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
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.
How would you counsel a parent regarding whooping cough?
How do we counsel for bronchiolitis?
How do we categorise the severity of croup?
How should you counsel on croup?
Describe the pathophysiology of asthma.
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?
How would you counsel a patient on asthma?
How should we counsel on Viral Induced wheeze?
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?
