Respiratory Flashcards
What are apnoeic events?
Pauses in breathing > 10 seconds or shorter if breathing associated with cyanosis, pallor, poor tone or bradycardia
Periodic respiration normal but apnoea is never normal
What are DDx for apnoea?
Resp infections - RSV, whopping cough UAO Sepsis Acidosis, electrolytes Central Cardiac, anaemia
What are the clinical features of asthma?
Wheeze - widespread
Cough (worse at night)
Tight chest, SOB
Symptoms worse early in the morning or at night
May be related to specific triggers - exercise, medications, allergens, cold weather
Hx of atopy (eczema, hayfever, food allergy)
What are the diagnostic considerations/issues for asthma in children?
Spirometry not feasible until ~5 years, therefore difficult to diagnose in children <5
Typically don’t diagnose asthma <2 years, more likely bronchiolitis or wheeze disorder - this is because difficult to diagnose clinically, no spirometry and may not go on to actually develop asthma
In children >5-6yr how can the severity of asthma be determined?
Mild - FEV1>80, limited day and night symptoms
Moderate - FEV1 60-80, more frequency day & night symptoms, limit activity or affect sleep
Severe - FEV1 <60 - frequent night symptoms, continuous day time, regular flare us and impacts sleep and activity
What are the considerations of spirometry in diagnosis of childhood asthma?
May be normal in some children with asthma, esp. if asymptomatic at the time
FEV1 may be normal - may see an increase in FEV1 (>12% from baseline) after bronchodilator administration (suggestive of diagnosis)
Can’t be performed <5 years
How can asthma be classified in children?
Infrequent intermittent - flare ups >6weeks apart, well between
Frequent intermittent - flare ups <6weeks apart
Persistent - mild, moderate, severe
What are the age considerations for effective use of bronchodilators and steroids in acute asthma?
Bronchospasm may not be due to reversible cause and may not have developed an effective smooth muscle response in preschool age children
Bronchodilators - not effective <6 months and typically not effective until at least >12 months
Steroids - not effective in preschool age. If life-threatening or previous ICU admission may administer anyway but otherwise not routine in this age group
What is the management for acute asthma?
- Bronchodilator via spacer +/- mask or O2 nebuliser
- O2 if sats <92%, titrate to 95%
- SABA bursts every 20minutes for first hour
- 6 puffs if <6 years, 12 puffs if >6 years - Assessment of severity and continuous re-assessment for effectiveness of bronchodilator therapy
- Arrange for immediate ICU transfer if severe
- If not responsive add:
1 = ipratropium - every 20 minutes for 1 hour only
2 = oral prednisolone 1mg/kg or IV methylpred - within the first hour
3 = aminophylline
4 = IV mag sulphate - Ventilatory support - CPAP, BiPAP or intubation
- Consider early intubation if required
What Ix are required in acute asthma?
Generally none - clinical assessment of severity and management accordingly
ABG rarely as distressing - if in ICU may perform
CXR also rarely required
What Ix can be performed in chronic asthma/assessment of asthma?
Spirometry >5yrs
Bronchial provocation challenge if diagnosis unclear and want to exclude asthma
Allergy testing - can be helpful particularly if recurrent wheezing which may be associated with triggers
CXR not routine - only if unusual respiratory symptoms
What key features on history should be elicited for child presenting for ongoing asthma management/new diagnosis?
Diagnosis
- who, how and what symptoms/situation lead to diagnosis
- When they have asthma, what symptoms do they get? Do they have nocturnal symptoms? Worse at night/early morning?
- What are the triggers?
- Is it perienneal or seasonal based?
- Do they have other allergies/eczema?
Management
- Do they use a preventer and or/reliever? what?
- How they use? i.e. with spacer?
- How often reviewed and by who?
- Compliance of medications
Control
- How often do they get symptoms?
- Do they have symptoms when well?
- How often to they use reliever, how many puffs?
- Do they ever need oral steroids?
- Immunisations - yearly flu?
Complications
- Hospitalisation, ICU or respiratory support?
- Impact of asthma on lifestyle and lifestyle on asthma (restrict activity?)
- Recurrent chest infections?
Other
- FHx asthma, atopy
- smoking and passive smoke exposure
- do they have an asthma plan?
What are the key features to address when counselling on an asthma management plan?
- Brief asthma history - symptoms, frequency, management and its effectiveness
- Determine if they have had one before, if they know what it is? Explain why it is important and that it needs to be accessible to all people involved in care of child
- Explain what it is - written information on how to manage asthma when child well, when they are unwell and when they have a flare up of asthma
- Discuss asthma triggers and avoidance, immunisations and healthy lifestyle for asthma management
- If on preventer discuss preventer dosage and frequency, how to use with spacer and how preventer works
- Advise on when to use reliever (what symptoms, if sick) and how to use, discuss steroid use
- Advise on recognition of worsening or severe symptoms and when to call for help
- Advise first aid management of asthma while waiting for help
- Advise should have review and review of plan every 6/12
What are the key components on educating on use of a spacer?
- Prime new spacer by firing several actuations before use
- Ensure puffer medication in date
- Shake puffer and connect end of puffer into spacer and fire one actuation
- Ensuring a tight seal around spacer, take 4 normal breathes per puff
- Shake puffer and replace into spacer before each puff
- If preventer medication use as many puffs as recommended
- If acute asthma, give 4 x 1 puff/4 breaths and wait 4 minutes. If no or inadequate response repeat 4x 1 puff/4 breathes. If still no improvement after 4 minutes call an ambulance
- Rinse mouth after steroid use to prevent oral thrush
- After using spacer, wipe out with dry clothe, do not wash (removes static forces which are required for effectiveness)
What are the preventer medication options and when are they considered?
No preventers <1
Consider in 1-2 yrs if asthma is persistent type
Consider in 2+ years if frequent intermittent or persistent type
1st line = low dose inhaled corticosteroid or montelukast
Sodium cromoglycate may be tried in 1-2 yrs
Trial treatment for 2-4 weeks and reassess to determine if effective
What is bronchiolitis?
Inflammation of the small airways due to viral infection in children <12 months
Most commonly caused by RSV
How many URTIs does the average child have a year and what are risk factors?
4-12/year
Passive smoke
Exposure to young children
What are the most common causes of AOM?
Viral - 25%
S. pneumoniae - 35%
What are the clinical features of AOM?
Tugging at ear/ear pain Ear discharge Fever - usually mild and generally systemically well Irritability N+V Associated URTI signs if viral cause Poorly defined middle ear landmarks Dull and opaque TM +/- bulge (no cone of light)
What is the management of AOM & indications for antibiotics?
Supportive - rest, fluids, simple analgesia
Consider lignocaine drops if severe pain
Antibiotics not indicated unless represent 24-48hrs without improvement in symptoms - typically only reduces pain by <24 hours in only 5% children
Amoxicillin
If very unwell exclude other serious cause of fever
What are the possible consequences and Rx options for OM with effusion or recurrent OM?
Prolonged course of amoxicillin Tympanostomy tube (gromets)
What is the most important bacterial cause of acute sore throat?
S. pyogenes –> Acute rheumatic fever, qunisy
HIB –> epiglotitis
What are the clinical indicators of viral vs. bacterial cause of acute sore throat?
Viral
- generalised LAD
- splenomegaly - EBV
- amoxicillin induced rash - EBV
- < 4 years age
- Cough, coryza
- Red throat but not oedematous
Bacterial
- tender cervical LAD
- generalised rash
- Unilateral symptoms (can be bilateral)
- red and swollen tonsils - may have discharge but not specific for bacterial cause
- > 4 years
- Risk group - ATSI, immunocompromised, remote/rural area
What is the management for acute sore throat?
Supportive - rest, fluids, analgesia
- Can consider corticosteroids if severe pain unresponsive to simple analgesia
If suggestive of bacterial infection (cervical LAD, swollen tonsils, rash, no coryza/cough, >4 years), immunocompromised or ATSI commence antibiotics
- Amoxicillin
- Roxithromycin if penicillin allergy
Throat swab - MCS for S. pyogenes - if negative cease antibiotics
If signs of upper airway obstruction - admission and ICU referral
What are the causes and epidemiological features of bronchiolitis?
Viral - most commonly RSV
Inflammation of the LRT
Occurs in <12 years - between 1-2y overlap with asthma
Peaks at 6 months age
Higher risk if - premature, chronic lung disease of prematurity, passive smoking, immunocompromised, maternal smoking in pregnancy
What are the clinical features of bronchiolitis?
SOB, respiratory distress (tracheal tug, subcostal and intercostal recession, nasal flaring), tachypnoea, apnoea (esp. if <6mths)
Reduced O2 sats
Widespread, expiratory wheeze
Widespread, fine, inspiratory crackles
Cough, fever, poor feeding, irritability
What is the natural hx of bronchiolitis?
Self-limiting ~7-10 days but cough can persist for weeks after
SOB and symptoms increase over 2-3 days and peak and then gradually subside
What are the complications of bronchiolitis?
SIADH
Apnoea (esp. <6 mths)
Dehydration
What are CXR features of bronchiolitis?
Patchy consolidation and areas of collapse
Hyperinflation
Peribronchial thickening
What is the Rx of bronchiolitis?
Admit if moderate-severe disease and often if <6mths
Supportive
- Simple analgesia
- Rest
- Fluids - NGT vs. IV - check Na and monitor if IV (SIADH)
- O2 if sats <92% - high flow as provides some ventilatory support (positive end expiratory pressure)
- CPAP or ventilation if required
No antibiotics (viral) or steroids (not effective in preschool age group)
What are the main differences between bronchiolitis & asthma?
Both associated with widespread expiratory wheeze
Bronchiolitis associated with fine inspiratory crackles
Age difference - bronchiolitis <12m, overlap between 1-2y but typically need to be >2y with recurrent attacks to diagnose asthma
Bronchiolitis associated with cough and coryza
What are the most common causes of pneumonia?
In young children
- 1 = viral
- 2 = s.pneumonia
- HiB, S. aureus
In >5 years
- 1 = mycoplasma
- As per young children
What are the clinical features of pneumonia?
Fever, tachypnoea, irritability, poor feeding, N+V (mucus)
Epigastric pain if lower lobar pneumonia
May not have many/any clinical respiratory findings - especially in young children - low index of suspicion for CXR
What Ix in pneumonia?
CXR - if lobar changes more likely S. pneumoniae
U&E - Na for SIADH
What is the management of pneumonia?
If mild and outpatient management - amoxicillin or roxithromycin (if suspect mycoplasma)
If very unwell or <3mths admit
Empiric antibiotics
-IV benzypencillin + gentamycin (if <3 mths)
- Add flucloxacillin if suspect S. aurues
- Roxithromycin 10-day course if mycoplasma
What is croup and its cause?
Viral inflammation of upper airways
Parainfluenza
What are the risk factors for croup?
Pre-existing airways narrowing
Previous hx of severe croup
What are the epidemiological features for croup?
Uncommon <6mths and rare <3m
Most common cause of acute stridor
What are DDx for croup?
Stridor/UAO
- Inhalation of foreign body
- Retropharyngeal abscess
- Epiglotitis
- Anaphylaxis
What are the clinical features of croup?
Barking, dry cough Fever, coryzal prodrome Stridor and respiratory distress Hoarse voice \+/- Widespread wheeze
What is the management of croup?
Minimal handling, no swabs or ENT examination - can exacerbate obstruction and cause further distress which also exacerbates
CXR - not usually indicated but if suspect epiglotitis
Mild-Moderate - generally outpatient Rx with prednisolone and supportive management
If severe - admission + nebulised adrenalin + IV dexamethasone
What is the cause of whooping cough and vaccine features?
Bordatella pertusis
Incomplete natural immunity
Vaccination - acellular component vaccination, lasts ~5-10 years
Receive vaccination at 2,4 and 6 months and 4 years
Recommended to pregnant women in 3rd trimester and all grandparents of young children
What is the natural history of whooping cough?
Incubation period ~7-10 days
2 phases - prodromal and paroxysmal
- prodromal - lasts ~1 week, cough and coryza
- Paroxysmal phase - cough becomes pronounced, have paroxysmal coughing fits which have characteristic whoop
Infectious for 3 weeks
What is the presentation and possible complications of whooping cough?
Prodromal coryza
Paroxysmal whooping coughing fits
Coughing fits often terminated by vomiting
Usually well between cough fits with no clinical signs
Fever is uncommon
Apnoea (common, especially in young infants), severe pneumonia, encephalopathy (fatal) Subconjuctival haemorrphages (coughing fits)
What is the Ix and Rx?
Nasopharyngeal aspirate - confirm diagnosis (Ab or culture)
Serology unreliable
Admit if <6mths
Supportive mangement
Antibiotics (macrolide) if within the prodromal phase will reduce period of infectivity (more public health/infection control benefit)
What are the contact precautions for whooping cough?
Avoid contacts for 5 days after antibiotics or 3 weeks of illness if no Rx
Can have vaccinations during illness
What are important features to ascertain on history for child presenting with URTI/Respiratory symptoms?
- Ear symptoms
- Nasal symptoms
- Sinuses - pain, pressure, post-nasal drip
- Throat - red, swollen, sore
- Cough and voice - characteristic cough, productive cough, hoarse voice, hot potato voice, lost voice
- Lumps and bumps - LAD, neck swelling
- Breathing - SOB, wheeze, stridor, apnoeas
- Feeding, irritability, wet nappies, vomiting (mucus)
- Rashes
- PHx - asthma, allergy, prematurity, other lung disease or chronic disease/immunocompromised
- Risk factors - maternal smoking in pregnancy, passive smoking exposure, sick contacts
- Vaccinations
