Respiratory Flashcards
What age group do children with bronchiolitis present?
They are typically less than 6 months but can be under a year
What is the presentation of bronchiolitis?
- Typically a preceding viral illness with coryzal symptoms (usually respiratory syncytial virus)
- Respiratory distress
- Dyspnoea
- Tachypnoea
- Poor feeding
- Mild fever
- Apnoeas
- Wheeze and crackles on auscultation
What are the signs of respiratory distress?
Intercostal and subcostal recession Head bobbing nasal flaring Tracheal tub Accessory muscle use Abnormal airway noises (wheezing, grunting, stridor)
How long does bronchiolitis last?
Usually worst 3-4 days after coryzal symptoms
Last 7 to 10 days
Fully recover in 2-3 weeks
Children with bronchiolitis are more predisposed to viral induced wheeze in childhood
What are the criteria for admission with bronchiolitis?
50% or less of their normal milk intake Aged under 3 months with preexisiting health condition Clinical dehydration Resp rate above 70 Oxygen sats under 90% Moderate to severe resp distress Apnoeas Parents not confident in ability to manage at home
What is the management of bronchiolitis?
Supportive
Ensure adequate feeding by oral or NG, do not overfeed as this will restrict breathing
Saline nasal drops and suctioning helps clear nose before feeding
Supplementary oxygen
Ventilatory support if required
What are high risk babies for respiratory syncytial virus given?
Palivizumab - monoclonal antibody that targets RSV
Given to at risk babies monthly
Provides passive immunity
What is viral induced wheeze?
In children under 3 with small airways they can become wheezy following viral illness
This is because of poiseuille’s law and the airway oedema causes wheeze
What features suggest viral wheeze instead of asthma?
Presenting before 3 years of age
No history of atopy
Only occurs during viral infections
What are the presenting features of viral wheeze?
Resp distress
SOB
Global wheeze - be cautious of focal wheeze as may be a foreign body
What is the management of viral wheeze?
The same as for acute asthma in children: Oxygen Salbutamol Hydrocortisone Ipratropium Theophylline
What is the presentation of acute asthma?
Worsening shortness of breath
Expiratory wheeze throughout chest
Fast resp rate
A silent chest in an ominous sign
How do you grade the different severities of asthma?
Mild: -Peak flow greater than 50% predicted -taking in normal sentences Severe: -Peak flow <50% predicted -Sats <92% -Unable to talk in full sentences -signs of resp distress -Resp rate >30, HR greated than 125 Life threatening -Peak flow <33% predicted -Talking in single words -Silent chest -Exhaustion, poor resp effort -Hypotension -Cyanosis -Confusion
How are asthma patients managed when their acute attack starts to subside?
Review the child and gradually step back down the ladder
typically step down the frequency and dose of the interventions e.g. 10 puffs 2 hourly, 10 puffs 4 hourly
What are some of the side effects of the salbutamol?
Causes tachycardia, tremor and hypokalaemia
When can children be discharged following an acute asthma attack?
Generally when they can have 6 puffs of their inhaler 4 hourly
What are the family features to ask about if suspecting asthma?
Asthma, eczema and allergies
What are the typical features suggestive of chronic asthma?
Episodic symptoms
Diurnal variation - typically worse at night and early in morning
Dry cough with wheeze and SOB
Typical triggers
Personal or family history of atopy
Widespread polyphonic wheeze heard by healthcare professional
Symptoms improve with bronchodilators
What are some typical triggers of asthma?
Cold air dust animals exercise smoke food allergens
How is asthma diagnosed?
It is a clinical diagnosis If still unsure then can use; -Peak flow diary -spirometry with reversibility testing -fractional expired NO
What is the management of chronic asthma in under 5s?
SABA
Corticosteroid
Leukotriene receptor antagonist e.g. montelukast
What is the management of chronic asthma in over 5s?
SABA Corticosteroid inhaler LABA e.g. salmeterol Increase steroid dose to medium Add montelukast Oral theophylline increase to high corticosteroid
How can regular inhaled steroids affect childrens deveolment?
They can slow growth however this affect is dose dependent
What is the typical presentation of pneumonia?
Cough (typically wet and productive) High fever (>38.5) tachycardia tachypnoea increased WOB lethargy delerium
What are the examination findings in pneumonia?
Bronchial breath sounds (inspiration same length as expiration)
Crackles - due to air moving through sputum
Dullness to percussion due lung tissue collapse or consolidation
What are the causes of pneumonia in kids?
Step pneumonia is most common Group A (Strep pyogenes) Group B occurs in pre-vacinated infants Staph aureus Haemophilus influenzae Viral causes include - RSV, Parainfluenza virus, influenza virus
What are the investigations for pneumonia?
FBC, U and E, blood cultures
Sputum culture, throat swabs for bacterial culture and viral PCR
Blood gas analysis can help monitor patients
CXR
What is the management of pneumonia?
Pneumonia is usually treated with amoxicillin
Adding a macrolide such as erythromycin covers for atypical pneumonias
What investigations should be done in children with recurrent pneumonias?
FBC for wcc
Chest x ray for structual abnormalities
Serum immunoglobulins to look for antibody deficiency
Specific IGG testing for immunity from vaccination e.g. pneumococcus and haemophilus
Sweat test for cystic fibrosis
HIV test
What is croup?
It is laryngotracheobronchitis, an upper airway oedema resulting from upper respiratory tract infection
What are the causes of croup?
Most commonly parainfluenza virus
Can aslo be influenze, adenovirus and RSV
What is the presentation of croup?
It causes increased work of breathing Stridor Barking cough Hoarse voice Low grade fever
What is the management of croup?
Usually self limiting with supportive treatment e.g. fluids and rest Stepwise treatment: -Oral dexamethasone -Oxygen -Nebulised budesonide (steroid) -Nebulised adrenaline -Intubation and ventilation
What is the cause of epiglotitis?
Most commonly caused by haemophilus influenza type B
Children are vaccinated against this
What are the presenting features of epiglottitis?
A child presenting with a sore throat and stridor Drooling High fever Tripod position Difficulty or painful swallowing Muffled voice
What are the investigations and findings for epiglottitis?
A lateral neck x ray with show a thumbprint sign - a swollen epiglottis that protrudes into the trachea
What is the managemet o epiglottitis?
It is a life threatening illness due to impending airway closure
Need to quickly involve a senior doctor and aesthetist so that they can intervene if this happens
Do not try to examine the child as this may cause closure
Once the airway is secure IV Ceftriaxone and steroids e.g. dexamethasone
What is a common complication of epiglottitis?
An epiglottic abscess that is treated in a similar way
What are the structual changes behind laryngomalacia?
There are shortened aryepiglottic folds that pull on the epiglottis leading to an oemega shaped epiglottis
The tissue around the supraglottic larynx is also floppier so it leads to stridor
What is the presentation of laryngomalacia?
It causes a whistling stridor that is often made worse when feeding or when resp infections
What is the management of laryngomalacia?
Usually resolves without intervention as child grows and larynx becomes more supported
Rarely surgery or tracheostomy may be required
What is the cause of whooping cough?
It is caused by bordetella pertussis (a gram negative bacteria)
What is the presentation of whooping cough?
usually mild coryzal symptoms, a low grade fever and a mild cough
In more severe cases it causes paroxysmal coughing fits where patients cannot breathe between coughs, this ends in a long inspiratory whoop
Patients can cough so hard that they develop a pneumothorax
How is a diagnosis of whooping cough made?
Within 2-3 weeks of onset - nasal swab PCR or bacterial culture
When cough present for more than 2 weeks can test for anti-pertussis toxin immunoglobulin G
What is the management of pertussis?
This is a notifiable disease
Need to prevent spread through hygiene measures
Typically supportive care with some patients with apnoeas or severe coughing fits requiring admission
Macrolide antibiotics such as clarithromycin can be beneficial
Close contacts are treated prophylactically with antibiotics
What is a long term complication of pertussis infection?
bronchiectasis
What is chronic lung disease of prematurity?
This is also known as bronchopulmonary dysplasia
It occurs in prem babies usually born before 28 weeks
They suffer from respiratory distress syndrome and require oxygen therapy
What are the features of chronic lung disease of prematurity?
low o2 sats
Increased WOB
Failure to thrive
Creps on ausculation
How is chronic lung disease of prematurity prevented?
If mothers are starting to show signs of premature labour at 36 weeks they can be given glucocorticoids e.g. betamethasone
This causes development of surfactant in the fetal lungs
Once the baby is born CLDP can be prevented y using CPAP instead of intubation and ventilation
Caffeine stimulates respiratory effort
What is the management of babies with chronic lung disease of prematurity?
They have a sleep study to assess oxygen saturations
They will be vacinated against RSV (very expensive) so have to meet certain criteria
What is the mode of inheritance and receptor affected in cystic fibrosis?
Autosomal recessive inheritance affecting the cystic fibrosis transmembrane conductance regulatory gene.
This affects chloride channels causing very thick mucus
What are the consequnces of the cystic fibrosis mutation?
This leads to thick mucus sectretions
It causes blockage of the pancreatic duct with secretions leading to lack of enzymes in the gut
Thick secretions in the lungs cause recurrent infections and colonisation
There is congenital bilateral absence of vas deferens in males
How can cystic fibrosis present in children?
Can be picked up on the newborn bloodspot test
Meconium ileus is a common presentation when babies become obstructed and do not pass black stool within 24 hours of birth
Can present later in childhood with recurrent respiratory tract infections or failure to thrive
What are the symptoms of cystic fibrosis?
Chronic cough Recurrent infections steatorrhoea Failure to thrive Abdominal pain and bloating
What are the causes of clubbing in children?
Cystic fibrosis Cyanotic heart disease Infective endocarditis Tuberculosis Inflammatory bowel disease Liver cirrhosis
What are the 3 methods to diagnose cystic fibrosis?
Gold standard is sweat test
Newborn blood spot testing
CFTR genetic testing
How does the sweat test work?
use a small current across the skin to cause sweating and measure the chloride concentration
What bacteria commonly colonise the lungs in CF?
Staph aureus and pseudomonas
Patients are usually on prophylactic fluclox
Why can children with cystic fibrosis not mix?
To reduce the risk of passing on pseudomonas as it is very hard to treat
What are the main aspects of CF management?
Chest physio CREON tablets to help digest fats high calorie diet prophylactic fluclox nebulised saline to clear secretions
What monitoring do CF patients require?
for diabetes, osteoporosis, vitamin D deficiency and liver failure
What is the mode of inheritance of primary ciliary dyskineasia?
It is autosomal recessive and more common in families with consangunity
How does primary ciliary dyskinesia present?
Presents in a similar way to CF due to cilia not clearing mucus
Recurrent infections and eventually bronchiectasis
Also affects cilia in fallopian tubes and sperms tails leading to infertility
What is kartagners triad?
Three key features in primary ciliary dyskinesia (not all required for diagnosis)
Paranasal sinusitis
Bronchiectasis
Situs Inversus (chest organs mirror image)
How is a diagnosis of primary ciliary dyskineasia made?
The key ingestigation if a sample of the ciliated epithelium that can be taken from nasal swab or on bronchoscopy
The action of the cilia is then examinined
