Respiratory Disorders Flashcards
Define Sinusitis.
Symptomatic inflammation of the mucosal lining of the nasal cavity and paranasal sinuses.
When do infections of the paranasal sinuses occur?
Infection of the paranasal sinuses may occur with viral URTIs
Occasionally you might get a secondary bacterial infection
The frontal sinuses are rarely affected because they do not develop until late childhood
How commonly are frontal sinuses affected?
The frontal sinuses are rarely affected in the first decade because they do not develop until late childhood
How should you think of managing sinusitis?
- Refer to hospital if specific symptoms and signs
- Think about symptoms lasting <10 days
- Think about symptoms lasting >10 day
What would warrant a referral to hospital in sinusitis?
- Refer to hospital if there are symptoms and signs of:
- Severe systemic infection
- Intraorbital or periorbital problems (e.g. periorbital cellulitis, displaced eyeball, double vision)
- Intracranial complications (e.g. features of meningitis)
How should you manage sinusitis with symptoms lasting < 10 days?
- Symptoms lasting < 10 days
- Do NOT offer an antibiotic
- Advice
- Acute sinusitis is usually caused by a virus and takes 2-3 weeks to resolve
- Symptoms, such as fever, can be managed using paracetamol or ibuprofen
- Some people may find some relief using nasal saline or nasal decongestants
- Can be given intranasal corticosteroid for congestion
- Medical advice should be sought if symptoms worsen rapidly, if they do not improve in 3 weeks or become systemically unwell
How should you manage sinusitis with symptoms lasting > 10 days?
- Symptoms lasting > 10 days but <4wks
- Commonly bacterial infection
- Consider high-dose nasal corticosteroid for 14 days for adults and children > 12 years old (e.g. mometasone)
- May improve symptoms but unlikely to affect duration of illness
- Could cause systemic side-effects
- Consider NO antibiotic prescription or back-up prescription
- Antibiotics are unlikely to change the course of the illness
- The back-up prescription should be used if symptoms get considerably worse or it has still not improved by 7 days
- 1st line: phenoxymethylpenicillin
- NOTE:clarithromycin if penicillin allergy
- 2nd line: co-amoxiclav
- Advise patients to seek medical advice if they develop complications or their symptoms don’t improve/worsen
Define acute otitis media.
An infection involving the middle ear space and is a common complication of viral respiratory illnesses
How common is otitis media? At what age is it common to get it?
Most children will have at least one episode of acute otitis media (up to 20% will have 3 or more episodes) – most commonly at 6-12 months of age
What are the causative pathogens of otitis media?
o RSV
o Rhinovirus
o Pneumococcus
o Haemophilus influenzae
o Moraxella catarrhalis
What is the pathophysiology of otitis media?
Infants and young children are susceptible to otitis media because their Eustachian tubes are short, horizontal and function poorly
Pathophysiology
o Normally, the mucociliary action and ventilatory function of eustachian tube clear nasopharyngeal flora that enter the middle ear
o But, upper respiratory viruses can infect the nasal passages, eustachian tube and middle ear causing inflammation and impairing these processes
o A middle ear effusion develops and nasopharyngeal bacteria contaminate the effusion - the effusion provides a good medium for bacterial growth
o In response, there is a suppurative inflammatory response leading to pain and fever
What are the potential complications of otitis media?
RARE:
o Mastoiditis
o Meningitis
What are the clinical features of otitis media?
Key features: ear pain and fever
Every child with a fever MUST have their tympanic membrane examined. In acute otitis media, the tympanic membrane is bright red and bulging with loss of the normal light reflection.
Occasionally, the tympanic membrane can perforate and pus can become visible in the external canal
What are the investigations of otitis media?
History and exam
MUST examine tympanic membrane
What is this?
Normal tympanic membrane
What is this?
Acute otitis media
What is this?
otitis media with effusion
What is this?
A grommet
When should you admit a patient with acute otitis media?
Admit if:
o Severe systemic infection
o Complications (e.g.meningitis, mastoiditis, facial nerve palsy)
o Children < 3 months with a temperature > 38 degrees
How should you treat acute otitis media?
- Advise that the usual course of acute otitis media is about 3 days but can last up to 1 week
- Advise regular doses of paracetamol or ibuprofen for pain
- There is no evidence to support the use of decongestants or antihistamines
- Antibiotic prescription management:
-
No antibiotic prescription - most cases will resolve spontaneously.
- Advise to seek help if the symptoms haven’t improved after 3 days or if the child deteriorates clinically
- Back-up antibiotic prescription - advise that the antibiotic is NOT needed immediately but should be used if the symptoms have not improved after 3 days or if they have worsened significantly at any time
-
Immediate antibiotic prescription - seek medical help if the symptoms worsen rapidly or the patient becomes systemically unwell
- Amoxicillin - 5-7 days is first-line
- Penicillin allergy: clarithromycin, erythromycin
- Note: antibiotics marginally reduce the duration of the pain but have no effect on risk of hearing loss
-
No antibiotic prescription - most cases will resolve spontaneously.
Define otitis externa.
Diffuse inflammation of external ear canal which may also involve pinna or tympanic membrane
Form of cellulitis involving skin and subdermis of external auditory canal
What are the common causes of otitis externa?
Pseudomonas aeruginosa and Staphylococcus species
Called swimmer’s ear
What are the symptoms of otitis externa?
Symptoms of otitis externa include:
- ear pain, which can be severe
- itchiness in the ear canal
- a discharge of liquid or pus from the ear
- some degree of temporary hearing loss
Usually only one ear is affected.
Presents with rapid onset of ear pain, tenderness, itching, aural fullness and hearing loss
What are the investigations of otitis externa?
- Clinical examination and history
- Otoscopy
What are the different types of otitis externa?
- Localised
- Acute
- Chronic
- Malignant
How should we manage a localised otitis externa?
• Localised otitis externa:
o Analgesia and local heat application using warm flannel. Often sufficient as folliculitis tends to be mild and self-limiting
o Oral antibiotics: rarely indicated
- Furunculosis or cellulitis spreading beyond ear canal
- Systemic infection, e.g. fever
- Diabetes mellitus or immunocompromised
o Referral for pus incision and drainage: rarely indicated
How should we manage acute otitis externa?
• Acute otitis externa: <3 months
o Ibuprofen/paracetamol can be used for pain management. If severe pain and >12yo, then can use codeine with the paracetamol
o Antibacterial ear drops: ciprofloxacin and dexamethasoneotic (0.3%/0.1%) 2x day for 7-14 days
- Ear needs to be cleaned of wax first and may need a wick to deliver the drops if the ear is too swollen
o Oral flucloxacillin OR clarithromycin (penicillin allergic): rarely indicated
- Cellulitis extending beyond external ear canal
- Ear canal occluded by swelling and debris, inhibiting wick insertion
- Diabetes or immunocompromised, or high risk of severe infection, e.g. Pseudomonas
How should we manage chronic otitis externa?
• Chronic otitis externa: >3 months
o Avoidance of triggers, e.g.swimming, scratching, aggressive cleaning
o If fungal infection suspected:
-
Mild-moderate:
- Clotrimazole 1% solution
- Acetic acid 2% spray
- Clioquinol and corticosteroid (e.g. Locorten-Vioform)
o Cause evident:
- Allergic dermatitis: topical corticosteroid
- Seborrhoeic dermatitis: antifungal/corticosteroid combination
o No cause evident: 7-day topical preparation containing only corticosteroid and no antibiotic. Consider co-prescribing acetic acid spray.
How should we manage malignant otitis externa?
Urgent admission
Define acute epiglottitis.
Intense swelling of the epiglottis and surrounding tissues associated with septicaemia
What is a complication of acute epiglottitis?
Life-threatening emergency due to high risk of respiratory obstruction
What causes acute epiglottitis?
Cause: Haemophilus influenzae type b (Hib)
o The introduction of the Hib vaccine has massively reduced the incidence of acute epiglottis
What age group is usually affected by acute epiglottitis?
1-6 yrs
What is the pathophysiology of acute epiglottitis?
Pathophysiology
o Inflammatory pathways lead to localised oedema of the airway, exponentially increasing airway resistance while narrowing the effective supraglottic aperture
o The glottis is usually not inflamed as process affects the supraglottic structures
What are the clinical features of acute epiglottitis?
VERY acute
o High fever is a very ill, toxic-looking child
o An intensely painful throat that prevents the child from speaking or swallowing; saliva drools down chin
o Soft inspiratory stridor and rapidly increasing respiratory difficulty over hours
o Child sitting immobile, upright, with an open mouth to optimise the airway (tripod positioning)
o Irritability
It is important to clinically distinguish between epiglottis and croup as they require different treatment
What are the differences between epiglottitis and croup?
What are the investigations of acute epiglottitis?
- Lying the child down, examining the throat with a spatula or performing a lateral neck X-ray should be AVOIDED because it can precipitate total airway obstruction
- o Note: on lateral neck X-ray would see markedly enlarged epiglottis (‘thumbprint sign’) but this is not usually done unless capable of securing the airway with proper equipment available during the Xray
- If epiglottis is suspected, urgent hospital admission and treatment are required
- Laryngoscopy
What is the management of acute epiglottitis?
If acute epiglottitis is suspected, urgent hospital admission to intensive care unit and treatment are required
Secure the airway (usually requires intubation) and give supplemental oxygen
Take a blood culture
Start IV 2nd or 3rd generation cephalosporins (e.g. ceftriaxone) for 7-10 days
In some patients, steroids and adrenaline may be used to reduce inflammation
In severe cases, prolonged intubation may be necessary
With appropriate treatment, most children will recover completely within 2-3 days
Once stable and extubated, give oral co-amoxiclav
Rifampicin prophylaxis to close contacts
Define pharyngitis.
Pharyngitis inflammation of the pharynx and soft palate with variably enlarged and tender local lymph nodes.
Define tonsillitis.
Tonsillitis is a form of pharyngitis causing intense inflammation of the tonsils, often with a purulent exudate.
What is pharyngitis usually caused by?
o Usually due to viral infection→mainly adenoviruses, enteroviruses and rhinoviruses
o In older children, group A beta-haemolytic streptococcus is common (strep throat)
▪ Accounts for 15-20% of pharyngitis in children aged 5-15 years
▪ Peaks during winter and early spring
▪ More common in school aged children
What causes tonsillitis?
May be caused by group A beta-haemolytic streptococci and Epstein–Barr virus (infectious mononucleosis or glandular fever)
Group A beta-haemolytic can be cultured from many tonsils but it is uncertain why it causes recurrent tonsillitis in some children but not in others
What are the clinical features of tonsillitis and pharyngitis?
o Pain on swallowing
o Fever
o Tonsillar exudate
- Particularly seen in Group A beta-haemolytic Streptococci
- BUT, in reality, it is difficult to distinguish clinically between bacterial and viral tonsillitis (can also be seen in adenovirus)
- However, marked constitutional disturbance (e.g. headache, apathy, abdominal pain, white tonsillar exudate and cervical lymphadenopathy) is more common with bacterial infection
o Other symptoms
o Headache
o Sore throat
o Abdominal pain
o Nausea and vomiting o Rash (Scarlet fever)
What are the investigations for tonsillitis/pharyngitis?
o Throat culture
o Rapid streptococcal antigen test – to identify GABHS
Should be ordered in children over 3 years old with high probability of GABHS as assessed by at least 3 Centor criteria
If RADT negative, follow up with throat culture criteria
Score of 4: treat
Score of 3: consider treatment
Score of 2: rapid test/culture
Score of 0-1: very low chance of Strep being cause
What is the centor criteria?
How should you think about the management of pharyngitis/tonsilitis?
- Consider Admission
- Antibiotics
- Advice
When should you admit a patient with tonsillitis/pharyngitis?
o Difficulty breathing
o Clinical dehydration
o Peri-tonsillar abscess or cellulitis
o Signs of marked systemic illness or sepsis
o A suspected rare cause (e.g.Kawasaki disease, diphtheria)
What is the medical management of tonsillitis/pharyngitis?
Antibiotics
- Given if either
- Group A Streptococcus has been confirmed: Immediate or back-up
- FeverPAIN score (4 or 5) or Centor score (3 or 4)
- Throat cultures
- Rapid antigen testing
- Person is experiencing severe symptoms, systemically very unwell, or high risk of complications: immediate prescription indicated
- Group A Streptococcus has been confirmed: Immediate or back-up
-
Phenoxymethylpenicillin
- Given for 5 to 10 days
- Clarithromycin - If penicillin allergy
- Avoid amoxicillin because it may cause a widespread maculopapular rash if the onsillitis is due to infectious mononucleosis
What advice should be given for pharyngitis/tonsilitis?
o Adequate fluid intake
o Paracetamol or ibuprofen when necessary
o Salt water gargling, lozenges or anaesthetic sprays (e.g. Difflam) may provide temporary relief of throat pain
o Children can return to school after fever has resolved and they are no longer feeling unwell and/or after taking antibiotics for 24 hours
o Patients with recurrent tonsillitis may require referral to ENT for tonsillectomy.
What is a complication of streptococcal tonsillopharyngitis?
Scarlet Fever
Define laryngitis.
Laryngitis is an inflammation of your voice box (larynx) from overuse, irritation or infection.
What are the two types of laryngitis? What is it usually caused by?
Laryngitis may be short-lived (acute) or long lasting (chronic).
Most cases of laryngitis are temporary and improve after the underlying cause gets better. Causes of acute laryngitis include:
- Viral infections similar to those that cause a cold
- Vocal strain, caused by yelling or overusing your voice
- Bacterial infections, although these are less common
What are the clinical features of laryngitis?
- Hoarseness
- Weak voice or voice loss
- Tickling sensation and rawness in your throat
- Sore throat
- Dry throat
- Dry cough
Define chronic laryngitis. What is it caused by?
Laryngitis that lasts longer than three weeks is known as chronic laryngitis. This type of laryngitis is generally caused by exposure to irritants over time. Chronic laryngitis can cause vocal cord strain and injuries or growths on the vocal cords (polyps or nodules). Chronic laryngitis can be caused by:
- Inhaled irritants, such as chemical fumes, allergens or smoke
- Acid reflux, also called gastroesophageal reflux disease (GERD)
- Chronic sinusitis
- Excessive alcohol use
- Habitual overuse of your voice (such as in singers or cheerleaders)
- Smoking
Less common causes of chronic laryngitis include:
- Bacterial or fungal infections
- Infections with certain parasites
What are the investigations for laryngitis?
Clinical diagnosis
If suspect something serious could refer to ENT
Laryngoscopy
Biopsy
How do we think about the management of laryngitis?
In terms of airway compromise
How should we treat laryngitis in which there is airway compromise?
- If there is airway compromise:
- Secure airway–emergency tracheostomy may be required
- If patient doesn’t have diphtheria then can give:
- Dexamethasone sodium phosphate: to reduce oedema
- Cefalozin AND cefalexin: administered IV to start and then changed to oral antibiotics
- If patient has diphtheria:
- Patient needs to be isolated
- Benzylpenicillin sodium IV/IM for 14d
- Diphtheria antitoxin
How should we treat laryngitis in which there is no airway compromise?
- If there is no airway compromise:
- Viral:
- Analgesia as required: paracetamol
- Vocal hygiene: voice rest for 3-7d, increase hydration, humidification, decreased caffeine intake
- Mucolytic can be given to help lubricate the vocal folds
- Bacterial:
- Phenoxymethylpenicillin for 14d
- Analgesia as required: paracetamol
- Vocal hygiene: voice rest for 3-7d, increase hydration, humidification, decreased caffeine intake
- Mucolytic can be given to help lubricate the vocal folds
- Viral:
Define whooping cough.
A highly contagious upper respiratory infection caused by Bordatella pertussis
What are the complications of whooping cough?
o Pneumonia
o Seizures
o Bronchiectasis
B pertussis infection can cause a primary pertussis pneumonia with subsequent respiratory failure and death
How is Bortadella Pertussis transmitted?
Transmission of disease occurs through direct contact with droplet discharges from respiratory mucous membranes of infected people
Highly contagious
What are the 3 stages of disease progression in whooping cough?
o Stage 1: catarrhal stage
▪ 1-2 weeks
▪ Rhinorrhoea, sneezing, low-grade fever, mild occasional cough
o Stage 2: paroxysmal stage
▪ 1-6 weeks
▪ Cough gradually becomes more severe
▪ Bursts of coughing increase in frequency, then remain constant and then gradually decrease in frequency
▪ Most diagnoses are made during this stage
o Stage 3: convalescent stage
▪ Recovery stage
▪ Cough becomes less paroxysmal and usually disappears over 2-3weeks
What are the clinical features of whooping cough?
- A week of coryza (catarrhal phase)
- Followed by the development of a characteristic paroxysmal or spasmodic cough followed by a characteristic inspiratory whoop (paroxysmal phase)
- Spasms of cough are often worse at night and may cause vomiting
- During the paroxysm, the child goes red or blue in the face and mucus flows from the nose and mouth
- Note: the whoop may not be present in infants
- Nosebleeds and subconjunctival haemorrhages can occur after vigorous coughing
- The paroxysmal phase can last up to 3 months
- The symptoms will eventually decrease (convalescent phase)
- Note: infants and young children suffering severe spasms of cough or cyanotic attacks should be admitted and isolated from other children
What are the investigations for whooping cough?
- Organism can be identified from culture of a perinasal swab or nasopharyngeal aspirate
- PCR of nasopharyngeal aspirate - more sensitive
- Serology
- FBC
- There is marked lymphocytosis
How would you think about managing whooping cough?
- Think about admitting
- Notify HPU
- Pharmacological Treatment
- Advice
- Think about close contacts
When should you admit a child with whooping cough?
o < 6 months old or acutely unwell
o Significant breathing difficulties (e.g. apnoea, severe paroxysms, cyanosis)
o Significant complications (e.g. seizures, pneumonia)
▪ NOTE: inform the hospital about need to isolate
What is the pharmacological treatment for whooping cough?
If admission is NOT needed, prescribe an antibiotic if the onset of the cough is within 21 days (MACROLIDE antibiotic is first-line)
o < 1 month = clarithromycin
o 1+ months/non-pregnant adult = azithromycin
o Pregnant adult = erythromycin
▪ Recommended from 36 weeks gestation to reduce the risk of transmission to the newborn
o NOTE: co-trimoxazole can be used if macrolides are contra-indicated or not tolerated (however, this is not allowed in pregnant adults or babies < 6 weeks old)
How should we advice parents regarding whooping cough? What should we advice for close contacts
o Rest, adequate fluid intake and the use of paracetamol or ibuprofen for symptomatic relief
o Inform the parents that, despite antibiotic treatment, the disease is likely to cause a protracted non-infectious cough that may take weeks to resolve
o Advise that children should avoid nursery until 48 hours of appropriate antibiotic treatment has been started or until 21 days after the onset of the cough if it was not treated
o Once the acute illness has been dealt with, advice parents to complete any outstanding immunisations
How would you counsel a parent regarding whooping cough?
What is the most common serious respiratory infection of infancy?
Bronchiolitis - winter time
What is the causative organism causing bronchiolitis?
o RESPIRATORY SYNCYTIAL VIRUS is the pathogen in 80% of cases
o Others: parainfluenza, rhinovirus, adenovirus, influenza virus, human metapneumovirus, swine flu (H1N1)
At what age does bronchiolitis occur?
90% of patients are 1-9 months
o >1 years = viral induced wheeze
What is the RF for bronchiolitis?
Infants born prematurely who develop bronchopulmonary dysplasia or with underlying lung disease, such as cystic fibrosis, or have congenital heart disease are more at risk from severe bronchiolitis
Describe the pathophysiology of bronchiolitis.
The virus infects the respiratory epithelial cells of the small airways→necrosis, inflammation, oedema, mucus secretion
Cellular destruction + inflammation→obstruction of small airways
Re-growth of epithelial cell layer does not occur until ~2w after infection with complete recovery requiring 4-8 weeks
What are the clinical features of bronchiolitis?
Coryzal symptoms followed by dry cough and increasing breathlessness
Feeding difficulty associated with increasing dyspnoea
Recurrent apnoea (serious complication)
Peaks day 5, lasts 10-14 days
Characteristic finding on examination
o Dry wheeze cough
o Tachypnoea and tachycardia
o Subcostal and intercostal recession
o Hyperinflation of the chest
▪ Can cause palpable liver edge
- *o Fine end-inspiratory crackles**
- *o High-pitched wheeze: expiratory > inspiratory**
What are the investigations for bronchiolitis?
Pulse oximetry – should be performed on all children with suspected bronchiolitis
Naso-pharyngeal aspirate: will show the virus
CXR or blood gases ONLY recommended if respiratory failure is suspected
When is hospital admission indicated for bronchiolitis?
o Apnoea
o Persistent oxygen saturation of <92% on air
o Severe respiratory distress
▪ Grunting
▪ Marked chest recession
▪ RR > 70 breaths/min
When should you consider admission for bronchiolitis?
o Respiratoryrate>60/min
o Difficulty with breastfeeding or inadequate oral fluid intake (50 75% of usual volume)
o Clinical dehydration
What is the management of bronchiolitis?
Consider admission
- Humidified oxygen - If saturation is persistently < 92%
-
Fluids -
- By nasogastric/orogastric tube if they cannot take enough fluid by mouth
- Give IV fluids if cannot tolerate nasogastric or orogastric fluids or have impending respiratory failure
- CPAP - If impending respiratory failure → if still hypoxic → Heated, humidified, high flow nasal cannula oxygen (HHFNCO)
-
Upper airway suction
- Do not perform routinely
- Perform if upper airway secretions are causing respiratory distress or feeding difficulties
What advice would you give for bronchiolitis?
o RSV is highly infectious, so infection control measures are needed to prevent cross-infection
o Most infants will recover within 2 weeks
o RARELY, the illness may cause permanent damage to the airways (bronchiolitis obliterans)
How can bronchiolitis be prevented?
o Infection control measures are required in the ward the patient is placed as RSV is highly infectious
o Palivizumab (monoclonal antibody against RSV) reduces the number of hospital admissions in high-risk preterm infants
How do we counsel for bronchiolitis?
What is the other name for croup?
LARYNGOTRACHEOBRONCHITIS
How common is croup? What commonly causes it?
It is a common respiratory disease of the childhood
Viral croup accounts for over 95% of laryngotracheal infections
Viral causes
o PARAINFLUENZA viruses are the most common cause o Rhinovirus
o RSV
o Influenza
At what age and at what time of the year is croup most common?
Typically occurs from 6 months to 6 years of age, but peak incidence is 2nd yr of life
Most common in autumn
Describe the pathophysiology of croup.
The symptoms result from upper airway obstruction due to generalised inflammation and oedema of the airways
The narrowed subglottic region is responsible for the seal-like barky cough, stridor (due to increased airflow turbulence), and sternal/intercostal indrawing
If obstruction worsens, can lead to respiratory failure→leading to asynchronous chest and abdominal wall motion, fatigue, hypoxia and hypercarbia
What’s the clinical presentation of croup?
• Typical features are coryza and fever followed by: HSBC
o Hoarseness – due to inflammation of the vocal cords
o A barking cough, like a sea lion – due to tracheal oedema and collapse o Harsh stridor
o Variable degree of difficulty breathing with chest retraction
▪ The degree of subcostal, intercostal and sternal recession is a more useful indicator of severity of upper airways obstruction than the RR
o Symptoms often start, and are worse at night
o Agitation can cause worsening of symptoms – so important to ensure comfort when examining
• If upper airway obstruction is mild, then the stridor and chest recession will disappear when the child is at rest so can be managed at home
o Decision to manage at home or hospital depends on illness severity, age of child (<12 months low threshold for admission), time of day, ease of access to hospital, and parental understanding and confidence about the disorder
How is the diagnosis of croup made?
Croup is largely a clinical diagnosis – history and exam
How do we think of managing croup?
- CATEGORISE severity
- Consider admission
- For all severitiies
- Mid croup
- Moderate
- Severe
How do we categorise the severity of croup?
Apart from severity what must be considered be admitting a child for croup?
Impending respiratory failure -
- increasing upper airway obstruction
- sternal/intercostal recession
- asynchronous chest wall and abdominal movement
- fatigue
- pallor/cyanosis
- reduced consciousness
- respiratory rate > 70 breaths per minute
What should we give for all severities of croup?
o Oral dexamethasone (0.15 mg/kg)
If oral medication not possible:
- Inhaled beclomethasone (2mg)
- IM dexamethasone (0.6 mg/kg)
If returns with mild stridor but otherwise well – can repeat dexamethasone
How should we manage mild croup?
o Hospital admission not required
o ADVICE
- Croup normally resolves after 48 hours
▪ Paracetamol or ibuprofen can be used if the child has a fever and is distressed
▪ Advise good fluid intake
▪ Advise parents to check the child regularly during the night
o Safety net:
- Advise to take child to hospital if continuous stridor heard or skin between ribs pulling in with every breath
- Advise to call an ambulance if child is:
- Very pale, blue, or grey (includes blue lips) for more than a few seconds
- Unusually sleepy or is not responding
- Having a lot of trouble breathing
- Upset (agitated or restless) while struggling to breathe and cannot be calmed down quickly
- Unable to talk, are drooling, or having trouble swallowing
How should you manage moderate/severe asthma?
While awaiting admission
o Give controlled supplementary oxygen if severe/impending respiratory failure
o Give dose of oral dexamethasone→if too unwell, give inhaled beclomethasone (2mg nebulised as single dose) or IM dexamethasone (0.6mg/kg single dose)
• SEVERE upper airways obstruction:
o Nebulised adrenaline with oxygen by face mask (1 in 1000 (1 mg/ml))
▪ Causes rapid but transient improvement
o Children should be closely monitored for 2-3hrs
How should you counsel on croup?
How common is asthma?
14% children in the UK - most common chronic respiratory disorder in childhood
Describe the epidemiology of asthma,a-
- Incidence increasing worldwide over the last 40 yrs → has now plateaud
- Important cause of school absence, restricted activity and anxiety for the child and family
- 20 deaths/yr in the UK
What are the three patterns of wheezing?
o Viral episodic wheeze: wheeze only in response to viral infections
o Multiple trigger wheeze: wheeze in response to multiple triggers and is morelikely to develop into asthma over time
o Asthma
Describe the pathophysiology of asthma.
Describe the clinical features of asthma.
- Asthma should be suspected in any child with wheezing on more than one occasion, especially if there are interval symptoms.
- More common in those with personal or family history of atopy
- Ask about wheeze, but wheeze presence is confirmed on auscultation to distinguish it from transmitted upper respiratory noises which are often loud and easy to
hear in child. - On auscultation, an asthmatic wheeze is a polyphonic noise coming from the airways
[occurs due to presence of many airways of different sizes vibrating from abnormal narrowing] - Examination of chest is usually normal between attacks
- Long-standing asthma may cause hyperinflation of the chest and generalised polyphonic expiratory wheeze with a prolonged expiratory phase
- Onset of the disease in early childhood can result in Harrison sulci
- Check for evidence of eczema and allergic rhinitis
How should asthma be diagnosed in a child under the age of 5?
• If < 5 years old: diagnosis is clinical (hx, ex, response to tx)
o Treat symptoms based on clinical observation
o Review child regularly
o If symptoms present even at age 5, carry out objective tests
Can do a skin prick test
How should asthma be diagnosed in over 5 yr olds?
- If > 5 years old
- Offer lung function tests (spirometry)
-
FEV1/FVC<70% of expected or below lower limit of normal is a positive result for obstructive airway disease
- Involves measurement of FEV1 (best of 3)
-
FEV1/FVC<70% of expected or below lower limit of normal is a positive result for obstructive airway disease
- Consider bronchodilator reversibility test if FEV1/FVC <70%
- Improvement in FEV1 of >12% after beta2-agonist is considered positive
- Consider FeNo testing (fractional exhaled nitrix oxide) if diagnostic
uncertainty and normal spirometry OR obstructive spirometry with negative bronchodilator reversibility test- This tests for airway inflammation
- A level > 35 ppb is considered a positive test
- Consider peak expiratory flow variability, if diagnostic uncertainty after initial assessment and a FeNo test (normal spirometry OR obstructive spirometry, negative BDR and FeNo >35ppb)
- For 2-4 weeks
- >20% variability in diurnal peak flow measurements is positive
- Less sensitive to changes in airway calibre than spirometry but is portable and hence helpful for serial measurements
- Poorly controlled asthma leads to inc peak flow variability, inc diurnal variation and day-to-day variation
- Evidence of atopy→Skin prick testing for common allergens may be performed – helps identify triggers and demonstrate atopy
- Positive skin
o Blood eosinophilia > 4%
o Raised allergen specific IgE
o These tests are NOT part of asthma diagnostic tests but may be done after formal asthma diagnosis has been made
- Positive skin
- Offer lung function tests (spirometry)
How would you medically manage asthma in someone less than 5 yrs old?
How would you medically manage asthma in someone over 5 yrs old?
What are the non-pharmacological aspects of asthma management?
o Assess patient’s baseline asthma status (can be done using Asthma Control Questionnaire or a lung function test (e.g. spirometry))
o Provide self-management education and a personalised asthma action plan (available from Asthma UK)
o Ensure child is up to date with routine immunisations
o Provide information about sources of support (Asthma UK)
o Advise about trigger avoidance (specific allergens, smoke, beta-blockers, NSAIDs)
▪ NOTE: parents should be advised to stop smoking
o Assess for the presence of anxiety and depression
o Ensure that the patient has their own peak flow meter
o Explain how to use inhalers with spacer
o Arrange follow up 6 weeks after diagnosis to check symptoms
What should we do at asthma reviews?
o Confirmadherencetomedication
o Reviewinhalertechnique
o Reviewiftreatmentneedstobechanged
o Askaboutoccupationalasthmaandtriggers
How would you counsel a patient on asthma?
What are the RFs for Viral induced wheeze?
- Maternal smoking during or after pregnancy
- Prematurity
- Male sex
- FH of allergy
How do we manage viral induced wheeze?
Important: do not diagnose these patients with asthma as many preschool children will grow out of their illness by the age of 6 and a diagnosis of asthma can affect a person’s future employment e.g. airline pilots, commercial drivers, armed forces, police will require normal pulmonary function tests
Management settings most commonly home or hospital.
- 1st line: salbutamol
- Burst Therapy is often used for viral-induced wheeze
- The child is given 10 puffs of salbutamol using a high-volume space. Give a puff every 30-60s
- They are then assessed for a response to treatment
- Repeat every 10-20 minutes
- If they can last 4 hours without the symptoms reappearing, they can be discharged
- They will be given a salbutamol weaning regime for the salbutamol inhaler with a spacer.
- Use inhaler as required at home in further episodes of VIW
- Escalate treatment as per ‘Acute asthma’ section
- If mild intermittent wheeze and respiratory symptoms that only occur with viral URTI, consider not giving maintenance treatment but planning a review in an agreed time interval.
- Encourage parents who are smokers to stop
- Follow-up required within 48h of presentation if not admitted to hospital, or 2 working days of discharge.
How should we counsel on Viral Induced wheeze?
When do children require admission for an acute asthma?
Children require hospital admission if, after high- dose inhaled bronchodilator therapy, they:
o Have not responded adequately clinically i.e. persisting breathlessness, tachypnoea
o Are becoming exhausted
o Still have a marked reduction in their predicted peak flow rate or FEV1 (<50%)
o Have a reduced oxygen saturation (<92% on air)
How do we assess severity of an asthma attack?
How should we manage a mild/moderate exacerbation of asthma?
How should we monitor a moderate exacerbation of asthma?
How should we manage life-threatening asthma?
What follow-up is needed after an exacerbation of asthma?
