Respiratory Flashcards
Define asthma
Chronic inflammatory disorder of airways associated with widespread airflow obstruction in response to stimuli
What are the most significant findings in a history for asthma?
Triad of Wheeze, Cough, Breathlessness
History of atopy, sx worse at night, FHx, trigger factors
What are the clinical findings for asthma?
Wheeze, cough, breathlessness, increased work of breathing, hyperexpanded chest
What are common signs of respiratory distress?
Nasal flaring, accessory muscle use, intercostal and subcostal recessions, grunting, tachypnoea
How does the acute treatment for mild, moderate, and severe asthma differ?
MILD
- inhaled salbutamol (<6=6 puffs, >6=12 puffs), review after 20 mins
MODERATE
- inhaled salbutamol (100mcg) 20 minutely x 3
- if poor response add ipratropium (atrovent) (20mcg) 20 minutely x 3 (<6=4 puffs, >6=8 puffs)
- oral pred 1-2mg/kg within 1 hour
SEVERE- maintain sats >94% - give O2
- continuous neb of salbutamol (5mg/mL)
- 20 minutely atrovent neb (250mcg or 500mcg)
- Oxygen >95%
- hydrocortisone IV 4mg/kg
*If not responding consider IV mag sulfate or aminophylline
- NETS
Explain how to manage asthma using puffer to parent
Using the 4x4x4 rule
- Use a spacer
- Give 4 puffs of reliever
- Take 4 breaths per 1 puff
- Wait 4 minutes
- If haven’t improved, give 4 more puffs
- Give 4 puffs every 4 minutes until the ambulance arrives
What are the defining features of Croup?
- <2yrs
- Sudden onset barking cough
- Inspiratory stridor
- Preceding URTI / coryza
- Worse at night
- “Steeple’s sign” on xray
- Predominately caused by parainfluenza virus
What are the defining features of Bronchiolitis?
- <12mo
- Coryzal symptoms
- Wet cough
- Increased WOB
- Can appear well
- “2 week illness”
- Creps, wheeze, hyperinflation on examination
- Predominately caused by RSV
What are the defining features of Epiglottitis?
- MEDICAL EMERGENCY!
- 3-7yrs
- Dysphagia and drooling
- Tripod position
- Acutely red epiglottis - “cherry red”
- Toxic fevers
- Most commonly caused by strep pyo, strep pneum, staph aureus
- *May need to intubate
What are the defining features of Whooping cough?
- Inspiratory whoop
- Caused by bordatella pertussis (bacteria)
- During coughing fits child may go blue and vomit
- Symptoms can persist for 3mo
- Vaccine available (DTP)
- Give erythromycin early! Decreases infectivity
Describe the pattern you would see on spirometry for a child with asthma
Obstructive pattern with scalloping expiratory flow volume loop
Reduced FEV1/FVC ratio
FEV1 improves with bronchodilator >12%
What is the mechanism of action of theophylline?
Phosphodiesterase inhibitor –> prevents cAMP activation –> bronchodilation
- also improves diaphragmatic contraction
How do you know when to send a kid home after an asthma attack?
- When clinically stable on 3 hourly bronchodilator
- Adequate oxygenation - >94% but assess if clinically well and has responded well to Rx
- Adequate oral intake
- Adequate parental education and ability to administer salbutamol via spacer
On discharge: - Continue oral pred 1mg/kg daily for 3 days
- Written action plan
- Observe inhaler technique
- See GP and/or paediatrician within 4-6 weeks
- Inform parent about available resources
What is the minimum amount of time a child needs to be observed for following an acute asthma attack?
3 hours after last dose
- If not able to last 3 hours between doses - admit
Describe the clinical difference between mild, moderate, and severe croup
*Minimal examination!
Mild: occasional barking cough, no stridor at rest, no distress, normal resp rate, no acc muscle use
Moderate: irritable, frequent cough, some stridor at rest, increased RR, acc muscle use
- give oral pred (1mg/kg) OR oral dex (0.15mg/kg)
- consider neb adrenaline (5mL / 5mg)
Severe: lethargic, frequent cough, severe stridor at rest, severe distress and marked retraction and acc muscle use
- give neb adrenaline (5mL / 5mg)
- IM dex (0.6mg/kg), oxygen, may require intubation
*Observe for 4hrs post adrenaline
*Consider discharge once stridor free at rest.
Describe the clinical difference between mild, moderate, and severe bronchiolitis
Mild: everything okay
Moderate: irritable, increased RR, tracheal tug, nasal flaring, retraction, brief apnoeas, 90-93%, reduced feeding
Severe: irritability + fatigue, marked increased RR, tracheal tug, nasal flaring, marked retraction, prolonged apnoeas, <90%
***unable to feed!
What are the common causative organisms of pneumonia in neonates, infants, children?
Neonates - GBS, E.coli
Infants - viruses (RSV, adeno), strep pneum, haem. influenzae and pertussis (I)
Children - strep pneum, haem. infl
What is the best antibiotic treatment for paediatric pneumonia?
Oral if tolerating or IV (depends on severity)
- Oral amoxycillin or IV benpen
- IV ceftriaxone
- Fluclox if severe illness
- Macrolide if suspect mycoplasma (erythro, azithro)
What illness gives a brassy cough?
Bacterial tracheitis
staph aureus
How do you deal with inhaled foreign body in the larynx / trachea?
Partial: place upright, arrange urgent removal
TOTAL:
1. Face down, 5 blows with open hand to interscapular region
2. Face up, 5 chest thrusts (like CPR)
3. Open mouth to see if cleared
4. Continue alternating until relieved
5. Positive pressure can push into a bronchus
6. Surgical airway last resort
How many puffs of ventolin (salbutamol) do you give to a 5 year old child in ED? 7 year old?
<6 years = 6 puffs
>6 years = 12 puffs
20 minutely x 3
How can you give steroids? How much?
Oral pred 1mg/kg
IV hydrocort 4-5mg/kg (adults 100-200mg)
IV methylpred 1mg/kg
What is the difference between infrequent episodic, frequent episodic and persistent asthma?
Infrequent episodic: attacks >6 weeks apart, normal lung function in between, asymptomatic between attacks, episodes are not severe
Frequent episodic: attacks <6 weeks apart, normal lung function in between, increasing symptoms between attacks, episodes are more severe
Persistent: symptoms most days, nocturnal symptoms each week, abnormal lung function in between, attacks are severe, multiple admissions
What is the first preventer you would start with new diagnosis of asthma in children?
LK inhibitors - Montelukast 5mg daily - assess response after 2-4 weeks - trial cromone as an alternative For severe symptoms of if inadequate response: Inhaled corticosteroid low dose - Beclometasone 100-200mcg - Budesonide 200-400mcg - Fluticasone 100-200mcg
Do you give steroids for bronchiolitis in a very young baby?
No
If a bit older and respond to ventolin, try steroids
What are the supportive treatment measures for bronchiolitis?
Oxygen, CPAP or intubate if necessary
Fluid/parenteral feeds
What are some common causes of stridor?
Foreign body Anaphylaxis Croup Laryngomalacia Tracheitis Epiglottitis
How do you treat croup?
Mild: give oral pred (1mg/kg) if tolerating or oral dex (0.15mg/kg)
Severe:
- signs of hypoxia or severe obstruction
- neb adrenaline (5mL), oral pred/ IM dex, oxygen, may require intubation
** Minimal handling - distress makes this worse, let them find their own position
How do you diagnose pneumonia?
Clinical diagnosis
- New onset cough, respiratory distress, fever, xray
What are the features of an atypical pneumonia?
Dry cough, more slow onset, headache, myalgias, abdo pain
When are children at greatest risk of pertussis?
< 6 months of age - immunisation response is not yet very good
Non-immunised children
How long are children with pertussis infective?
Just prior to and for 3 weeks after cough onset
What are the different phases of pertussis?
Catarrhal phase - cough/coryza for one week
Paroxysmal phase - coughing spells (with vomit/apnoea)
What are some differential diagnoses for neonatal respiratory distress?
Transient tachypnoea of newborn Hyaline membrane disease - RDS Infection - sepsis/pneumonia TOF Mec aspiration CHD Diaphragmatic hernia
What is the treatment for neonatal respiratory distress?
Oxygen
CPAP
Intubation
Trt for cause (e.g. ABx, surfactant for RDS)
What does hyaline membrane disease / neonatal respiratory distress syndrome look like on x-ray?
Low lung volumes, diffuse reticulogranular ground glass appearance with air bronchograms
- From alveolar atelectasis contrasting with aerated airways
What is hyaline membrane disease / respiratory distress syndrome?
Progressive respiratory failure after birth combined with characteristic CXR findings
- Common in preterm infants
- Presents at birth
Occurs due to deficiency of pulmonary surfactant from type 2 pneumocytes –> increased surface tension inside alveoli –> alveoli collapse –> atelectasis –> respiratory distress –> type 2 respiratory failure
What is transient tachypnoea of the newborn? How does it present on x-ray?
Most common cause of respiratory distress in neonates
- Period of rapid breathing (>30-60 bpm)
- Likely due to amniotic fluid remaining in the lungs after birth - Delayed absorption of fetal lung fluid from the pulmonary lymphatic system
- Usually resolves over 24-48hours
- Treatment is supportive and may include supplementaloxygenandantibiotics
- CXR: hyperinflation + prominent pulmonary vascular markings, flattening of thediaphragm, fluid in the horizontal fissure of the right lung
What are you thinking if there is respiratory distress and failure to pass NGT?
TOF
Oesophageal atresia
Diaphragmatic hernia
What are the common causes of acute otitis media?
Viral
Bacterial: strep pneumoniae, Hib, moraxella catarrhalis
What are the management options for acute otitis media? What period of time do you expect for recovery?
AOM is usually self-limiting, spontaneously resolves
Treatment goals: resolve infection, eliminate fever, maintain hearing, prevent reoccurrence, prevent complications
> 6mo
- Unilateral, non-discharging, well
Rx: Panadol and symptomatic measures, review 2 days
*Should start to feel better within 48 hours, resolve by 72hours
Antibiotics: amoxycillin 30mg/kg BD
Indications for antibiotics:
- Bilateral
- Discharge
- Systemically unwell (fever >39, vomiting, lethargy)
- ATSI
- <6mo
- No improvement
What are some complications of acute otitis media?
Middle ear effusion
Acute mastoiditis
Chronic otitis media
Persistent otitis media with effusion (glue ear)
How does the tympanic membrane appear during acute otitis media?
Red
?pus
Loss of light reflex
Effusion (bulging, no movement on pneumoatic otoscope, air-fluid level behind TM, perforation with otorrhoea)
What is the definition of chronic suppurative otitis media (CSOM)?
Middle ear infection + perforation + discharge for >6weeks after course of antibiotics
What is a cholesteatoma?
Accumulation of squamous epithelium in the middle ear –> keratinised mass –> local destruction –> mastoid / facial nerve / vertigo
Appears as white flakes
Requires surgical management
What is the management for chronic suppurative otitis media?
When infection and perforation and discharge >6 weeks
- Dry aural toilet with tissue spear until dry
- Topical ciprofloxacin 0.3% ear drops 5 drops, 12-hrly until the middle ear has been free of discharge for 3/7
What is persistent otitis media with effusion (glue ear)? How is it different to chronic suppurative otitis media?
Persistent OME (glue ear) = middle ear effusion >3mo CSOM = middle ear infx + perforation + discharge for >=6wks
How does persistent otitis media with effusion present?
Opaque TM (loss of lucency)
Visible grey-white or blue fluid
Immobile TM with dilated blood vessels on pneumatoscopy
No acute inflammation
Hearing loss / performing poorly at school
When is referral to ENT indicated?
Effusion lasting <3mo associated with speech delay or educational handicap
Effusion lasting >3 months and audiometry that shows bilateral hearing loss
structural damage to the tympanic membrane (significant retraction, cholesteatoma)
What are the indications for antibiotics in AOM?
Indications for antibiotics:
- Bilateral
- Discharge
- Systemically unwell (fever >39, vomiting, lethargy)
- ATSI
- <6mo without systemic features
- If symptoms persist >2days or worsen (Ear pain >72hrs)
What organisms commonly cause otitis externa? What are the common clinical features?
Bacterial: Staph, Pseudomonas
Fungal
Seborrhoic dermatitis, allergic/rhinitic dermatitis
Presentation: ear pain, itch, discharge
Otoscopy: red, swollen, or eczematous canal
What is the initial management for otitis externa?
Aural toilet
Topical drops - otodex/sofradex (combined antibiotic with steroid - dexamethasone, framycetin and gramicidin)
Pain management
Oral antibiotics if infection is spreading, need to culture
Describe the differences between mild, moderate, and severe persistent asthma
MILD: FEV1 >80% predicted, day symptoms >1/week, night symptoms >2/month
MODERATE: FEV1 60-80% predicted, day symptoms daily, night symptoms >1/week, symptoms sometimes restrict activity/sleep
SEVERE: FEV1 <60% predicted, day symptoms continual, night symptoms frequent, flare ups frequency, symptoms often restrict sleep/activity
What is the dose of inhaled corticosteroids for children?
Beclometasone: 100-400 (max)
Budenoside: 200-800 (max)
Fluticasone: 100-500 (max)
At what age should a regular preventer be considered for asthma? What preventer is recommended?
Age 2 if very severe symptoms: trial ICS low dose and review in 4 weeks
Age >2: regular montelukast 4mg - review in 2-4 weeks
- if symptoms do not resolve consider low dose ICS
Age >6 and mod/severe persistent asthma: trial ICS and review in 4 weeks
**Children aged 1-2 years can consider sodium cromoglycate TDS for review 2-4weeks
How often should you review a child with asthma after starting medication?
2-4 weeks for montelukast
4 weeks for ICS
Describe the step up management of asthma in children
SABA for everyone
then
Montelukast 4-5mg OR ICS low dose (OR cromone)
then
ICS high dose OR ICS low dose + montelukast OR ICS/LABA combo (low dose)
then
Refer
What are the differences in presentation for mild, moderate, and severe acute asthma?
MILD: >94%, talking, no accessory muscle use, alert
MOD: 90-94%, mild tachy, phrases, mild accessory muscle use, engaged
SEV: <90%, tachy, unable to speak, severe accessory muscle use, altered LOC, cyanosis
How do you manage exercise-induced asthma?
Salbutamol 15mins beforehand
Describe the acute first aid for anaphylaxis
- Lay flat or sit up if able and prevent further exposure allergen
- IM adrenaline into lateral thigh:
• Child <5 yrs= AI: 150mcg (or by weight)
• Child >5 yrs / Adult= AI: 300mcg (or 500mcg / 0.5mg in hospital) - Call an ambulance
Monitor ABCs! - Oxygen >94%
- Obtain IV access and give resusc fluids
- Repeat every 5 mins as needed
*If multiple doses are required for a severe reaction (e.g. 2-3 doses), consider adrenaline infusion (1mg - 1mL diluted into in 1L bag)
*Give asthma reliever medications as required for respiratory distress with wheezing
*Observe patient for at least 4 hours after last dose of adrenaline
*Antihistamines may be given for symptomatic relief of pruritus
What are the different nebs you can give for severe asthma?
Continuous neb salbutamol = 5mg/mL
Neb atrovent = 250mcg for <6yrs or 500mcg for >6yrs
When can a child with croup be discharged?
Four hours post nebulised adrenaline (if given) and/or half an hour post oral steroid, and stridor free at rest
How do you assess a child with croup? Other differentials?
Minimal examination! Do not look in throat
- barking cough, worse at night, peak night 2-3
- inspiratory stridor
- may have associated widespread wheeze
- increased work of breathing
- may have fever, but no signs of toxicity
DDx: Inhaled foreign body, Epiglottitis, Bacterial tracheitis
When do you consider magnesium sulfate treatment for an asthma attack?
Intravenous magnesium sulfate can be given in addition to bronchodilators and
corticosteroids in children presenting with moderate – severe / life-threatening asthma
not responding to inhaled bronchodilators
NOT recommended <2yrs
How do you diagnose anaphylaxis?
Clinical diagnosis!
- Should consider when 2 or more body systems are affected
- clear history of exposure shortly followed by the multisystem signs and symptoms
- Consider serum tryptase levels: elevated serum tryptase level (<3 hrs of onset of symptoms) followed by a normal level at least 24 hours after all the symptoms have settled supports the diagnosis of anaphylaxis
- NOT specific though!
How does adrenaline relieve symptoms of anaphylaxis?
Decreases mediator (e.g. histamine and leukotrienes) release from mast cells and basophils
- Alpha 1 adrenergic agonist effects: Vasoconstriction, Increased peripheral vascular resistance, Reduce mucosal oedema
- Beta-1 adrenergic agonist effects: Increased inotropy, Increased chronotropy
- Beta-2 adrenergic agonist effects: Bronchodilation
What is a ‘delayed’ anaphylactic reaction?
Recurrence of symptoms after the resolution of the initial presentation even though the individual is not re-exposed to the allergen
- Due to the production of cytokines by mast cells - inflammatory rxn - recurrence of symptoms which begins 2-4 hours after the immediate rxn but this reaction peaks approximately 24 hours later and gradually subsides
- delayed reactions can occur up to 72 hours later
- Best to keep em in overnight and administer corticosteroids to reduce delayed rxn
What is the management for neonatal respiratory distress syndrome / HMD?
- Assisted ventilation - nasal CPAP to provide PEEP
- Caffeine - enhance CPAP, increase respiratory drive for infants <28 weeks
* Monitor ABGs and need for intubation - Exogenous surfactant (endotracheal or aerosolised administration) - reduce mortality and morbidity in preterm infants, most effective given in first 30-60mins of life
- Supportive care: thermoregulation, fluid balance and perfusion, nutrition
What preventative measures can be taken antenatally to prevent neonatal respiratory distress syndrome?
Antenatal corticosteroid therapy should be administered to all pregnant women <34 weeks who are at increased risk of preterm delivery within the next 7 days
Compare and contrast neonatal respiratory distress syndrome and transient tachypnoea of newborn
NRDS:
- main risk factor prematurity
- usually present with respiratory distress shortly after birth which usually worsens over the next few days
- CXR: diffuse ground glass lungs with low volumes and a bell-shaped thorax
TTN:
- main risk factor caesarean section
- usually presents with tachypnoea shortly after birth and often fully resolves within the first day of life
- CXR: heart failure type pattern (e.g. interstitial oedema and pqleural effusions), normal size heart, resolves
Describe the APGAR score
A - Appearance (pink all over, blue limbs, blue all over)
P - Pulse rate (>100, <100, nil)
G - Grimace/irritability (cough, grimace, nil)
A - Activity (active, limbs flexed, flaccid)
R - Resp (strong/cyring, weak, nil)
>7 is normal
