Respiratory Flashcards
What is croup and how does it occur?
Laryngotracheobronchitis:
- Upper respiratory tract infection caused by viral infection - normally parainfluenza, influenza and RSV
- Leads to swelling of the larynx, trachea and bronchi causing some degree of upper airway obstruction
Presentation of croup…
- Barking cough
- Stridor
- Hoarse voice
- Coryzal symptoms - nasal congestion
- Low grade fever
- Normally seen in 6mths- 6 yrs
Management of croup…
Mild -moderate:
- Dexamethasone (0.15mg/kg PO STAT) or Prednisolone (1-2mg/kg STAT) - can be sent home if good response
Severe:
- Nebulised adrenaline
- ITU admission if worsening
- Oxygen may be needed if SpO2 <92%
What causes epiglottitis?
Normally caused by haemophilus influenzae type B
How does epiglottitis present?
- Sudden onset with continuous stridor
- Drooling secretions
- No barking cough
- Toxic and feverish
- Swollen, cherry red epiglottis will be seen
Treatment of epiglottitis?
Cefotaxime
Key features of viral induced wheeze…
- Normally occur between 12 mths - 5 yrs
- Wheeze only during viral illness
- Rapid onset of wheeze
- Responsive to beta agonists e.g. salbutomol
Management of viral induced wheeze…
Moderate (able to talk, mild recessions, RR<40):
- Salbutomol inhaler - 6-10 puffs via spacer and mask
Severe (difficulty talking, use of neck muscles, RR >40):
- Salbutomol inhaler - 10 puffs via spacer, then 2 more doses of 10 if required
- May need secondary care if no improvement
Life threatening (low GCS, cyanosis, silent chest):
- Nebulised salbutomol
- Emergency care required
What is the commonest cause of bronchiolitis?
RSV infection
Can also be caused by adenovirus, rhinovirus, parainfluenza
Presentation of bronchiolitis…
- Normally seen in <1 year olds
- Coryzal symptoms seen first
- Sharp, non-productive cough
- Difficulty feeding due to breathlessness
Examination findings for bronchiolitis…
- Fine-end inspiratory crackles
- Expiratory wheeze
- Intercostal recessions
Management of bronchiolitis…
In the community:
- Saline nasal drops
- Nasal suctioning
- Baby sleeps propped up
- Feed little and often
Secondary care required if ; <50% normal food intake, RR>50, dehydrated, exhaustion
- Humidified oxygen
- NG feeding
Why do beta agonists not help in bronchiolits?
Beta receptors have not yet developed therefore beta agonists cannot work effectively.
Pathophysiology of asthma…
- Bronchial hyperactivity and smooth muscle hypertrophy
- Causes chronic inflammation of airways
- Widespread reversible bronchospasm
Risk factors for childhood asthma…
- Family history
- Low birth weight
- Bottle fed
- Atopy
- Prematurity
What are the symptoms of moderate asthma attack, and where are they managed?
- Able to talk in sentences
- Peak flow >50% of best/ predicted
- HR<140 and RR<40 in 2-5 y/o
- Normal skin colour
- No chest sounds/ slight wheeze
Management = admitted, or watchful waiting then go home
What are the symptoms of severe asthma attack, and where are they managed?
- Only speaks few words/ unable to feed
- Peak flow = 33-55% of best/predicted
- HR >140 and RR >40 in 2-5 y/o
- Pallor
- Wheeze is heard
Management= admitted to hospital
What are the symptoms of life-threatening asthma attack, and where are they managed?
- Unable to speak or cry
- Exhausted
- Drowsy/ confused
- Peak flow <33% of best/ predicted
- Cyanotic
- Silent chest
Management = escalation to ITU
Management of acute asthma attack…
O SHIT ME (not in that order!)
- High flow oxygen if sats <94% - aiming for 94-98%
- SABA back to back nebs - may add Ipratropium Bromide if poor response to SABA alone
- Nebulised magnesium sulphate can be added
- Oral prednisolone 40-50mg - continued for up to 3 days
- Consider escalation to PICU
- First line IV treatment= IV magnesium sulfate
- IV aminophylline
Follow up after acute asthma attack…
- Take detailed history to identify cause of asthma attack
- Review asthma medications and inhaler technique
- Create asthma action plan
- GP review within 2 working days
- Seen in clinic in 4 weeks
- Should not be discharged until PEFR >75%
Name some common inhalers and the drug included in them…
Salbutomol = blue inhaler - SABA Beclomethasone = brown inhaler - ICS Symbicort = red inhaler - ICS + SABA Seretide = purple inhaler - ICS +LABA Spiriva = green inhaler - LABA
Long term management of paediatric asthma…
- SABA as intermittent reliever therapy
- Very low dose ICS = regular preventer
- Initial add on = LABA or LTRA with ICS in combination inhaler e.g. seretide
- Increase ICS to low dose
- Referral to specialist care
What is cystic fibrosis ?
Autosomal recessive disease caused by mutations in CFTR gene.
This causes exocrine gland dysfunction - which has a variety of clinical manifestations.
Presentation of cystic fibrosis…
Exocrine gland dysfunction:
- Meconium ileus in neonates
- Lung disease similar to bronchiectasis, leading to reccurent pneumonia, wet cough (due to mucus)
- Biliary disease - neonatal jaundice, gallstones
- Pancreatic insufficiency - diabetes, steatorrhoea (due to malabsorption), pancreatitis
- Failure to thrive
How is cystic fibrosis diagnosed?
- Heel prick test at birth - genetic testing
- Sweat test = >60mmol/L of Cl- in sweat sample
Management of cystic fibrosis…
- Meconium ileus = nasogastric drainage, enema washout
- Chest physiotherapy - taught to parents for percussion and postural drainage, forced expiration techniques in older children
- Oral antibiotics for recurrent infections
- Inhaled corticosteroids
- CREON for pancreatic insufficency
- Diabetes management
What causes respiratory distress syndrome in infants?
- Deficiency of surfactant in premature babies means the alveoli are less able to stay open during ventilation
- First breath is very important as it opens the terminal airways but without surfactant this becomes very difficult and so infant will have difficulty with breathing
Presentation of respiratory distress syndrome…
First 4 hours of birth:
- Intercostal recessions
- Tachypnoea
- Nasal flaring
- Grunting
Risk factors for respiratory distress syndrome…
- Premature birth
- Maternal diabetes
- C-section
Investigations for respiratory distress syndrome…
Chest x-ray shows:
- Widespread opacification
- Air bronchograms
Management of respiratory distress syndrome…
- Oxygen
- Intubate if <26 weeks
- Prophylactic surfactant
- Fluids
- Normally self resolves when endogenous surfactant is eventually produced (within 1 week of age)
What is transient tachypnoea of newborn, and who is at risk?
When the fluid in the lungs is not reabsorbed naturally it leads to a transient episode of tachypnoea as lung function is reduced.
Risk factors = male, SGA and LGA, prematurity
What is the treatment for meconium aspiration syndrome?
Baby takes forceful gasps during birth leading meconium aspiration which may cause pneumonitis.
- Antibiotics are given for pneumonitis
- Assistance for breathing is required
