Respiratory Conditions Flashcards
What is the most common cause of Croup, and what is the most common age?
Parainfluenza Virus
6months- 3 years
What are the main symptoms of croup?
- Starts with Croyzal Symptoms
- Barking cough (worst at night)
- Stridor
What score is used to classify Croup and what is the appropreate managment based on that?
Westley Score
* Mild: 0-2–> Oral Dex and discharge
* Moderate: 3-7–> Admission and oral Dex
* Severe: 8-11–> Admit+ Dex+ Adrenaline
* Impending Resp Failure (RR<70)–> Admit+Dex+Adrenaline
When do you consider admission on a patient with Croup?
<3 months old
RR<70
Toxic looking
Other co-morbid condition
What are the main differences between Croup and Epiglotitis?
What is the causative organism of Epiglotitis?
What is the most common age?
Haemophilus Influenza B (HiB)
1-6 years of Age
What is the typical presentation of Epiglotitis?
- Difficulty Breathing (Stridor)
- Droozling (painful to swallow)
- Tripod position: leaning forward
- High Fever (toxic looking child)
Medical Emergency
What is the appropriate Managment of Epiglotitis?
- Do not examine oral cavity, call for anaesthitist
-
Refer to Peadiatrics
3.** Blood Cultures** - Emprical Antibiotics(cefuroxime) + Dexa
- Provide antibiotics for household members as well (Rifampicin)
This is an emergency scenario
What is the most common cause of Bronchiolitis?
What is the most coomon age?
RSV (Respiratory syncytial virus)
1 month to 9 months
What is the presentation of Bronchiolitis and how to differentiate from other infections (CROUP)?
- Pre-existing cryozal symptoms
- SoB
- Grunting
- Cough
- Hyperinflation/ Subcostal/intercostal recessions
How to differentiate: Auscultation
- bi-basal end inspiratory crackles
- Stridor (expiration> inspiration)
What is the appropriate managment of Bronciolitis?
- if infant <3months then admission to hospital
- Supportive managment of oxygen and hydration (NG fluids/feeds)
- if infant is pre-term or high risk (immunosupressed, congenital abnormility) then give monoclonal RSV antibodies (PALIVIZUMAB)
Would you give Salbutamol to an infant <6 months?
<6m old = no beta receptors in lungs so salbutamol won’t work – would give it if over 1yo
What are the signs and Symptoms of asthma (history and examination)
- Wheeze end-expiratory, polyphonic
- Cough
- SoB
- Chest Pain
Symptoms are worse at night/ morning
Personal or Fmx of Atopy
Not triggered by viral cause
How does one diagnose Asthma, what are the appropriate investigations?
<5 years old: clinical diagnosis
>5 years old: Spirometry, Peak flow, bronchodialator response, FeNO tetsting
What is the managment of Asthma in children in an Outpatient Setting?
(1) SABA :
Salbutamol PRN (consider stepping up when using inhaler ≥3x a week)
* Can use a spacer if young or difficulty using
Acute dose = 1 puff per 30-60s (≤10 puffs) – 5 tidal breaths / puff
Normal dose = do not exceed 4-hourly puffs (i.e. 4 puffs a day)
(2) ICS: Low dose inhaled corticosteroid
E.G. Becotide (BECLOMETASONE DIPROPIONATE)
(3) **2-16yo LTRA ** Leukotriene Receptor Antagonist (Oral Montelukast),
review 4-8w
* 5-16yo; if fail on review, switch LTRA to LABA
* <5yo; if fail on review, stop LTRA and refer to **specialist **
(4)** ICS increased dose** Larger dose ICS; consider reducing dose once asthma controlled
E.G. Flixotide (FLUTICASONE PROPRIONATE)
(5)** Oral steroid ** Lowest dose to maintain control (prednisolone), managed by specialist
Used in any severity exacerbation of asthma for 3-5 days
What is the appropriate management of Asthma in a hospital setting?
Admit those of SEVERE or LIFE-THREATENING classification
-
Burst step (if wheezy and hx of atopy) – give all the below: +** O2 therapy** (maintain SpO2 >92%)
3x salbutamol nebs (or up to 10 inhales on a pump) SE (of too much) = shivering, vomiting
2x ipratropium bromide (Atrovent) nebulisers
1x oral Prednisolone (benefit after 4-6h) – ONLY USED IN ASTHMA (general hypoxia does not use this)
Involve seniors after burst therapy has failed to work
2. IV bolus step – give one of the below:
**1st –> IV bolus MgSO4 **
IV bolus Salbutamol Monitor ECG
IV bolus Aminophylline Monitor ECG, infuse slow (arrhythmias)
If “2<age<5”, consider montelukast
3.** IV infusion step** – give one of the below:
IV Salbutamol
IV Aminophylline
4. Panic step
Intubate and ventilate if classified as life threatening
Transfer to ICU
After patient has stabilised… give salbutamol 1-hourly–> 2-hourly –> 3-hourly –> 4-hourly –> home when…
**Stable on 4-hourly treatment **(can then wean further when at home)
Peak flow at 75% of best predicted
SpO2 >94%
Follow-up within 2 days of discharge / leaving A&E
What medications are contraindicated when on beta-agonist (salbutamol)
Contraindications on beta-agonists / salbutamol:
- Beta blockers
- NSAIDs
- Adenosine
- ACEi
What are the red Flags in a case of Sinusitis?
- Systemic Infection
- Intra or Peri-orbital symptoms (periorbital cellulitis, displaced eyeball, double vision)
- Intracranial Complications (signs of Menengitis)
If these are present then consider reffering to hospital
What is the appropriate managment of Sinusitis?
- Proper Education of patients:
- most likely a virus, it needs to run its course
- Just because something is aleviating a symptoms it does not mean that it is shortenting the course of the illness
Symptoms lasting <10 days:
1. No antibiotic
2. Advice – virus, takes 2-3 weeks to resolve, only 2% get bacterial complication, simple analgesia
* Some people may find some relief using nasal saline or nasal decongestants
* Medical advice if symptoms worsen rapidly, do not improve in 3w, systemically unwell
Symptoms lasting >10 days:
1. High-dose nasal corticosteroid for 14 days (if >12yo; e.g. mometasone)
* May improve symptoms but unlikely to affect duration of illness
* Could cause systemic side-effects
ABx not indicated (as per guidelines) but can give back up prescription
* 1st line: phenoxymethylpenicillin (clarithromycin if penicillin-allergic)
* 2nd line: co-amoxiclav
What is the most common age for Acute Otitis Media?
What are the most common causative organisms?
6-12 months (due to short, hortizontal eustathian tubes)
H.influenza, S.pneumoniae, RSV
What is the P/C and appropriate investigations for Acute Otitis Media?
P/C: fever and ear pain
Investigations:
1. Fever
2. Otoscopy: bright red tympanic membrane, performation and effusion, loss of normal light reaction
When should you admit someone with Acute Otitis Media?
- Less than 3 months old with a fever over 38
- Complications: mastoiditis, menengitis, facial nerve palsy
- Severe Systemic Infection
What is the management of Acute Otitis Media without Effusion?
Reasure that this is something that will resolve over 3 days to 1 week
Paracetamol/ ibuprofen should be used for pain-relie
Anti-histamines/ Decogenstants do not help
No need for antibiotics
If child <2 years and systemic unwell–> amoxicillin for 5 days
penicillin allergy: clarithromycin, erythromycin
What is the management of Acute Otitis Media with Perforation?
Antibiotics for 5 days Amoxicillin
Review in 6 weeks to check for healing
What is the management of Acute Otitis with Effusion? (OME/glue ear)
Refer to ENT if co-existing with:
- Down Syndrome
- Cleft pallete
- Hearing loss
- Abnormal anatomical structure
- Cholesteatoma discharge
if not, then active check for 6-12 weeks with pure tone audiometry test (3 months apart)
If stil present after 6-12 weeks:
Non surgical:
* Hearing aids and monitor for 3 months
Surgical:
* myringotomy and grommets
What are the different types of Otitis Externa?
Acute Diffuse Otitis Externa: “swimmers ear”
- moderate temperature
- Lymphadenopathy
- Diffuse swelling
- Variable pain and pruritus
- Moving ear/jaw is painful
- Impaired hearing
- Bacterial infection common
Chronic Otitis External: immunocompromised, fungal infection
- Discharge and itch are common
- Less acute
Necrotising otitis externa: – life-threatening extension into mastoid and temporal bones
- Mainly due to P. aeruginosa or S. aureus
- Mainly in elderly
- Criteria – pain, oedema, exudate, micro abscess, granulation tissue, pseudomonas culture
- Urgent referal to ENT
What is the managment of Acute Otitis Media?
Topical drops of…
1.** Acetic acid** but is only effective for 1 week
2. Antibiotics (cream)– neomycin or clioquinol
Wicking and removal of debris
o If this fails, reconsider diagnosis
o If cellulitis or cervical lymphadenopathy–>oral antibiotics
What are the organisms that commonly cause Tonsilitis?
- Group A β-haemolytic streptococcus (GAS) (unlikely for <3years or >45years)
- EBV
What scoring system can be used to predict of Tonsilitis is bacterial or viral?
CENTOR score
1. Cough Absent
2. Exudate
3. Temperature
4. Palpable Lymph Nodes
5. Age 3-14 years
The higher the score, more likely that it is GAS
1: not likely
2-3: do rapid strep test
4-5: do rapid strep test and give Empirical Antibiotics
What is the appropriate management of Tonsilitis?
Admission if:
- Difficulty breathing
- Clinical dehydration
- Peri-tonsillar abscess (quinsy) or cellulitis
- Marked systemic illness or sepsis
- Suspected rare cause (e.g. Kawasaki disease, diphtheria)
Medical Management (if bacterial tonsillitis is confirmed using rapid streptococcal antigen testing)
-
Phenoxymethylpenicillin, 10 days, QDS–> prevent sequelae like rheumatic fever
* N.B avoid amoxicillin as can cause widespread maculopapular rash if due to mono
–> Clarithromycin if pen-allergic
Advice:
* Adequate fluid intake
* Paracetamol or ibuprofen when necessary
* Saltwater gargling
* Lozenges or anaesthetic sprays (e.g. Difflam)
What can a GAS infection progress to ?
Scarlet fever
What are the main Symptoms of Scarlet fever?
What is its management?
(1) Fever, coryza (fever, headache, vomiting, myalgia)
(2) Rash (12-48 hours later) ± erythroderma:
* Neck + chest –> spread to trunk + legs
* Characteristic ‘sandpaper’ texture
* ‘Pastia’s lines’ (rash in prominent skin creases)
(3) Strawberry tongue (≤2 days = white tongue ≥2 days = desquamated strawberry tongue)
Mx: phenoxymethylpenicillin (2nd line: azithromycin), notify PHE
What is Cystic Fibrosis?
What are some common Signs and Symptoms ?
Cystic Fibrosis: autosomal reseceive condition in which mucus gets thicker and stickier- – cAMP dependent chloride channel, chromosome 7
(1)Meconium ileus (surgery may be needed)
(2)Growth faltering (difficulty putting on weight)
(3)Recurring chest infections, wheezing, coughing, SoB
(4)Damage to the airways (bronchiectasis)
(5)ABPA, nasal polyps, sinusitis
(6)Jaundice (cirrhosis, portal HTN)
(7)Diarrhoea or constipation
(8)**Diabetes mellitus **
(9)**Male sterility **(absence of the vas deferens)
(10)CLUBBING FINGERS
What are the appropriate investigations for CF?
Screening at birth =** heel prick test for IRP** / Immunoreactive Trypsinogen (if +ve, further tests are done):
* Sweat test (abnormally high NaCl in sweat) – normal (10-40mmol/L), CF (60-115mmol/L)
* Genetic tests
CXR (hyperinflation, peri-bronchial shadowing, bronchial wall thickening, ring shadows)
What is the management of CF?
Respiratory:
(1) Increased monitoring with spirometry and symptoms watches
(2) Physiotherapy twice a day → airway clearance manoeuvres and devices + encourage physical activity
(3) Mucolytic therapy:
* 1st line: rhDNase
If too young to tolerate, use mannitol dry powder (INH)
* 2nd line: rhDNase + hypertonic saline
Infection:
- Prophylaxis oral antibiotics (flucloxacillin and azithromycin to reduce exacerbation chance)
- **Rescue packs **(for prompt IV ABx with any symptoms or signs of infection)
- If end stage CF lung disease – transplant is the only option
- Minimise contact with other CF sufferers
Nutrition:
1. High calorie + high fat diet (150% of normal) + fat-soluble vitamin supplements
2. Pancreatic enzyme replacement (with every meal) CREON ©
Pshychological
Liver problems (i.e. cirrhosis, portal HTN) may ultimately require transplantation
Ursodeoxycholic acid therapy (improve bile flow)
What is Laryngomalacia and at which age is it more common?
Congenital Abnormality of the Larynx where the epiglotis obstructs the way during breathing
Symptoms peak at 2-6 weeks old
Usually resolves by 18-24 months
What are the Signs and Symptoms of Laryngomalacia?
Stridor during inspiration, worse when supine, feeding or agitated
GORD symptoms
Normal Cry
What is the management of Laryngomalacia?
Conservative (close observation and monitoring of growth)–> resolve by 18-24 months (70% by 1-year-old)
May initially worsen with age, max at 6-8 months
Complications: respiratory distress, failure to thrive, cyanosis
Endoscopic supraglottoplasty if airway compromise or feeding disrupted sufficiently to prevent normal growth
What are the commonest causes of Pneumonia in younger and older children?
Younger: Usually viral
- Neonates: GBS from mother’s genital tracts
- Infants: RSV, S. pneumoniae, H. influenzae, Bordetella pertussis, C. trachomatis, S. aureus
Older: usually bacterial
> 5yo = M. pneumoniae, S. pneumoniae, Chlamydia pneumoniae
All ages = Mycobacterium tuberculosis should be considered
How to differentiate Pneumonia from Bronchiolitis on Ascultation?
bronchiolitis = fine crackles; pneumonia = coarse crackles
What is the appropriate management of Pneumonia, when should you admit?
Hospital admission if…
(this is the same for any respiratory condition)
- SpO2 <92% on air
- Grunting
- Marked chest recession
- RR >60/min (severe tachypnoea)
- Cyanosis
- T >38C
- Child <3months
- Low feeding
- Low consciousness
Whilst awaiting hospital admission–> supplemental oxygen if SpO2 <92%
Antibiotics (cannot distinguish viral from bacterial, so give anyway):
Child <2yo with mild LRTI–> do not have pneumonia usually (so, no ABx)
1st line / mild CAP = amoxicillin, 7-14 days
2nd line / severe CAP = Co-amoxiclav + macrolides (clarithromycin)
Alternative = cefaclor
Macrolides for pen-allergic patients (i.e. clarithromycin)
In pneumonia associated with influenzae, co-amoxiclav is recommended
What is the management of Tuberculosis?
Ix: manteaux test (if -ve, excludes) –> IGRA test (if -ve, prophylaxis; if +ve, treat)
- Manteaux >5mm = +ve in immunodeficiency
- Manteaux >10mm = +ve in at-risk groups (child <4yo, healthcare workers, IVDU)
- Manteaux >15mm = +ve in normal population
Mx: RIPE, RiCES or prophylaxis:
- (MTB) RIPE = 6m Rifampicin, 6m Isoniazid, 2m Pyrazinamide, 2m Ethambutol
- (NTM) RiCES = Rifampicin, Clarithromycin, Ethambutol ± Streptomycin/amikacin
- Prophylaxis = isoniazid
What can cause Chronic Lung Disease (CLD) to an newborn/babie?
AKA: Bronchopulmonary dysplasia
- Delay in lung maturation (i.e. premature)
- Pressure and volume trauma from artificial ventilation
- Oxygen toxicity
- Infection
What will an CXR show in Chronic Lung Disease/ Bronchopulmonary Dysplasia
Widspread opacification
What is the management of CLD/Bronchopulmomary Dsiplasia?
Artificial ventilation [bad CLD]
CPAP or high-flow nasal cannula [normal CLD]
Corticosteroids (low-dose, short course; fear of abnormal development) –> induce earlier weaning
Which organisms causes Whooping Cough?
Gram negative bacterial, Bordetella pertussis
What are the signs and Symptoms of Whooping Cough?
1-week coryzal symptoms (catarrhal phase) followed by…
Continuous coughing followed by inspiratory whoop ± vomiting ± epistaxis ± conjunctival haemorrhages
Child = worst at night, may go red/blue
Infants = apnoea rather than a whoop
Which investigations for Whooping cough?
Culture ± PCR NPA (Naso-Pharyngeal Aspirate – i.e. nasal swab) for Bordetella pertussis
Notify HPU
What is the appropriate management for Whooping cough?
Admit (and isolate on ward) if
<6mo or acutely unwell:
Treatment
(if admission is not needed, prescribe an antibiotic if the onset of the cough is within 21 days):
<1 month = oral clarithromycin
1+ months = oral azithromycin
2nd line = co-amoxiclav (if macrolides are contra-indicated; not in pregnant adults or babies <6w)
Advice:
1. Rest, fluids, paracetamol or ibuprofen
2. Educate parents – disease is likely to cause a protracted non-infectious cough (may take weeks to resolve fully); complete any outstanding immunisations;
3. Close contacts prophylaxis macrolides
4. Avoid nursery until 48 hours of antibiotics or until 21 days after the onset of the cough if not treated
