Respiratory Flashcards
What does sleep disordered breathing occur due to?
What is the most common cause in children?
What are pre-disposing causes of sleep disordered breathing?
Occurs due to either obstruction or a problem with central hypoventilation or can be a combination.
The most common cause in children is adenotonsillar hypertrophy.
Pre-disposing causes include:
- NM disease (e.g Duchenne’s muscular dystrophy)
- Craniofacial abnormalities
- Dystonia of upper airway muscles
- Severe obesity
- Children with down’s syndrome (as they have upper airway restriction as well as hypotonia)
What are key aspects in the history for a child with sleep-disordered breathing?
Snoring
Witnessed pauses in breathing
Restlessness
Disturbed sleep
What behaviours does a child present with as a result of OSA?
Hyperactivity or sleepiness
Learning and behaviour problems
Faltering growth
In severe cases- pulmonary hypertension
How is OSA assessed?
Pulse oximetry overnight
Polysomnography in more complex cases - HR/resp effort/airflow/co2 measurement
What are the different types of treatment for OSA?
Surgery - removal of adenoids and tonsils (adenotonsillectomy)
Nasal of face mask with CPAP or BiPAP to maintain the upper airway at night
What are some signs of a) moderate b)severe respiratory distress that may been seen in a child?
Moderate: tachycardia, tachypnoea, intercostal and subcostal muscle recession, Tracheal tug, head retraction, inability to feed,
Severe: cyanosis, tiring because of increased work of breathing, reduced conscious level, oxygen sats <92 despite O2 therapy
Which children are particularly at risk of respiratory failure?
Ex pre-term infacts with bronchopulmonary dysplasia, disorders causing muscle weakness, CF, immunodeficiency, haemodynamically significand Cong HD
What conditions does the term URTI embrace?
Common cold (coryza)
Pharyngitis and tonsillitis
Acute otitis media
Sinusitis
What are come of the complications of URTIs?
Difficulty feeding (in infants)
Febrile convulsions
Acute exacerbations of asthma
What are the classical features of a common cold (coryza)?
What are the most common pathogens?
Runny nose, clear or mucopurulent nasal discharge
Most commonly viral - rhinovirus, coronavirus or respiratory syncytial virus
What are common causative pathogens for tonsillitis in children?
Group A Beta-haemolytic streptococcus
Epstein Barr Virus (infectious mononucleosis)
What percentage of tonsillitis is bacterial?
1/3
Why is amoxicillin best avoided in children who have to be admitted for tonsillitis?
Because if the underlying cause is EBV then is may cause a widespread maculopapular rash
What can group A strep infection occasionally result in?
Scarlet fever
Describe the timeline of scarlet fever, how it is treated and why it is treated (e.g complications if not treated)
Fever usually precedes the presence of headache and tonsillitis by 2-3 days
Appearance of the rash is variable, typical appearance is ‘sandpaper-like’ maculopapular rash with flushed cheeks and perioral sparing
Tongue is white and coated and may be sore or swollen (STRAWBERRY TONGUE)
Treatment: Antibiotics (pen V and erythromycin)
Complications if not treated are:
- Otitis media (most commonly)
- Renal problems (acute glomerulonephritis)
- Very rarely (in high income countries) rheumatic fever
0 Invasive complications e.g bacteraemia, meningitis, necrotising fasciitis
Why are infants and young children prone to acute otitis media?
Eustachian tube is short, poorly functioning and horizontal
What is the appearance of the ear on tympanectomy in a child with acute otitis media?
Bulging, red, loss of light reflection
What is the treatment of acute otitis media?
Generally pain relief Antibiotic prescription (amoxicillin) may be prescribed with a 2-3 day delay
What are some of the causative organisms of acute otitis media?
Viruses - rhinovirus/RSV (respiratory syncytial virus)
Bacteria - pneumococcus, haem influenzae or Moraxella catarrhalis
When is the peak for otitis media with effusion (glue ear)?
2-7 years
What are the complications of otitis media with effusion?
Conductive hearing loss
What is the surgical management of glue ear? How long does this often last?
Grommets
12 months
Why is frontal sinusitis rare in the first decade of life?
Because the frontal sinuses do not develop until later
What are the indications for tonsillectomy?
Recurrent severe tonsillitis
Peritonsillar abscess
OSA
What are the indications for adenoidectomy?
Recurrent otitis media with effusion with hearing loss
OSA
What is the difference between wheeze and stridor?
a) In terms of when they occur
b) in terms of their underlying pathophysiology
Wheeze is expiratory and stridor is inspiratory
Wheeze is due to obstruction of the lower respiratory tract (larynx, trachea and bronchi, small airways) where as stridor is obstruction of the airway outside the chest cavity (nasopharynx, larynx, trachea and bronchi)
What age group does bronchiolitis most commonly affect?
90% of children affected are aged 1-9 months
Can affect children up to the age of 2
What are the causative organisms of bronchiolitis?
RSV in 80%
Parainfluenza, rhinovirus, adenovirus, influenza virus
When is admission due to bronchiolitis usually recommended?
If any of the following are present:
Apnoea
Inadequate oral intake (50-75% of normal volume)
Persistent O2 sats <90% on air
Severe respiratory distress (grunting, marked chest recession, or RR >70)
What are the characteristic findings in a patient with bronchiolitis?
Dry, wheezy cough Tachypnoea or tachycardia Subcostal and intercostal recession Hyperinflation of the chest Fine end inspiratory crackles High pitches wheezes - expiratory > inspiratory
What investigations are carried out on children with suspected bronchiolitis?
O2 saturations
Blood gases/CXR are only carried out if ?Respiratory distress
NPA- nasopharyngeal aspirate to look for if the causative organism is RSV
What is apnoea?
The cessation of breathing
How can bronchiolitis be prevented?
Monoclonal Ab to RXV (Palivizumab, given monthly IM) - reduces risk of hospital admission in high risk pre-term infants (but use limited as requires 17 babies treated to avoid 1 admission)
Typically given for 5 months over the winter
What is the management of bronchiolitis?
Supportive management:
O2 (humidified) via nasal cannulae or head box
Fluids via NG/IV. May be given continuous or anal feeds. If more sever IV is required
(If required - small percentage): CPAP
Infection control measures required as RSV is highly infectious
Suction if there is excessive upper airway secretions
What is the fundamental (pathophysiological) problem in patients with CF? What is the effect of this on: Airways? Intestine? Pancreas? Sweat glands?
There is a mutation in the CFTR gene. This results in abnormal ion transport across epithelial cells. The effect on the:
Airways - Reduction in the airway surface liquid layer and consequent impaired ciliary function and retention of mucopurulent secretions. Recurrent infections
Intestines: thick viscid meconium produced
Pancreas: pancreatic ducts become blocked, leads to pancreatic enzyme deficiency and malabsorption
Sweat glands: XS sodium and chloride in the sweat
Why is screening for CF important?
Because it enables CF to be picked up early and reduces diagnostic delay. It lowers the risk of presenting with a faltering growth or established chronic infection
(most children are identified through screening) however, if this isn’t the case how may a patient with CF present?
Recurrent chest infections, faltering growth, or malabsorption
What are the common causative organisms of infection in the airways of patients with CF?
Staph aureus
Haem influenzae
Pseudomonas aeruginosa
If pancreatic exocrine insufficiency in CF patients is not treated how may this present?
Maldigestion and Malabsorption
About 10-20% of infants with CF present in the neonatal period with meconium ileus. What can this lead to?
What are the symptoms of this?
Bowel obstruction can result
Vomiting, abdominal distension and failure to pass meconium in the first few days of life
What is the diagnostic procedure for CF?
Chloride Sweat test
>60 mol/L
How often should patients with CF have physiotherapy? How is this carried out in a) younger b)older children?
Every day, twice a day, from the day of diagnosis
In younger children their parents are taught how to perform chest clearance using chest percussion and postural drainage
In older children deep breathing exercises are taught which can be used alongside a variety of physiotherapy devices
What is the approach towards Abx in patients with CF?
Many CF specialists recommend continuous prophylactic Abx with additional rescue oral antibiotics for any increase in respiratory symptoms or decline in lung function
What treatment may be required for more severe CF?
More regular IV Abx therapy
If venous access becomes troublesome a subcut access port may be required
What is the therapeutic treatment for end stage CF lung disease?
Bilateral sequential lung transplantation
What is the treatment for pancreatic insufficiency in CF patients?
What other dietary advise are patients given?
Pancreatic enzyme replacement (creon) - taken with all meals and snacks
Other dietary advice includes: high-calorie diet and dietary intake 150% of normal
High calorie and high fat with pancreatic enzyme supplementation for every meal
What is the condition called that can affect the bowel in older CF patients?
Distal intestinal obstruction syndrome
What are some late respiratory complications that patients with CF can get as the disease progresses?
Pneumothorax and life threatening haemoptysis
Also mucous sitting in the lungs can lead to biofilm formation
Why are males with CF virtually always infertile?
Due to the absence of vas deferens
What percentage of infants with CF get meconium ileus?
10-20%
What are the 3 patterns of wheeze?
Viral wheeze
Multi-trigger wheeze
Asthma
Explain how viral episodic wheeze comes about
What age group of children does it affect?
Child is born with narrower airways. When the child gets a viral infection they get a wheeze because they are more likely to narrow and obstruct due to inflammation
Up to 5 years of age
Most children who are pre-school and have a wheeze have viral wheeze
Describe an asthmatic wheeze
Why does an asthmatic wheeze arise?
It is polyphonic (multiple pitch)
It is believed to represent many airways of different sizes vibrating from abnormal narrowing
What are the key features associated with a probability of a child having asthma?
Symptoms worse at night and in the early morning
Symptoms that have non-viral triggers
Interval symptoms i.e symptoms between acute exacerbations
Personal of family hx of an atopic disease
Positive response to asthma therapy
Signs of what other conditions may be seen in a patient with asthma?
Eczema
Sinusitis (should examine the nasal mucosa) - hayfever
If there is uncertainty in the diagnosis of asthma or disease monitoring needs to be carried out what investigations may be carried out?
If asthma is poorly controlled what may you see on PEFR?
What are usual findings on spirometry?
PEFR or Spirometry
If poorly controlled you will see increased variability on PEFR - both diurnal variability and day to day variability
Usual findings on spirometry = obstructive. Reversible on administration of SABA
What are the clinical features of a life-threatening asthma attack?
Silent chest , cyanosis Poor respiratory effort Exhaustion Arrhythmia, hypotension Altered consciousness Agitation, confusion Peak flow <33% O2 sats <92%
What is stridor and what can it be caused by? (give examples)
Inspiratory wheeze caused by partial upper airway obstruction Croup Acute epiglottitis Inhaled foreign body Laryngomalacia
What is croup?
What is croup characterised by?
It is a form of upper respiratory tract infection seen in infants and toddlers. (Viral laryngotracheobronchitis)
Characterised by
- Stridor which is caused by a combination of laryngeal oedema and secretions
- Barking cough (worse at night)
- Fever
- Coryzal symptoms
On examination of a child what is a good indicator of the severity of the upper airway obstruction?
The degree of subcostal, intercostal and sternal recession
When is there a low threshold for children with croup?
What is first line in the treatment of croup?
If the child is <12 months, if they have known upper airway abnormalities (e.g with Down’s syndrome), or if there is uncertainty about the diagnosis (important differentials include acute epiglottitis
First line treatment =
Oral dexamethasone OR Oral prednisolone
(Given if croup is causing chest recession at rest)
What is the treatment for severe upper airway obstruction secondary to croup?
O2 and nebulised adrenaline
What is acute epiglottitis?
What is the causative organism?
Intense swelling of the epiglottis and surrounding tissues associated with septicaemia
Causative organism = Haemophilus influenzae B (HiB)
How can acute epiglottitis be prevented?
HiB vaccination
What are the characteristic features of acute epiglottitis?
very acute presentation
High fever in a very ill, toxic looking child
Absence of cough
Drooling as too difficult to swallow (intensely painful cough)
Soft inspiratory stridor and rapidly increased resp effort over hours
Child sitting immobile, upright, with an open mouth to optimise the airway
What are the steps that should be taken if acute epiglottitis is suspected?
Inform senior anaesthetist, paediatrician, ENT surgeou
Transfer to ICU/anaesthetic room
Intubation under GA
If intubation not possible urgent tracheostomy carried out
THEN
Blood cultures and IV Abx
Tracheal tube can usually be removed after 24 hours and give Abx for 3-5 days
How does acute epiglottitis vary compared to croup?
Acute epiglottitis there is minimal or absent cough (which is in contrast to croup)
What are the most common causative organisms of pneumonia in:
a) Newborn
b) Infants and young children
c) Children over 5
Newborn: Organisms from mothers genital tract e.g: - Group B strep - Gram negative enterococci and bacilli Infants and young children: - Respiratory viruses (RSV) - Bacterial infections e.g strep pneumoniae or H influenzae. Bordetella pertussis and chlamydia - Infrequent but serious = staph aureus Children over 5: - Mycoplasma pneumoniae - Strep pneumoniae - Chlamydia pneumonia IN ALL AGES - MUST EXCLUDE TB
When is the HiB vaccine given?
Given as part of the 5 in 1 at 2,3 and 4 months
HiB booster at 12 months
What is the most sensitive clinical sign in pneumonia?
Resp rate (is asthma it in not sensitive)
In a small proportion of children what may the pneumonia be associated with? What can this lead to?
Effusion
Can lead to empyema and fibrin strands may form, leading to septations
What are the indications for admission of a child with pneumonia?
O2 sats <92, recurrent apnoea, grunting and/or an inability to maintain adequate fliud/feed
If a child has a parapneumonic effusion and has a persistent fever despite 48 hours of Abx what does this suggest? What is the treatment of this?
Suggests and pleural collection which requires draining. Chest drain is inserted via US guidance
What are the most common causative organisms of tonsillitis?
Group A beta-haemolytic strep
EBV (infectious mononucleosis)
What is the treatment of tonsillitis? How long for?
What proportion of tonsillitis’ is this treatment useful for?
Penicillin V or Erythromycin in penicillin allergy
For 10 days
Only a 1/3 of tonsillitis is caused by bacteria but they may hasten recovery from strep infection
Why is penicillin given in the treatment of tonsillitis rather than amoxicillin?
Why is a 10 day course given?
To eradicate the bacteria completely and prevent scarlet fever and also rheumatic fever from developing (they can develop from group a beta-haemolytic strep)
How long should a child with whooping cough be excluded from school for?
2 days after commencing antibiotics or 21 days from onset of symptoms if no antibiotics
What investigation may be carried out to look for the cause of bronchiolitis?
Nasal-pharyngeal aspirate
Describe the rash that children get with scarlet fever
Where is it most commonly seen
Fine punctate erythema (pinhead)
Generally starts on the torso and SPARES the palms and soles
More obvious at the flexures
Described as having a rough ‘sandpaper’ texture
How is scarlet fever spread?
How is it diagnosed?
Via the respiratory route - by inhaling or ingesting respiratory droplets
Direct contact with nose and throat discharges
A throat swab is normally taken but antibiotic treatment should be commenced immediately, rather than waiting for the results
What are the high risk groups from bronchiolitis?
-
What are the different severities of croup?
MILD: Occasional barking cough with no stridor at rest No or mild recessions Well looking child MODERATE: Frequent barking cough and stridor at rest Recessions at rest No distress SEVERE: Prominent inspiratory stridor at rest Marked recessions Distress, agitation or lethargy Tachycardia
What are some risk factors for respiratory distress syndrome?
(It only occurs in premature infants so being premature isn’t a risk factor)
Male sex
Diabetic mothers
C section
Second born of premature twins
What is the management of respiratory distress syndrome?
- Prevention during pregnancy with maternal corticosteroids
- O2
- Assisted ventilation
- Exogenous surfactant given via endotracheal tube
In what age group is salbutamol considered to be of little use in the treatment of wheeze? Why?
In children <1
They do not have the beta receptors for salbutamol to act on
What values of FEV1/FVC are suggestive of a restrictive deficit?
> 70%
What values of FEV1/FVC are suggestive of an obstructive deficit?
<70%
