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Year 4 PAEDS > RESPIRATORY > Flashcards

RESPIRATORY Flashcards

1
Q

What is the most common presenting symptom of asthma in childhood? How common is this in the background population?

A

WHEEZE is the predominate symptom

1/2 of children in first 3 years of life will have wheeze at some point but this does not mean they have asthma

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2
Q

What are the two types of wheeze and what sort of conditions does each one suggest?

A

TRANSIENT EARLY WHEEZE: wheezing early in the expiration - usually due to infection and normally viral (BRONCHIOLITIS) - narrower airways more susceptible to obstruction with even small degrees of inflammation. Often accompanies by coryza symptoms - disappears by age 5 (bigger airways). Peak at 2y, M>F

RECURRENT & PERSISTENT WHEEZE: due to environmental trigger, wheeze peaks later on (4, 5, 6yo)

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3
Q

Describe a wheeze classical of asthma

A

Is persistent and recurrent, relieved by bronchodilators. Symptoms often worse in morning
Wheeze following specific trigger

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4
Q

Why does the wheeze occur in asthma?

A

When child is exposed to allergen there is an IgE mediated immune response causing inflammation of the small airways (ATOPIC). Also there is bronchial oedema, excessive mucus production and infiltration of cells (basophils and eosinophils)

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5
Q

Give some examples of asthma triggers

A

Cold weather, exercise, pet dander, dust mites, pollen, smoking in the home (ALWAYS ASK ABOUT SMOKING IN THE HOME IN Hx)

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6
Q

What factors should you include in the assessment/history for asthma?

A

Clinical diagnosis so no form ix necessary but ask about:

  • reversibility with bronchodilators (strongly suggestive of asthma)
  • always plot growth (retardation in severe asthma)
  • Ask about / examine for eczema
  • Ask about current medications and effect
  • Ask about time off school / exercise tolerance
  • BASELINE PEFR is always good idea
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7
Q

What might you find on clinical examination for asthma?

A

Between exacerbations not a lot… If long standing and poorly managed:

  • Hyperinflation of chest
  • Harrison sulcus
  • Generalise polyphonic wheeze
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8
Q

Management of chronic asthma in community

A
  1. SABA - Salbutamol Blue Inhaler 100-200mcg
    * **if they are using inhaler more than 3 times a week then add additional therapy
  2. CORTICOSTEROID inhaler (ICS) 200mg budesonide
    * **if still not responsive then add…
  3. LEUKOTRIENE RECEPTOR ANTAGONIST (4-10mg age dependent)
    * **if still not covered
  4. Discontinue LKRA and ADD LABA e.g. salmeterol
    * **and then add the LKRA back in
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9
Q

Management of acute asthma in children

A
  1. SALBUTAMOL NEBULISER 2.5-5mg
  2. STEROIDS: oral prednisolone or IV hydrocortisone if severe
  3. IPRATROPIUM BROMIDE (250-500mg) NEB
  4. MAGNESIUM SULPHATE if symptoms are severe and sats are <92%
  5. AMINOPHYLLINE 500-700mcg/kg/hr can be considered if severe or life-threatening
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10
Q

What is croup?

A

Inflammation and increased secretions of the larynx, epiglottis and upper airway

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11
Q

What organisms most commonly cause croup?

A

Parainfluenza viruses most common
Human metapneumovirus
RSV

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12
Q

Who does croup occur in most commonly and is there a seasonal peak?

A

Children aged 6m-3y

Seasonal peak in autumn

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13
Q

What are the clinical features of croup?

A 
Barking, 'seal-like' cough 
Harsh stridor - AIRWAY OBSTRUCTION 
Hoarseness
Background of preceding coryzal symptoms 
***symptoms often worse at night
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14
Q

Describe an assessment for a child with croup

A

The most important factor is making sure you’re assessing for any signs of AIRWAY OBSTRUCTION (listening for stridor, checking oxygenation)
Check for breathing effort (recession, RR, head bobbing, accessory muscle use)
NEVER EXAMINE THE THROAT OF CHILD WITH CROUP - risk of creating an obstruction

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15
Q

What would be concerning features for a child with croup?

A

STRIDOR - if this begins to occur at rest then the child absolutely has to be admitted.
Low threshold for admission for young children, children who aren’t feeding or children at risk of airway obstruction

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16
Q

How do you treat croup?

A

DEXAMETHASONE 150mcg/kg can be given via mouth or IV depending on severity (prednisolone alternative if dex not available)

If airway obstruction is SEVERE:
- Nebulised adrenaline with oxygen face mask - hopefully by the time the adrenaline has worn off the dexamethasone will have started having an affect

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17
Q

What is epiglottitis? How serious is it?

A

Inflammation of epiglottis, VERY SERIOUS. Even higher risk of airway obstruction than croup

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18
Q

What organisms cause epiglottitis?

A

The main cause of haemophius type B - due to vaccination regime the incidence of this has decreases massively

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19
Q

When do children get the Haemophilus B vaccination?

A

in the 5-in-1 at 2, 3 and 4 months

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20
Q

What is the clinical presentation of epiglottitis and what is characteristic about it?

A

Fever+++ - toxic looking child
Intensely painful sore throat stopping the child from swallowing or speaking
- this leads to DRIBBLING and this is characteristic
Soft inspiratory stridor - child often sat upright to maximise airway/breathing - DO NOT LIE CHILD DOWN TO ASSESS

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21
Q

Management of epiglottitis

A

Immediately admit and contact paediatrics
Will likely have to be intubated by experienced anaesthetist (HDU/PICU)
- take blood cultures and start IV CEFUROXIME
- ET tube can usually be removed after 24 hours when abc have started to work. Abx continued for 3-5 days

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22
Q

If a child has Hib what do you need to do?

A

ALL CONTACTS NEED RIFAMPICIN PROPHYLAXIS

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23
Q

What are some causes of stridor?

A

Croup
Epiglottitis
Foreign body
Laryngomalacia (congenital softening of cartilage - resolves by 2y)

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24
Q

Croup vs. epiglottitis: high fever

A

Epiglottitis

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25
Q

Croup vs. epiglottitis: Stridor

A

Both but more croup

26
Q

Croup vs. epiglottitis: Speech

A

E - unable to speak

C - hoarse voice

27
Q

Croup vs. epiglottitis: Saliva

A

Dribbling in epiglottitis

28
Q

What are the most common causes of pneumonia in children of different ages?

A

In younger children the cause is more often viruses
In older children the cause is more often bacteria

**clinically the distinction is hard

29
Q

What are the common causatives organisms of pneumonia at different ages?

A

NEONATE (from birth tract)

  • Group B Strep
  • Gram negative enterococci

INFANTS AND YOUNG CHILDREN

  • RSV
  • Strep Pneumonia
  • HiB
  • Bordatella Pertussis
  • Chlamydia trachomatis

OLDER CHILDREN >5

  • Mycoplasam pneumonia
  • Strep pneumonia
  • Chlamydia pneumonia

***consider tuberculosis at all ages in high risk groups

30
Q

Presentation of pneumonia

A

Cough (productive of purulent sputum)
SOB or dyspnoea, Fever, malaise, anorexia, lethargy, poor feeding
Bacterial infections lead to neck stiffness or localised chest pain

31
Q

Clinical examination findings in pneumonia

A

Nasal flaring, recession (intercostal, subcostal, sternal), accessory muscle use, head bobbing)
Tachypnoea, end inspiratory crackles (might not be localised), dullness of percussion, decreased breath sounds/bronchial breathing, decreased O2 sats

32
Q

Investigations for pneumonia

A

CXR can be helpful but unless there is a well defined lobar pneumonia they are not useful at distinguishing bacterial from viral
- but look for empyema or effusions

Sputum culture

33
Q

What are some indications for admission for pneumonia?

A

O2 sats <93%
Severe tachypnoea or signs of increase effort (grunting, recessions)
Poor feeding or young age
Family unable to provide appropriate care

34
Q

Management of pneumonia

A

Oxygen therapy if hypoxic
Analgesia if pain
IV fluids if dry
ABX:
- Older children managed with oral amoxicillin
- Newborns / infants should be given broad spectrum (co-amox)
- Children over age of 5 can be given amoxicillin or erythromycin

If you suspect mycoplasma then use a macrolide = ERYTHROMYCIN

35
Q

Who does bronchiolitis occur in and when?

A

VERY COMMON (2-3% of all children every winter)

Most aged between 1-9 months (very rare after 1y)
PEAK INCIDENCE 3-6months

36
Q

What is the main cause of bronchiolitis?

A

RSV in 80% cases

Others: rhinovirus, adenovirus, parainfluenza virus

37
Q

Presentation of bronchiolitis

A

Coryza symptoms will usually occur first (cough, colds) they are followed by a dry cough and increasing breathlessness

  • Dyspnoea common cause of admission
  • FEEDING DIFFICULTIES commonly occur because babies are nasal breathers
  • Tachypnoea, recession, hyper inflated chest (prominent sternum with liver displaced downward)
  • Wheezing (more so on expiration)
  • Tachycardia
  • Fine end inspiratory crackles
  • Cyanosis or pallor
38
Q

What investigations should you do for bronchiolitis?

A

NASAL SWAB PCR - to identify RSV
CXR - hyperinflation and acute bronchiectasis
BLOOD GAS (usually CBG) - done to identify hypercarbia which would be an indication for ventilatory support

39
Q

What are some criteria for admission with bronchiolitis?

A
  • apnoea
  • child appears very unwell
  • Central cyanosis
  • Severe resp distress (grunting, recessions, RR>60, persistent O2 sats <92%)
  • difficulty feeding (taking <50-75% feeds)
  • clinical dehydration
  • low threshold for younger children
40
Q

Management for bronchiolitis?

A

humidified o2 can be given via nasal cannulae - aim for sats 94-98%
DO NOT GIVE BRONCHODILATORS - have not been shown to help
Maintenance fluid and feeds via NGT if necessary
Ventilatory support if retaining CO2
HIGHLY INFECTIOUS - isolate or group RSV children together

41
Q

How long will bronchiolitis last?

A

Usually around 2 weeks - some will have lingering cough or wheeze

42
Q

How is cystic fibrosis inherited and how common is it?

A

Autosomal recessive - the most common autosomal recessive condition
1 in 2500 live births
Carrier rate 1 in 25

43
Q

Describe the pathophysiology of cystic fibrosis

Which faulty gene is most common?

A

The genetic mutation leads to a fault chloride channel meaning salts can be pumped across membranes into secretions. The water content of these secretions therefore drops making them thick and sticky - leads to symptomology

DeltaF508 is most common on chromosome 7

44
Q

Clinical effects of CF: respiratory

A

Thick secretions lead to repeated infections (characteristically with pseudomonas aeruginosa)
Dyspnoea, chronic cough (productive of purulent sputum), Hyperinflation of chest
Coarse inspirator crackles/creps
Expiratory wheeze

45
Q

Clinical effects of CF: other than resp

A

MECONIUM ILEUS (thick sticky meconium that is not cleared in the first 48 hrs) - common first identification (in 10-20%)
Secretions blocking pancreatic duct leads to poor release of digestive enzymes leading to malabsorption and FTT
High concs of sodium and chloride in sweat - SWEAT TEST
FINGER CLUBBING (only in older children)
REPRODUCTIVE TRACT FAILURE - women will have thick mucus plug and will need assistance conceiving. men will have absent vas deferens and be infertile

46
Q

How is CF detected?

A 
Meconium ileum at birth 
Sweat test (chloride >60mmol/L)
GUTHRIE TEST (heel prick) looking for immunoreactive trypsinogen
47
Q

How is CF managed?

A

MDT APPROACH (specialist doctors, nurses, physiotherapist, OTs, dieticians, school education)
The most damaging problem is the recurrent chest infections and so this is where a lot of management is focussed - consider PROPHYLACTIC FLUCLOXACILLIN
- might need to attach PICC line (portacath) to administer
++ additional rescue abx for active infections
Phsyiotherapy to clear mucus (percussion)
Nebulised DNAase or hypotonic saline to slacken mucus
Lung transplant in end-stage disease
NUTRITIONAL MANAGEMENT:
- high calorie diet (150% normal)
- Young children might require gastrostomies so they can be fed overnight. Then they eat normally during day)

48
Q

In which patients does TB commonly occur?

A

Usually in patients who are not of British descent
FOREIGN TRAVEL
In those with an HIV co-infection or some sort of immunocompromise
In those with an infective contact (always ask about infection in home contacts)

49
Q

How does TB present initially?

A

The vast majority will be asymptomatic
They might have a cough in the primary phase but this will subside as the child enters the latent phase…The TB will then resurface when there is another infection that might cause strain on immune system

50
Q

If the child develops symptoms of TB then what does this mean and what would these symptoms be?

A 
This suggests that the body has failed to keep bacilli sealed in the tubercles in the lungs...Sx include:
- Cough 
- Fever
- Anorexia 
- Weight loss 
- Haemoptysis 
- Lymphadenopathy + Lung lesions 
Symptoms from other organs (kidneys, bones, joints and CNS)
51
Q

How do we investigate possible TB infection?

A

Mantoux test - inject with some of the tuberculin and if the person has a reaction then they’ve probably already been exposed (give BCG)

CXR - tubercles, peri-bronchiole lymphadenopathy, collapse and consolidation in affected lungs, pleural effusions

INTEFERON GAMMA RELEASE ASSAY (extracting T cells and seeing how much of a response they have to tuberculin antigens in vitro)

52
Q

How do we treat TB?

A

TRIPLE OR QUADRUPLE THERAPY:
Rifampicin, Isoniazid, Pyrazinamide and Ethambutol

AFTER 2 MONTHS:
Reduce to just rifampicin and isoniazid

TREATMENT USUALLY LASTS 6 MONTHS
?Pyridoxine in children to prevent peripheral neuropathy

53
Q

How do we treat children presenting with tuberculosis meningitis?

A

Dexamethasone

54
Q

How do we manage contact preventing in cases of TB?

A

PHE should be informed
BCG should be offered to all high risk individuals at birth
DO not give BCG to HIV+ or other individuals at risk of immune compromise due to risk of dissemination
ALWAYS SCREEN FAMILY MEMBERS

55
Q

What is the causative organism of whooping cough?

A

The bacteria Bordatella Pertussis

56
Q

How does whooping cough present?

A

There will be a one week history of coryzal symptoms (runny nose, sore throat) and then the cough will start…
The cough is SPASMODIC - it is so intense that when the child is finished he/she will GULP for air (whoop)
- During these coughing fits they often change colour (might go red or blue)
- APNOEA might predmoninate in the very young in whom the characteristic whoop is not heard
- Cough might be so intensive as to cause sub-conjunctival haemorrhage or epistaxis

57
Q

What would happen if whooping cough were not treated?

A

It is SELF-LIMITING
The spasmodic cough would usually last somewhere between 3-6 weeks and then the intensity of the cough would drop
HOWEVER a low-intensity cough will often linger for months afterwards (convalescent phase)

58
Q

What are some common complications of whooping cough?

A

Pneumonia, conjunctivitis and bronchiectasis

59
Q

How do we investigate whooping cough?

A

Peri-Nasal swab can be done to identify the organism

FBC should be done as part of routine bloods as there will often be a marked lymphocytosis

60
Q

How do we treat whooping cough?

A

ERYTHROMYCIN does eradicate the bordatella pertussis but ONLY IF STARTED EARLY, in the catarrhal phase and so shouldn’t really be given after this
- in practice it is often given anyway as it reduces spread - it is also given prophylactically to close contacts

61
Q

Will children with whooping cough require exclusion from school?

A

They WILL REQUIRE exclusion from school/play groups for 2 days after the erythromycin has been given OR up to 21 days after symptoms have started

Year 4 PAEDS (18 decks)

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