Respiratory Flashcards
Causes of a wet cough?
Acute - infection (bacterial, viral, pertussis)
Subacute (3-8 weeks) - post viral, recovery from pneumonia
Chronic (>8 weeks) - persistent bronchitis, bronchiectasis, immune issues, recurrent aspiration.
Causes of stridor?
Congenital - laryngomalacia, choanal atresia
Acquired -
Infective: Croup, acute epiglottitis, infectious mononucleosis
Non-infective: post-intubation, foreign body, anaphylaxis, hereditary angioedema, inhalation injury, trauma.
Differentials for wheeze?
Asthma LRTI - bronchiolitis Foreign body Cystic fibrosis Primary ciliary dyskinesia Heart failure Bronchopulmonary dysplasia Vocal cord dysfunction External compression
Risk factors for asthma?
Family history of atopy
Antenatal factors - maternal smoking, viral infection during pregnancy
Exposure to cigarette smoke
Low birth weight
Not being breastfed
Exposure to high concentrations of allergens and air pollution.
Features of asthma?
Episodic cough (worse at night), dyspnea, expiatory wheeze, chest tightness
Expiratory wheeze on auscultation, reduced peak expiratory flow rate
Investigations of asthma?
Spirometry:
FEV1 reduced
FVC normal
FEV/FVC ratio <70%
Spirometry with bronchodilator reversibility test
Fractional exhaled nitric oxide (FeNO) - iNOS levels tend to rise in inflammatory cells/eosinophils.
Management of asthma aged 5-16
SABA
SABA + low dose ICS (beclomethasone)
SABA + low dose ICS + oral LTRA (montelukast)
SABA + low dose ICS + LABA (salmeterol)
SABA + MART regimen - low dose ICS + LABA
SABA + MART - moderate dose ICS + LABA
Speak to asthma specialist, increase doses, trial additional drug.
Management of asthma aged <5
SABA
Trial moderate dose ICS + SABA for 8 weeks:
- if sx don’t resolve - find alternative diagnosis
- if sx resolve but recur >4 weeks of stopping trial - repeat trial
- if sx resolve in trial but recur <4 weeks of stropping trial, move on to step 3.
SABA + low dose ICS
SABA + low dose ICS + LTRA
Stop LTRA, continue low dose ICS + SABA and refer to specialists.
Stepping down treatment in asthma?
Consider stepping down every 3 months or so.
Take into account duration of treatment, side effects and patient preference.
Wean off inhaled steroids, reduce by 25-50% at a time.
Features of moderate, severe and life-threatening asthma attack?
Moderate - sats >92, no clinical features of severe asthma, PEF >50% (>5 years)
Severe - sats <92, use of accessory muscles, struggle to talk, PEF 33-50%, tachycardia, tachypnoea
Life-threatening - normal pCO2, sats <92, silent chest, reduced consciousness, cyanosis, agitation, PEF <33%
Management of acute asthma attack?
Mild-moderate - hospital not required.
Bronchodilator therapy - give a SABA via a spacer, 1 puff every 30-60 seconds up to 10 times. If symptoms persist refer to hospital.
Steroid therapy - give to all children with asthma exacerbation, for 3-5 days.
Acute severe - hospital admission
Oxgen
Salbutamol nebs - 2.5mg for 2-5, 5mg for >5.
Oral prednisolone - 30-40mg if >5 years, 20mg if 2-5 years, 10mg if <2 years. Continue for 3 days.
Add neb ipratropium bromide (250mcg if 2-12, 500mcg if >12).
Consider adding 150mg magnesium sulphate to nebs
Alternative - IV salbutamol, aminophylline, IV magnesium sulphate.
Intubate and ventilate if necessary.
Features of Cystic Fibrosis?
Recurrent chest infections, chronic wet cough
Exocrine pancreatic insufficiency, malabsorption, failure to thrive
Neonate - meconium ileus, protracted jaundice, electrolyte abnormalities
Distal intestinal obstruction syndrome - due to thickening intestinal content.
Others - male infertility, female subfertility, DM, short stature, nasal polyps, delayed puberty, rectal prolapse
Diagnosis of CF?
Newborn screening test
Sweat test - high sweat chloride levels - normal is <40, CF value >60.
Causes of false positive sweat test?
Malnutrition, adrenal insufficiency, glycogen storage diseases, nephrogenic DI, hypothyroidism, hypoparathyroidism, G6PD, ectodermal dysplasia.
Organisms that colonise in CF patients
Staph aureus
Pseudomonas aeruginosa
Aspergillus
Burkholderia cepacian
Management of CF?
Chest physio and postural drainage twice daily
High chloride and high fat diet
Vitamin supplementation
Pancreatic enzyme supplements with meals
Heart and lung transplant
Minimise contact with other CF patients to prevent cross infection
Ivacaftor and lumacaftor - treats CF patients who are homozygous for delta F508 mutation.
What is bronchiolitis and what causes it?
LRTI - acute inflammation of bronchioles
Usually due to respiratory syncytial virus (RSV), but also due to mycoplasma and adenovirus.
Most common cause of serious LRTI in <1 years
Higher incidence in winter.
Features of bronchiolitis?
Coryzal symptoms - runny nose, cough, fever
Dry cough
Dyspnoea
Wheezing, fine inspiratory crackles
Feeding difficulties due to increased SOB
Investigations and management of bronchiolitis?
Immunofluoresence of nasopharyngeal secretions may show RSV.
Management is supportive:
Fluids to avoid dehydration
Ibuprofen/paracetamol to bring down fever
Humidified oxygen if sats <92
NG feeding if severe feeding difficulties
Suction for excessive upper airway secretions
Infection usually clears up within 2 weeks without treatment.
Palivizumab to prevent RSV in children who are at risk of severe disease:
Premature infants
Infants with lung or heart abnormalities
Immunocompromised infants
Signs and symptoms of pneumonia? In newborns, infants and adolescents
Newborn - poor feeding, irritability, tachypnoea, grunting, hypoxia.
Infants - cough, tachypnoea, hypoxia, retractions, congestion, fever, irritability, poor feeding
Adolescents - all of above plus headache, pleuritic chest pain, abdominal pain, vomiting, diarrhoea, pharyngitis, otitis.
Causes of pneumonia? In newborns, infants and adolescents
Newborns - group B strep, listeria monocytogenes, e.coli, RSV
Infants - strep pneumonia, RSV
Adolescents - Mycoplasma pneumonia, strep pneumonia.
What do you find on examination of pneumonia and what investigations do you need?
Resp rate:
<2 months - >60 breaths/min
2-11 months - >50 breaths/min
12-59 months - >40 breaths/min
O2 sats
Auscultation - reduced air entry, bronchial breathing, crackles
Cultures, serology, FBC, CXR, USS
Management of pneumonia?
First line - amoxicillin
Add macrolide if no response - erythromycin, clarithromycin
Use macrolide for mycoplasma
Co-amoxiclav recommended in pneumonia associated with influenza.
Features of viral wheeze?
High pitched expiratory whistle that occurs during respiratory viral infection. Choryzal symptoms Cough Shortness of breath Expiratory wheeze on auscultation Fever Signs of respiratory distress
How is viral wheeze different to asthma?
Presents before age of 3
No atopic history
Only occurring during viral infection
Usually lasts 2-4 days, and symptom-free between viral episodes.
Management of viral wheeze?
Oxygen if sats <95%
Salbutamol with spacer - 10 puffs every 2 hours
If fails, consider nebulised salbutamol and/or ipratropium bromide
Second line is intermittent LTRA (montelukast), intermittent ICS or both.
Typical step down regime might be 10 puffs 2 hourly to 10 puffs 4 hourly to 6 puffs 4 hourly.
When to discharge a patient who has viral wheeze? And how to wean down the salbutamol inhaler?
When child on 6 puffs 4 hourly.
Should go onto 6 puffs 4 hourly for 48 hours then 4 puffs 6 hourly for 48 hours then PRN.
Finish 3 days total steroids if started
Provide safety-net information.
What is croup and what is it caused by?
URTI characterised by stridor.
Often due to parainfluenza viruses.
6 months - 3 years more common
More common in autumn.
Features of croup?
Stridor
Barking cough
Fever
Coryzal symptoms
Classification of croup?
Mild - occasional barking cough with no stridor at rest. No or mild recession. Looks well.
Moderate - Frequent barking cough and stridor at rest. Recessions at rest, no distress.
Severe - Prominent inspiratory stridor at rest. Marked recessions. Distress, agitation, lethargy, tachycardia.
Management of croup?
Single dose oral dexamethasone (15mg/kg) to all children regardless of severity.
Emergency treatment - high flow oxygen and nebulised adrenaline.
What is laryngomalacia?
Supraglottic larynx structured in a way that allows it to cause partial airway obstruction.
Leads to chronic stridor on inhalation, as larynx flops across airway as infant breathes in.
What age is laryngomalacia common? Features? Management?
Peaks at 6 months.
Problem resolves as larynx matures and grows.
Feeding problems.
Stridor.
No interventions requires usually, grow out of condition.
What are the structural changes in laryngomalacia?
Shortened aryepiglottic folds change shape of epiglottis, giving characteristic omega shape.
Tissue surrounding supraglottic larynx softer and has less tone meaning it can flop across the airway.
What causes acute epiglottis?
Inflammation and swelling of epiglottis caused by infection.
H. influenza type B.
Less common since vaccination, higher suspicion in unvaccinated children.
Features of acute epiglottis?
Swell to point of complete obstruction of airway.
Life threatening
Can become severe within hours
Similar features to croup
Aged 2-6 years.
Features - rapid onset, sore throat, stridor, drooling, scared quiet child, muffled voice, painful swallowing, fever.
Management and prognosis of acute epiglottis?
Do not distress patient - leave them alone in comfort zone.
Alert senior paediatrician and anaesthetist
Ensure airway is secure and patent - may require intubation.
IV abx - cefotaxime
Steroids - dexamethasone
Nebulised adrenaline.
Prognosis:
Most children recover without requiring intubation, steroids or adrenaline.
25% can develop epiglottic abscess.
Rarely death can occur if not properly diagnosed and managed in time.
Causes of pleural effusion?
Transudate - congestive heart failure, malignancy, hypoalbuminaemia, nephrosis.
Exudate - infection (pneumonia, TB), SLE, malignancy, PE, pancreatitis.
Features of pleural effusion?
Systemically unwell with fever
Difficulty breathing, struggling to catch breath
Tachycardia
Chest pain on breathing
Diagnosis, management and complications of pleural effusion?
CXR, sample of fluid may be required.
Treat underlying cause
Breathing exercises to help aid lung expansion.
Chest drain
Complications:
Respiratory failure, sepsis, bronchopleural fistula, pneumothorax, pleural thickening.
Features of inhaled foreign body in larynx or main bronchus? Management?
Cough, stridor, dyspnoea, vomiting.
Total obstruction - unconscious and cardiac arrest.
Partial obstruction - place upright position and arrange urgent removal in surgery - encourage patient to cough.
Total obstruction and conscious - 5 back blows, 5 abdominal thrust (chest thrusts < 1 years), repeat cycle.
Total obstruction and unconscious - CPR.
Features of inhaled foreign body lower than main bronchus? Management?
Previous episode of choking, coughing, wheezing.
Persistent wheeze, cough, fever, dyspnoea.
Patient may be asymptomatic after initial event.
Examination - asymmetrical chest movement, tracheal deviation, wheeze, decreased breath sounds, respiratory exam may be normal.
Place in upright position and arrange urgent removal in surgery.
Risk factors for progression of TB disease?
<4 years of age
Environment (overcrowding, poor housing, inadequate ventilation).
Immunocompromised children (due to conditions or medications).
Presentation of TB?
Pulmonary - chronic cough, weight loss, night sweats, failure to thrive.
Diagnosis and management of TB?
Clinical dx
Tuberculin skin test, interferon gamma release assays, CXR
Sputum analysis, bronchoalveolar lavage, acid-fast staining.
Rifampicin, isoniazid, pyrazinamide, ethambutol.
What is Kartagener’s syndrome?
Aka Primary ciliary dyskinesia.
Bronchiectasis, recurrent sinusitis, subfertility.
Associated with dextrocardia or complete situs inversus.
Other associations - congenital heart lesions, asplenia, hydrocephalus, renal disease.
Causes of whooping cough?
Gram negative Bordetella Pertussis.
Immunisations at 2, 3, 4 months and 3 years.
Features of whooping cough?
2-3 days of coryza preceding other symptoms.
Coughing bouts, usually worse at night and after feeding. Vomiting and central cyanosis.
Inspiratory whoop
Spells of apnoea.
Persistent coughing may cause subconjunctival haemorrhage or anoxic seizures
Symptoms can last 10-14 weeks.
Marked lymphocytosis.
Diagnosis of whooping cough?
Acute cough lasting >14 days without apparent cause and one or more of following:
- paroxysmal cough
- Inspiratory whoop
- Post-tussive vomiting
- Undiagnosed apneic attacks in young infants.
PCR and serology for Bordetella pertussis.
Management of whooping cough?
<6 months - admission
Notifiable disease
Oral macrolide if onset of cough within 21 days to eradicate organism and reduce spread.
Household contacts should offered prophylactic abx
School exclusion for 2 days after commencing abx or for 21 days form onset of symptoms if no abx given.
Complications of whooping cough?
Subconjunctival haemorrage
Pneumonia
Bronchiectasis
Seizures
When is Vaccination of whooping cough in pregnancy women offered?
20-32 weeks.
