Respiratory Flashcards
Child presents with Coryza, stridor, hoarse voice and a “barking” seal-like cough, what’s the likely diagnosis?
Croup
These patients tend to be systemically well
What causes Croup [1]
Epidemiology [1]
Tx croup [3]
Parainfluenza Type 1 - Peak: 6m-3y, autumn Mx: - Dexamethasone - admit if moderate, severe - Neb Adrenaline, inhaled ICS (if severe)
What management should be enacted for any kid with a respiratory infection?
Assess their oxygenation, hydration and nutritional status then attend to these if necessary
Most kids won’t need anything more than this for Respiratory infections
Kid presents systemically very unwell with stridor and drooling, what do you think might be happening?
Epiglottitis
What cause epiglottitis? [1] Immediate management [2] Subsequent management [4] Subsequent investigations [2] Definitive management
H. Influenzae B for which there is a vaccine
• Initial assessment: ABCDE and urgent ENT or anaesthetic assessment
Subsequently…
• Nebulised ADRENALINE and IV DEXAMETHASONE
• Ix: blood and throat cultures
• Abx: IV PENICILLIN and CEFTRIAXONE
• IV fluids and analgesia
• Definitive mx: EUA and intubation in theatre
List at least 3 bacteria and viruses known to cause LRTIs?
- Pneumococcus
- H Influenzae
- Morazella Catarrhalis
- Mycoplasma Pneumoniae
- Chlamydia Pneumoniae
- RSV
- Adenovirus
- Parainfluenzae 3
- Influenzae A & B
- Rhinovirus
What’s the most common LRTI in infants?
Ep [2]
Name causative organisms [2]
Bronchiolitis
Ep: <1 yo, winter
Viral cause: mostly by RSV or sometimes parainfluenzae 3
How would you expect bronchiolitis to present? [6]
One off episode of:
- ~3day h/o progressive
- Nasal stuffiness, coryzal symptoms
- tachypnoea, feeding problems
- crackles +/- wheeze
How would you investigate [2] and treat [2] an infant with bronchiolitis?
Ix: NPA (viral swab) & O2 sats is all that’s needed
Focus on their oxygen, hydration & nutrition and most will recover on their own
(Remember it’s viral so it can’t be treated with Abx)
Mom brings in her son saying he’s been going through episodes all winter of a rattly cough & post-coughing vomit that’s mucousy.
Dx [1]
Clinical picture [4]
What does it sound like? Classic sign [1]
Mx
Bronchitis
Tend to see:
- Mostly well kid
- Relapsing remitting pattern
- Post-tussive Vomit (“glut”)
- No wheeze/creps
- Loose rattly Cough
Mx: reassurance
Pathogenesis of bronchitis? [4]
Usually a viral infection e.g. RSV [1] disturbs the mucocilliary clearance [1] leading to a secondary bacterial infection with:
- Haemophilus Influenzae [1]
- Pneumococcus [1]
Bronchitis is generally managed with reassurance and waiting, when would we be more worried? [6]
Red Flags include:
- <6months / 4yrs
- Static or dropping weight
- Disrupts child’s life
- SOB when not coughing
- Acute admission
- Co-morbidities e.g. neuro/gastro
Kid comes in with mum complaining of a 2 day history of Fever, SOB & Coughing, dx?
What are the 5 symptoms in the history?
What are 3 signs on examination?
Don’t call it pneumonia as it unnessarily scares parents. What are 4 signs of pneumonia?
A LRTI or Chest Infection
Symptoms: 48hrs of fever, sob, cough, grunting
Signs: +/- wheeze, reduced/bronchial breath sounds & creps
Focal signs
Crepitations
HIgh fever
CXR signs
LRTI/chest infection/community acquired pneumonia? How do you investigate [1] and treat: Mild symptoms [2] First line if worsening [1] Second line rx [1] When is iv indicated [1]
Generally no need for inflammatory markers, CXR or medications, if its bad you can do FBC, CRP, CXR etc.
- Mild = no meds, always offer to review if things get worse
- Worse? = Oral amoxycillin –> Oral Macrolide 2nd line –> IV if vomiting
What characterizes Pertussis? [4]
Causative organism
How does vaccination effect pertussis? [2]
Management [2]
Whooping cough:
- “coughing fits”, paroxysmal
- vomiting and colour change, post-tussive vomiting
- Conjunctival hematoma
- May last up to 6m
- apnoeic spells (infants)
- inspiratory whoop
Bortadella pertussis
Vaccination reduces risk and severity but doesn’t confer life-long protection
Mx oral erythromycin only if <3w sx (this is to reduce spread antibiotic therapy has not been shown to alter the course of the illness), give home contact prophylaxis
What is needed to diagnose Asthma? [5]
Describe cough in asthma [3]
Chronic
Episodes of wheeze, cough & SOB at rest
Variable/Reversible
Responds to asthma meds
It can help to look for a h/o or FH/o asthma & atopic conditions e.g. hayfever, eczema or food allergy
Cough: dry, nocturnal, exertional
How do we test for asthma? [2]
Trial for 2 months with low dose ICS
Spirometry and FeNO
What mnemonic can you use to assess how well the child’s asthma is controlled? [4]
SANE:
- SABA /wk
- Absence from school/nursery
- Nocturnal symptoms /wk
- Exertional symptoms /wk
Lifestyle modifications for asthma management [3]
Stopping smoke exposure
Removing environmental triggers e.g. cat or dog
Diet, humidity, wt & hypoallergic duvets etc don’t help
How do you deliver inhaled drugs in kids? [2]
MDI Spacer increases lung deposition
Dry powder inhaler, only start using it properly when they’re about 8
Asthma management 5-16 year olds [7]
- SABA
- SABA + ICS
- SABA + ICS + LTRA
- SABA + ICS + LABA (stop LTRA)
- SABA + MART (combined ICS and LABA within single inhaler)
- SABA + MART (moderate dose ICS)
- theophylline
Asthma management <5yo
BTS 2019 + NICE 2017
SABA as adjunct
Step 1: Very low (paediatric) dose ICS or LTRA
Step 2: Very low dose ICS + LTRA
Step 3: Low dose ICS + LTRA
Step 4: Specialist referral
Acute exacerbations: moderate
Clinical definition [2]
Management [3]
SpO2 >92%, PEF >50% predicted Mx: SABA (spacer) Consider oral prednisolone Review in 1h
Acute exacerbations: severe
Clinical definition [3]
Management [2]
SpO2 <92%, too SOB to talk or eat, use of accessory muscles, PEF 33-50% predicted
Mx:
- SABA (spacer) or neb
- Neb ipatropium
Acute exacerbations: life threatening
Clinical definition [2]
Management [5]
SpO2 <92% and ANY of: - silent chest, poor respiratory effort, agitation, reduced GCS or cyanosis (increased PCO2) Mx: - Intubation & ventilation - Neb SABA + Ipratropium - Oral prednisolone (IV hydrocortisone if vomiting) 3-5 days - IV Mg sulfate - IV theophylline, salbutamol
Inhaled foreign body presentation [4]
Management [1]
Mx for total upper airway obstruction
Mx for partial upper airway obstruction [2]
Mx for obstruction lower than main bronchus [3]
Coughing
Choking, vomiting
Stridor, LOC
Cardiorespiratory arrest
Mx:
- ABCDE
• Total upper airway obstruction (can’t speak): BLS choking algorithm (or cardiac arrest algorithm)
• Partial upper airway obstruction (can speak): get child in upright comfortable position and arrange for urgent removal in theatre
• Obstruction lower than main bronchus: inspiratory and expiratory CXR
- put in upright comfortable position and arrange for urgent removal in theatre
Signs that inhaled FB is lower than main bronchus [5]
- unexplained fever, cough
- SOB, recurrent or persistent pneumonia
- assymetrical chest movement
- tracheal deviation
- chest signs e.g. wheeze, bronchial breath sounds
Chronic asthma management in young person 6-12 years old
SABA as adjunct
Step 1: Very low dose ICS Step 2: Very low dose ICS + LTRA/LABA Step 3: - If no response to add-on, stop it - Low dose ICS + LTRA/LABA Step 4: moderate dose ICS (as part of fixed dose or MART) Step 5: choose one - high dose ICS - Add theophylline - Specialist referral
Causes of stridor [4]
Croup
Acute epiglotitis
Inhaled FB
Laryngomalacia
What prompts immediate referrals in bronchiolitis? [5]
- apnoea (observed or reported)
- child looks seriously unwell to a healthcare professional, severe respiratory distress eg:
> grunting, marked chest recession
> respiratory rate of over 70 breaths/minute - central cyanosis
persistent oxygen saturation of less than 92% when breathing air.
Whooping cough
Investigations [3]
Management [2]
Ix: nasal swab culture, PCR, serology
Mx:
- Infants under 6m admit
- macrolide
Pre-school wheeze in children types [4]
Episodic viral induced wheeze
- only wheezes when viral URTI
- symptom-free in between episodes
Multiple trigger wheeze
- viral induced wheeze +
- other factors exercise, allergens, cigarette smoke
Management of episodic viral wheeze [4]
Stop smoking - parents
Treat when symptomatic
First line is tx with SABA via spacer
Intermittent LTRA and/or intermittent ICS
Management of multiple trigger wheeze [2]
Trial of inhaled ICS
or trial of LTRA
For 4-8 weeks
