Respiratory Flashcards
RFs for transient early wheezing?
Maternal smoking
Prematurity
What are the causes of childhood wheeze?
- Transient early wheezing
- Atopic asthma (IgE mediated)
- Non-atopic asthma
- Recurrent aspiration of feeds
- Inhaled foreign body
- CF
- Recurrent anaphylaxis in child with food allergies
- Congenital abnormality of lung, airway or heart
- Idiopathic
Features associated with asthma? Ie not early wheeze
- Sx worse at night and early morning
- Cough after exercise or early morning, disturbing sleep
- Sx that have a trigger i.e. pets, exercise, dust, cold air, emotions
- Interval symptoms ie sx b/w acute exacerbations
- Personal/family history of atopic disease
- Positive response to asthma therapy
Ddx of asthma
- Asthma
- GORD
- CF
- Viral induced wheezing (= early transient wheeze)
- Bronchiolitis
- Croup
Clinical features of moderate asthma?
- Marked pulsus paradoxus
- O2>92%
- PEFR >50% predicted or best value
- No clinical features of severe
Clinical features of severe asthma?
- Breathlessness interferes with talking
- O2 sats <92%
- Use of accessory neck muscles
- RR> 50/min age 2-5
- RR>30/min age >5
- HR>130/min age 2-5
- HR> 120/min age >5
- PEFR <50% predicted or best value
Clinical features of life-threatening asthma?
- Cyanosis, fatigue and drowsiness are all late signs
- Silent chest = emergency – child is about to arrest
- Poor respiratory effort
- Altered consciousness
- O2<92%
- PEFR<33% predicted/ best value
Management of acute asthma?
Moderate
– Short acting B2 agonist via spacer, 2-4 puffs, increasing by 2 puffs every 2 minutes to 10 puffs if required
– Consider oral prednisolone
– Reassess within 1h
Severe:
- Oxygen
- Give short acting B2 agonist 10 puffs via spacer or nebulizer
- Oral prednisolone or IV hydrocortisone should be given
- Nebulised ipratropium bromide if poor response
- Repeat bronchodilators every 20-30mins as needed
Life threatening:
– Oxygen
– Nebulised B2 agonist plus ipratropium bromide
– IV hydrocortisone
– The case discussed with a senior clinician and the PICU team
– Repeat bronchodilators every 20-30 minutes
Management of asthma in <5y?
Step 1 – Inhaled short acting B2 agonist as required
Step 2 – Add inhaled steroid 200-400mcg/day or leukotriene receptor antagonist if steroid cannot be used
Step 3 – Consider adding leukotriene receptor antagonist to inhaled steroid or visa versa
- In children under 2 consider moving to step 4
Step 4 – Refer to respiratory paediatrician
Management of asthma 5-12y?
Step 1 – Inhaled short acting B2 agonist as required
Step 2 – Add inhaled steroid 200-400mcg/day
- Start at dose appropriate to severity of disease
Step 3 – Add LABA and assess control
- If good then maintain
- Benefit from LABA but control still inadequate: continue and increase steroid to 400mcg/day
- No response: stop LABA and increase steroid to 400mcg/day, if this is still inadequate then trial leukotriene receptor antagonist or theophylline
Step 4 – Increased inhaled steroid to 800mcg/day
Step 5 – Use daily steroid tablet in lowest dose to give control whilst
maintaining inhaled steroid at 800mcg/day
- Also refer to respiratory paediatrician
What pathogen is most common in bronchiolitis?
RSV
Clinical features of bronchiolitis? S+S
- Coryzal sx precede dry cough and increasing breathlessness
- Feeding difficulty associated with dyspnoea often reason for admission
- Recurrent apnoea is a serious complication, esp in young infants
- Those born prem, with CLD, CF or congenital heart disease are most at risk of severe bronchiolitis
Characteristic clinical findings O/E include:
- Sharp dry cough
- Tachypnoea
- Subcostal and intercostal recessions
- Hyper-inflated chest (prominent sternum and liver displaced downwards)
- Fine end-inspiratory crackles
- High-pitched wheezes (expiratory>Inspiratory)
- Tachycardia
- Cyanosis or pallor
- Prolonged expiration
Management of bronchiolitis?
Humidified O2 through nasal cannula
Conc determined by sats
Fluids IV or NG if nec
Assisted ventilation (CPAP or nasal mask) if needed
Mist, abx, neb bronchodilators no benefit
Most recover within 2w
- 50% recurrence of cough/wheeze
- Occasional permanent lung damage
Common pathogens for pneumonia by age?
Newborns – organisms from mother’s genital tract:
- Group B strep
- Gram negative enterococci
Infants and young children:
- RSV = most common
- Strep pneumonia
- H.influenzae
- Bordetella pertussis and chlamydia trachomatis can also be a cause
- Infrequently staph aureus can be a cause and is very serious
Children over 5:
- Mycoplasma pneumonia
- Strep pneumonia
- Chlamydia pneumoniae
Suspect TB at all ages also
S+S pneumonia?
- Fever and difficulty breathing
- Usually preceded by URTI
- Cough, lethargy, poor feeding and an ‘unwell child’
- Chest, abdo/ neck pain –> pleural irritation- suggests bacterial
Signs:
- Tachypnoea, nasal flaring and chest indrawing
- End-inspiratory coarse crackles over affected area
- Classic signs of consolidation often absent in young children
- Decreased sats = indication for hospital admission
Ix for pneumonia?
CXR - yet can’t distinguish viral/bacterial
Nasal pharyngeal aspirate - viral identification
Treatment of pneumonia?
O2, analgesia, IV fluids
Abx
- Neonated - broad spectrum IV
- Older - oral amoxicillin
Treatment of pertussis?
Erythromycin
- Only reduces sx if started in catarrhal phase
- Treat close contacts also and ensure everyone vaccinated
Treatment of TB?
Quadruple therapy:
- Rifampicin
- Isoniazid
- Pyrazinamide
- Ethambutol
Reduced to rif and ison after 2m (sensitivities known)
Treatment for 6m, longer if complicated
If asymptomatic but mantoux positive –> treat wit 2 drugs for 3m
Diagnosis of CF?
- Heel prick for immunoreactive trypsinogen used to screen
Confirmed by looking for exact CF mutation and sweat test - high Cl
Clinical features of CF by age group?
Neonate:
- Diagnosed through newborn screening
Infancy:
- Meconium ileus in newborn period
- Prolonged neonatal jaundice
- FTT
- Recurrent chest infections
- Malabsorption, steatorrhoea
Young child:
- Bronchiectasis
- Rectal prolapse
- Nasal polyp
- Sinusitis
Older child and adolescent:
- ABPA
- DM
- Cirrhosis and portal hypertension
- Distal intestinal obstruction (DIOS, meconium ileus equivalent)
- Pneumothorax or recurrent haemoptysis
- Sterility in males
Management of CF?
Physio
- At least 2x/d
- To clear airway secretions
Medication
- Prophylactic abx (fluclox)
- Rescue abx
- Neb DNAase - decrease viscosity of saliva
Surgery
- Bilat lung transplant for end stage disease
Nutrition
- Oral enteric coated pancreatic replacement with all food
- High calorie diet - 150%
- Often overnight gastrostomy feeding to achieve this
- Fat sol vitamin supplements
Clinical features of epiglottitis?
Usually 1-9y
- Onset = v acute
- High fever in ill, toxic-looking child
- V painful throat - prevents speaking/swallowing - drool
- Soft inspiratory stridor
- Rapidly increasing respiratory difficulty over hours
- Sitting immobile, upright, with open mouth to optimise airway
- In contrast to viral croup cough minimal or absent
What must not be done in epiglottitis?
- Attempts to lie child down
- Examine mouth with spatula
- Perform lateral neck x-ray
–> Can precipitate total airway obstruction and death
Management of epiglottitis?
- Urgent hosp admission and treatment
- Senior anaesthetist, paediatrician and ENT surgeon summoned and treatment initiated
- Child intubated
- After airway secure abx and other treatment started
- Tube usually removed after 24h of abx and remaining course given over 3-5d
- Prophylaxis with rifampicin offered to close household contacts
Distinguish epiglottitis from croup
Epiglottitis:
- Quicker onset (over hours)
- No preceding coryza
- Absent/silent cough
- Not able to drink
- Drooling
- Looks clinically v unwell
- Fever >38.5
- Soft stridor (harsh in croup)
What pathogen causes epiglottitis?
HiB
Pathogens of otitis media?
Viruses - RSV, rhinovirus
Bacteria - pneumococcus, HiB, moraxella catarrhalis
Serious complications of otitis media?
Mastoiditis
Meningitis
Both rare
Treatment of otitis media?
Usually resolves alone
- Analgesia (regular not PRN better)
- Abx (amoxicillin) can recude duration
Common pathogens for tonsillitis?
Group A strep
EBV
–> 1/3 bacterial
Management of tonsillitis?
- Should cure itself
- If abx –> penicillin or erythromycin
- Avoid amoxicillin as may give rash if EBV
- Hospitalisation for IV fluids if unable to swallow
- Surgery if >5x in 1y
Epidemiology of croup?
6m-6y
Most common in 2nd y of life
Commonest in Autumn
Pathogen in croup?
Most common = parainfluenza
S+S of croup?
Barking cough Harsh stridor Hoarseness Preceded by coryza + fever Sx often start and are worse at night
Management of croup?
Mild
- Oral prednisolone
- Oral dexamethasone
- Neb steroids
- -> All shown to decrease duration and severity and reduce hospitalisation
Severe
- Neb epinephrine with O2 gives transient relief
Management of choking child?
- Assess severity then call for help
- If effective cough encourage coughing and continue to check for deterioration
- If cough ineffective give 5 back blows followed by 5 thrusts (chest for infant and abdo for >1 y) if conscious
- If unconscious airway, give 5 breaths and start CPR
What is bacterial tracheitis?
Management?
- Rare but dangerous condition v similar to croup with exception that child has high fever, appears toxic and has rapidly progressive airway obstruction with copious thick airway secretions
- Caused by infection with staph aureus
- Treatment = IV abx and intubation and ventilation if required
Management of smoke inhalation?
- Pt taken to safety and placed in fresh air
- Give high flow and humidified oxygen to breathe
- 100% oxygen helps remove CO from blood quickly and reduces any poisoning affect that it may have had
- CO = leading cause of cardiac arrest and death before pts reach hospital
- About 50% of patients will need intubation and PEEP to maintain airway
