Respiratory conditions Flashcards
URTI symptoms
LRTI symptoms
URTI: Coryza, sore throat, earache, sinusitis and stridor
LRTI: Cough, wheeze, respiratory distress
! Infants have compliant chest walls and poorly developed respiratory muscles and hence are greatly susceptible to respiratory failure!
Signs of respiratory failure: Moderate and severe
Moderate:
- Tachypnoea
- Tachycardia
- Nasal flaring
- Use of accessory muscles
- Intercostal and subcostal recession
- Head retraction
- Inabilty to feed
Severe:
- Cyanosis
- Tiring (due to increased effort of breathing)
- Reduced conscious level
- Oxygen saturation < 92 % - despite oxygen therapy
ASTHMA: Natural Hx of asthma during childhood
- Wheeze/symptoms worsened by exercise/ill health/changes in weather
- Symptoms responsive to bronchodilation e.g. LRTA
- Should be expected in any child presenting with wheeze > x1 occasion
- Non-viral induced
- No associated coryzal symptoms
- No formal diagnosis until 5 years - ‘childhood wheeze’
- FHx of atopy
ASTHMA: Key features of history and examination that support a diagnosis of asthma
History:
- Symptoms: Wheeze, non-productive & dry cough1, dyspnoea, tightness of chest, respiratory distress
- Diurnal variation of symptoms
- Worsened by change in weather/illness/exercise
- Family/personal Hx of atopy (eczema, hayfever, asthma)
- Recurrent episodes of wheeze, with interval symptoms2
- NO coryzal symptoms/LRTI - evidence no virally induced wheeze
- Positive response to asthma therapy (bronchodilators)
Examination:
- Inspection: Inhaler, oxygen, nebuliser, respiratory distress, pectus cariatum, Harrison’s sulci, chest hyperinfltion
- Chest ausculation: Audible general expiratory polyphonic wheeze, reduced air entry, prolonged expiration
1: In some children coughing may be the main symptom. Particularly at night.
2: Symptoms persisting in the absence of viral infection/between acute exacerbations
ASTHMA: Be familiar with the other common clinical conditions that can mimic asthma
(consider signs/symptoms to allow rule in/out)
- Viral induced wheeze
- Cystic fibrosis
- Chronic aspiration
- Gastroesophageal reflux disease
- Bronchopulmonary dysplasia
- Tracheo-bronchomalacia
ASTHMA: Be able to manage an acute exacerbation of asthma
- ASSESS SEVERITY
- Once identified as mild/moderate, severe or life threatening then commence treatment
ASTHMA: Know the 5 steps of the SIGN/NTS guidelines for the management of asthma
ASTHMA: Be able to assess asthma control in childhood
- Assess inhaler technique
- Confirm frequency of preventer use
- > x3 a week indicates need to progress to next management step
- Woken from sleep > x2 weekly indicates need to progress to next management step
- Any recent acute exacerbations?
- Was hospitalisation required?
- What treatment was required?
- Review symptoms and frequency
- Night time waking?
- Disturbance to activities - school/social
- Peak flow or spirometry should be performed
ASTHMA: Be able to advise parents about how to care for a child with asthma
Removal of environment triggers
- Remove feather/woollen bedding
- Cleaning of carpets and furniture
- No pets in house if there are allergies
- Discourage smoking in the car and house/at all
Inhaler technique
- Encourage use of spacer device
- Encourage mouth wash/drink after use of the steroid inhaler to avoid oral thrush
Always carry ‘preventer’ with you
Does not need to limit activities
Advice for in the event of an acute asthma attack
- Firstly try 10 puffs. If there is no improvement then call 999
ASTHMA: Know details of the drugs used to treat chronic and acute asthma and understand their mechanism of action
CHEST INFECTIONS - BRONCHIOLITIS: Understand the aetiology and natural history of bronchiolitis
Aetiology:
- Viral: RSV (70%), adenovirus
- Inflammation and accumulation of mucus within the airways
- Premature infants with bronchopulmonary dysplasia, congenital heart defects and CF are at increased risk
- IM vaccine available for at risk groups
Natural history:
- Condition of infancy: Up to 1 year of age
- More common in the winter months
- Symptoms typically worsen at around day 3-5
- May begin to experience reduced feeding and respiratory distress
- Coryzal like symptoms → cough → day 4/5 peak → resolution by 2 weeks → dry cough may persist for several weeks
CHEST INFECTIONS - BRONCHIOLITIS: Recognise and be able to describe the clinical features of bronchiolitis and be able to relate these to normal physiology
Inspection of room:
Oxygen, fluids on drip/evidence of fluid challenge (syringe)
End of bed inspection:
Respiratory distress, tachypnoea, mucus production, dry wheezy cough, cyanosis/pallor
Palpation:
Expansion unaffected, liver displaced inferiorly, chest hyperinflation
Ausculation:
Prolonged expiratory wheeze, fine end-inspiratory wide spread crepitations, reduced air entry, tachycardia
Percussion:
-
Other findings:
Reduced CRT if dehydrated, pyrexia,
Parental findings:
Reduced feeding, apnoea, prodromal coryza,
CHEST INFECTIONS - BRONCHIOLITIS: Know how to treat acure bronchiolitis
Remember, the 2 main reasons for admission in bronchiolitis are LOW OXYGEN SATURATION and DEHYDRATION.
Management
- Minimal handling to minimise respiratory distress
- Provision of oxygen
- Fluid challenge
- ORT orally → with syringe → NG tube → IV
- Inhaled therapies ! Little evidence of providing benefit
- Ipatropium is preferred
- Beta 2 agonists are not effective under 6 months of age
- NPA to allow for bed management, blood gas to assess respiratory support, ENT examination
CHEST INFECTIONS - BRONCHIOLITIS: Be able to advise parents how to care for a child with bronchiolitis
Course of bronchiolitis
- Recovery should be made within 2 weeks, although a dry cough may persist
When to seek medical help
- Signs of respiratory distress: grunting, cyanosis, subcostal recession, tracheal tug, excessive respiratory rate
Monitor:
- Fluid intake and subsequent urine output
- Temperature: May use paracetamol if feverish
CHEST INFECTIONS - PNEUMONIA: Know and understand the aetiology and natural history of pneumonia including knowledge of the common causative organisms
Aetiology
- Bacterial or viral infection of the small airways (LRTI)
Common causative microorgansisms
Common bacterial causes: Streptococcus pneumonia, staphyloccus aureus, haemophilus influenzae, mycoplasma
Common viral causes: Adenovirus, rhinovirus, RSV
Introduction of HiB vaccine has reduced this as a cause
Most common cause in newborns: Group B Streptococcus
Most common cause in infants/young children: RSV (generally respiratory viruses)
Most common cause in children > 5: Mycoplasma pneumoniae, streptococcus pneumoniae, chlamydia pneumoniae
Natural History
Preceeding URTI → fever, cough, tachypnoea, pleuritic chest pain and/or abdominal pain
CHEST INFECTIONS - PNEUMONIA: Recognise and be able to describe the clinical features of pneumonia and be able to relate these to normal physiology
Inspection of room:
Oxygen, sputum pot, tissues, ?fluids
End of bed inspection:
Respiratory distress cyanosis, sweating, FTT, tachypnoea
Palpation:
Reduced expansion (unilateral), delayed CRT
Auscultation:
Focal crackles, reduced air entry
Percussion:
Dullness
Other findings:
Reduced oxygen saturation
Parental observations:
Reduced feeding, recent URTI
Clinical features
- Tachypnoea (most sensitive clinical finding)
- Fever/pyrexia
- Productive cough
- Respiratory distress
- Abdominal/chest/neck pain - caused by pleuritic pain, indicates bacterial aetiology
THROAT SWAB - May be performed to allow for aetiolgy to be confirmed (bacterial vs viral)
CHEST INFECTIONS - PNEUMONIA: Have knowledge of the treatments available for children with pneumonia
(including antibiotics, oxygen and physiotherapy)
Treatment
- Oxygen therapy
- Ensure adequate hydration: Fluid intake and output
- Analgesia
- Reduce pyrexia
- Reduce pain during respiration
-
Antibiotic therapy: May be oral or IV (suspected sepsis, complications, severe hospital acquired infection). Agent is determined by severity.
- 1st choice for non-severe symptoms: Amoxicillin
- 1st choice in the presence of severe symptoms: Co-amoxiclav (amoxicillin + clavulanic acid)
- Atypical pathogen suspected (mycoplasma): Clarithromycin or erythromycin (macrolide)
-
Physiotherapy
- Not routinely recommended - no benefit e.g. reduction in RR or length of hospital stay
CHEST INFECTIONS: Be able to advise parents about how to care for a child with a chest infection
- When to seek further medical help
- Signs of respiratory distress
- Not improving (in given time frame)
- Insufficient fluid/food intake
- Monitor fluid intake
- Monitor fluid output (urine)
- May be paracetamol for fever control
- Ensure medications are taken as directed, and the full course (Abx)
- Saline drops may be administered to loosen mucus
CHEST INFECTIONS - PERTUSSIS: Know the aetiology and natural history of pertussis
Aetiology
- Bordella pertussis (gram negative)
- ! Highly contagious
Natural history
-
1 week of coryza followed by the development of a paroxysmal/spasmodic cough followed by a characteristic inspiratory whoop
- Coughing worse nocturnally
- May induce vomiting
- Mucus from mouth and nose
- Cough may persist for a prolonged period - 100 day cough
- CHECK FOR EPISODES OF APNOEA - any cyanosis? Requires admission for supportive oxygen therapy - other wise managed at home
- Infectious up to 3 weeks from onset of symptomd
- Diagnosis via perinasal swab and culture, also lymphocytosis on FBC
-
Macrolide Abx: Only effective if given in the catarrhal phase.
- Prophylactic Abx should be given to relatives/friends
- Pertussis vaccination advised in pregnancy
CHEST INFECTIONS - PERTUSSIS: Understand the effect of immunisation on presentation of clinical features
Not always effective.
30% of infections come from a fully vaccinated sibling.
CHEST INFECTIONS - PERTUSSIS: Be able to advise parents of a child with suspected pertussis
What to expect
- Cough can persist for quite an extensive period of time - the ‘100’ day cough
- Symptoms are typically worse at night
- Persistent coughing may cause vomiting to be induced
- Can have mucus from mouth and nose
- Can cause epistaxis and subconjuncival haemorrhage (blood spot on eye, will resolve spontaneously)
Management
- Notifiable disease: Must stay off school/nursey for 5 days after starting Abx or 21 days from onset of symptoms
- Can be managed at home
- Paracetamol for fever if required, ensure adequate fluids
- Abx may be given if within catarral phase/first 21 days
- Abx for family/close contacts
When to seek further help
- Any periods of apnoea or cyanosis
- Requires admission for oxygen
- Particularly important if under 6 months of age (low threshold)
- Evidence of rib fracture, intra-ventricular haemorrhage
- Parental concern
Provide written information
CHEST INFECTIONS - TUBERCULOSIS: Be able to recognise the clinical features of tuberculosis in children
SHOULD BE CONSIDERED FOR those with persistent productive cough and those with suspected pneumonia/pleural effusion that is unresponsive to abx therapy
CXR findings: Marked hilar or paratracheal lymphadenopathy is highly suggestive of TB
Symptoms
- Fever (of unknown origin)
- Weight loss/faltering growth
- Blood cough
- Night sweats
- Lethargy
- Unexplained lymphadenopathy
CHEST INFECTIONS - TUBERCULOSIS: Have a knowledge of treatment options required and the difficulties in ensuring adherance in children
Requires 6 months of antibiotic therapy
- isoniadzid, rifampicin, pyrazinamide and ethambutol for 2 months, then
- isoniazid and rifampicin for a further 4 months
Can used fixed-dose combination tablets as part of the TB regimen
CYSTIC FIBROSIS: Know and understand the aetiology and natural history of cystic fibrosis
Aetiology
- An autosomal recessive condition
- Pathological variant in CFTR gene
- Causes defective chloride transport and subsequent increased viscosity of mucus
Natural history
- Detected on newborn spot test
- Raised immunoreactive trypsinogen
- Hypoechogenic bowel on USS
- Delayed passage of first meconium
- Meconium ileus
- Faltering growth
- ‘salty’ taste to child
CYSTIC FIBROSIS: Recognise and be able to describe the clinical features of cystic fibrosis and be able to relate these to normal physiology
Recurrent chest infections
- Mucus in the airways prevent clearance of bacteria
- Recurrent infections → scarring/bronchiectasis → respiratory failure
- Staph aureus and haemophilus influenzae then pseudomonas
Faltering growth
- Pancreatic insufficiency → failure to digest fat → steatorrhoea
- Diagnosed by low faecal elastase
- Salt depletion → dehydration
Nasal obstruction/polyps
- Uncommon in under 5s
- CF should be ruled out in any child with nasal polyps
Bowel obstruction
- Dehydrated faecal matter
- Meconium ileus in neonatal period OR
- Distal intestinal obstruction syndrome (DIOS) in childhood
- Forceful defaecation leads to rectal prolapse
CYSTIC FIBROSIS: Be aware of the treatments available to children with cystic fibrosis including medications, physiotherapy and nutrition
Medications
- Prophylactic abx
- Flucloxacillin (staph. A)
- Pancreatic supplements (Creon)
- Multivitamins
- Fat soluble A, D, E & K
- Inhalers
- Mucolytic agent
- Nebulised NaCl
- Management of CF related diabetes
Physiotherapy
- Respiratory physio to help ease mucus clearance
- Devices may be used
Nutrition
- Dietician input
- Increase energy intake in faltering growth or oral nutritional supplements if the former is unsuccessful
- Multivitamins
ENT: Recognise the clinical features of epiglottitis
- Associated with septicaemia
- High fever (very ill-looking child)
- Intensely painful throat that prevents swallowing
- Open mouthed to optimise the airway
- Drooling salivia
- Inspiratory stridor
- Respiratory distress
- Minimal or absent cough
NOTE: Epiglottitis is RARE due to HiB vaccination
ENT: Be able to distinguish epiglottitis from other causes of upper airway obstruction
Key ddx in airway obstruction include viral laryngotracheobronchitis (croup) and epiglottitis
ENT: Recognise the importance of otitis media, be aware of causative organisms and the treatment options available
Recurrent acute otitis media → otitis media with effusion → conductive hearing loss → speech and learning difficulties
Complications: Mastoiditis, meningitis
Causative organisms
Viral: RSV, rhinovirus
Bacterial: Streptococcus pneumoniae, haemophilus influenzae, Moraxella catarrhalis
Treatment options
- Spontaneous resolution
- Abx therapy:
- Amoxicillin
- Marginally shortens the duration of pain
- Suitable for bilateral infection, systemically unwell or neonates
- Paracetamol or ibruprofen for pain
CLINICAL EXAMINATION: Any child with a fever should have their tympanic membrane examined
ENT: Be able to advise parents about how to care for a child with acute otitis media
Explain diagnosis
- Infection of the ear
What to expect
- Ear drum may perforate: Discharge of blood/pus, attend GP, heal spontaneously
- Should recover in 3-5 days
Care
- Abx may be given
- Give paracetamol or ibuprofen for pain
- Ensure adequate fluid and nutrition intake
When to seek further help
- Symptoms of mastoiditis or meningitis
- Tenderness behind the ear
- Fever, non-blanching rash
- Symptoms worsen significantly or become systemically unwell
- Not recovered within 1 week
Offer written information/direct to website
ENT: Know and understand the aetiology and natural history of tonsillitis including knowledge of the common causative organisms
Aetiology
- Inflammation of the tonsils
- May be viral (most commonly) or bacterial
Natural history
- Group A streptococcus infection: 2/3 days of fever and headache → tonsillitis (→ scarlet fever)
- Clinical features:
- Sore throat
- Odynophagia
- Fever
- Headache
- Reduced oral intake
- Bacterial more likely if: Absent cough, tender cervical lymphadenopathy, high fever, tonsillar exudate
- Physical examination: Erythema of the tonsils, cervical lymph node enlargement, tonsillar exudate (bacterial)
Common causative organisms
Bacterial: Group A streptococcus
Viral: EBV
ENT: Be able to advise parents about how to care for a child with tonsillitis
Explain diagnosis
- Infection of the tonsils, at the back of the throat
What to expect
- Should begin to recover within 3 days
Ongoing care
- Ensure adequate fluid intake
- Salt water gargling, lozenges to provide temporary pain relief
- May return to school after fever has resolved/feeling well OR after taking abx for 24 hours
- Paracetamol or ibuprofen for fever
- Tonsillectomy is only considered after recurrent episodes (> 7 per year etc.) and requires referral to ENT specialist first
When to seek further help
- Symptoms do not improve after 3 days
- Fever > 38.3°C
- Development of dysphagia
- Development of rash
Offer written advice/direct to website
ENT: Know and understand the aetiology and natural history of URTI including knowledge of the common causative organisms
Aetiology
Infection of the upper respiratory tract, including the ears and sinuses.
Natural history
- URTI includes common cold, sore throat, acute otitis media and sinusitis
- Hospital admission is rarely required UNLESS feeding and fluid intake is inadequate
Common causative organisms
Coryza/common cold: Rhinovirus, coronavirus, RSV
Tonsillitis:
Viral (most common): Adenovirus, enterovirus, rhinovirus
Bacterial: Group A streptococcus (older children)
Acute otitis media:
Viral: RSV, rhinovirus
Bacterial: Pneumococcus, haemophilus influenzae, moraxella catarrhalis
ENT: Know the physiological consequences of fever and the therapeutic options and indications for treatment of fever durring childhood
Consequences of fever
- Febrile convulsions
- Delirium
Indication for treatment of childhood fever
- Fever is defined as a temperature of 38ºC or higher
- Systemically unwell or uncomfortable
Treatment of childhood fever
-
Antipyretic monotherapy: Paracetamol or ibuprofen
- Combination therapy may be used if monotherapy of both agents is ineffective
- Check age dose requirements!
- Do not use aspirin in children under 16 years of age
- Upkeep of fluid intake
- Hospital admission may be required - perform assessment using the NICE feverish child criteria
0-3 months: > 38ºC is red (high risk of serious illness)
3-6 months: > 39ºC is amber (intermediate risk of serious illness)
ENT: Be able to advise parents about how to care for a child with an URTI
Explain diagnosis
- Infection of the airway - any part above the lungs
- Can be caused by viruses or bacteria
- Very common
What to expect
- Cough can persist for 4 weeks with coryza
Ongoing care
- Ensure adequate fluids and food
- Control of fever
When to seek futher help
- Symptoms worsen or no improvement in recommended time frame
- If febrile convulsions experienced
Written advice or direct to website
ENT: Know and understand the aetiology and natural history of viral croup including knowledge of the common causative organisms.
Common causative oganisms:
- Parainfluenzae
- RSV
- Rhinovirus
Aetiology:
Viral laryngotracheobronchitis sees tracheal oedema and collapse
Natural Hx:
Typically occurs from 6 months to 6 years of age - peak incidence at 2 years of age
- Preceding coryza
- Hoarseness
- Barking cough (‘seal-like’)
- Stridor (harsh)
- Respiratory difficulties
- Degree of recession is a very useful indicator of the severity of upper airways obstruction
- Symptoms often start, and are worse, at night (nocturnal worsening)
- Symptoms usually resolve within 48 hours
ENT: Know the management options available for viral croup, including drugs, oxygen and supportive therapy.
ENT: Be able to advise parents about how to care for a child with viral croup.
- ‘Steam treatment’ has often been advised but there is no evidence that it helps symptoms. It is not recommended
- Try to calm and comfort your child on your lap
- Paracetamol and ibuprofen may be used if the child is distressed due to fever
- Symptoms usually resolve withi 48 hours
When to seek help
- Call an ambulance in the event of cyanosis or severe breathing difficulty
- Child begins to drool or have difficulty swallowing
- Respiratory distress: Sternal recession
- Child becomes drowsy or difficult to wake
- Child becomes restless or agitated
ENT: Be able to make a confident differential diagnosis for the various causes of upper airway obstruction.
- Croup *most common*
- Foreign object
- Epiglottitis
- Tracheitis
- Allergic laryngeal angioedema
- Inhalation of smoke/hot fumes in fires
- Trauma to the throat
- Retropharyneal abscess
- Hypocalcaemia
- Severe lymph node swelling - TB, infectious mononucleosis, malignancy
- Measles
- Diphtheria
- Laryngomalacia (floppy larynx)
- Congenital deformity
REMEMBER obstruction of the lower portion of the upper airway causes stridor to be heard
ENT: Be able to provide immediate care for a choking child.
- Ask the child to attempt to cough.
- If the cough is ineffective or the child is unconsciousness/unable to cough then proceed to back blows
- Under 1 year: Lie across legs and apply 5 back blows
- Over 1 year: Lean forward and apply 5 back blows
- If back blows are ineffective…
- Chest thrusts for children < 1 year. Give 5.
- Abdominal thrusts for children > 1 year Repeat up to 5 times.
- If the child is unconsciousness then CPR should be performed
ENT: Be able to recognise the clinical features of bacterial tracheitis a.k.a. bacterial croup
Gradual onset
Normally preceded by a viral infection
Pyrexia (>38ºC)
Febrile, toxic-appearing and in respiratory distress
Barking cough, stridor
Difficulties swallowing
Pseudomembrane: Mucopurulent exudates acutely obstruct/narrows the trachea
Tracheal narrowing on radiographic imaging of the neck
Causative agent: Staph. aureus, streptococcus
SMOKE INHALATION: Understand the immediate danger posed by burns and smoke inhalation in relation to the anatomy of the airway and be familiar with emergency protocols for their management.
Management
- Administer 100% oxygen
- Basic monitoring
- Establish IV access
- Intubation may be indicated
