Respiratory Flashcards
What can rhinitis be a prodrome to?
- Pneumonia
- Bronchiolitis
- Meningitis
- Septicaemia
When does rhinitis usually occur?
Very common 5-10 per year but concentrated in the Winter months
How long does a runny nose usually last?
10-14 days
How long can earache last?
Up to 8 days usually
What is otitis media?
A common self-limiting infection of the ear
How does otitis media present?
- Painful ear
- Erythema in ear
- Bulging drum (may spontaneously rupture)
What organisms can cause otitis media?
- Primary viral infection
- Secondary infection with pneumococcus or haemophilus influenza
How is otitis media managed?
- Analgesics
- Antibiotics have more side effects than benefits so are generally not used
What antibiotic should not given in tonsillitis/pharyngitis?
Amoxicillin
How long does a sore throat usually last?
About 2-7 days
How is tonsillitis/pharyngitis treated?
Either nothing or 10 days of penicillin if known strep infection
What organism is responsible for croup?
Para’flu I
What organism is responsible for epiglottitis?
H. influenza type B
How does croup present?
- Coryza
- Stridor
- Hoarse voice
- Barking cough
How does epiglottis present?
Stridor and drooling
How is croup treated?
Oral dexamethasone
How is epiglottitis treated?
Intubation and IV antibiotics
How long does croup usually last?
2-3 days
What common agents are implicated in LRTI?
Bacterial overgrowth
- Strep pneumoniae
- Haemophilus influenza
- Moraxella cararrhalis
- Mycoplasma pneumoniae
- Chlamydia pneumoniae
Viral infection
- RSV
- Parainfluenza III
- Influenza A and B
- Adenovirus
- Rhinovirus
What are the principles of management for LRTI?
- Make a diagnosis
- Assess the patient (oxygenation, hydration, nutrition)
- Treat or wait for resolve
What is the most common LRTI of childhood?
Bronchitis
How does bronchitis present?
- Loose rattly cough
- Post-tussive vomit - “glut”
- Chest free of wheeze/creps
- Child very well
What organisms are associated with bronchitis?
- Haemophilus
- Pneumococcus
What is the mechanism of bacterial bronchitis?
- Disturbed mucociliary clearance due to Minor airway malacia and RSV/adenovirus
- Lack of social inhibition!
- Bacterial overgrowth is secondary
What is the cycle of bronchitis?
- Resp virus obtained
- Clearance stops for <4 weeks
- Cough and rattle
- Clearance almost recovered
- Child picks up another virus
What are the red flags of bronchitis?
- Age <6 mo, >4yr
- Static weight
- Disrupts child’s life
- Associated SOB (when not coughing)
- Acute admission
- Other co-morbidities (neuro/gastro)
How long does a cough usually last?
Can be 4-25 days
What are the 3 points in the management of persistent bacterial bronchitis?
- Make the diagnosis
- Reassure
- Do not treat
What organisms can cause bronchiolitis?
- RSV
- Paraflu III
- HMPV
How does bronchiolitis present?
- Nasal stuffiness
- Tachynpnoea
- Poor feeding
- Crackles +/- wheeze
What is the incidence of bronchiolitis?
Affects 30-40% of all infants
What is the expected course of bronchiolitis/
- Child is well days 1+2 of cough
- Gets worse days3-5
- Parent usually seeks medical attention about day 5
- Child stabilises days 6+7
- Recovery days 7-14
When does RSV infection usually occur?
Christmas period
When does bronchiolitis incidence peak?
Around 3 months old
When is it bronchiolitis?
- <12 months old
- One off
- Follows the typical history
How is bronchiolitis managed?
- Maximal observation
- Minimal intervention
How is bronchiolitis investigated?
- NPA (nursing in same ward/ cubicles)
- Oxygen saturation for severity
What is there no routine need for in bronchiolitis?
- CXR
- Bloods
- Bacterial cultures
What medications are proven to work in bronchiolitis?
NONE
When should an LRTI be suspected?
- 48 hrs, fever (>38.5oC), SOB, cough, grunting
- Wheeze makes bacterial cause unlikely
- Reduced or bronchial breath sounds
When can you call a LRTI pneumonia?
- Signs are focal
- Crepitation’s
- High fever
What is the BTS guidelines for the management of community acquired pneumonia?
- Nothing is symptoms are mild
- Oral Amoxycillin first line
- Oral Macrolide second choice
- Only for iv if vomiting
How is pertussis characterised?
Coughing fits with vomiting and colour change
Why does pertussis still occur despite vaccination?
-Vaccination reduces risk and severity but does not eliminate the possibility
When is otitis media treated?
Oral amoxicillin if <2 years with bilateral OM
When is LRTI/pneumonia treated?
History of 2 days fever, cough and focal signs then treat with oral amoxycillin
What is treatment for acute respiratory infections aimed at?
Maintaining oxygenation, hydration and nutrition
What is asthma?
- Chronic respiratory condition characterised by variability and reversibility
- Presents with wheeze, cough and SOB
- Multiple triggers
- Responds to asthma treatment
Give examples of asthma triggers.
- URTI
- Exercise
- Allergen
- Cold weather
What are the key words associated with asthma?
- Wheeze
- Variability
- Response to treatment
What is the epidemiology of asthma?
- 1 million UK children
- 100, 000 in Scotland
- 5% of UK children on inhaled steroids!
What is the multiple hits theory of asthma?
- Genes
- Inherently abnormal lungs
- Early onset atopy
- Later environmental exposure including rhinovirus, exercise and smoking
What type of asthma does not exist?
Cough variant
How can we differentiate wheeze form other sounds?
- Over half of parents report generic respiratory sounds as wheeze
- True wheeze sounds like a whistle on expiration
How can SOB at rest be identified?
- Significant respiratory difficulty
- Airway obstruction
- Sooking in of ribs
What is the association between asthma and atopy?
- Secondary to the same process
- May have FMH
- May have personal history of eczema, hayfever or food allergies
How is asthma treatment trialled?
2 month trial of ICS with steroid holiday after
What is the ideal presentation for asthma diagnosis?
- Wheeze with and without URTI
- SOB at rest
- Parental asthma
- Responds to treatment
What is the differential diagnosis for asthma with onset <5 years?
- Congenital
- CF
- PCD
- Bronchitis
- Foreign body
What is the differential diagnosis for asthma with onset >5 years?
- Dysfunctional breathing
- Vocal cord dysfunction
- Habitual cough
- Pertussis
When is it unlikely to be asthma?
Symptoms in under 18 months
- Most likely to be infection
- STILL MAY BE ASTHMA
What are the goals of asthma treatment?
- “Minimal” symptoms during day and night
- Minimal need for reliever medication
- No attacks (exacerbations)
- No limitation of physical activity
- Normal lung function
How is asthma control assessed?
SANE Questions
- Short acting beta agonist/week
- Absence school/nursery
- Nocturnal symptoms/week
- Excertional symptoms/week
What must be checked if asthma remains uncontrolled while on treatment?
- Compliance
- Taking medication correctly
- Diagnosis
What is the step up, step down approach to asthma?
- Start on low dose ICS
- Review after 2 months
What classes of medication can be used in asthma?
- Short acting beta agonists
- Inhaled corticosteroids (ICS)
- Long acting beta agonists
- Leukotriene receptor antagonists
- Theophyllines
- Oral steroids
How does child asthma management differ from adults?
- Max dose ICS 800 microg (<12 yo)
- No oral B2 tablet
- LTRA first line preventer in <5s
- No LAMAs
- Only two biologicals
When should a regular asthma preventer be added?
- Diagnostic test
- B2 agonists >two days a week
- Symptomatic three times a week or more, or waking one night a week.
What adverse effects can occur with ICS?
- Height suppression (0.5-1cm)
- Oral candidiasis
- Adenocortical suppression (mainly fluticasone inhalers)
What 2 things do you need to remember about using a LABA in kids?
- Do not use without ICS
- Use as fixed dose inhaler
What is step 3 in asthma management?
Add on LABA
What leukotriene receptor antagonist is available for kids?
Montelukast
What biologic may be used with extremely resistant asthma?
Omalizumab
What types of delivery systems are used for children’s asthma medication?
- MDI with spacer
- Dry powder device
How can medication delivery be increased with a spacer?
- Shake inhaler between puffs
- Wash spacer monthly to reduce static
What is the role of dry powder inhalers in childhood asthma?
- Licensed in the over 5s
- Not used in the under 8s
- Achieve 20% lung deposition
- Generally girls use them at an earlier age than boys
What are the advantages of MDIs compare to nebulisers?
- Quieter
- Quicker
- Valve mechanism
- Don’t break down
- Portable
- Cheaper
What non-pharmacological management of asthma is there?
- Stop tobacco and smoke exposure
- Remove environmental triggers including animals
How are steroids used in asthma?
- Chronic/maintenance treatment= inhaled
- Acute treatment= oral
