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PAEDIATRICS > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Define asthma

A

Chronic inflammatory disorder of airways associated with widespread airflow obstruction in response to stimuli

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2
Q

What are the most significant findings in a history for asthma?

A

Triad of Wheeze, Cough, Breathlessness

History of atopy, sx worse at night, FHx, trigger factors

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3
Q

What are the clinical findings for asthma?

A

Wheeze, cough, breathlessness, increased work of breathing, hyperexpanded chest

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4
Q

What are common signs of respiratory distress?

A

Nasal flaring, accessory muscle use, intercostal and subcostal recessions, grunting, tachypnoea

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5
Q

How does the acute treatment for mild, moderate, and severe asthma differ?

A

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

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6
Q

Explain how to manage asthma using puffer to parent

A

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
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7
Q

What are the defining features of Croup?

A
  • <2yrs
  • Sudden onset barking cough
  • Inspiratory stridor
  • Preceding URTI / coryza
  • Worse at night
  • “Steeple’s sign” on xray
  • Predominately caused by parainfluenza virus
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8
Q

What are the defining features of Bronchiolitis?

A
  • <12mo
  • Coryzal symptoms
  • Wet cough
  • Increased WOB
  • Can appear well
  • “2 week illness”
  • Creps, wheeze, hyperinflation on examination
  • Predominately caused by RSV
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9
Q

What are the defining features of Epiglottitis?

A
  • 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
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10
Q

What are the defining features of Whooping cough?

A
  • 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
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11
Q

Describe the pattern you would see on spirometry for a child with asthma

A

Obstructive pattern with scalloping expiratory flow volume loop
Reduced FEV1/FVC ratio
FEV1 improves with bronchodilator >12%

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12
Q

What is the mechanism of action of theophylline?

A

Phosphodiesterase inhibitor –> prevents cAMP activation –> bronchodilation
- also improves diaphragmatic contraction

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13
Q

How do you know when to send a kid home after an asthma attack?

A
  • 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
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14
Q

What is the minimum amount of time a child needs to be observed for following an acute asthma attack?

A

3 hours after last dose

- If not able to last 3 hours between doses - admit

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15
Q

Describe the clinical difference between mild, moderate, and severe croup

A

*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.

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16
Q

Describe the clinical difference between mild, moderate, and severe bronchiolitis

A

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!

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17
Q

What are the common causative organisms of pneumonia in neonates, infants, children?

A

Neonates - GBS, E.coli
Infants - viruses (RSV, adeno), strep pneum, haem. influenzae and pertussis (I)
Children - strep pneum, haem. infl

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18
Q

What is the best antibiotic treatment for paediatric pneumonia?

A

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)
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19
Q

What illness gives a brassy cough?

A

Bacterial tracheitis

staph aureus

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20
Q

How do you deal with inhaled foreign body in the larynx / trachea?

A

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

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21
Q

How many puffs of ventolin (salbutamol) do you give to a 5 year old child in ED? 7 year old?

A

<6 years = 6 puffs
>6 years = 12 puffs
20 minutely x 3

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22
Q

How can you give steroids? How much?

A

Oral pred 1mg/kg
IV hydrocort 4-5mg/kg (adults 100-200mg)
IV methylpred 1mg/kg

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23
Q

What is the difference between infrequent episodic, frequent episodic and persistent asthma?

A

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

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24
Q

What is the first preventer you would start with new diagnosis of asthma in children?

A 
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
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25
Q

Do you give steroids for bronchiolitis in a very young baby?

A

No

If a bit older and respond to ventolin, try steroids

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26
Q

What are the supportive treatment measures for bronchiolitis?

A

Oxygen, CPAP or intubate if necessary

Fluid/parenteral feeds

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27
Q

What are some common causes of stridor?

A 
Foreign body
Anaphylaxis
Croup
Laryngomalacia
Tracheitis
Epiglottitis
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28
Q

How do you treat croup?

A

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

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29
Q

How do you diagnose pneumonia?

A

Clinical diagnosis

- New onset cough, respiratory distress, fever, xray

30
Q

What are the features of an atypical pneumonia?

A

Dry cough, more slow onset, headache, myalgias, abdo pain

31
Q

When are children at greatest risk of pertussis?

A

< 6 months of age - immunisation response is not yet very good
Non-immunised children

32
Q

How long are children with pertussis infective?

A

Just prior to and for 3 weeks after cough onset

33
Q

What are the different phases of pertussis?

A

Catarrhal phase - cough/coryza for one week

Paroxysmal phase - coughing spells (with vomit/apnoea)

34
Q

What are some differential diagnoses for neonatal respiratory distress?

A 
Transient tachypnoea of newborn
Hyaline membrane disease - RDS
Infection - sepsis/pneumonia
TOF
Mec aspiration
CHD
Diaphragmatic hernia
35
Q

What is the treatment for neonatal respiratory distress?

A

Oxygen
CPAP
Intubation
Trt for cause (e.g. ABx, surfactant for RDS)

36
Q

What does hyaline membrane disease / neonatal respiratory distress syndrome look like on x-ray?

A

Low lung volumes, diffuse reticulogranular ground glass appearance with air bronchograms
- From alveolar atelectasis contrasting with aerated airways

37
Q

What is hyaline membrane disease / respiratory distress syndrome?

A

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

38
Q

What is transient tachypnoea of the newborn? How does it present on x-ray?

A

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
39
Q

What are you thinking if there is respiratory distress and failure to pass NGT?

A

TOF
Oesophageal atresia
Diaphragmatic hernia

40
Q

What are the common causes of acute otitis media?

A

Viral

Bacterial: strep pneumoniae, Hib, moraxella catarrhalis

41
Q

What are the management options for acute otitis media? What period of time do you expect for recovery?

A

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

42
Q

What are some complications of acute otitis media?

A

Middle ear effusion
Acute mastoiditis
Chronic otitis media
Persistent otitis media with effusion (glue ear)

43
Q

How does the tympanic membrane appear during acute otitis media?

A

Red
?pus
Loss of light reflex
Effusion (bulging, no movement on pneumoatic otoscope, air-fluid level behind TM, perforation with otorrhoea)

44
Q

What is the definition of chronic suppurative otitis media (CSOM)?

A

Middle ear infection + perforation + discharge for >6weeks after course of antibiotics

45
Q

What is a cholesteatoma?

A

Accumulation of squamous epithelium in the middle ear –> keratinised mass –> local destruction –> mastoid / facial nerve / vertigo
Appears as white flakes
Requires surgical management

46
Q

What is the management for chronic suppurative otitis media?

A

When infection and perforation and discharge >6 weeks

  1. Dry aural toilet with tissue spear until dry
  2. Topical ciprofloxacin 0.3% ear drops 5 drops, 12-hrly until the middle ear has been free of discharge for 3/7
47
Q

What is persistent otitis media with effusion (glue ear)? How is it different to chronic suppurative otitis media?

A 
Persistent OME (glue ear) = middle ear effusion >3mo
CSOM = middle ear infx + perforation + discharge for >=6wks
48
Q

How does persistent otitis media with effusion present?

A

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

49
Q

When is referral to ENT indicated?

A

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)

50
Q

What are the indications for antibiotics in AOM?

A

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)
51
Q

What organisms commonly cause otitis externa? What are the common clinical features?

A

Bacterial: Staph, Pseudomonas
Fungal
Seborrhoic dermatitis, allergic/rhinitic dermatitis

Presentation: ear pain, itch, discharge
Otoscopy: red, swollen, or eczematous canal

52
Q

What is the initial management for otitis externa?

A

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

53
Q

Describe the differences between mild, moderate, and severe persistent asthma

A

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

54
Q

What is the dose of inhaled corticosteroids for children?

A

Beclometasone: 100-400 (max)
Budenoside: 200-800 (max)
Fluticasone: 100-500 (max)

55
Q

At what age should a regular preventer be considered for asthma? What preventer is recommended?

A

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

56
Q

How often should you review a child with asthma after starting medication?

A

2-4 weeks for montelukast

4 weeks for ICS

57
Q

Describe the step up management of asthma in children

A

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

58
Q

What are the differences in presentation for mild, moderate, and severe acute asthma?

A

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

59
Q

How do you manage exercise-induced asthma?

A

Salbutamol 15mins beforehand

60
Q

Describe the acute first aid for anaphylaxis

A
  1. Lay flat or sit up if able and prevent further exposure allergen
  2. 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)
  3. Call an ambulance
    Monitor ABCs!
  4. Oxygen >94%
  5. Obtain IV access and give resusc fluids
  6. 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
61
Q

What are the different nebs you can give for severe asthma?

A

Continuous neb salbutamol = 5mg/mL

Neb atrovent = 250mcg for <6yrs or 500mcg for >6yrs

62
Q

When can a child with croup be discharged?

A

Four hours post nebulised adrenaline (if given) and/or half an hour post oral steroid, and stridor free at rest

63
Q

How do you assess a child with croup? Other differentials?

A

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

64
Q

When do you consider magnesium sulfate treatment for an asthma attack?

A

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

65
Q

How do you diagnose anaphylaxis?

A

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!
66
Q

How does adrenaline relieve symptoms of anaphylaxis?

A

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
67
Q

What is a ‘delayed’ anaphylactic reaction?

A

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
68
Q

What is the management for neonatal respiratory distress syndrome / HMD?

A
  1. Assisted ventilation - nasal CPAP to provide PEEP
  2. Caffeine - enhance CPAP, increase respiratory drive for infants <28 weeks
    * Monitor ABGs and need for intubation
  3. Exogenous surfactant (endotracheal or aerosolised administration) - reduce mortality and morbidity in preterm infants, most effective given in first 30-60mins of life
  4. Supportive care: thermoregulation, fluid balance and perfusion, nutrition
69
Q

What preventative measures can be taken antenatally to prevent neonatal respiratory distress syndrome?

A

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

70
Q

Compare and contrast neonatal respiratory distress syndrome and transient tachypnoea of newborn

A

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
71
Q

Describe the APGAR score

A

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

PAEDIATRICS (9 decks)

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