Respiratory Disease in Childhood Flashcards
What is the most common respiratory problem in premature babies?
Respiratory Distress Syndrome - relative surfactant deficiency results in high surface tension and can cause lung collapse
Inverse relationship with gestation
What is surfactant?
A phospholipid secreted by child at 30-32/40 weeks
Lack of surfactant results in atelactasis (partial collapse/incomplete inflation of lungs) and impairment of gas exchange
Clinical presentation of respiratory distress syndrome?
High RR (in children, normal is 60 breaths/min)
Sternal recession
Grunting
No breath sounds on side of chest affected
Prophylactic treatment of respiratory distress syndrome?
Mother in premature labour is given steroid injection, to stimulate surfactant production by child
Complications of respiratory distress syndrome?
Ventilation - can cause problems so must ensure it is gentle and not for too long
Sudden deterioration - can cause increase O2 requirement
Iatrogenic cause of problems in respiratory distress syndrome?
Pneumothorax (air in pleural space) - risk factors include RDS and increased incidence with IPPV (Intermittent Positive Pressure Ventilation), CPAP (Continuous Positive Airway Pressure) and ventilation
Non-iatrogenic causes of pneumothorax in babies?
Spontaneous - occurs in ~1% vaginal deliveries and 1.5% of caesarian sections
What is chronic neonatal lung disease classified as?
AKA bronchopulmonary dysplasia (BPD)
O2 requirement beyond 36 weeks corrected gestation + evidence of pulmonary parenchymal disease on CXR
When does chronic neonatal lung disease occur in neonates?
Generally, follows RDS
Clinical presentation of chronic neonatal lung disease?
Barotrauma - lung damage due to pressure changes
Volume trauma
High inspired oxygen
Healing of chronic neonatal lung disease?
Associated with continued lung growth over 2-3 years - often wheezy
Diaphragmatic hernia in neonate?
Diaphragm not formed properly do gut goes through and so lungs do not develop properly (associated pulmonary hypoplasia)
Commonest diaphragmatic hernia in neonate?
Posterolateral (Bochdalek) that is left-sided
Treatment of a diaphragmatic hernia?
Avoid bag-mask IPPV (do not want to blow up the gut more)
Respiratory support
Surgical
Key points in examination of older children?
Weight and height plotted - growth may be stunted due to energy usage in illness
Finger clubbing
Chest shape - pestus excavatum (sternal recession), Harrison’s sulcus (horizontal groove along the lower border of the thorax corresponding to the costal insertion of the diaphragm)
Auscultation
Diagnosis of respiratory problems in children?
Spirometry - difficult with young kids, could potentially do it in 7+ years of age
What is cystic fibrosis?
Autosomal recessive genetic disorder due to mutations in CFTR gene on chromosome 7 (most common mutation is Δ508)
Incidence of cystic fibrosis?
Now becoming an adult problem due to increased life expectancy
All kids in Scotland get heel prick test measuring IRT (immunoreactive trypsin) which is raised in those with CF; if +ve result, repeat; if +ve again, then do CF genetics
Clinical presentation of CF?
Respiratory infections are recurrent and prominent
Absorption problems - pancreas makes sticky secretions so:
Growth stunted
Salty on skin
Differential diagnosis with CF?
CF Immune deficiency Ciliary dyskinesia? Asthma Kartagener's/immotile cilia syndrome - rare
Care of CF patient?
Physiotherapist - exercises to remove sticky secretions
Clinical psychologist - CF impacts on mental health (patients not allowed to meet one another due to risk of attaining infection from one another = isolation)
Dietician - too thin/overweight can impair lung function further
Clinical features that increase asthma probability?
One or more:
Wheeze - tends to be atopic wheeze that is recurrent; not every kid with wheeze has asthma
Cough
Chest tightness
Difficulty breathing
Atopy (personal/family history), e.g: asthma
WIDESPREAD WHEEZE ON AUSCULTATION
Response to treatment (Rx - prescription)
What to do with low, intermediate and high probabilities of asthma?
Low - consider Ix (investigation) and referral
Intermediate - watchful waiting, spirometry (response), Rx and evaluate
High - diagnosis of asthma likely so trial of Rx; further Ix if poor response
Spirometry curve in asthma?
Scallop-shaped:
Flow decreases with increasing volume
ADD PICTURE
Management of childhood asthma?
Stage 1: Treat with inhaled beta-agonists when needed
Stage 2: Treat with regular inhaled steroids
Stage 3A: Regular inhaled steroids + Long Acting Beta Agonists
Stage 3B: Stage 3A + Leukotriene Antagonists
Passive smoking effect on children?
Reduces birth weight Perinatal mortality increase Teratogenic - airways, cleft lip/palate Glue ear Carcinogenic Increased likelihood of asthma attack if living with parents that smoke
Treatment of acute problems in children?
Oxygen Nebulised bronchodilator Oral prednisolone i.v salbutamol i.v aminophylline i.v magnesium Ventilatory support
Pathological changes during an asthma attack
Muscle walls of airways (bronchi and bronchioles) bronchoconstrict
Increased mucous secretion
Inflammation of alveolar linings causes further narrowing of airway diameter
Bronchiolitis in children?
Bronhciolitis is a lower RTI that occurs in children usually under 18 months old
Usually caused by a virus - commonly Respiratory Syncitial Virus (RSV)
When is bronchiolitis more severe?
In younger babies, ex-premature babies, family of smokers
Clinical presentation of bronchiolitis?
Tachypnoea
Poor feeding
Irritating cough
Apnoea (suspension of external breathing) in small babies
Increased incidence of wheezing episodes in next 10 years
Treatment of bronchiolitis?
Supportive
Pneumonia bacterial causes in neonates?
GBS (Group B Strep.), E.coli, Klebsiella, Staph. aureus
Pneumonia bacterial causes in infants?
Strep. pneumoniae, Chlamydia
Pneumonia bacterial causes in school age children?
Strep. pneumoniae, Staph.aureus, GRA (Group A Strep.), Bordetella, Mycoplasma, Legionella
What is croup?
AKA laryngotracheobronchitis
Childhood condition that affects trachea, bronchi and larynx
Usually triggered by an acute viral infection of the upper airway
Clinical presentation of croup?
Stridor
Barking cough
Treatment of croup?
Oral steroid to reduce inflammation
Describe pulmonary TB
Caused by Mycobacterium tuberculosis
Spread by droplet infection
Prevention of TB?
BCG
Drug treatment of TB?
2 months - Isoniazid, Rifampicin, Pyrazinamide
4 months - Isoniazid, Rifampicin
6 months total treatment
Common respiratory problems in children?
Infant Respiratory Distress Syndrome CLD Congenital diaphragmatic hernia Cystic fibrosis Asthma Bronchiolitis Childhood pneumonias Croup Tuberculosis
