Respiratory Flashcards
Define Bronchiolitis
Infection and inflammation of the Bronchioles
Most common infection is respiratory syncytial virus
may also be parainfluenzae III
Most affects babies and infants <12 months
Peak during autumn and spring months`
Bronchiolitis Symptoms
Dry and persistent cough
Fever (low grade <39 degrees)
Coryza - Cold symptoms
Typically a 9 day illness
3 days prodrome with harsh cough and cold
3 days Ill with fever, high itched wheeze and
breathlessness
3 days recovery
Signs of Bronchiolitis
Increase Respiratory effort
Tachypnoea, Tracheal Tug, Subcostal/intercostal
Recession, head bobbig and grunting
Hypoxia –> cyanosis
ON AUSCULTATION –> coarse creps
Expiratory wheeze
Downward displaced Liver - Hyperinflated lungs
Investigation of Bronchiolitis
Test for signs of Dehydration Dipped fontanelle Dry mouth and skin Drowsiness Oliguria
Nasopharyngeal aspiration for viruses
CAPILLARY blood gas would show respiratory acidosis if severe
Urine or blood tests
CXR would show hyperinflated lungs
Though Bloods Xray and cultures not routinely required
What children are at risk of severe bronchiolitis?
Premature babies (<35wks) until the age of 6mo
chronic lung disease within the 1st2 years (CF)
Significant Congenital Heart disease within 1st 2 years
Treatment of Bronchiolitis
Supportive: - keep child upright with plenty fluids, keep air moist to ease respiration, smoke free environment, antipyrexials and saline nasal drops
Palavizumab (RSV monoclonal Antibody) given MONTHLY to at risk babies for 6 months during RSV season as prophylaxis
Definition of Croup
Acute laryngotracheobronchitis (LTB)
Viral Infection
Inflammation of the upper respiratory tract
Pathology of Croup
Subglottic oedema, inflammation - causes narrowing of the tract
Signs and Symptoms of Croup
‘Barking’ cough
Hoarse voice from obstruction in larynx region
Stridor - worse on exertion
increased effort of respiration - use of accessory muscles - tachypnoea, sub-costal recessions
Investigations for Croup
SaO2/Pulse oximetry - < 95% indicates severe respiratory impairment.
FBC - White cell count and viral pattern
CXR - exclude inhaled foreign body etc.
Management of Croup
Oral Corticosteriods - Pred or Dexa - this will reduce swelling in the throat
Fain Relief - Ibuprofen or paracetamol
DO NOT USE COUGH MEDICATIONS - they do not help with croup symptoms and can cause drowsiness which is not good in a child with respiratory issues
Prevention of Croup
Sin1 Vaccination with Pre-school booster
Pregnant women are offered the vaccine.
Definition of Epiglottitis
Bacterial infection resulting in inflammation of the epiglottis. Now rare with the introduction of the Hib vaccination (haemophilius influenzae B)
Less common cause may be strep Pneumonaie
1-6 year olds most commonly - medical emergency
Clinical presentation of epiglottitis
Fever Toxic Looking child Dysphagia Sore throat Stridor - may be improved by leaning forward Irritability or restlessness Drooling Minimal cough
Investigation and treatment of epiglottitis
NOTHING IS TO BE DONE UNTIL AIRWAY IS SECURE
avoid interventions and CXR - anything that might precipitate airway obstruction
ENT/Anaesthetic review to secure airway
Rx infection with broad spectrum Abx.
WBC count
CT to check for level of swelling
Prevention of Epiglottitis
Children should receive 5 in 1 vaccine DTaP/IVP/HIB which also prevents against diphtheria, tetanus, whooping cough and polio
Receive at 2, 3 and 4 months with a booster at 12
months
Definition of Whooping cough (pertussis)
Highly contagious bacterial infection of the lungs and airways
Bordetella pertussis
Clinical features of Whooping Cough
Clod like symptoms for 2-3 days followed by spasmodic coughing and an inspiratory whoop.
Runny nose, temperature, vomiting after coughing.
Young babies may present with apnoea
systems may persist for 10 - 12 weeks (the 100 day cough)
Investigations for whooping cough
Blood tests for Bordatella and increased WBC
Pre-nasal Swab
Management of Whooping cough
Supportive - Rest Fluids and analgesia
Admit if cyanotic or presenting with apnoea
May need IV Abx and steroids to reduce the swelling
Young babies may present much worse - O2 mask/ventilation support
Definition of Cystic Fibrosis
Serious autosomal recessive condition
multi-system disease characterised by increased mucus viscosity, resulting in
Frequent RTIs
Pancreatic Insufficiency
Pathology
Autosomal ressecive disorder affecting the CysticFibrosis Transmembrane regulator gene (CFTR) - Ch7
Na-Cl channel dysfunction = thick mucosal secretions - mainly lungs and pancreas
Most common mutation is deltaF508
Clinical Features of CF
New Born infants - Meconium ileus (see later) Young children Failure to thrive Recurrent RTI - Staph A. HIB, Pseudomonas persistent cough steatorrhoea malabsorption rectal prolapse
Investigations of CF
Heel prick (Guthrie) test - immunoreactive trypsinogen increased in newborns with CF - routine now
Sweat test - measures Na and Cl in sweat - GOLD STANDARD - 2 abnormal tests = diagnostic
CXR - shadows and exaggerated bronchial marking - Bronchiectasis
management of CF
MDT approach Respiratory care IV Abx, bronchiodilators/inhaled steroids and physiotherapy Nutrition Pancreatic enzyme supplementation high-calorie diet Liver Disease UDC acid may reduce progression Lungs Bilateral transplant may be indicated
Meconium Ileus
Meconium is thicker and stickier than usual - causes obstruction of ilium at birth
90% of babies with Meconium ileus will have DF
Symptoms of meconium ileus
Delay in passing meconium (normally within 24 hours of birth)
Poor Feeding - May get bilious vomiting
irritable
distended abdomen
Investigation of meconium ileus
X-ray abdomen
management of meconium Iieus
may be possible to dissolve by injecting enema
NG tub to drain collected bile
IV fluids
Abx for possible infection
Take home points on Croup
para’ Flu I
Common
Coryza ++, stridor, Hoarse voice ‘barking cough’
Oral Dexa/Pred
Take home points on Epiglottits
H. Influenzae type B Rare Toxic Child Stridor and Drooling Intubate and Abx Medical Emergency.
Asthma
Chronic inflammatory disorder characterised by reversible obstruction of the airways.
hard to Dx under 3 years old - overlap with VIW
typically assoc. with Hx of atopy
Clinical Assessment of asthma (PROPS)
P - Peak Flow R - Respiratory Rate O - Oxygen saturation P - Pulse rates S - Sentences
Asthma is severe if a child >5 years old presents with any of…
P - Les than 50% of Best/Predicted R - more than 30/min O - less than 92% (life threatening P - >125/min S - Too breathless to talk or has to use accessory mm.
Life threatening Features of Asthma - 33, 92 chest
RR - >33 O2 sats <92% C - Cyanosis H - Hypotension E - Exhaustion with poor reps effort S - Silent Chest T - Tired and Confused i.e. reduced consciousness
Management of Asthma
Mild/Moderate
Often Manages in Community
Inhaled Beta-2 agonist (salbutamol) via spacer
up to 10 puffs, 30s apart - repeat every 4 hours
Oral pred for 3 days (10mg for <2, 20 2-5, 30mg >5
Admit if not responding
Severe
Transfer to Hospital
High flow O2
Beta - 2 agonist Neb - 2.5mg <5, 5mg >5
BURST THERAPY - every 20-30 minutes checking
PFR
+ Ipratropium Neb 250 micrograms if not
responding
IV hydrocortisone - 4mg/kg every 4 hours
If not responding or life threatening PICU Above Rx + magnesium sulphate Aminophylline or Salbutamol by infusion if still no improvement
O SHIT ME it asthma
O2 - increase to 94 - 98%
S - Salbutamol Neb
H - Hydrocortisone/Prednisolone
I - ipratropium
T - Theophylline
M - Magnesium Sulphate
E - Esalate Care
Know your inhalers
Blue inhaler - Salbutamol
Yellow/Brown Cap - Low Does Steroid (2x per day)
Pink inhaler - Seretide (B-agonist + steroid)
Viral induced Wheeze
Wheezing episode with Viral URTI
<5 years old
Absence of strong atopic Hx (diff. From Asthma)
NO INTERVAL SYMPTOMS - no SOB/Cough when cold or running (also Diff. From Asthma)
DDx for Asthma
Onset under 5 Onset over 5
Congenital Dysfunctional Breathing
CF Vocal cord dysfunction
PCD Habitual Cough
Bronchitis Pertussis
Foreign Body
What are the goals of asthma Rx?
Limited symptoms during day and night
minimal need for reliever medication
no attacks/exacerbation
No limitation to physical activity
How do we Measure Asthma Control
SANE
SABA/week
Absence from school
Nocturnal symptoms/week
Excertional symptoms/week
when do we use a regular preventer of asthma in children? and what is it?
When using B2 agonist > 2 x a week
if symptomatic 3 times a week or more, waking up at night once a week
What - Start with very low dose ICS
What is the initial add on preventer of asthma
Add on LABA or LTRA
increase ICS dose
2 things to reember about B2 agonist
DO NOT use without ICS (in children)
Use as a fixed dose inhaler
When should spacers and Dry Powder devices be used
Children of primary school age should use a spacer
Those of secondary school age should be given a dry powder device
