Respiratory conditions Flashcards
Describe the presentation of respiratory distress in children
Moderate:
- Tachypnoea + tachycardia
- Nasal flaring
- Grunting
- Chest well recessions/retractions
- Use of accessory muscles
Severe:
- Cyanosis
- Tiring, shallow breathing (normal PCO2)
- Drowsiness
- Sats <92%
What is the difference between intra and extrathoracic airway obstruction in terms of presentation?
- Intrathoracic: worsens on expiration (when the airways are at their smallest) eg. wheeze
- Extrathoracic: worsens on inspiration (decreased intraluminal pressure) eg. stridor
What is included in the term URTI?
- Coryza (cold)
- Sinusitis
- Otitis media
- Tonsillitis, pharyngitis
Which pathogens are responsible for the common cold? How does it present?
What is the management?
- Viral eg. rhinovirus, RSV, coronaviruses
- Presents with blocked + runny nose, sneezing, sore throat, etc.
- Reassurance, explain it will pass in days-weeks
- Conservative management: fluids, rest, paracetamol
- Can try: steam inhalation, vapour rub
- No evidence for cough syrups, etc though can use if you want (in >6s)
Which pathogens are responsible for pharyngitis/tonsillitis? How does it present?
- Sore throat, difficulty swallowing, swelling, erythema, lymphadenopathy, fever, may occur with other URTI symptoms eg. rhinorrhoea
- Viral common: adenovirus, rhinovirus, EBV, also Group A Strep
How can you distinguish bacterial and viral tonsillitis?
Features suggesting bacterial infection:
- Fever >38
- Purulent exudate
- No cough or coryza (viral symptoms)
- Lymphadenopathy
A 7 year old girl is brought to A&E by her grandmother. Her grandmother reports she has been complaining of a sore throat for the past 2 days and is not eating or drinking because of the pain. She measured her temperature at home as 38.4˚. The girl does not have a cough or cold symptoms, and no rash. What would you do next including management based on the most likely differential.
- Want to take a full history
- Examine: ENT including inspection of the throat and ears, palpation of the cervical lymph nodes. Also assess for severity of dehydration
- Vital signs including HR, RR, BP, temp, sats
- Throat swab for rapid antigen test (Group A Strep)
This sounds like tonsillitis/pharyngitis, which would be confirmed by examination. If this is a possible bacterial origin:
- Explain diagnosis of tonsillitis
- Prescribe antibiotics eg. phenoxymethylpenicillin for 10 days (clarithro if penicillin allergy). Should have effect in 24-48 hours. Important to take full course!
- Encourage rest + fluids, salt water gargle, lozenges
- Seek medical attention if fever not coming down, difficulty breathing, gets worse
What is considered recurrent tonsillitis?
7 in 1 year, 5 in 2 years, 3 in 3 years
-Refer to ENT for tonsillectomy
Group A Streptococcus tonsillitis can result in which complications?
Infectious: sinusitis, otitis media, pneumonia, sepsis, etc.
Auto-immune:
- Scarlet fever
- Rheumatic fever
- Glomerulonephritis
- PANDAS
Describe the presentation of scarlet fever. How is it treated?
High fever -> headache and pharyngitis, rash
Rash: rough ‘sandpaper’ maculopapular rash, flushed cheeks with perioral sparing. White/strawberry tongue
Notify the health protection team
Treat with antibiotics (phenoxymethylpenicillin) for 10 days
Symptomatic treatment eg. paracetamol, lozenges
A 9 month old boy is brought to the GP by his mother. He has a fever of 37.8, is extremely irritable, and is not feeding like usual. Describe your approach.
- Full history to look for signs of localised infection, etc
- Examination: brief abdo, chest exam, look for rash, ENT
- Based on examination findings -> further investigations
eg. urine dip, throat swab
Describe the presentation of acute otitis media
- Fever, irritability/crying, ear pain, vomiting, cold symptoms, systemically unwell
- Bulging, erythematous tympanic membrane without cone of light, +/- fluid level, +/- perforation with visible pus
Describe the management of acute otitis media
- Conservative: paracetamol/ibuprofen, fluids, rest
- Antibiotics if symptoms last >3 days/severely unwell (amoxicillin)
What is the complication of recurrent acute otitis media? What is the management?
- Recurrence can lead to effusion (glue ear)
- Can present with hearing loss +/- speech difficulties
- O/E: tympanic membrane is dull, retracted, with fluid level
- Refer to ENT, may require grommet insertion (drain)
Describe the management of sinusitis
- Sinusitis is usually caused by a viral infection, takes 2-3 weeks to resolve
- Best management is conservative
eg. paracetamol/ibuprofen, fluids, rest, steam inhalation - Return if not any better after 10 days of symptoms, increasing fever or worsening symptoms
- > 10 days: consider prescribing antibiotics (phenoxymethylpenicillin- Penicillin V) for 5 days.
Peritonsillar abscess is also known as__
Quinsy
Name some causes of stridor
- Croup
- Acute epiglottitis
- Foreign body aspiration
- Angioedema
- Diphtheria
What should you never do in a child with stridor?
Examine the throat without resources for life support/resusc due to risk of precipitating full closure
What is croup? What is the common cause? How does it present?
Croup is an infection of the upper airways (laryngotracheobronchitis). Usually caused by parainfluenza virus, RSV, etc.
Presents with:
- Viral prodrome: runny nose, low fever
- Loud barking cough, stridor, difficulty breathing
- Symptoms are worse at night
- Respiratory distress is uncommon and severe
What is the age group commonly affected by croup? Bronchiolitis?
Croup is very common, affects children 6 mos-6 years, with peak in the 2nd year.
Bronchiolitis is slightly more common than croup, and affects young infants typically 1-9 months old
An 18 month old child is brought to A&E by his mother. She reports he developed a loud cough late yesterday evening after a period of cold-like symptoms. On examination, he appears well, with no visible chest recessions, tachypnoea, or signs of respiratory distress. When you look in his ears he starts to cry, and you notice a mild stridor. His oxygen saturations are 99% on air, temperature is 37.5˚. What is your management?
The history and examination finding of stridor makes the diagnosis of croup most likely (viral prodrome followed by cough and stridor). The child is systemically well, with stridor heard only when crying. Therefore, this is MILD croup and the correct management is to administer dexamethosone 0.15mg/kg PO and send home.
- Explain the diagnosis to mother and management
- Fluids, rest, paracetamol, checking in the night
- Safety net: come back if not improving. Call 999 if you are worried eg. trouble breathing, significantly worse
Describe the management of croup
Want to classify if mild, moderate, severe or life-threatening
- Mild: cough but no stridor at rest
- Mod: cough, stridor at rest
- Sev: cough, stridor at rest, agitation/lethargy
- Life-threatening: signs of significant respiratory distress eg. cyanosis, extreme tachypnoea, drowsy
Mild: PO dex and send home. Paracetamol, fluids, rest, check in the night
Mod/sever/life-threatening: admit for monitoring. Consider nebulised steroids or nebulised adrenaline if life-threatening
What is epiglottitis? What is the typical cause? What is the presentation?
Acute epiglottitis is inflammation of the epiglottis associated with septicaemia, typically due to Haemophilus influenza B.
Presents with upper airway obstruction:
- Fever, systemically unwell
- Severely painful throat preventing speaking/swallowing -> drooling + mouth open
- Soft stridor, difficulty breathing
What should you do if you suspect acute epiglottitis?
- Call for help immediately (senior paeds + anaesthetics)
- Secure the airway
- Start sepsis 6: take cultures + lactate, give O2 and fluids, IV antibiotics (ceftriaxone), measure urine output
- Can use steroids + adrenaline to decrease inflammation
- Rifampicin prophylaxis to close contacts
Describe the presentation of bronchiolitis
- Viral prodrome: runny nose, fever, etc.
- Dry cough, wheezing, shortness of breath, difficulty breathing
- Respiratory distress if severe: tachypnoea + tachycardia, recessions, grunting, nasal flaring, cyanosis, low saturations, drowsiness
What are the risk factors for severe bronchiolitis?
- Prematurity esp. chronic lung disease of prematurity
- Other lung disease
- Age <6 weeks
- Congenital cardiac disease
A mother brings her 3 month old infant to A&E because he is having trouble feeding. She describes a cold-like illness starting several days before, that has now progressed into a non-productive cough. He is struggling to feed normally due to his breathing, with frequent breaks in feeding. What is your approach?
Depending on how unwell the child is: A->E
- Full history including amount of feeding recently and nappies to gauge severity of dehydration, ask about wheezing, temperature. Birth history including prematurity, immunisations, other lung disease/cardiac disease + recurrent chest infections. Anyone smoking at home.
- Examination: listen to chest, signs of respiratory distress, assess for dehydration
- Vitals eg. RR, HR, oxygen saturations, temperature
- Ix: Consider CXR + VBG if respiratory distress, bloods if acutely unwell/high temp
Management: the most likely diagnosis is probably bronchiolitis
- If severe: admit for monitoring and continuous O2
- If mild: send home, give advice on conservative management and safety netting
What can be used in infants with lung disease to prevent bronchiolitis?
Palivizumab
You have just seen an infant in A&E with a diagnosis of mild bronchiolitis. How would you counsel the parent?
- Explain diagnosis: bronchiolitis is inflammation of the lungs, usually caused by a virus. It is very common in younger children and infrequently children need admission. Most will get better within 3-5 days at home. No other treatments are proven to speed up recovery
- Conservative management: fluids, rest, paracetamol, check during the night, stop smoking!!!
- Safety net: if getting worse come back. If having lots of trouble breathing, going blue, very drowsy etc, call 999
Name some causes of wheeze in children
- Bronchiolitis
- Viral episodic wheeze
- Multi trigger wheeze
- Asthma
Describe the spectrum of asthma/wheeze in children
- Viral episodic wheeze: very common in infants and younger children (1-5 years), presents with cough + wheezing triggered by viral infection. NOT asthma, does not require management, does not predispose to asthma. Management depends on the severity as with asthma eg. salbutamol burst therapy when symptomatic, LKA/ICS for prevention taken at the start of URTI.
- Multi-trigger wheeze: quite common in younger children. Cough + wheeze (similar to asthma) triggered by many different things eg. dust, pollen, viruses, cold air etc. Not asthma but some children go on to develop asthma later in childhood. Salbutamol for symptomatic episodes, can consider ICS
- Asthma: typically only diagnosed >5 years old. Cough + wheeze on multiple days of the week over several weeks, often worse at night. Managed with salbutamol as needed + low dose ICS with escalating drug therapy.
Describe the clinical characteristics of asthma
- Recurrent episodes of symptoms with asymptomatic periods between episodes. Can have triggers eg. viral infection, allergens, cold air
- Exacerbations: dry cough, wheeze, shortness of breath, chest tightness. Diurnal variation (worse at night/early morning)
- Objective evidence of airway obstruction + reversibility eg. auscultated wheeze/reduced PEF during symptomatic periods, none when asymptomatic
- Personal or family history of atopy