Respiratory And ENT Flashcards
When does bronchiolitis mostly occur age wise?
Peak 3-6 months, mostly under 1 year but definitely under 2 years
What are the 3 most common causes of bronchiolitis?
Respiratory syncytial virus RSV
Human metapneumovirus hMPV
PIV
What type of year sees most bronchiolitis?
November - March
What feeding method is considered protective vs bronchiolitis?
Breastfeeding
What precedes the LRTI symptoms of bronchiolitis?
1-3 days of coryzal prodrome
Main signs and symptoms of bronchiolitis?
Persistent cough Tachypnoea, increased work of breathing Desats and apnoeas if less than 6 weeks Recessions Wheeze and or crackles
What non-specific non chest symptoms are seen in bronchiolitis?
Low grade fever and poor feeding
What is the natural course of bronchiolitis?
Worse around 3-5 days before cough resolved by 2-3 weeks
Management of suspected bronchiolitis?
Clinically diagnose and don’t over investigate
Monitor sats and consider O2 therapy to maintain over 92%
Consider cpap and ng feeding if required
Suction if apnoeas or significant secretions
What is the preventative measure for bronchiolitis and who is it given to?
Palivizumab RSV vaccine given to those with significant respiratory or cv long term conditions or neuro
What is croup otherwise known as?
Laryngotracheobronchitis
What age does croup typically affect?
6m-3 years with peak in second year of life
What most commonly causes croup?
URTI due to PIV, flu virus infection and infection of larynx, trachea and bronchi with white cell infiltration
What bacteria may cause croup?
Diphtheria, staph, strep
Symptoms and signs of croup?
Barking cough, inspiratori stridor and breathlessness worse at night
Vocal hoarseness
Fever
Coryzal symptoms prodromally
What must be considered as differentials for croup?
Epiglottitis Subglottic stenosis if prev intubation or congenital, GORD related Airway foreign body Retropharyngeal abscess Bacterial trachietis
What sign is visible on CXR of croup?
Steeple sign
What scoring system is used to assess severity of croup?
Westley score
What westley score indicates mild croup?
2 or less
What westley score indicates moderate croup?
3-5
What westley score indicates severe croup?
6-11
What westley score for croup indicates impending respiratory failure?
12 or more
What is the treatment for croup and when is it given?
For mild-moderate croup give single dose dexamethasone orally 0.15mg/kg or oral pred
Can repeat dose after 12 hours
What medication may be given for moderate to severe croup?
Adrenaline neb
How long does croup tend to last?
May be really bad for 1-2 days before easing over 3-7 days, gone by 2 weeks
What are 2 bacterial superinfections that may occur after croup?
Pneumonia
Bacterial trachietis
What bacteria used to be responsible for most of epiglottitis?
Haemophilus influenza B
What are the 2 age peaks of epiglottitis infection?
2-5 years and 40s-50s
What is now the most common cause of epiglottitis?
Strep pneumoniae
Also staph, pseudomonas
When can reactive epiglottitis occur?
Post head and neck chemo
How does epiglottitis present?
Acute emergency with sore throat, dysphagia/odynophagia, drooling, muffled ‘hot potato’ voice, fever
Also anterior neck pain over hyoid, ear pain, cervical lymphadenopathy
What sign may be visible on lateral neck XR for epiglottitis?
Thumbprint sign
What symptom is often a major discriminator between croup and epiglottitis?
Cough present in croup but absent in epiglottitis
What are the major differentials for epiglottitis?
Pharyngitis/laryngitis
Inhaled foreign body
Croup
Retropharyngeal
What should absolutely not be done if suspected epiglottitis?
Examination with tongue depressor
What is gold standard investigation for epiglottitis?
Urgent fibre optic laryngoscopy
Management of epiglottitis?
Careful airway management - intubation or cricothyrectomy if necessary
Abx cover with cephalosporins plus penicillin ampicillin cover for strep
What are the most common viral causes of pneumonia?
RSV
PIV
Flu
What are the most common bacterial causes of community acquired pneumonia?
Strep pneumoniae
H influenza
Strep pyogenes
S aureus
Treatment of pneumonia in patients who are clinically well?
7 days oral amoxicillin
What is the antibiotic management of patients who present acutely unwell with pneumonia?
IV amoxicillin, co amoxiclav or clarithromycin if allergic to penicillin
How does the prevalence of asthma vary with age and sex in kids?
More common in young boys than girls
Equal in adolescence
More common in women than men
So girls are more likely to have it persist than boys
5 factors that mean early wheezers are more likely to persist into asthmatics?
Later presentation - under 2 years is likely to resolve by mid childhood
Co-existent or familial atop
Female sex
More severe or frequent wheezing episodes
Increased airway responsiveness and abnormal PFT function
What may be the only major symptom of exercise or nocturnal asthma?
A dry non-paroxysmal cough
3 differentials for a congenital wheeze?
Structural abnormality e.g. Bronchogenic cyst or vascular ring
Laryngeal abnormality if weak cry or stridor
Heart failure - congenital heart disease
5 differentials for wheeze presenting shortly after birth?
BPD if premature and or ventilated Immunodeficiency CF PCD/Kartageners GORD
What management should be taken if high probability of asthma?
Trial of treatment for 2-3m of inhaled corticosteroid
What management could be taken if asthma diagnosis unsure e.g. In under 4-5 year olds?
Can watch and wait with trial of treatment or further PFTs with reversibility testing when older
What usually defines reversibility on PFTs?
Improvement of PEF/FEV1 by over 12% 10 minutes after bronchodilator
What markers are generally suggestive of a moderate or less asthma attack?
SpO2 over 92%
PEF over 50% predicted
Talking in full sentences
What marker suggests acute life threatening asthma?
SpO2 less than 92% in room air
What does a PEF of 33-50% of expected/best suggest about the severity of an asthma attack?
Acute severe
What does a PEF of less than 33% of best/expected suggest about the severity of an asthma attack?
Life threatening
What are 5 signs of life threatening asthma?
Silent chest Cyanosis Poor respiratory effort/exhaustion Hypotension Confusion
What do alterations in heart rate suggest with worsening asthma attacks?
Rising heart rate suggests worsening asthma
But then falling heart rate with no clinical improvement is pre-terminal
What is the first step in management of an acute asthma attack where SpO2 is less than 94%?
High flow 15L O2 via nc if young, non-rebreathe face mask if older
Initial management of acute severe asthma attack?
If moderate-severe try inhaled SABA with pMIDI/spacer up to 10 puffs
If severe or worse give nebbed salbutamol 2.5-5mg every 20-30 mins
With nebbed ipratropium 250 micrograms in each if poor initial response
What steroid treatment is indicated in acute severe asthma? Doses?
Oral pred 10mg if under 2 years, 20 if 2-5 years, 30-40 if over 5 years
When is IV hydrocortisone indicated in acute severe asthma?
If really bad and e.g. Vomiting so can’t retain PO meds
What should be considered in acute severe asthma if patient is vomiting?
IV hydrocortisone
What dose of nebulised salbutamol is given in acute severe asthma attacks? How often?
2.5-5mg every 20-30 mins
What dose of ipratropium bromide nebulised is given for acute severe asthma?
250 micrograms with 5mg of salbutamol
What other nebulised substance may be considered in acute severe asthma and why?
If SpO2 less than 92% with swift deterioration consider 150mg MgSO4 in every neb over 1st hour
What 3 IV medications besides steroids may be indicated in acute severe asthma and why?
Salbutamol bolus plus infusion
Aminophylline loading dose then infusion
MgSO4 if not responding to rest
What dose of salbutamol may be given IV for bolus then infusion?
15 micrograms per kg bolus
Then 1-2 micrograms/kg/min after
What monitoring does IV salbutamol require?
U and Es and ECG, preferably in ICU
What dose is used for IV aminophylline loading and maintenance? When is loading not required?
Loading 5mg per kg
Then maintenance of 1mg/kg/hour
Loading not required if already on oral theophylline
What dose of MgSO4 is used IV for acute severe asthma maintenance and what is the risk associated with it?
40mg/kg/day - risk of hypotension
4 criteria for discharge from acute severe asthma attack requiring inpatient therapy?
On 3-4 hourly inhaled bronchodilators which can be managed at home
PEF > 75% of best or expected
SpO2 over 94% on room air
BTS care bundle in place
What follow up should be in place post-discharge for acute severe asthma attack?
See primary care by 2 days post discharge
Paediatric asthma clinic appointment within 1-2 months
What inhaled bronchodilator use should be considered excessive for asthma and warrant urgent assessment?
Not controlled by 10 puffs of salbutamol every 3-4 hours
How much inhaled SABA use per week or month is an indication of poorly controlled asthma?
3 or more puffs in one week
1 or more inhaler per month
What is the first step of preventer therapy for asthma management in kids? How does this vary with age?
If under 12 - very low dose paediatric dose ICS
If over 12 - low dose ICS
What is an alternative to either ICS or LABA in under 5s as early preventer therapy for asthma?
LTRA
What is a reasonable preventer dose for ICS in asthma?
200-400 micrograms per day
What does initial add on therapy for asthma consist of varying with age?
If 5 or over add LABA or LTRA
If under 5 add LTRA
What is the next step after initial add on therapy for asthma management?
Assess response to LABA - if there is one but not enough, increase ICS dose to low dose (in under 12s, medium in over 12s) or add LTRA
If no response, stop LABA and increase dose of ICS
What if additional add on therapy doesn’t work for asthma management? What is this called?
Persistent poor control - consider medium (if under 12) or high (if over 12) dose of ICS
Or add a 4th drug e.g. SR oral theophylline
When should referral to specialist care be made in asthma management?
Persistent poor control - maxed out ICS and other preventers
What is the next step after inhaled therapy for asthma?
Oral steroids possibly daily
In kids over 12, what other drugs may be considered as add on preventer therapy for asthma?
LAMA
B agonist therapy
What may be considered for asthma in kids that is particularly poorly controlled (not inhaled or steroids?)
Omalizumab - an anti IgE Mab
What is Omalizumab?
An anti-IgE Mab used for poorly controlled asthma
Requirements for omalizumab use?
Child over 6 years, on high dose ICS and LABA, symptomatic with frequent exacerbations and atopic
How is omalizumab given and how often? What is the risk?
2-4 weekly subcut injections - risk of anaphylaxis even on first dose
What is Mepolizumab?
An anti-IL5 Mab sometimes used in asthma management
What causes grunting and what is it a sign of?
Breathing against a partially closed glottis to provide PEEP and splint against distal airways
Therefore a sign of distal airway dysfunction and severe respiratory distress
5 differentials for severe respiratory distress e.g. Causing grunting?
Pneumonia Bronchiolitis Cardiac e.g. Heart failure NRDS Sepsis
Investigating severe respiratory distress in infants?
Sats monitoring with O2
Blood gas
CXR
Bloods e.g. CRP
What is an intermediate method of management for respiratory distress between high flow O2 in mask and I+V?
High flow nasal cannula HFNC e.g. Optiflow, humicare
Which acts like nasal cpap - humidified O2 plus air
Empirical treatment for CAP in kids?
Amoxicillin
Empirical treatment for CAP if already had amoxicillin?
Cephalosporin or macrolide
What can occur in severe croup post nebbed adrenaline therapy?
Rebound worsening - needs careful monitoring
What is sternal recession typically associated with?
Upper airway obstruction
What inspiratory/expiratory phase change may occur in severe wheeze?
Prolonged expiratory phase
What side effect does aminophylline have?
Vomiting
What are rhonchi?
Wet sounding large airway phlegmy sounds
What are the two most common causes of OSA?
Adenotonsillar enlargement
Obesity
4 risk factors for more severe bronchiolitis?
Prematurity
Cardiac disease
Underlying resp disease
Neuromuscular disease
What might be the large mediastinal mass in CXR in kids aged 2-8?
Thymus
What is a congenital cystic adenoid malformation?
Differential for CDH - cystic appearance in lungs often unilateral
Ddx for big ‘lobar’ pneumothorax in kids?
Congenital lobar emphysema
What does meconium aspiration look like on XR and why?
Streaky hilar region with LNs, looks like bad infection
With hyperinflation due to ball valve effect inflating distal airways
What is round pneumonia?
Type seen in kids on XR, semicircular appearance
If you can’t see the R heart border on XR and there is consolidation, which lobe is affected?
R middle
