Respiratory Flashcards
Give 3 signs of respiratory distress in a child.
- Tachypnoea, RR 40-60.
- Subcostal and intercostal recession.
- Stridor.
- Tracheal tug.
- Cyanosis
What virus can cause croup?
Parainfluenza virus
Describe the epidemiology of croup.
Peak incidence at 6 months - 3 years
More common in autumn
What is croup?
Acute laryngotracheobronchitis - trachea, bronchi and larynx are all affected.
What are 4 features of croup?
stridor
barking cough (worse at night)
fever
coryzal symptoms
Clinical Knowledge Summaries (CKS) suggest using the following criteria to grade the severity of croup.
Mild:
Occasional barking cough
No audible stridor at rest
No or mild suprasternal and/or intercostal recession
The child is happy and is prepared to eat, drink, and play
Moderate:
Frequent barking cough
Easily audible stridor at rest
Suprasternal and sternal wall retraction at rest
No or little distress or agitation
The child can be placated and is interested in its surroundings
Severe:
Frequent barking cough
Prominent inspiratory (and occasionally, expiratory) stridor at rest
Marked sternal wall retractions
Significant distress and agitation, or lethargy or restlessness (a sign of hypoxaemia)
Tachycardia occurs with more severe obstructive symptoms and hypoxaemia
What are the criteria to admit a child with croup?
CKS suggest admitting any child with moderate or severe croup. Other features which should prompt admission include:
< 6 months of age
Known upper airway abnormalities
Uncertainty about diagnosis
What is the mx of croup?
A single dose of oral dexamethasone (0.15mg/kg)
Prednisolone is an alternative
What is the emergency tx of croup?
High-flow oxygen
Nebulised adrenaline
Give 3 signs of bronchiolitis.
Coryzal symptoms precede:
- dry cough
- increasing breathlessness
- wheezing, fine inspiratory crackles (not always present)
- feeding difficulties associated with increasing dyspnoea are often the reason for hospital admission
What viruses can cause bronchiolitis?
RSV = main causative organism!
Also: rhinovirus, influenza, adenovirus, parainfluenza virus.
Describe the epidemiology of bronchiolitis.
< 1yr olds (90% are 1-9 months, with a peak incidence of 3-6 months).
Maternal IgG provides protection to newborns against RSV
Higher incidence in winter
Give 5 bacterial organisms that commonly cause pneumonia in children.
- Group B strep in neonates.
- S.pneumoniae.
- H.influenzae.
- K.pneumoniae.
- M.pnuemoniae.
Give 5 signs of pneumonia in children.
- Fever.
- Difficulty in breathing
- Increased respiratory rate (best clinical sign)
- Cough.
- Poor feeding.
- Lethargy.
- Localised chest, abdominal and neck pain (feature of pleural irritation and suggests bacterial infection)
What investigations might you do in a child who you suspect has pneumonia?
- CXR -> look for consolidation.
- Blood cultures.
It is often difficult to get a sputum sample.
Describe the treatment for a child with pneumonia.
- 1st line- Amoxicillin
- Macrolides eg Erythromycin may be added if there is no response to first line therapy
- Macrolides should be used if mycoplasma or chlamydia is suspected
- Pneumonia associated with influenza- Co-amoxiclav
What is the difference between wheeze and stridor?
Wheeze: polyphonic noise heard on expiration.
Stridor: monophonic high pitched noise heard on inspiration.
Describe the aetiology of recurrent wheeze.
- Persistent infantile wheeze.
- Viral episodic wheeze.
- Asthma.
What is persistent infantile wheeze normally associated with/exacerbated by?
Persistent infantile wheeze tends to affect the small airways. It is associated with parental smoking or post-viral infection.
Are inhalers likely to help a child with persistent infantile wheeze?
No. Inhalers are unlikely to help; symptoms will improve as the child gets older.
What is viral episodic wheeze normally associated with/exacerbated by?
It normally follows a URTI. The child will have no interval symptoms.
Are inhalers likely to help a child with viral episodic wheeze?
Bronchodilators may help but there is no benefit from inhaled steroids.
Symptoms are likely to improve with age.
How would you manage an acute exacerbation of asthma in a child?
Pg 292 of sunflower book
Inhalers: name 2 ‘preventers’.
ICS act as ‘preventers’ e.g. beclomethasone, budenoside.
Inhalers: name 2 ‘relievers’.
Beta agonists e.g. salbutamol.
Muscarinic antagonists e.g. ipratropium bromide.
Give 3 long term risks of systemic steroids.
- Adrenal suppression.
- Growth suppression.
- Osteoporosis.
Why might asthma treatment fail in children?
- Poor adherence.
- Wrong diagnosis.
- Environmental factors.
- Choice of drug.
- Bad disease.
Name 3 URTI.
- Rhinitis.
- Otitis media.
- Pharyngitis.
- Tonsillitis.
- Laryngitis.
Name 3 LRTI.
- Bronchitis.
- Croup.
- Epiglottitis (bacterial).
- Tracheitis.
- Bronchiolitis.
- Pneumonia.
Would you expect a patient with bronchitis or with bronchiolitis to be hypoxic and tachypnoeic? Explain why.
Bronchiolitis.
Bronchiolitis affects the respiratory portion of the airway, where gas exchange takes place therefore you may see hypoxia and tachypnoea.
Bronchitis affects the conducting portion of the airway and so is unlikely to have these effects.
Give 3 signs of bronchitis in children.
- Chronic cough.
- Cough worst at night.
- No fever.
Name 4 LRTI that could be caused by RSV.
- Acute bronchiolitis.
- Wheezy bronchitis.
- Asthma exacerbation.
- Pneumonia.
- Croup.
Why are infants more susceptible to descending infection?
Infants have a poor innate immune response
Name a bacteria that causes acute epiglottitis.
H.influenzae B.
Acute epiglottitis is a severe acute illness.
Give 5 signs of acute epiglottitis.
- High fever in an ill, toxic-looking child
- Intensely painful throat
- Dribbling.
- Huge inflamed epiglottis that blocks the oesophagus and trachea-> soft inspiratory stridor
- Sitting immobile, upright, with an open mouth to optimise the airway
Name 2 respiratory illnesses that can present with stridor.
- Croup - often a louder stridor.
2. Acute epiglottitis - often a quieter stridor due to inflamed epiglottis blocking oesophagus and trachea.
Describe the immediate management for acute epiglottitis.
Secure the airway - anaesthetist, ENT surgeon.
What is pneumonia?
Inflammation of the lung parenchyma with congestion
Describe the diagnostic criteria for pneumonia in children.
- If <3: pyrexial, chest recession and RR>50 = pneumonia.
- If older and the child has a history of breathing difficulties, cough and increased RR = pneumonia.
Describe the treatment of pneumonia.
- Amoxicillin is first-line for all children with pneumonia
- Macrolides may be added if there is no response to first line therapy
- Macrolides should be used if mycoplasma or chlamydia is suspected
- In pneumonia associated with influenza, co-amoxiclav is recommended
What antibiotics might you use in a child with pneumonia caused by mycoplasma pneumoniae?
Mycoplasma pneumoniae is intracellular and so amoxicillin won’t work therefore give macrolides e.g. clindamycin, erythromyocin.
What is a unilateral pleural effusion suggestive of?
Infection e.g. parapneumonic or empyema.
What is a bilateral pleural effusion suggestive of?
Fluid overload e.g. HF or nephrotic syndrome.
What are the moderate, severe and life threatening features of asthma?
Moderate: PEFR 50-75% best or predicted Speech normal RR < 25 / min Pulse < 110 bpm
Severe: PEFR 33 - 50% best or predicted Can't complete sentences RR > 25/min Pulse > 110 bpm
Life-threatening: PEFR < 33% best or predicted Oxygen sats < 92% Silent chest, cyanosis or feeble respiratory effort Bradycardia, dysrhythmia or hypotension Exhaustion, confusion or coma
List 2 causes of pulmonary hypoplasia.
- oligohydramnios
2. congenital diaphragmatic hernia
