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Paeds > Respiratory > Flashcards

Respiratory Flashcards

1
Q

RFs for transient early wheezing?

A

Maternal smoking

Prematurity

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2
Q

What are the causes of childhood wheeze?

A
  • 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
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3
Q

Features associated with asthma? Ie not early wheeze

A
  • 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
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4
Q

Ddx of asthma

A
  • Asthma
  • GORD
  • CF
  • Viral induced wheezing (= early transient wheeze)
  • Bronchiolitis
  • Croup
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5
Q

Clinical features of moderate asthma?

A
  • Marked pulsus paradoxus
  • O2>92%
  • PEFR >50% predicted or best value
  • No clinical features of severe
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6
Q

Clinical features of severe asthma?

A
  • 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
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7
Q

Clinical features of life-threatening asthma?

A
  • 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
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8
Q

Management of acute asthma?

A

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

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9
Q

Management of asthma in <5y?

A

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

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10
Q

Management of asthma 5-12y?

A

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

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11
Q

What pathogen is most common in bronchiolitis?

A

RSV

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12
Q

Clinical features of bronchiolitis? S+S

A
  • 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
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13
Q

Management of bronchiolitis?

A

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
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14
Q

Common pathogens for pneumonia by age?

A

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

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15
Q

S+S pneumonia?

A
  • 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
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16
Q

Ix for pneumonia?

A

CXR - yet can’t distinguish viral/bacterial

Nasal pharyngeal aspirate - viral identification

17
Q

Treatment of pneumonia?

A

O2, analgesia, IV fluids
Abx
- Neonated - broad spectrum IV
- Older - oral amoxicillin

18
Q

Treatment of pertussis?

A

Erythromycin

  • Only reduces sx if started in catarrhal phase
  • Treat close contacts also and ensure everyone vaccinated
19
Q

Treatment of TB?

A

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

20
Q

Diagnosis of CF?

A
  • Heel prick for immunoreactive trypsinogen used to screen

Confirmed by looking for exact CF mutation and sweat test - high Cl

21
Q

Clinical features of CF by age group?

A

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
22
Q

Management of CF?

A

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
23
Q

Clinical features of epiglottitis?

A

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
24
Q

What must not be done in epiglottitis?

A
  • Attempts to lie child down
  • Examine mouth with spatula
  • Perform lateral neck x-ray

–> Can precipitate total airway obstruction and death

25
Q

Management of epiglottitis?

A
  • 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
26
Q

Distinguish epiglottitis from croup

A

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)
27
Q

What pathogen causes epiglottitis?

A

HiB

28
Q

Pathogens of otitis media?

A

Viruses - RSV, rhinovirus

Bacteria - pneumococcus, HiB, moraxella catarrhalis

29
Q

Serious complications of otitis media?

A

Mastoiditis
Meningitis
Both rare

30
Q

Treatment of otitis media?

A

Usually resolves alone

  • Analgesia (regular not PRN better)
  • Abx (amoxicillin) can recude duration
31
Q

Common pathogens for tonsillitis?

A

Group A strep
EBV
–> 1/3 bacterial

32
Q

Management of tonsillitis?

A
  • 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
33
Q

Epidemiology of croup?

A

6m-6y
Most common in 2nd y of life
Commonest in Autumn

34
Q

Pathogen in croup?

A

Most common = parainfluenza

35
Q

S+S of croup?

A 
Barking cough
Harsh stridor
Hoarseness
Preceded by coryza + fever
Sx often start and are worse at night
36
Q

Management of croup?

A

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

37
Q

Management of choking child?

A
  • 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
38
Q

What is bacterial tracheitis?

Management?

A
  • 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
39
Q

Management of smoke inhalation?

A
  • 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

Paeds (15 decks)

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