Respiratory Flashcards
1
Q
Bronchiolitis evaluation and management
A
Hx
- Onset
- > 10 day illness (cough may last weeks)
- > symptoms worst day 2-3
- Typical symptoms
- > cough
- > tachypnoea
- > wheeze
- > apnoea episodes = severe
- Feeding
- > maintaining >50 normal feeds?
- Toileting
- > 2-3 wet nappies per day?
- Playing
- > yes?
- Sleeping
- > issues?
- Risk factors for severe
- > age <10wks
- > lung disease
- > CHD
- > neurological disease
- > immunodeficiency
- > trisomy 21
Severity assessment
- Mild
- > behaviour = normal
- > RR = normal
- > accessory muscles = nil/some
- > O2 sats >92% on room air
- Moderate
- > behaviour = irritable
- > RR = tachypnoea
- > accessory muscles = nasal flaring/retractions/grunting
- > O2 sats = 90-92% room air
- Severe
- > behaviour = flat/lethargy
- > RR = marked tachypnoea/bradypnoea
- > accessory muscles = nasal flaring/retractions/grunting
- > O2 sats <90% on room air/not corrected by O2
Management
- Disposition
- > mild = discharge (consider timing/risk factors)
- > moderate = inpatient for monitoring
- > severe = admit and tertiary referral
- Monitoring vitals
- > mild = at least for 4 hrs
- > moderate = 1-2hrly
- > severe = continuous with close nursing
- Feeding support
- > over 50% = smaller/more frequent feeds
- > under 50% = NG 2/3 maintenance
- > requiring NPPV = IV fluids 2/3 maintenance
- Respiratory support
- > mild = PWS (panadol/wrap/suck + nasal drops)
- > moderate = nasal prongs /high flow
- > severe = consider CPAP/intubation
2
Q
Croup evaluation and management
A
Hx
- PC
- > preceding URTI (fever/non barking cough/coryza)
- > barking/seal cough
- > stridor
- > symptoms worse at night/with agitation
- Risk factors for severe
- > younger age
- > previous croup admissions
- > pre-existing upper airway disease
Severity assessment
- Mild
- > behaviour = normal
- > stridor = only when active/upset
- > RR = normal
- > accessory muscles = none/minimal
- > O2 sats = normal
- Moderate
- > behaviour = irritable
- > stridor = intermittent at rest
- > RR = tachpnoea
- > accessory muscles = yes
- > O2 sats = normal
- Severe
- > behaviour = drowsy/lethargy
- > stridor = persistant at rest
- > RR = tachypnoea/bradypnoea
- > accessory muscles = yes
- > O2 sats = hypoxia is late sign
Management
- General
- > avoid examining/investigating
- > minimal handling
- > child adopts position to support own airway
- > keep with carer/avoid distressing
- Disposition
- > mild/moderate = at home
- > severe = admit (consider ICU/tertiary if refractory)
- Mild/moderate
- > 0.15mg/kg dexamethasone oral
- > 1mg/kg prednisone oral (repeat dose next evening)
- Severe
- > 0.5-5mL of 1:1000 nebulised adrenaline
- > 0.6mg/kg (max 12mg) IV/IM dexamethasone
- > may require intubation
- > more than 2 nebs = tertiary care
- Discharge criteria
- > consider risk factors + social context
- > stridor free
- > 4 hrs post nebuliser adrenaline or
- > 30 mins post oral steroids
3
Q
Whooping cough evaluation and management
A
Evaluation
- Catarrhal stage
- > URTI symptoms
- Paroxysmal stage
- > paroxysmal cough
- > post tussive emesis
- > inspiratory whoop
- > may have apnoea/cyanosis with paroxysms
- Convalescent stage
- > cough declining in frequency
- > ongoing URTI symptoms
- Risk factors
- > sick contacts
- > infected >34 weeks gestation
- > school teacher/health care worker
- Exam
- > rarely remarkable
- > fever is rare
- Investigations
- > usually unnecessary for diagnosis/needed for tracing
- > nasopharyngeal swab for PCR (negative >21 days / 5 days treatment)
- > IgA serology (2 weeks after onset)
- > FBC shows lymphocytosis
Management
- Indications for antibiotics
- > within 3 weeks of cough (catarrhal/early paroxysmal)
- > complications (apnoea/cyanosis/pneumonia)
- > hospitalised
- Efficacy of antibiotics
- > early use reduces severity/prevents spread
- > late use has no effect
- Regime
- > neonate = azithromycin 10mg/kg oral for 5 days
- > child = clarithromycin liquid 7.5mg/kg BD for 7 days
- Prevent spread
- > notifiable disease = within 1 meter for 1 hr is contact
- > isolate for 5 days of treatment/21 days of cough
- Consider prophylaxis
- > infants <6 months
- > women >34 weeks gestation
- > childcare workers
- > household contacts
4
Q
Acute asthma attack evaluation and management
A
Hx
- Onset and duration of symptoms
- Treatments already given
- > reliever
- > preventer
- Presence of risk factors
- > family hx
- > atopy
- > eczema
- > hay fever
- Presence of trigger
- > URITI
- > pollen
- > animal fur
- > exercise
- > dry cold air
- Previous episodes
- > need for admission
- > IV treatment
- > ICU treatment
- Risk factors for severe
- > poor compliance
- > poor control
- > previous ICU
- > previous anaphylaxis
Severity assessment
- Life threatening (COARSE)
- > cyanosis
- > O2 <90%
- > altered level of consciousness
- > respiratory rate decreasing
- > silent chest
- > exhausted
- Severe (SOB
- > sentence incomplete
- > O2 = 90-94%
- > breathing hard
- Mild
- > walking and talking
Management
- Mild
- > under 6 years = MDI salbutamol 6 puffs
- > over 6yrs = MDI salbutamol 12 puffs
- > review after 20 mins
- > consider oral prednisone
- > discharge at 1hr with action plan/safety net/follow up
- Severe
- > involve senior
- > provide O2 if desaturating
- > MDI salbutamol every 20 mins for 1 hour
- > review after 3rd dose to decide timing of next
- > oral prednisone 2mg/kg
- > consider MDI ipratroprium 4-8 puffs every 20 mins x3
- Life threatening
- > continuous 2x2.5mg nebulised salbutamol (monitor K)
- > nebulised ipratropium 250-500mcg every 20 mins x 3
- > methylprednisone IV 1mg/kg
- > consider ICU/tertiary transfer
- > consider CPAP/BiPAP/intubation
- > mag sulfate/aminohyline/neb adrenaline/IV salbutamol
- > CXR/VBG/maybe antibiotics
- Discharge
- > once salbutamol >4 hrly
- > consider social context/risk factors for severe
- > written weening plan
- > written asthma action plan
- > prednisone 1mg/kg for days 2-3
- > discussed triggers/technique/safety net/follow up
5
Q
Long term asthma evaluation and management
A
Hx
- PC
- > recurrent wheeze
- > dry cough (worse at night)
- Presence of risk factors
- > family hx
- > atopy
- > eczema
- > hay fever
- Presence of trigger
- > URITI
- > pollen
- > animal fur
- > exercise
- > dry cold air
- Previous episodes
- > respiratory admissions
- > ICU treatment
Exam
- Usually normal
- > may have harrisons sulci
- Atopy
- Exclude CHD
Investigations
- Hyper-responsiveness challenge
- > histamine
- > mannitol
- > exercise
- Reversible airway obstruction
- > 12% or 200mL improvement
- > FEV1 or FVC
- Consider
- > skin prick for atopy
- > FBC for eosinophilia
- > bronchoscopy for tacheomalacia/foreign body
- > CXR shows hyperinflation
- > sweat test for CF
Management -1. -SABA as needed 2. -SABA as needed -plus low dose ICS BD -consider montelukast daily instead of ICS (exercise) 3. -SABA as needed -plus low dose ICS/LABA BD or -low dose ICS/LABA maintenance and reliever 4. -SABA as needed -plus high dose ICS/LABA BD -consider tiotropium or -medium dose ICS/LABA maintenance and reliever 5. specialist referral -Step up ->poor control ->good compliance ->proper technique ->considered cormorbidities/alternate diagnosis -Step down ->3 months of good control
Review (3 monthly)
- Establish/maintain therapeutic alliance
- Review recent exacerbations
- Discuss current treatment
- > compliance
- > SE
- Control
- > day symptoms >2 per week
- > need SABA > 2 per week
- > any night symptoms
- > any limitation of function
- Inhaler technique
- > 4 puffs/4 deep breaths
- Discuss triggers/risk factors
- > second hand smoke
- Asthma management plan
- > recognising exacerbation
- > medication adjustment
- > when to seek medical attention
- Lung function testing
- > after ED admission/exacerbations
- > worsening control
- > periodically 1-2 years
6
Q
CF evaluation and management
A
Hx
- Respiratory
- > distress
- > wet cough
- > haemoptysis
- GI
- > steatorrhoea
- > reflux
- > insatiable appetite
- Antenatal
- > meconium
- > blood spot test
- Past
- > failure to thrive
- > recurrent pneumonia/bronchitis
- > bowel obstruction
- > recurrent/chronic pancreatitis
- Family
- > autosomal recessive
Exam
- Growth
- > FTT
- Development
- Inspect
- > nasal polyps
- > clubbing
- Chest
- > hyperexpansion
- Abdo
- > stool mass RIF
- > hepatosplenomegaly
Investigations
- Sweat test
- > pilocarpine stimulation
- > chloride content analysed
- Genetic testing
- > CFTR gene
- Sinus xray
- > pansinusitus
- Deep throat swab
- > post gag
- > respiratory pathogens
- Vitamins
- > PT for K
- > serum A,D,E
Management
- Meconium ileus
- > lactulose + nasogastric decompression +- surgery
- Acute respiratory infection
- > mild = oral amoxicillin/clavulonate
- > severe = IV tobramycin + ticarcillin/clavulonate (pseudp/aureus)
- > manual chest physio/VEST therapy
- > salbutamol PRN
- > dornase alfa neb + inhaled hypertonic saline
- Lung maintenance
- > chest physio
- > bronchodilator PRN
- > mucolytic BD
- > inhaled tobramycin BD month on month off
- > azithromycin three times weekly
- GI maintenance
- > pancreatic enzyme replacement + esomeprazole
- > fat soluble vitamin replacement (KADE)
- Specialist treatment
- > CFTR modulator therapies
- > lung transplant
