Respiratory Flashcards
What age group is most affected by bronchiolitis
infants, 1-9 months
When is bronchiolitis most common?
during annual winter epidemics
What is the most common pathogen causing bronchiolitis?
Respiratory syncytial virus
what other viruses cause bronchiolitis
parainfluenza
rhinovirus
adenovirus
influenza
What are the symptoms and signs of bronchiolitis
symptoms coryzal symptoms dry wheezy cough high pitched wheeze temporarily stop breathing breathlessness
signs tachypnoea and tachychardia subcostal and intercostal recession hyperinflation of chest fine inspiratory crackles
What investigations would you do for bronchiolitis?
Pulse oximetry
if respiratory failure - ABG, CXR
when do you admit infants with bronchiolitis?
if apnoea
sats less than 90
inadequate oral intake (50-70% of usual)
severe resp distress
what is the management for bronchiolitis?
- humidified oxygen
- fluids NG or IV
- non invasive resp support - CPAP
- good infection control measures as RSV is highly contagious
how soon do children with bronchiolitis recover and what are the possible complications?
- most recover within 2 weeks
complications
- rarely - adenovirus infection, can go on to cause Bronchiolitis Obliterans
Which group of children are considered high risk for bronchiolitis?
premature babies with
- bronchopulmonary dysplasia
- congenital heart disease
- CF
What can be given to prevent Bronchiolitis? Who is it for?
monoclonal antibody to RSV
palvizumab - monthly via IM injection
for high risk preterm babies, reduces hospital admissions
Which bacterium causes whooping cough?
Bordatella pertussis
what are the three phases of whooping cough?
Coryzal (catarrhal phase)
Paroxysmal phase (paroxysmal cough followed by inspiratory whoop)
Concalescent phase (symptoms decrease)
When are symptoms of whooping cough worse and what can they cause?
Symptoms are worse at night,
can cause vomiting
What are the symptoms of whooping cough?
- during paroxysm- child goes red or blue
- in infants, whoops can be absent, apnoea may occur
- epistaxis and subconjuntival haemorrhage after significant coughing
What are some uncommon complications of whooping cough
Pneumonia
Seizures
Bronchiectasis
What investigations should you do for whooping cough?
Prenasal swab culture
PCR is more sensitive
Blood count - marked lymphocytosis
What is the management for whooping cough?
Macrolide antibiotic - eradicate organism and decrease symptoms (clarithromycin
Close contacts - macrolide prophylaxis
unimmunised infant contacts - immunise!
List some of the causes of recurrent/persistent cough in children?
- recurrent respiratory infections (or following RSV, Mycoplasma or Pertussis)
- Asthma
- Persistent lobar collapse following pneumonia
- recurrent aspiration
- suppurative conditions e.g CF, cilliary dyskinesia, immune deficiency
- persistant bacterial bronchitis
- inhaled foreign body
- cigarette smoke - active or passive
- TB
- airway anomalies e.g trachea-bronchomalacia, trachea-oesophageal fistula
Define Pneumoniae
Disease characterised by inflammation of lung parachyma with congestion caused by viruses or bacteria or irritants
What are the causes of Pneumonia ?
Newborns: organisms from mothers genital tract - esp. GBS but also gram negative enteroccoci and bacilli
most common viral: RSV
most common bacterial cause:pneumococcus
Also Hib, S.aureius K.pneumoniae mycobacterium Tuberculosis
Which age range is viral causes of pneumoniae more common?
viral causes more common in younger children
bacterial in older children
Symptoms of pneumoniae?
fever, cough and rapid breathing usually precede URTI
lethargy, poor feeding, unwell child
- localised chest, abdominal and neck pain suggests ????
what does localised chest, abdominal and neck pain suggest in pneumoniae?
bacterial infection!
what are some of the signs of penumoniae?
- Tachypnoea
- nasal flaring
- chest indrawing
- high RR - most sensitive sign
end-inspiratory coarse crackles over the affected areas (consolidation - dull to percussion) - decreased breath sounds
- bronchial breathing
How do you diagnose pneumoniae in a child?
- history of cough +/- difficulty breathing (<14 days) with increased RR - age dependant
> 2 months: > 60 / min
2 - 11 months: > 50 / min
11 months: > 40 / min
- CXR dense or fluffy opacity over a portion or entire lobe. can contain air bronchogram
what investigations would you do for pneumoniae?
CXR - can show pleural effusion or empyema
Nasopharyngeal aspirate
when should you admit a child with pneumonia and what is the management?
admit if: <92% sats, recurrent apnoea, grunting, inability to maintain adequate fluid/feed intake. (supportive care - oxygen and analgesia. + iv fluids)
IV benzylpenicillin
or oral co-amoxiclav - 7-14 days
what does persistent fever despite 48h abx in children with pneumoniae suggest and what should you do?
suggests pleural collection
requires drainage
what are complications of pneumoniae?
what should you do?
Lobar collapse, atelectasis
repeat CXR after 4-6 weeks
what are the four stages of pneumoniae?
- consolidation
- red hepatization
- grey hepatization
- resolution
Which is the most common causative organism of lobar pneumonia?
streptococcus pneumoniae
What does Streptococcus pneumoniae look like under the microscope?
Gram +ve cocci, in pairs
Which organisms might cause pneumonia in a HIV-positive child?
- Mycobacterium tuberculosis
Others
- Pneumocystis jiroveci
- Mycoplasma pneumoniae
what is the genetics of CF
- autosomal recessive
- defective CFTR on chromosome 7
- commonest in caucasions
What is the pathphysiology of CF?
- abnormal ion transport across epithelial cells (reduced cl- out of cells, increased Na+ reabsorption)
- thicker mucus secretions
- chronic pseudomonias auerugonosia infecion
Clinical features of CF?
typical, newborn, infancy, young child and older children/adults
- persistent wet cough, purulent sputum
- newborn - meconium ileus
- infancy - prolonged neonatal jaundice,
growth faltering, recurrent chest infections, malapsorption, steatorrhoea
young child - bronchiectasis, rectal prolapse, sinusitis and nasal polyps
- older children and adults
• Allergic bronchopulmonary aspergillosis, DM, Cirrhosis and portal HTN, Pneumothorax, recurrent haemoptysis, Distal intestinal obstruction, sterility in males
What are the signs of CF?
- hyperinflation of chest due to air trapping
- coarse inspiratory crepitations and/or expiratory wheeze
- Finger clubbing
Diagnosis of CF?
abnormally raised immunoreactive trypsinogen on heel prick test
CFTR mutations on genetic tests
confirmed with sweat test - >60mmol/L Cl ions supports the diagnosis
CXR: hyperinflation, cysts, bronchial dilation (+)
what can cause false positives and negatives in the sweat test?
False Positive
- Atopic eczma
- Adrenal insufficiency
- hypothyroidism
- dehydration
- malnutrition
False negative
oedema
How is CF managed? - Resp
- regular lung function measurement using spirometry
- physio 3x daily to clear airway secretions
- percussion and postural drainage
- continuous abx prophylaxis (flucloxacillin)
- rescue abx -Ticarcillin (>1 month) + gentamicin
- bilateral lung transplant in end stage CF disease
How is CF managed - gastro and nutrition?
- enteric coated pancreatic replacement enzymes
- high calorie diet - may need overnight gastrostomy feeding
- fat soluble vitamin supplements
What are the phases of TB?
Primary phase:
- Latent phase - asymptomatic, uninfectious - treat with chemoprophylaxis to prevent disease
- Active phase - symptomatic/ clinical evidence e.g x-ray, lymph nodes
Dormancy and dissemination
Reactivation
Post-primary TB
What is the stain for Mycobacterium tuberculosis?
Ziehl-Neelsen stain
Why may a mantoux test be positive other than in TB?
Due to BCG vaccine
Interferon gamma release assay does not have false positives (looks for antigens only on mycoplasma tubeculosis) but does not rule out false negatives
What are the symptoms of TB
fever
sweats
weight loss
cough
What are the tests you can do for TB?
Sputum CXR Tissue Mantoux interferon gamma release assay
What do you have to do for TB ?
Contact tracing
test with IGRA and mantoux
Treatment for TB?
+ side effects
Active phase
- Rifampicin - 6 months (hepatitis - raised bilirubin)
- Isoniazid - 6 months (neuropathy)
- Pyrazinamide - 2 months
Latent phase
- Rifampicin - 3 months
- Isoniazid - 3 months
What should you do with children <2 years who have been in contact with someone with a +ve sputum sample
- start on prophylactic isoniazid
- if mantoux and IGRA negative 6 weeks later give BCG vaccine
who provides additional support in TB
community TB nursing team
What is primary ciliary dyskinesia?
impaired mucociliary clearance
What does primary ciliary dyskinesia lead to?
- recurrent URTI and LRTI - can lead to bronchiectasis
- recurrent productive cough, purulent nasal discharge, chronic ear infection
What is primary ciliary dyskenia associated with?
dextrocardia and situs invernus
kartagener syndrome - when they have both PCD + ^
How is Primary Ciliary Dyskinesia diagnosed?
examination of nasal epithelial cells brushed from nose
How do you manage primary ciliary dyskinesia?
- daily physiotherapy
- treatment of infections with abx
- ENT follow up
what is otitis media?
infection of the middle ear inflammation and build up of fluid behind ear drum
Which age range is acute otitis media most common in and why?
6-12 months
- risk due to short eustachian tubes that are horizontal and function poorly
What are the signs and symptoms of AOM
- bright red and bulging tympanic mebrane
- with loss of normal light reflection
- may be acute perforation of eardrum + pus
which pathogens cause AOM?
- Viruses - RSV, Norovirus
- Bacterial - pneumococcus, H.influenza, moraxella etc
What are the complications of AOM?
mastoiditis
meningitis
Treatment of otitis media?
- Analgesia for pain
- Amoxicillin if unwell after 2-3 days
What can recurrent ear infections lead to? what are the risks?
- otitis media with effusion
- can cause conductive hearing loss
- manage by: ventilation tubes + adenoidectomy
Define Pharyngitis and what is it usually due to?
When pharynx and soft tissue are inflamed, local lymph noeds enlarged and tender
Usually due to viral infection (adenovirus, enterovirus, rhinovirus)
older children also get group A beta haemolytic strep
Define Tonsilitis and what is the most common cause?
form of pharyngitis where there is intense inflammation of tonsils often with purulent exudate
common pathogens =
- Group A beta haemolytic strep
- Ebstein Barr Virus
Although it is difficult to tell the difference clinically between bacterial and viral tonsilitis, what is more commonly seen in bacterial?
- headache
- apathy
- abdo pain
- white tonsiller exudate
- cervical lymphadenopathy
How do you treat tonsilitis?
- Pencillin V or Eryhtomycin (if allergic)
- 10 days
Why do you treat tonsillitis for 10 days?
eradicate and prevent rheumatic fever
What else can Group A Beta haemolytic strep also cause besides tonsillitis that is a possible complication?
Scarlet fever
Rheumatic fever
What are the signs of Scarlet fever as a complication of tonsillitis and what is a further complication?
What is the Tx?
- fever 2-3 days before tonsillitis and headache
- sandpaper like maculopapular rash
- flushed cheeks, perioral sparing
- tongue often white and coated, may be swollen
Tx - Abx
further complications = acute glomerulonephritis + rheumatic fever
What is epiglottitis
Swelling of epiglottis and surrounding tissue, associated with septicaemia
Why is acute epiglottitis considered a life threatening condition?
Due to the risk of respiratory obstruction
What is the most common cause of acute epiglottitis?
Haemophilus influenza b
When do you vaccinate for Hib?
2, 3 and 4 months
What do you expect to see in a child with acute epiglottitis?
o High fever
o Child appears toxic
o Painful throat making it difficult to swallow or talk
o Child sits still and upright with open mouth (drooling) to optimize airway
o Soft inspiratory stridor, increasing resp distress
o Cough minimal or absent
How do you manage acute epiglottitis?
o Senior anaesthetist, paeds and ENT – all
o Intubate under GA
o Urgent tracheostomy may be needed
o After airway secured – blood culture, IV abx
o Prophylaxis with rifampicin for close household contacts
