Respiratory Flashcards
What is the incidence of asthma in children?
Why is Dx difficult?
Affects 15-20% children
Approx 50% all children wheezy unto 3y/o
What are the 2 types of wheezing and how are they different?
Transient early:
Grow out of + due to resp infection
Due to inflamm/narrowing of small airway
RF - mum smoking
Persistent recurrent:
Continues into school aged + due to common inhalant allergens (IgE - mediated)
Persistent symptoms + reduced lung func
RF - allergies (≥1 = atopic)
What are some features of asthma that differentiate it from viral wheeze? (5)
Interval symptoms b/wn acute exacerbations Symptoms worse at night/early morn Symptoms w. trigger (e.g. pets) \+ve response to therapy PMH/FH
What would be seen O/E in asthma (not in acute exac)? (3)
What 3 signs may be seen in long-term?
Harrison sulci
Other allergic disorders (eczema, rhinitis)
Growth normal
Hyperinflation
Generalised expiratory wheeze
Prolonged expiratory phase
What 3 signs would indicate chronic infection rather than asthma? (CF/bronchiectasis)
Clubbing
Wet productive cough
Poor growth
When are Ix done for asthma?
What Ix can be done (3)
Only to exclude other conditions (asthma is clinical Dx)
Skin prick test
CXR
PEFR
What would PEFR show in asthma (2)
Only in >5yrs
Shows diurnal/daily variations (lower in morn)
10-15% improvement in PEFR with treatment
What 5 other common conditions can mimic asthma?
Viral-induced wheeze Bronchiolitis Reflux CF Croup
What incidence/age group does viral induced wheeze occur in?
50% of U3s
More commonly boys
Grow out of by 5 (airways bigger)
What features must be assessed/looked for in acute asthma exacerbation? (12)
Wheeze Tachypnoea (>50 2-5s; >30 5+s) Tachycardia (>150; >120) Recession O2 sats (92%) PEFR
Severe:
Accessory mm
Pulsus paradoxus
Too breathless to talk/feed
Life-threatening:
Cyanosis
Lethary/drowsiness
Silent chest
What O2 sats / PEFR would be seen in mild acute exacerbation of asthma?
How is it managed (3)
Sats > 92%
PEFR > 50%
SABA (via spacer) - 2-4 puffs (+2 /2mins and up to 10)
Oral prednisolone
Reassess within 1hr
What O2 sats / PEFD in severe asthma attack?
How managed? (4)
Sats < 92%
PEFR < 50%
O2
SABA 10 puffs / 20-30mins - spacer/neb
Oral prednisolone / IV hydrocortisone
If no response to steroid → Neb ipratropium bromide
What O2 sats / PEFR in life-threatening asthma attack?
How managed? (6)
Sats <92%
PEFR < 33%
O2 Neb B2-agonists / 20-30mins Neb ipratropium bromide IV hydrocortisone Senior review/PICU Oral prednisolone upto 3d
List the different types of drugs used in asthma (8) + how each works
B2-agonists - B2-Rs
Anticholinergic bronchodilators (ipra) - via sympathetic
Inhaled steroids - prevent inflame prots/ reduce IgE response
LABAs
Methylxanthines (theophylline) - relax bronchiole SM
Oral steroids
Leukotriene inhibitors (stops leukotriene bronchoconstricting)
Anti-IgE (omalizumab)
Describe the Asthma management guideline steps for children 5-12? (5)
How is it different for U5s?
- SABA prn
- Steroid (inhaled)
- LABA (± increase steroid / ± leukotriene antag / ± theophylline)
- Increase inhaled steroid
- Oral steroids
- SABA prn
- Steroid / leukotriene antag
- leukotriene antag / Steroid
- Senior referral
What things can be done to advise parents on managing asthma? (4) (PERFO)
Provide PLAN (regime + technique)
EDUCATE on drugs (usage + compliance)
Educate on RED FLAGS (worsening cough / SOB/ wheeze; difficulty walk/talking/sleeping; less bronchodilator relief)
Provide ORAL steroid dose
What age does bronchiolitis present in
What is the incidence
What are the RFs
<18m (90% 1-9m)
20-30% (1/4) all infants every winter
RFs: Premature (/ventilated) CLD CF Congenital heart disease
How does Bronchiolitis present?
Coryzal symptoms → Dry cough + SOB → Feeding difficulties (worst at day 4)
List the clinical features of bronchiolitis (ACBDE + Resp signs)
A: Cyanosis / Pallor B: Unsettled, cannulae/nebs C: no change centiles but current feeding probs D: possibly with feeding probs E: Tachypnoea/cardia, Sats, Temp
Periph stigmata: none
RESP: I: Sharp dry cough, Nasal flaring, recession (inter/subcostal/sternal), Tracheal tug, P: hyperinflation, P: Displaced liver, A: Prolonged expiration + Exp wheeze, End-inspiratory crackles
What Ix can be done for bronchiolitis?
PCR of NPA (may show RSV)
Continuous O2 sats
Rarely: blood gases (only if considering artificial vent), CXR
How is bronchiolitis managed? (5)
SUPPORTIVE NOT CURATIVE Humidified O2 via nasal cannulae Monitor for apnoeas IV fluids / NG tube Assisted vent in small %
What management is NOT useful in bronchiolitis? (4)
Mist
Abx
Steroids
Neb bronchodilators
What are the common causative organisms of pneumonia in the newborn? (2)
in infants + young children (4)
>5y/o? (3)
All ages? (1)
NB younger = viral; older = bacterial
Newborn: GrpB strep, E.Coli
Infants: RSV, S./Chlamydia pneumonia, HiB, Pertussis
Children: Mycoplasma/S./Chlamydia pneumoniae
All ages: consider TB
What are the main features seen in pneumonia? (2)
+ other possible features? (5)
Fever + Increased WOB
Preceding URTI Cough Lethargy Poor feeding Chest/abdo/neck pain (pleural - bact inf)
What signs may be seen O/E in pneumonia?
NB what signs (common in adults) in pneumonia are often absent in children (3)
Tachypnoea (>60/>50/>40)
Chest recessions + nasal flaring + tracheal tug
Poss end-inspiratory crackles over affected area
NB absent - dull percussion/bronch breathing/ reduced breath sounds
What are the indications for hosp admission with child pneumonia? (4)
Sats <93%
Severe tachypnoea / WOB
Not feeding
Family unable to provide approp care
Describe the management of pneumonia (5)
General supportive:
O2 (for hypoxia)
Analgesics
IV fluids
Abx (newborns - broad spec; infants/older - amoxi) Chest drain (if develop empyema)
What complications of pneumonia would require a FU at 4-6wks (3)
Lobar collapse
Atelactasis (partial collapse / incomplete inflation)
Empyema
FU CXR
What advice can be given to parents on caring for chest infection (as most are managed at home)? (5)
Supportive care Analgesics Abx S+S of concern (indicative symps for admission) Reassurance
Describe the presentation / natural history of Pertussis (Whooping cough)
1wk Catarrhal phase (coryza)
3-6wks Paraoxysmal phase
Months - Convalescent phase (symps gradually decrease)
Describe 4 features about the cough in Pertussis
What 3 subsequent symptoms may it lead to?
Spasmodic + inspiratory whoop
Infants show apnoea instead of inspiratory whoop
Worse at night
May → vomiting
May → epistaxis/subconjunctival haemorrhages
May → red/blue in face
How is whooping cough Dx? (2)
Nasal swab - cultures
Blood film - lymphocytosis
What are the RFs for Pertussis?
What are the complications of Pertussis? (3)
Incomplete Vx at 4m
Pneumonia
Convulsions
Bronchiectasis
How is Pertussis managed? (3)
Eventually self-resolves
Erythromycin (only reduces symptoms if catarrhal phase)
Erythromycin prophylaxis for close contacts
What symptoms (5) may be seen in TB?
Symptoms: Fever Cough Lethargy Night sweats Failure to thrive/wt loss (anorexia)
Where else in the body may be affected by normal TB?
Where is affected in disseminating military TB?
Where in body affected in seeding?
Superficial LNs / gut/ skin
Disseminated: bones / joints / kidneys / pericardial /CNS
Seeding (infants/young) → CNS (meningitis)
What are some of the treatment options for TB in 1. uncomplicated 2. complicated 3. latent infection 4. if child post-puberty What is the biggest problem?
Uncomplicated - 6m: Quadruple therapy (rifampicin/isoniazid/pyrazinamide/ethambutol) → double therapy after 2m
Meningitis/disseminated: >6m
Latent: 2drugs 3m
Post-puberty - pyridoxine (prevent isoniazid → perish neuropathy)
Biggest prob is adherence
List the DDx of an infant with tachypnoea + wheeze (8)
Bronchiolitis Pneumonia Transient early wheezing Viral-induced wheeze Atopic asthma Cardiac failure Inhaled foreign body Aspiration of feeds
What is the carrier/incidence rate of CF?
What is the genetic cause?
1 in 25 carriers
1 in 2500 incidence
Defective CFTR (transport memb protein) on csome 7
What is the main pathophysiology from the defective gene in CF? (6)
→ Abnorm Cl ion transport across epithelium
Increased + thickened mucopurulent secretions (impaired ciliary func + chronic infection)
How is CF Dx? (3)
Meconium ileus strongly indicates
Heel prick (immunoreactive trypsinogen)
Sweat test (Cl high)
Genetic testing
If not already picked up on screening, how may CF present? (3)
Recurrent chest infections
Poor growth
Malabsorption/steatorrhoea
List some clinical respiratory features of CF (3S+4S)
Recurrent chest infections (esp Pseudomonas)
Producing purulent sputum
Persistent loose cough
Chest hyperinflation (prom sternum + liver) (due to air trapping)
Coarse inspiratory crackles
Expiratory wheeze
Finger clubbing (in estab disease)
List the complications / long-term effects of CF? (6)
Diabetes (panc insufficiency) Liver disease (1/3rd) Intestinal obstructions Pneumothorax Haemoptysis (life-threatening) Males infertile (vas blockage)
List the various different management measures in CF (7) (LNNPPPP)
Physio (2+/day)
Physical exercise encouraged
Nutritional (fat-sol vits, overnight feeding / extra cals)
Neb DNAase / Hypertonic saline
Prophylactic Abx (fluclox, anti-pseudomonas, + rescues)
Lung/liver transplant
Panc replacement therapy (oral enteric coated tabs)
What CXR changes may be seen in TB? (3)
Collapse / consolidation of affected lung
Peribronchial LN enlargement (bronch obstruction)
Poss pleural effusion
