Respiratory Disorders Flashcards
Are respiratory infections usually viral or bacterial
90% viral
Reasons why children are more susceptible to respiratory infections
Chest wall more compliant than that of adult. Fatiguability of respiratory muscles. Increased mucous gland concentration. Poor collateral ventilation. Low chest wall elastic recoil
4 types of upper RTI
Common cold - acute nasopharyngitis
Sore throat - pharyngitis and tonsillitis
Acute Otis media (+/- effusion)
Sinusitis
Features of common cold (coryza)
Clear / mucopurulent discharge
Cough, fever, malaise
Treatment of common cold
Paracetamol / ibuprofen for symptomatic relief of pain / fever
Sore throat usually caused by a virus (especially in
Group A b- haemolytic strep
Features of sore throat
Sore throat , fever, constitutional upset
What features might indicate a bacterial sore throat
Severe pain, lymphadenopathy and purulent exudate
Treatment of sore throat
Sx relief (paracetamol / ibuprofen) Bacterial - penicillin
What abx can be given in sore throat if allergic to penicillin
Erythromycin
How long corse of abx for sore throat
10/7 to eradicate organism and prevent rheumatic fever
What abx should not be given with sore throat and why
Amoxicillin - can cause widespread maculopapular rash in EBV infection
Complications of sore throat
Retro pharyngeal abscess
Peritoneal are abscess (quinsy )
Rheumatic fever
Post strep glomerulonephritis
Causes of acute Otis media
Viral - RSV, influenza
Bacterial - pneumococcal, h influenzae, group b strep, maraxella catarrhatis
Does sinusitis usually occur on own
Often with viral URTIs
Features of sinusitis
2^ bacterial infection causes pain, swelling and tenderness over the cheek from infection of maxillary sinuses
Treatment of sinusitis
Abx and analgesia
Indications for tonsillectomy
Recurrent tonsillitis
Peritoneal are abscess (quinsy)
Obstructive sleep apnea
Why do adenoids cause obstructive sleep apnea
Grow proportionally faster than airway -> narrowing effect greater at 2-8 years
Indications for adenoidectomy
Obstructive sleep apnea
What percent of children snore / have obstructive sleep apnea
10%, 1%
Usual cause of OSA
Airway obstruction due to adenohyperthrophy
Features of OSA
Hx of snoring followed by 30-45 seconds of apnea with disturbed sleep and struggling for breath
Treatment of OSA
Adeno-tonsillectomy
Disorders which can cause sleep disordered breathing
Craniofacial - eg. Pierre-robin sequence
Neuromuscular eg. Muscular dystrophy
Hypotonia eg. Downs
Treatment of sleep disordered breathing
Overnight nasal mask ventilation
What should always be ruled out in laryngeal and tracheal infections
Inhaled foreign body
Egs of tracheal / laryngeal infections
Croup
Diphtheria and bacterial tracheitis
Acute epiglottitis
What is often caused by laryngeal / tracheal infections and why
Upper airway obstruction due to mucosal inflammation
Features of upper airway obstruction
Stridor
Hoarseness - due to inflammation of vocal cords
Barking cough - sea lion like
Dyspnea
Basic management of laryngeal / tracheal infections ? What should you not do !
Don’t examine throat.
Monitor for signs of decreased O2 / deterioration.
Add nebuliser adrenaline if in doubt and intubate if deterioration
What is croup
Viral laryngotracheaobronchitis
Most common cause of laryngotracheal infections and its cause
Croup - para influenza virus most common
Hx of croup
URTI for 1-2 days (coryza and fever) then barking cough and stridor
When are symptoms of croup worst
Night
What causes the barking cough and stridor in croup
Sub glottic inflammation and oedema
How long is management of croup symptomatic
3/7 as most improve spontaneously
When do children require hospital admission with croup
Young age (
Hospital management of croup ?
What else can be used
Small dose of oral dexamethasone (0.15mg/kg), oral prednisolone and nebulised steroids (budesonide)
Nebulised adrenaline can be used
What causes diphtheria
Corynebacterium diptheriae
What is bacterial tracheitis also called
Pseudomembranous croup
What causes bacterial tracheitis
Staph aureus / h influenzae
Rare but serious
Features od bacterial tracheitis
Similar to viral croup but with high fever, toxic apperance and rapidly progressing airway obstruction
Why do you get rapidly progressing airway obstruction in bacterial tracheitis
Copious thick airway secretions
Treatment of bacterial tracheitis
Abx eg IV flucoxacilin
Intubation (if required)
How serious is acute bacterial epiglottitis and what causes
Life threatening
Haemophilus influenza type B (HiB) - rare due to immunisation
Onset of acute bacterial epiglottitis
Rapid onset (hrs) after intesely painful throat
Features of acute bacterial epiglottitis ?
Ill, toxic, febrile child who is unable to speak or swallow with soft inspiratory stridor
Tend to sit upright with open mouth to maximise airway and might drool saliva
What does acute epiglottitis need to be distinguished from ? How?
Croup as different management
Fast onset, no coryza, little or no cough, drooling saliva, >38.5 fever
How do you confirm diagnosis of acute epiglottitis and management
Examination under anaesthetic followed by intubation to secure airway
3rd gen ceflasporin eg. CEFUROXIME
Why should you not examine throat in acute epiglottitis
May cause complete airway obstruction
3 common types of LRTI
Pneumonia
Bronchiolitis
Pertussis (whooping cough)
What is characterised by pneumonia
Inflammation of the parenchyma and consolidation of the alveoli
Causative organisms by age of pneumonia
Neonates - group b strep, E. coli, chalmydia (from mother genital tract)
Infants - respiratory viruses eg RSV, adenoviruses, strep pneumonae, h influenzae, bordetella pertussis
Child - strep pneumoniae, h influenza, group A strep, mycoplasma pneumonia
Symptoms of pneumonia? When else should it be considered?
Fever and difficulty breathing usually preceded by URTI symptoms. Cough, lethargy, poor feeding.
Chest / neck pain / acute abdomen
What does localised chest / neck pain imply in pneumonia
Pleural irritation and bacterial infection
Signs of pneumonia
Respiratory distress - flaring, tracheal tug, sub / intercostal recession
Crepitations/ wheeze +/- bronchial breathing (darth Vader)
Decreased SaO2
Investigations for pneumonia and results ?
CXR - lobar consolidation -> bacterial pneumonia
FBC - neutropenia -> bacterial
USS - distinguish between effusions and empyema
Management of pneumonia
Close SaO2 monitoring (
Abx in bacterial pneumonia ? If severe? If mycoplasma ?
1st line - penicillin
Cefuroxime / flucloxacillin in severe
Macrolide eg. Erythromycin if mycoplasma
What is the commonest sever respiratory infection in infants
Broncholitis (90% occurs in 1-9 months)
Commonest cause of bronchiolitis ? Others?
RSV - 80% Human metapneumovirus (MPV) and other respiratory viruses eg adenoviruses, parainfluenza
Features of bronchiolitis ? What may small infants develop?
Coryzal precede dry cough and progressive breathlessness
Apnoeic episodes (
Physical signs of bronchiolitis
Tachypnea with respiratory distress
Chest hyperinflation (prominent sternum / downward displaced liver)
Fine end inspiratory crackles and high pitches wheeze
Is the wheeze in bronchiolitis louder inspiratory or expiratory
Expiratory
Risk factors for bronchiolitis
Preterm infants
Infants with CHD / chronic lung disease (eg. CF, bronchiopulmlnary displasia)
What is given to preterm infants to prevent bronchiolitis
RSV monoclonal antibody (PALIVIZUMAB)
How do you detect RSV
Nasopharyngeal swabs -> detect by immunofluorescence
What investigation for bronchiolitis
Swabs
CXR - hyperinflation with air trapping and focal atelectasis (collapse)
Management of bronchiolitis
Supportive
oxygen for hypoxia, maintain hydration
Cause of whooping cough
Bordetella pertussis
Features of whooping cough (pertussis)
Catarrhal stage - 1/52 of coryza
Paroxysmal stage - cough with inspiratory whoop (worse at night & child may go blue).
Convalescent stage -(recovery)
How long does whooping cough last
3-6/52
What can occur after vigourous coughing
Subconjunctival haemorrhage and epistaxes (nose bleed)
Diagnosis of pertussis
Lymohocytosis characteristic
Perinasal swab cultures
Treatment of whooping cough
Erythromycin
Define asthma
Chronic inflammatory disorder of the airways associated with widespread REVERSIBLE AIRWAY OBSTURCTION
3 types of wheezing
Transient early wheeze
Non atopic wheeze
IgE mediated wheeze (atopic asthma)
How to distinguish viral induced wheeze from asthma
No interval symptoms (main feature is symptoms only with infection)
No excess of atopy
Likely to improve with age (however lots of asthma does too)
No benefit from regular inhaled steroids
What’s affected in transient early wheezing
Small airways (often during viral infections)
Risk factor for transient early wheeze
Maternal smoking during pregnancy
Prognosis of transient early wheezing
Most resolve by 5 years of age (probably due to increased airway calibre)
What is non atopic wheezing and usual cause
Normal lung function in early life but a LRTI due to virus (usually RSV) leading to increased wheezing in first 10 years
Prognosis of non atopic wheeze
Usually improves as progresses to adolescence
Pathogenesis of IgE mediated (atopic) asthma
Genetic predisposition & environmental factors
- > bronchial inflammation
- > bronchial hyper reactivity
- > triggers
- > mucosal oedema, mucosal secretions, bronchoconstriction
- > airway narrowing
- > cough, wheeze, chest tightness, breathlessness
Trigger factors for asthma
Smoking, cold air, RTIs, allergens (house dust mite / pollens), exercise, emotional upset / excitement
5 stages of asthma management
Inhaled short acting b2 agonist (salbutamol / terbutaline)
Regular inhaled steroid 200-400mg/day (beclamethasone, budesonide, fluticasone)
Add long acting b2 agonist (salmeterol, formeterol)
Increase steroid to 800mg/day
Continuous / frequent use of oral steroids and refer to paediatric respiratory physician
Two outcomes of adding LABAs that don’t fix asthma
Benefit but not adequate -> increase steroid to 400mg/day
No response to LABA -> stop, increase steroid (400mg/day) and trial other therapies
What other therapies can be trailed if LABA is ineffective
Leukotriene receptor antagonists (MONTELUKAST), theophylline (slow release)
What is the usual continuous oral steroid used in asthma stage 5 treatment
Prednisolone
Complications with inhaled steroids
Adrenal suppression
Brief slowing of growth (no evidence saying affects final adult height)
How do b2 agonists work
Relax smooth muscle
Side effects of b2 agonists
Tachycardia
Hypokalaemia
Restlessness
How does theophylline work
Phosphodiesterase inhibitor
Side effects of theophylline
Restlessness, arrythmias, diuresis
Eg of anticholinergic for asthma
Ipratropium bromide (“atrovent”)
How do anticholinergics work in asthma
Inhibit choline rigid brinchoconstriction
Side effects of anticholinergics
Dry mouth, urinary retention
How do steroids work in asthma
Inhibit synthesis of inflammatory mediators (cytokines, leukotrines, prostaglandins)
-> decreased airway hyperresponsiveness
Local side effects of steroids? How to reduce
Oral candidiasis
Wash mouth with dry powder inhaler / use spacer with metered dose inhalers
Features of acute asthma attack
Respiratory rate >50bpm in under 5 (>30 in over 5)
Pulse >140bpm in under 5 (>120 in over 5)
Use of accessory muscles
Too breathless to talk
Feature of life threatening asthma
Central cyanosis
Silent chest (insufficient air flow to generate wheeze)
Exhaustion / poor respiratory effort
Agitation & diminished conciousness (severe hypoxia )
What is CFTR
Camp dependent chloride channel
ATP-binding cassette transporter
What is carrier rate of CF
1 in 25
How many affected by CF
1:2500
Cause of cf
Deletion of d-F508 of CFTR gene on chromosome 7
What do mutations in CFTR gene cause ? Especially where?
Defective chloride ion transport across epithelial cells &
Increased viscosity of secretions
Respiratory tract and exocrine pancreas
What is the diagnostic test for cf and why
Sweat test
Abnormal transport in sweat glands -> increased NaCl in sweat
Features of cf
Recurrent RTI and failure to thrive
Cough with purulent sputum, hyperinflation, Crepitations, wheeze, finger clubbing
Deficient pancreatic enzymes -> Steatorrhoea, failure to thrive and malnutrition
Pancreatic enzymes deficient in cf
Protease, amylase, lipase
What can be first sign of cf
10% get meconium ileus
Systems affected by cf
Airway and GI Pancreas / endocrine Reproductive Joints Vascular Hepatic Psychological
Cf in Airway and Gi
Nasal polyps, distal ileal obstruction syndrome
Cf in pancreas / endocrine
Diabetes, poor growth, osteoporosis
Cf in reproductive
Infertility in males - absent vas deferens
Cf in joints
Athropathy
Cf in vessels
Vasculitis
Cf in hepatic
Portal hypertension -> ascities, varicies, hepatic encephalopathy
Sweat test result needed for cf diagnosis ?
What’s used to test?
Two tests showing chloride of >60mmol/L
Pilocarpine iontoploresis
Management of cf 2 aims
Prevent progression of lung disease
Promote adequate nutrition and growth
Members of cf MDT
Parents, specialist paediatrician, specialist nurse, physiotherapist, dietician
Most important part of resp management in cf ? What’s involved ?
Physiotherapist - 2x/day
Chest percussion with postural drainage, breathing exercises, positive expiratory pressure masks
What is monitored in cf ? What are used to hell with symptoms ?
Fev1 - declines with disease progression
Mucolytics eg nebulised DNase & hypertonic saline (aid mucocilary clearance )
What is given to many cf patients ? Why?
Prophylactic Abx eg flucoxacilin.
Need additional cover against common resp pathogens (s aureus, h influenzae, pseudomonas aeurgnosa)
What’s given for nutritional management of cf
High calorie
Vitamin supplements
Pancreatic enzymes supplements
Which vitamins are essential to be given as supplements in cf
Fat soluble (ADEK )
Eg of pancreatic enzymes supplement and effect
Crean
Improve Steatorrhoea and allow catch up growth
What is the genetic screen for cf ? What else does it screen for ?
Guthrie test
Cf, phemylketanuria, congential hypothyroidism, MOAD deficiency, sickle cell, thalassaemia
Specifically looked for in genetic test of cf
Immunoreactive trypsin
Specifically looked for in genetic test of phenylketonuria
Phenylalanine
Specifically looked for in genetic test of congential hypothyroidism
TSH
