Respiratory Differentials Flashcards
Bronchiolitis - Explanation, Dx and management
What is it? 1
Age? 1
Common Cause 1
Explanation of Pathophysiology 4
(4th step Net effect =…)
Presentation 8
Work of breathing
Mild- 2
Mod- 2
Severe- 2
Diagnosis 3
Severity peaks 1
Admit if… 1
Management 3* + 4
Inflammation of the small airways
Infant age (< 1 y/o) 80% caused by RSV ( Respiratory Syncytial Virus)
Explanation of Pathophysiology
1) RSV invades nasopharyngeal epithelium
2) Spreads to LRT where causes…
3) Inc mucous production -> Desquamation -> Bronchiolar obstruction via airway oedema + mucous plugging
4) Net effect = Pulmonary hyperinflation + atelectasis (collapse of one lung/ cannot inflate)
Present:
- Coryzal symp
- Dry cough
- WOB
- Poor feeding
- End - expiratory crackles
- Wheeze (which is obvs expiratory)
- Recessions
- Nasal Flaring
WOB
Mild- Sub and Intracostal recessions
Mod- + Tracheal tug + Nasal flaring
Severe- Sternal Recessions + Head bobbing
Diagnosis
- Clinical diagnosis
- Measure pulse oximetry
- CXR or Cap Blood Gas only if concerned about Resp Failure
Severity usually peaks Day 3
Admit if need breathing support or feeding support
Management IS SUPPORTIVE
- 1) Humidified O2 ( aim to reach SpO2 > 92%)
- 2) CPAP ( continuous positive airway pressure) if ventilation is required
- 3) Limit feeding to 2ml/kg/hr and use NG tube if significant resp distress
4) Bronchodilator for wheeze (useful around 1 y/o)
5) Mech Ventilation if recurrent apnoea or resp failure
6) Anti-viral therapy- Osiltamavir
7) Mucolytic therapy
Croup aka… 1
what? 1
Cause 1* + 3
Age range 1
Peak age 1
Presentation 7
Manage
- normal 2
- severe 2
Extra 1
Acute Epiglottitis
Cause- 1
What? 2
Emergency why? 1
Presentation 5
Incidence reduced by …. 1
Viral Laryngotracheobronchitis
- Upper airway infection
Cause
- Parainfluenze viruses
- Also Rhinovirus, RSV, Influenza
Age 6 Months- 6y/o
Peak age 2
Presentation - Coryzal - Fever - Barking cough - Harsh stridor (INSPIRATORY) is rasping - Variable SOB - No apparent LRTI - can be worse a night Manage - Observe + Oral/ Nebulised steroids (dexamethasone / budenoside) - Severe = Nebulised adrenaline + O2
Keep calm on examination and don’t stress out/ startle child!
Acute Epiglottitis
Cause- Influenza B
What? Acute swelling of epiglottis + Sepsis
Emergency- high risk of airway obstruction
Presentation
- High grade fever
- Unwell looking child
- Drooling
- No cough
- Soft stridor
Incidence reduced by 99% due to universal vaccine
Cystic fibrosis (I know this is genetic too)
Genetic tendency =…… affecting…..
This causes …. to be affected therefore….. =
Presentation-
- Most 1
- Neonates 1
- Children 5
Other problems they may encounter 4
Investigations 3 which mutation
Management
Resp 4
GI 2
Targeted 1/2
Autosomal recessive condition affecting the CFTR Protein
Membrane chloride channel affects sodium transportation = Thick sticky secretions
Presentation:
- Most are picked up via heel prick screening test
Neonates - Meconium ileus
Children- Freq infection, failure to thrive, wheeze, cough, steatorrhoea (excess lipid in feaces)
Other problems include: Freq sinusitis, pancreatitis, diabetes, fertility
Investigations:
Heal prick test
sweat test (High Chloride)
Genetic testing for specific mutation - F508
Management- a lifelong MDT approach
- Resp: Mucolytics, Prophylactic antibiotics, Chest physio, Vaccines
- GI: Annual OGTT (Oral Glucose Tolerance Test), Creon replacement (pacreatic enzyme)
- Targeted: Ivacaftor (increased chloride transport by potentiating the channel-open probability (or gating) of the G551D-CFTR protein) / Lumacaftor
Pneumonia
What?
2
Causes:
Most common are… 1
Common bacterial by age:
Neonate: 4
Infant: 2
School age: 5
Presentation 6
Examination 5
Investigations 3
Management
3
Admit if:
3
What?
- Infection of LRT and lung parenchyma leading to consolidation
Causes:
Most common are viral - Influenza Pneumonia
Common bacterial by age:
Neonate: E.coli, Klebsiella, Staphylococcus Aureus, Group B streptococcus
Infant: Streptococcus pneumoniae, Chlamydia
School age: Streptococcus pneumoniae, Staphylococcus Aureus, Group A Streptococcus, B. Pertussis, Mycoplasmic pneumoniea
Presentation
- Fever
- Cough
- Inc WOB
- Tachypnoea
- Letheragy
- Poor feeding
Examination
- Tachypnoea
- Coarse crackles
- Dec O2 sats
- Nasal flaring
- Recessions
Investigations
- CXR may confirm diagnosis
- NPA aspirate ( Naso-pharyngeal) for vial PCR
- Bloods genera;;y unhelpful
Management - Antibiotics - Supportive care- O2 + fluids Admit if: - O2 sats <92% - Apnoea/ grunting - Unable to maintain fluid intake
Wheeze
- On inspiration or expiration?
- Indicates? 1
- Causes 5/7
- Treatment
- Absence of wheeze in acute resp patients may indicate 1
Expiration Indicates narrowed airway Causes: Bronchiolitis, Asthma, Viral induced, Foreign body aspiration, structural abnormality, Congenital Heart Defect, GORD Treatment: - O2 - SABA - Absence of wheeze in patient who presents with acute asthma may suggest impending respiratory failure- make sure you hear air movement though the lungs!
Asthma ILOs: Acute asthma, explanation, assessment and management, Long term management
What?
3 key words
Presentation - Recurrent episodes of 4 - - - - -
Diagnosis: 4 steps and overlap with previous Q!
Assessment: Examination + Spirometry
Examination 3
Spirometry
4 KNOW THEM!
Acute Management: 5 STEPS!
Long Term management: 5 STEPS!! (last is refer)
also take into account age!
What?
- Chronic airway inflam. which is reversible obstruction and bronchohyperactivity
Presentation
- Recurrent episodes of wheeze, chest tightness, cough, breathlessness
- Identify trigger (viral, allergen, exercise)
- Diurnal variation
- Seasonal changes
- Family history of atopy
- History of asthma, eczema, hayfever (allergic rhinitis)
Diagnosis:
- Episodic symptoms (is there a pattern?)
- Wheeze confirmed by healthcare prof
- Diurnal variability
- Atopic history ( Asthma, Eczema, Allergic rhinitis)
Assessment: Examination + Spirometry
Examination
- Barrel shaped chest
- Hyperinflation -> hyper-resonance on percussion
- Wheeze + prolonged expiratory phase of resp
Spirometry
- Peak Exp Flow Rate (PEFR) +ve if >20% below prediction for height
- FEV1/ FVC +ve if <70% of lower limit for age
- +ve Bronchodilator response ( 12% Inc FEV, or PEFR with B2 agonist
- FeNO +ve if >30ppm ages 4-16 showing eosinophilic!
Acute Management:
1) Oxygen
2) Bronchodilators (which also dec. bronchospasm) SABA- Short A B2 Agonist eg Salbutamol, terbutaline AND ICS ( Budenoside or Beclamethasone)
3) Bronchodilators, Short acting Ach inhibitors! (anti-cholinergics) eg ipratropium bromide
4) CALL FOR HELP + Cardiac monitor
5) Aminophylline (dec bronchospasm), IV Salbutamol, Mg sulphate (smooth muscle relaxer)
Long Term management
1) SABA when needed (blue) + very low dose ICS such as beclamethasone (brown)
2) Regular preventer - very low dose ICS OR < 5y/o can use monteleukast a leukotriene receptor anatgonist
3) Initial add on- very low dose ICS AND < 5y/o LRTA monteleukast a leukotriene receptor anatgonist, if > 5y/o LABA eg Salmetarol, formoteral
4) Additional controller therapies: Low dose ICS if > 5y/o add LRTA or LAB, if LABA doesn’t help then stop
5) Refer for specialist care (add PO Corticosteroid, consider IgE MAB such as Omalizumab)
Viral Induced Wheeze
Common causes 5
Presentations
MIld/Mod 5
Severe 7
Life threatening 7
- RSV
- Rhinovirus
- Coronavirs
- Parainfluenze
- Influenza
Mild/ Mod: SpO2 >92% RR < 30 over 5s and < 40 in under 5s No/ minimal accessory muscles used Feeding well/ full sentences Wheeze only audible through stethoscope
Severe: SpO2 <92% PEFR 33-50% of predicted RR > 30 over 5s and > 40 in under 5s Accessory muscles used Too breathless to Feed HR > 125 (over 5s) > 140 in under 5s Wheeze audible
Life threatening: SpO2 <92% PEFR 33% of predicted Silent Chest Poor resp effort Altered consciousness Exhaustion Cyanosis
Paediatrics Normal Values Ages: <1 (infant), 1-2, 2-5, 5-12, >12 -RR - Systolic BP - HR
<1 (infant),
- RR 30-40
- Systolic BP 70-90
- HR 110-160
1-2
- RR 25-35
- Systolic BP 80-95
- HR 100-150
2-5
- RR 25-30
- Systolic BP 80-100
- HR 95-140
5-12
- RR 20-25
- Systolic BP 90-110
- HR 80-120
> 12
- RR 15-20
- Systolic BP 100-120
- HR 60-100
