Respiratory Disorders Flashcards
Risk Factors for respiratory disease in children/young people
Age distribution of acute respiratory infections in children
Parental
- genetic, maternal smoking during pregnancy
Child/young person
- prematurity/LBW
- Bronchopulmonary dysplasia, CHD
- Disorders of muscle weakness, reduced immune function
- Lack of complete immmunisation or cigarette/vaping use
Environmental
- househould/air pollution
- allergens
- number of siblings
- low SES
- cigarette smoke/vaping
URT presentations
URTI examples (4)
What can they cause? (2)
Coryza
Sore throat
Earache
Sinusitis
Stridor
Wheeze
URTI examples:
- common cold (coryza)
- sore throat (pharyngitis and tonsillitis)
- acute otitis media
They can cause:
- problems feeding and breahting
- febrile seizures
LRT infections
Cough
Increased rate of breathing
Increased work/effort of breathing
Chest recession
- intercostal
- suprasternal, sternal, subcostal
- see saw chest and abdomen
Extra respiratory noises
- wheeze = partial obstruction
- coarse crackles = increased secretions
Reduced oxygen saturation
Signs of impending respiratory failure
cyanosis persistent grumbling
reduced o2 sats despite o2 therapy
rising pCO2 on blood gas
exhaustion, confusion, reduced conscious level
ADDITIONAL RESPIRATORY SUPPORT REQUIRED
Coryza/common cold
Classical features (2)
Most common pathogens (3)
Management
Complications
clear/mucopurulent discharge and nasal blockage
rhinovirus, coronavirus, RSV
self-limiting, no abx (2o bacterial infection is uncommon), reassure parents, paracetamol/ibuprofen for pain
cough may persist 4 months after common cold
Sore throat (pharyngitis/tonsillitis)
Cause of each
features of each
Group A b-haemolytic streptococci toxin and bacterial infection symptoms
strep tonsillitis Mx and indications
What abx to avoid
if recurrent tonsilitis or sleep disorder breathing
Pharyngitis (viral)
- adenovirus, enterovirus, rhinovirus
- inflammation of pharynx and soft palate w/ variably enlarged and tender local lymph nodes
Tonsillitis (form of pharyngitis)
Key words: infectious mononucleosis/glandular fever, scarlet fever, rhuematic fever
- purulent exudate
- group A b-haemolytic stretococci (<33% tonsillitis, BACTERIAL) and EBV (infectious mononucleosis/glandular fever)
- toxin made by GRBS -> scarlet fever rash
- bacterial infection -> headache, pathy, abdominal pain
Strep tonsillitis mx:
- Penicillin V or erythromycin hasten recover by 16 hours
- indications = prevent rheumatic fever (complication) in high incidence countries/children at increased risk of severe infection -> 10 days abx
- unable to swallow solids/liquids = ADMIT for IV fluid and analgesia
Other mx:
- AVOID amoxicillin = causes widespread maculopapular rash if due to infectious mononucleosi
Recurrent tonsillitis or complications (e.g. peritonsillar abscess/quinsy) or sleep disorder breathing (e.g. obstructive sleep apnoea):
- tonsillectomy and/or adenoidectomy (top/bottom tonsil) -> in UK = 7 or more episodes of significant sore throat in last 12 months, 5 or more in each of last 2 years, 3 in each of last 3 years
NB: sleep disorded breathing -> record child during sleep to decide need for sleep recordings or surgery
CENTOR criteria for strep tonsillitis/pharyngitis
score of 3 or more would benefit taking abx leading to a 1 day reduction in overall recovery time
current guidance is to offer tx for 5-10 days (erythromycin) to ensure complete eradication of strep. pneumoniae (most likely cause) and prevent further complications
Acute otitis media: why children? what age?
symptoms
O/E
pathogens
complications
mx
when to use abx
Eustachian tubes short, horizontal and function poorly, 6-12 months of age
Earache and fever
O/E otoscope:
- TMB bright, red, bulging
- loss of normal light reflection
- occassionally = acute eardrum performation w/ pus visible in external canal
Pathogens = RSV, rhinovirus, pneumoccocus, HI, Moraxella catarrhalis
Complications = mastoiditis (one ear forward) and meningitis)
Mx:
- Analgesia up to a week
- Usually resolves spontaneously
- abx little shorten pain duration
Abx indications: (e.g. AMOXICILLIN)
- eardrum perforated
- <2 years old and bilateral infection
- present for 4+ days
- <3 months old
Otitis media with effusion (glue ear): what children?
symptoms
O/E
Complications and what to do if they happen
2-7 years
asymptomatic (maybe decreased hearing)
O/E = eardrum dull and retracted, often with visible fluid level
Mx:
- resolves spontaneously usually
- nasal inflation opens eustachian tube (needs to be school age)
Complications:
- conductive hearing loss -> tympanostomy tube insertion aka grommet surgery (image attached) w/ or w/o adenoid removal (benefits don’t last more than a year)
- interfere with normal speech development
Sinusitis
2o bacterial infection sx
type uncommon in first decade in life
mx
Inflammation of paranasal sinuses (viral)
occasionally 2o bacterial infection = pain, swelling and tenderness over cheek from infection of the maxillary sinus
frontal = frontal sinuses does not develop until late childhood
abx and analgesia
Asthma history questions
Atopic triad
O/E
CF features (3)
- Wheeze? (whistling in chest when child breathes out)
- Cough, skin changes?
- Breathlessness (quantify, on rest/activity)?
- How frequent are the symptoms?
- What triggers the symptoms? Sport/general activities affected
- How often is sleep disturbed by asthma?
- How severe are the interval symptoms between exacerbations?
- How much school has been missed due to asthma?
Key features:
- wheeze, cough, breathlessness worse at night and early morning
- wheeze and breathlessness with non-viral triggers
- interval symotoms
- personal or family history of an atopic disease (atopic eczema, asthma, allergies)
- positive response to asthma therapy
O/E:
- auscultation = polyphonic expiratory wheeze + prolonged expiratory phase
- atopy = nasal mucosa for allergic rhinitis, skin for eczema
- chest hyperinflation (long-standing asthma)
- Harrison’s sulci (early onset of disease in childhood)
NB: CF is wet cough productive of sputum, growth faltering, finger clubbing
Triggers (CATPOLES)
- Cold
- Allergies
- Travel
- Pets
- Occupation (near factory)
- Laughter
- Exercise
- Smoking (parental)
Asthma pathophysiology
Viral Episodic Wheeze (trigger, interval sx, RFs)
Multiple Trigger Wheeze (triggers, mx, RFs)
Viral episodic wheeze
- triggered by viral URTI
- no interval sx between episodes
- RFs = maternal smoking, prematurity, male
Multiple trigger wheeze
- asthma triggers
- Mx = SABA for acute and ICS for long term
- RFs = 3+ episodes cough a year and wheeze 10+ days with viral infection, cough and wheeze betweene episodes, laughing or excitement causing wheeze, allergic sensitiation, eczema, food allergy, FHx of asthma
Asthma investigations
Children <5 years old = H+E, response to treatment, maybe skin prick testing, CXR not necessary unless other conditions need to be excluded]
>5 years old:
- PEFR
- Spirometry obstructive picture (reduced FEV1, normal FVC) -> FEV1:FVC <80%. Children with mild-moderate asthma may have normal spirometry when well
- Bronchodilator therapy (>20% PEFR or >12% FEV1 change)
- Exhaled nitric oxide concentration (FeNO, fractional exhaled nitric oxide) = inflammatory marker, elevated in untreated asthma and allergic rhinitis, if diagnostic uncertainty
Causes of recurrent or persistent childhood wheeze
Viral episodic wheeze
Multiple Trigger wheeze
Asthma
Recurrent anaphylaxis (e.g. in food allergy)
Chronic aspiration
CF
Bronchopulmonary dysplasia
Bronciolitis obliterans
Tracheo-bronchomalacia
Examples of Drugs in asthma
NB: LABA are bronchodilators, not relievers
Anti-IL5 monoclonal antiboy = mepolizumab
Symbicort = bedosnide and formoterol (ICS + LABA)
Bronchodilators (treat bronchoconstriction)
ICS (decrease inflammation)
Add-on therapy
MART therapy
Additional therapies for children and young people with severe asthma
SABA
- max effects after 10-15 minutes
- as required for acute asthma attacks
- 2x a week -> start preventer therapy
- SALBUTAMOL SIDE EFFECT TACHYCARDIA
LABA
- first choise add-on therapy for child >5 years old
- effective for 12 hours
- NOT for acute asthma
- NOT without ICS (increased mortality)
- good for exercise-induced asthma
Ipratroprium bromide
- anticholinergic bronchodilator
- given to young infants when other bronchodilators ineffctive or to tx severe acute asthma
ICS
- low-dose = decrease in height velocity
- high-dose systemic side effects = impaired growth, adrenal suppression, altered bone metabolism
Add-on therapy
- montelukast = child <5 years old, or when LABA cannot controla asthma when child >5 years old
- slow-release oral theophylline = high incidence of side-effects (vomiting, insomnia, headaches, poor concentration)
MART therapy
- not useful
Severe asthma (specialist paediatric asthma service)
- oral predisolone = alternate days to minimise effect on growth, for severe persistent asthma when other tx failed
- Injectable monoclonal antibodies = IgE mediates allergy, IL-5 mediates eosinophila ctivation
Treatment of asthma in children (escalating and de-escalating tx)
NB:
- dust-mite-impermeable bedding in children who have allergies to house dust mite
- avoidance of triggers
- patient should be advised about the harmful effecrts of inhaling second-hand cigarette smoke and e-cigarette vapour
Criteria for admission to hospital for acute asthma attack
Severe asthma
- not responding clinically i..e persisting breathlessness or tachypnoea
- becoming exhausted
- still have a marked reduction in their predicted (or usual best) peak flow rate or FEV1 (<50%)
- reduced O2 saturation <92%
CXR only indicated is unuussal features (chest asymmetry for pneumothorax/lobar collapse) or signs of severe infections
Causes of acute breathlessness in the older child
Asthma
Pneumonia or LRTI
Foreign body
Anaphylaxis
Pneumothorax or pleural effusion
Metabolic acisodosis = DKA, inborn error of metaboliusm, LA
Severe anaemia
Heart failure
Panic attacks (hyperventilatin)
Acute asthma management
Note:
- High flow oxygen for severe + life-threatening
- SABA for all (space, 10 puffs, nebuliser)
- oral prednisolone or IV hydrocortisone for severe + lfie-threatening
- discuss with PICU for severe
- if back to back nebulisers, beware of tremor/tachycardia/hypokalaemia -> get cardiac monitoring
- may need blood gases/CXR
Choosing the right inhaler
Pressurised MDI and spacer
- 0-2 years facemask, >3 years mouthpiece
- space for all children as increase drug deposition in lungs, reduces oropharyngeal deposition, less systemic side effects
Dry powder
- 4 years+
- need good inspiratory flow, less good for severe asthma and during asthma attack, ‘out and about’ in older children
Nebuliser
- less efficient of drug deliver than MDI
- Always administed using high-flow O2 NOT air
- only used in acute asthma when oxyegn is needed
Periodic assessment of the child or young perosn with asthma
NB: OFFER influenza vaccine (nasal spray contraindicate with severe asthma who are taking oral steroids as it is a live attenuated vaccine and regular steroid use poses rise of immunocompromise)
What should you review with the child and family prior to discharge from hospital after an acute admission
- When drugs should be used (regularly or ‘as required’)
- How to use the drug
- What each drug does (relief vs prevention)
- How often and how much can be used (frequency and dosage)
- What to do if asthma worsens (a written personalised asthma plan should be completed)
Before discharge: review medications, consider moving up a step on the management ladder. Educate about smoking for parents and children. Review inhaler technique. Agree on a written home management plan. Provide a symptom diary and community follow up so medications can be adjusted as necessary to avoid hospital admissions. Educate on importance of adherence to daily inhaler use even if symptoms under control. Educate about allergen avoidance/dusting/hovering at home.
Croup/viral layngrotracheobronchitis
aetiology
decision to mx at home factors
mx chest recession at rest
mx severe
recurrent croup is related to atopy
parainfluenzea virus (+rhinovirus, RSV, influenza)
coryza + fever:
- hoarseness due to inflammation of vocal cords
- barking cough due to tracheal oedema and collapse
- harsh stridor
- variable degree difficulty in breathing with chest recession
- symptoms often starting, and being worse, at night
decision to mx at home factors:
- severity
- child’s age (<1 year old)
- time of day
- ease of access to hospital
- parental understanding and confidence about the disorder
mx chest recession at rest:
- PO prednisolone, PO dexamethosone, nebulised steroids (budesonide) -> reduces hospitalisation
mx severe:
- acute = nebulised adrenaline + 02 face mask
- observe 2-3 hours after administration while corticosteroids take effect
bacterial tracheitis and acute epiglottitis
Mx
Croup vs bacterial tracheitis and acute epiglottitis
acute epiglottitis is rare as children in most countries vaccinated against HI
Mx: ADMIT
- Nebulised adrenaline + 02
- intubation/airway maintenance under senior anaesthetist/paediatrician/ENT surgeon w/ GA
- If impossible -> urgent tracheostomy
- blood cultures and abs after intubation
Causes of acute stridor (upper airway obstruction)
Another common cause is a foreign body
The child with acute stridor
Causes of chronic stridor
structural
- laryngomalacia (floppy upper larynx) = congenital anomaly, presents 4 weeks of age, worse when agitated/feeding/lying on back, resolves by 2 years, no further ix if child is thriving
- subglottic stenosis
- external compression (e.g. vascular ring, double aortic arch, lymph nodes, tumours)
