Respiratory Disease

Question 1

The paediatric upper airway

Answer 1

• Large head and short neck
• Relatively large tongue
• Adenotonsillar hypertrophy
• Larynx is more anterior and muscles immature
• Epiglottis is U shaped and more floppy
• Obligate nasal breathers to 3-6 months

Question 2

The paediatric lower airway

Answer 2

• Short soft trachea
• Airway cartilage softer
• All airways are narrower (if radius is halved, resistance increased by 16 times)
• Fewer alveoli at birth

Question 3

Chest wall and respiratory muscles

Answer 3

• Rib cage
  
  • Pliable
  • Horizontal
• Diaphragm
  
  • Inserted more horizontally
  • Decreased fatigue resistant fibres at birth
  • Abdominal breathing pattern <1 year
• Muscles
  
  • Less muscle mass and less fatigue resistant fibres

Question 4

Red flags

Answer 4

• Neonatal onset
• Cough with feeding
• Weight loss/night sweats
• History of choking
• Relentlessly progressive
• Signs of chronic lung disease

Question 5

Croup

Answer 5

• 6 months to 3 years
• Slow onset (1-2 days)
• No drooling
• Barking cough
• Fever rarely >39
• Hoarse voice
• Supine position
• Increased respiration
• Anxious
• Hypoxia unusual
• Usually caused by parainfluenza
• Treat with oral dexamethasone and give nebulised adrenaline in severe cases
• Upset can make stridor worse so keep child calm

Question 6

Epiglottitis (causes stridor)

Answer 6

• 2-7 years
• Rapid onset (hours)
• Drooling
• No cough
• Fever usually >39
• Muffled voice
• Sitting forward neck extended
• Refusing to swallow
• Pale/toxic appearance
• Laboured respiration
• Hypoxia frequent

Question 7

Asthma

Answer 7

• Trigger causes cytokine release, airway oedema, bronchoconstriction and then mucus hypersecretion
• Wheeze, cough, chest tightness and SOB
• Triggers include URTI, cold weather, exercise, emotion, smoking, pets and allergens
• See Respiratory for complete management]
  
  • SABA
  • Add preventer with ICS
  • Add LABA
  • Consider leukotriene receptor agonist
  • Oral steroids

Question 8

Bronchiolitis

Answer 8

• RSV, rhinovirus, influenza and parainfluenza
• <1 year in Europe, <2 years in US
• Nasal discharge, cough, tachypnoea, recession, wheeze and bilateral crackles
• Seasonal (October to April)
• Incubation period of 5 days following coryzal symptoms for 1-3 days - symptoms can last 7-21 days with peak on days 3-5
• Supportive treatment of O2, NG feeding and IV fluids

Question 9

Signs of severe CAP in children

Answer 9

• When to admit?
  
  • Hypoxaemia
  • Dehydration
  • Underlying risk factors
  • Parental factors
• Amoxicillin is first line and then macrolides if no response

Question 10

Cystic fibrosis

Answer 10

• AR condition - life limiting disease
• 1 in 25 carriers in caucasion population
• CFTR gene defect - commonest mutation DF508 deletion
• Leads to chronic respiratory infections - colonisation
• Can cause bowel obstruction (meconium ileus, distal intestinal obstruction syndrome), pancreatic dysfunctuion (lack of enzymes, diabetes) and liver disease
• Treat infection with antibiotics - may require portacath for repeated doses
• Treat pancreatic insufficiency with creon
• Vitamins, inhalers, nebulisers and insulin may also be required
• Physiotherapy for clearing mucus

Question 11

APLS Normal Ranges

Answer 11

Question 12

Foreign body

Answer 12

• >6-12 years
• Sudden onset
• Variable respiration
• Lots of coughing
• No drooling
• Normal appearance
• Variable hypoxia