chest infections, poor growth and malabsorption
Examination (resp) in CF
Hyperinflation (air trapping), coarse inspiratory creps and/or expiratory wheeze
Established disease - clubbing
Disease in older CF children
DM due to pancreatic dysfunction
Diagnosis of CF
Sweat test
Cl 60-120 (10-40normal)
Stimulated by pilocarpine iontophoresis
Drugs in CF
Prophylactic antibiotics - usually flucloxacillin
Nebulised DNAse or hypertonic saline to decrease sputum viscosity
Macrolide antibiotic azithromycin - immunomodulatory not antibiotic action
Eventual treatment for CF lung disease
Lung transplant
Fortunately not needed in childhood
Usually 50% 10 year survival rate
Diet in CF
High calorie 150% of normal
Fat soluble vitamin supplements
Organ problems in older patients with CF
1/3 have evidence of liver disease - hepatomegaly or LFT abnormalities
Fertility in CF
Females normal
Males always infertile due to absent vas deferens (have sperm therefore can have kids with ICSI)
What is Guthrie test
Heel prick test for CF for all children
