Respiratory Flashcards
What is the other name for croup
Laryngotracheobronchitis
What other symptoms would you see in bacterial tracheitis
Fever
child looks toxic
What are the clinical features of croup
- Barking cough ‘seal-like’
- Harsh stridor
- Hoarseness
- Respiratory distress and dyspnoea
- Preceded by low grade fever and coryza
- Chest wall/ sternal indrawing – chest recessions
- Symptoms start and are worse at night and increased agitation
- Central cyanosis and drowsiness indicated severe hypoxaemia = URGENT INTERVENTION
What is the most common cause of croup
Parainfluenza virus types 1 and 2
What is the most common cause of bronchiolitis
Respiratory syncytial virus
what is the chronological order of Bronchiolitis
Preceding coryzal symptoms with clear secretions (1-2 days)
Symptoms peak at 3-5 days:
• Dry cough (resolves in 90% of infants within 3 weeks)
• Increasing breathlessness
• Feeding difficulty
• Recurrent apnoea (serious complication)
• Fever (30% of cases less then 39ᵒC)
wheeze and inspiratory crackles on auscultation
How would you diagnose bronchiolitis
Mostly clinical diagnosis
• PCR analysis of nasopharyngeal secretions (swabs)
• Chest x ray may show hyperinflation of the lungs due to small airway obstruction, air trapping and focal atelectasis
• Pulse oximetry for arterial oxygen saturation
• Capillary Blood gas sample for severe cases with worsening respiratory distress (supplemental oxygen greater than 50%)
How to manage bronchiolitis
- humidified oxygen via nasal cannula if sats less then 92%
- monitored for apnoea
- fluids either IV or via nasogastric tube
- assisted ventilation via CPAP or full ventilation in small percentage of infants for those with impending respiratory failure
- kept in separate room due to how contagious RSV is
What are the main causes of stridor
Croup- Epiglottitis- Bacterial Tracheitis - Diphtheria - Laryngomalacia - Inhaled foreign body- Angioedema / anaphylaxis
What are the main cause of wheeze
Asthma
bronchiolitis
viral induced wheeze
pneumonia
What are the main signs of respiratory distress
cyanosis tracheal tug subcostal/intercostal recessions hypoxia, tachypnoea wheeze stridor head bobbing
How can pneumonia present
Cough, fever, tachypnoea, chest recession, nasal flaring, head bobbing, hypoxia, hypotension, confusion…. SHOCK!!!
What are the typical bugs to look out for in pneumonia and where to they occur
Streptococcus pneumonia is most common
Group B strep occurs in pre-vaccinated infants, NEONATES!
Staphylococcus aureus - chest x ray findings of pneumatocoeles (round air filled cavities) and consolidations in multiple lobes.
Haemophilus influenza pre-vaccinated/unvaccinated children.
Mycoplasma pneumonia, also common in children may develop erythema multiforme (red circular rash)
RSV is the most common viral cause, influenza is also an important cause… a viral cause is more common in < 2 yr olds.
What investigations are needed for pneumonia
CXR, blood culture, FBC, sputum culture, throat swabs for bacterial culture and Viral PCR, capillary blood gas
What is the treatment for pneumonia
Treatments
Neonates – IV Broadspectrum abx
Older children 1st line – Amoxicillin 2nd line erythromycin
Add co-amoxiclav if associated with influenza
Treat with erythromycin for mycoplasma pneumoniae
Macrolides will cover the atypical pneumonias.
How does an acute asthma attack present
Progressively worsening shortness of breath + Signs of respiratory distress + Tachypnoea + Expiratory wheeze + with reduced air entry… A silent chest is an ominous sign.
How is an acute asthma attach managed
1 puff every 30-60 s of salbutamol up to a max of 10 puffs…
Supplementary high flow oxygen nebulised salbutamol nebulised ipratropium bromide Oral prednisone (1mg per kg for 3 days) IV hydrocortisone IV Salbutamol IV aminophylline IV magnesium sulphate
Call an anaesthetist and the intensive care unit.
They may need intubation and ventilation
How is an acute asthma attack managed after admission to hospital
Prescribed a reducing regime of salbutamol
Finish the course of oral prednisolone (typically 3 – 5 days total)
Provide safety-net information, 1 week GP follow up
Provide an individualised written asthma action plan
How is asthma managed in a <5 year old
Short-acting beta agonist – salbutamol
Add a low dose corticosteroid inhaler
Add leukotriene receptor antagonist (LTRA) - oral montelukast
How is asthma managed in a 5-12 year old
Start a SABA – salbutamol as required
Add a regular low dose corticosteroid inhaler
Add a LABA inhaler - salmeterol.
Titrate up the corticosteroid inhaler to a medium dose.
Oral leukotriene receptor antagonist - montelukast
Increase the dose of the inhaled corticosteroid to a high dose.
What is the presentation of anaphylaxis
Urticaria, Itching, Swelling of lips, tongue, eyes (angioedema), Wheeze, Stridor (laryngeal involvement), Shortness of breath, Tachycardia, Abdominal pain, Collapse, hypotension.
What is the immediate management of anaphylaxis
ABCDE, oxygen, IV fluids, IM adrenaline, hydrocortisone IV and antihistamines oral.
Adrenaline can be repeated in 5 mins
Measure tryptase
Give epi pen
+ 2 further doses ofPrednisolone.
What is the presentation of viral induced wheeze
fever, coryzal symptoms, expiratory wheeze, <3 years old
What are the common causes of viral induced wheeze
Commonly RSV or rhinovirus, a small amount of inflammation and oedema, this slight narrowing leads to a proportionally larger restriction in airflow… Leading to a wheeze.
What is the treatment for viral induced wheeze
supplementary oxygen
salbutamol and inhaled corticosteroids
Montelukast
What is the treatment for croup
oral dexamethasone oxygen nebulised budesonide nebulised adrenalin DONT EXAMINE AIRWAY
What is the main cause of epiglottitis
Haemophilus influenza B
What are the key signs and symptoms of epiglottitis
Drooling, sore throat, dysphagia, stridor, fever, looking septic.
Laryngoscopy - Beefy-Red-Stiff oedematous epiglottis
lateral x-ray of the neck shows a characteristic “thumb sign”
What is the treatment/management of acute epiglottitis
Get ITU - Need to protect the airway - Nasotracheal intubation
IV cefotriaxone + dexamethasone
blood culture + close contact prophylaxis with Rifampicin, because they probably aren’t vaccinated either.
What is the presentation of laryngomalacia
intermittent chronic stridor, made worse with feeding and crying
What is the cause of laryngomalacia
This is congenital stridor.
Part of the larynx above the vocal cords (the supraglottic larynx) is structured in a way that allows it to cause partial airway obstruction.
Chronic stridor on inhalation, when the larynx flops across the airway as the infant breathes in.
A characteristic “omega” shape epiglottis on Bronchoscopy.
What is the treatment of laryngomalacia
no treatment, should resolved in 18 months
What is the presentation of pertussis
coryzal, violent coughing that brings on vomiting and gasping for air, inspiratory whoop of air
What is the cause of pertussis
an upper respiratory tract infection - the “100-day cough”
Gram –ve cocobacilli - Bordetella Pertussis
How is pertussis diagnosed
Per nasal-pharynx swabs and culture for pertussis
anti-pertussis toxin immunoglobulin G
What is the treatment of pertussis
Part of the 6 in 1 vaccine given at 2, 3, 4 months and 3-5 yrs.
*it is also important to vaccinated mother between 20 – 32 weeks.
Macrolides - azithromycin, erythromycin or clarithromycin (< 1 month)
Complications – bronchiectasis, pneumothorax
What is the cause of CF
autosomal recessive - cystic fibrosis transmembrane conductance regulatory gene on chromosome 7.
Most common is the delta-F508 mutation.
Codes for chloride channels.
What are the key signs and symptoms of CF
Thick pancreatic and biliary secretions - blockage of the ducts, resulting in a lack of pancreatic enzymes.
Thick airway secretions - reduce clearance = bacterial colonisation.
Congenital bilateral absence of the vas deferens
Meconium ileus - not passing meconium within 24 hours, abdominal distention and vomiting.
How is CF diagnosed
Newborn blood spot testing
The sweat test is the gold standard for diagnosis
Genetic testing for CFTR gene by amniocentesis or CVS
How is CF managed
Particularly susceptible to staph aureus and pseudomonas.
Pseudomonas - nebulised antibiotics tobramycin / Oral ciprofloxacin
staph aureus – prophylactic flucloxacillin
Chest physiotherapy/exercise is essential to clear mucus
High calorie diet + CREON tablets to replace pancreatic enzymes
Prophylactic flucloxacillin + Vaccinations (pneumococcal, flu and varicella)
Bronchodilators such as salbutamol inhalers
Nebulised DNase (dornase alfa) - break down DNA material in respiratory secretions, making secretions less viscous and easier to clear
Nebulised hypertonic saline
Fertility treatment involving testicular sperm extraction for infertile males
Genetic counselling (average life expectancy is almost 50 yrs now)
Other complications – pancreatic insufficiency & diabetes
