Respiratory disorders Flashcards
What organisms cause most childhood respiratory infections?
Viruses cause 80-90%.
Most commonly: respiratory syncytial virus, rhinoviruses, parainfluenza, influenzas, adenoviruses
Most important bacteria: strep, pneumoniae, haemophilus influnzae
What host and environmental factors increase the risk of getting a respiratory infection?
Parental smoking, especially maternal Poor socioeconomic status - large family size, overcrowding, damp housing Poor nutrition Underlying lung disease Male gender Congenital heart disease Immunodeficiency
What are the classifications of respiratory infection according to the level of the respiratory infection?
Upper respiratory tract infection Laryngeal/tracheal infection Bronchitis Bronchiolitis Pneumonia
What does the term upper respiratory tract infection encompass (URTI)?
Common cold (coryza)
Sore throat (pharyngitis, including tonsillitis)
Acute otitis media
Sinusitis
What is the commonest presentation of an URTI?
Nasal discharge and blockage Fever Painful throat Earache Cough Difficult in feeding in infants Febrile convulsions Acute exacerbations of asthma
What is a classic feature of the common cold (coryza)?
A clear or mucopurulent nasal discharge and nasal blockage.
What are the commonest organisms that cause the common cold (coryza)?
Rhinoviruses
Coronaviruses
RSV
How do you treat the common cold (coryza)?
Fever and pain are treated with paracetamol or ibuprofen
What is pharyngitis?
The pharynx and soft palate are inflamed and local lymph nodes are enlarged and tender
What are the common pathogens that cause pharyngitis?
Adenoviruses, enteroviruses and rhinoviruses. In the older child, group A beta-haemolytic streptococcus is a common pathogen
What is tonsillitis?
A form of pharyngitis, where there is intense inflammation of the tonsils, often with a purulent exudate.
What are the common pathogens that cause tonsillitis?
Group A strep, EBV
What are some symptoms associated with bacterial tonsillitis?
Marked constitutional disturbances, such as headache, apathy and abdominal pain, white tonsillar exudate and cervical lymphadenopathy is more common with bacterial infection
How would you treat tonsillitis?
Often penicillin or erythromycin, in severe cases children may require admission for IV fluid and analgesia if they are unable to swallow solids or liquids
What would you NOT use to treat tonsillitis?
Amoxicillin is best avoided as it may cause a widespread maculopapular rash if the tonsillitis is due to infectious mononucleosis
What age is acute otitis media most common?
At 6-12 months old
What are infants and young children at increased risk of acute otitis media?
Their Eustachian tubes are short, horizontal and function poorly.
How does acute otitis media present?
Pain in the ear and fever. The tympanic membrane is seen to be bright and red and bulging with loss of the normal light reflection.
What pathogens cause acute otitis media?
Viruses, especially RSV and rhinovirus and bacteria including pneumococcus, H.influenzae.
How would you treat acute otitis media?
Pain should be treated with paracetamol or ibuprofen. Most cases resolve spontaneously. Amoxicillin is widely used.
What can recurrent ear infections lead to and what does this look like?
Otitis media with effusion. The eardrum is seen to be dull and retracted, often with a fluid level visible.
In what age is otitis media with effusion very common?
Between the ages of 2 and 7 years old, with a peak incidence between 2.5 and 5 years.
How do you treat otitis media with effusion?
It is usually self-resolving, but it can cause hearing loss, in which case insertion of ventilation tubes (grommets) or adenoidectomy can be beneficial.
How can you diagnose otitis media with effusion?
Flat tract on tympanometry, in conjunction with evidence of a conductive loss on pure tone audiometry or reduced hearing on a hearing test.
What is sinusitis?
Infection of the paranasal sinuses that may occur with URTI
How do you treat sinusitis?
Antibiotics and analgesia are used for acute sinusitis in addition to topical decongestants
What are some differential diagnoses of acute upper airways obstruction?
COMMON: croup
Uncommon: epiglottitis, bacterial tracheitis, inhalation of smoke and hot air in fires, trauma
What are the complications of laryngeal and tracheal infections?
The mucosal inflammation and swelling produced by laryngeal and tracheal infections can rapidly cause life-threatening obstruction of the airway in young children.
What are the characteristic acute upper airway obstruction signs and symptoms?
Stridor (rasping sound on inspiration)
Hoarseness due to inflammation of the vocal cords
A barking cough
A variable degree of dyspnoea
How do you assess the severity of upper airway obstruction?
Clinically: the degree of chest retraction (none, only on crying, at rest) and agree of stridor (none, only on crying, at rest of biphasic)
What are the signs of severe upper airway obstruction?
Increasing respiratory rate, heart rate and agitation. Central cyanosis or drowsiness indicates sever hypoxaemia and the need for urgent intervention.
What is the basic management of acute upper airways obstruction?
DO NOT EXAMINE THROAT
Reduce anxiety, be calm, confident and well organised
Observe signs of hypoxia or deterioration
If severe, administer nebulised adrenaline and contact anaesthetist
If respiratory failure, urgent tracheal intubation
Why do you not examine the throat in acute upper airways obstruction?
Total obstruction of the upper airway may be precipitated by examination of the throat using a spatula.
What is croup/laryngotracheobronchitis and why is it serious?
Mucosal inflammation and increased secretions affecting the airway, but it is the oedema of the subglottic area that is potentially dangerous in young children because it may result in critical narrowing of the trachea
What are the organisms that cause croup?
> 95% are viral. Parainfluenza viruses are the commonest causes.
What age and seaon is croup most common?
It occurs from 6 months to 6 years of age but the peak incidence is in the second year of life. Most common in autumn
What are the typical features of croup?
Barking cough, harsh stridor and hoarseness, usually preceded by fever and coryza. The symptoms often start, and are worse, at night
How do you treat croup?
Oral dexamethasone, oral prednisolone and nebulised steroids reduce the severity and duration of croup, and the need for admission. In severe cases, nebulised adrenaline with oxygen is needed.
Why do you need to monitor croup after the administration of adrenaline?
Due to the risk of rebound symptoms once the effects of the adrenaline diminish after about 2 hours
What is bacterial tracheitis?
Similar to croup except that the child has a high fever, appears toxic and had rapidly progressive airways obstruction with copious thick airway secretions
How do you treat bacterial tracheitis?
IV antibiotics and intubation and ventilation if required
What is acute epiglottitis?
A life threatening emergency due to high risk of respiratory obstruction. Intense swelling of the epiglottis and surrounding tissues associated with septicaemia
At what age is acute epiglottitis most common?
In children aged 1-6 years old
What are the clinical features of epiglottitis?
High fever in an ill, toxic-looking child.
An intensely painful throat that prevents the child from speaking or swallowing, saliva drools down the chin
Soft inspiratory stridor and rapidly increasing respiratory difficulty over hours
The child sitting, immobile, upright with an open mouth to optimise the airway.
Minimal cough
How would you treat epiglottitis?
Urgent admission and referral ITU with anaesthetist, paediatrician and ENT surgeon. Child should be intubated. After airway is secured blood should be taken and IV antibiotics started.
What are the main symptoms of acute bronchitis in children?
Cough and fever are the main symptoms
How does whooping cough (pertussis) present?
After a week of coryza, there is a characteristic paroxysmal or spasmodic cough followed by a characteristic inspiratory whoop (paroxysmal phase). During a paroxysm, the child goes red or blood in the face, and mucus flows from the nose and mouth.
When is whooping cough worse?
The spasms of cough are often worse at night and may culminate in vomiting. Epistaxis and subconjunctival haemorrhages can occur after vigorous coughing
How long may the symptoms of whooping cough last?
The paroxysmal phase lasts for 3-6 weeks. The symptoms gradually decrease (convalescent phase) but may persist for many months
What are the complications of whooping cough?
Pneumonia, convulsions and bronchiectasis.
How would you treat whooping cough?
Erythromycin eradicates the organism but only decreases symptoms if given in the coryza phase. Close contacts should receive erythromycin prophylaxis
In what age is bronchiolitis most common?
90% are aged 1-9 months, rare after 1 year
What is the organism that causes most cases of bronchiolitis?
RSV is the cause in 80% of cases
What are the clinical features of bronchiolitis?
Coryzal symptoms precede a dry cough and increasing breathlessness. Feeding difficult associated with increasing dyspnoea.
Which children are at increased risk of getting bronchiolitis?
Premature infants who develop bronchopulmonary dysplasia or with underlying lung disease, such as CF or have congenital heart disease
What are the characteristic findings of bronchiolitis on examination?
Sharp, dry cough Tachypnoea Subcostal and intercostal recession Hyperinflation of the chest - prominent sternum and liver displaced downwards Fine end-inspiratory crackles High-pitched wheezes - expiratory > inspiratory Tachycardia Cyanosis or pallor
How do you investigate bronchiolitis?
Virus identified by PCR of nasopharyngeal secretions. CXR not needed in simple cases. Pulse oximetry
What would a CXR show if bronchiolitis was present?
Hyperinflation of the lungs due to small airways obstruction, air trapping and often focal atelectasis
How do you manage bronchiolitis?
Supportive treatment. Humidified oxygen. Fluids may need to be given by nasogastric tube or intravenously.
What are the most common organisms that cause pneumonia?
Viruses are the most common cause in younger children, while bacteria are commoner in older children
What are the clinical features of pneumonia?
Fever and difficulty breathing, usually preceded by an URTI. Other symptoms include cough, lethargy, poor feeding and an ‘unwell’ child. Localised chest, abdo or neck pain is a feature of pleural irritation and suggests bacterial infection
What would you find on examination of pneumonia?
Tachypnoea, nasal flaring and chest indrawing. Increased respiratory rate. There may be end-inspiratory respiratory coarse crackles over the affected area, but the classic signs are often absent in young children. Sats may be reduced
What are the complications of pneumonia?
Pleural effusion, some of which develop into empyema and fibrin strands, may form, leading to septations, which make drainage difficult
How can you distinguish between parapneumonic effusion and empyema?
Ultrasound of the chest
What are the indications for admission for pneumonia?
Oxygen sats <93%, severe tachypnoea and difficulty breathing, grunting, apnoea, not feeding or family unable to provide appropriate care
How do you supportively manage pneumonia?
Oxygen for hypoxia and analgesia for pain, IV fluids if necessary for dehydration and maintain adequate hydration and salt balance
How do you medically manage pneumonia?
New-borns require broad-spectrum IV antibiotics. Older infants can be managed with oral amoxicillin, with broad-spectrum being saved for serious cases
What is transient early wheezing?
Most wheezy preschool children have virus-associated wheeze. It is more common in males and usually resolves by 5 years of age
What is the cause of transient early wheezing?
Small airways are more likely to narrow and obstruct due to inflammation and aberrant immune responses to viral infection.
What are the risk factors of transient early wheezing?
Maternal smoking during and/or after pregnancy and prematurity. A family history of asthma or allergy is not a risk factor.
What is atopic asthma?
Recurrent wheezing associated with evidence of allergy to one or more inhaled allergens. They have persistent symptoms and decreased lung function
What are the clinical conditions to consider in the infant with tachypnoea or wheeze?
Bronchiolitis Pneumonia Transient early wheezing Non-atopic wheezing Atopic asthma Cardiac failure Inhaled foreign body/aspiration
What is the pathophysiology of asthma?
Genetic predisposition and atopy and environmental triggers. Bronchial inflammation Bronchial hyperresponsiveness Airway narrowing Symptoms
What is wheeze?
A polyphonic noise coming from the airways believed to represent many airways of different dimensions vibrating from abnormal narrowing
What are the key features of asthmatic symptoms?
Worse at night and early in the morning
Triggers such as exercise, pets, dust, cold air, emotions, laughter
Interval symptoms
Personal or family history of an atopic disease
Positive response to asthma therapy
What might you find on examination of long-standing asthma?
Hyperinflation of the chest, generalised polyphonic expiratory wheeze and a prolonged expiratory phase
How does asthma affect peak flow?
Increased variability in peak flow, with both diurnal variability (morning PEFR usually lower than evening) and day-to-day variability (change in PEFR over the course of a week).
What are some short-term bronchodilators used in asthma?
Beta2-agonists - salbutamol or terbutaline
How long do salbutamol and terbutaline last for?
They have a rapid onset of action, are effective for 2-4 hours and have few side effects
What are some long-term bronchodilators used in asthma and how long are they effective for?
Long acting beta-2 agonists (LABAs) such as salmeterol or formoterol, they are effective for 12 hours
How do inhaled corticosteroids work in asthma?
They decrease airways inflammation, resulting in decreased symptoms, asthma exacerbations and bronchial hyperactivity.
What are the side effective of inhaled corticosteroids that can be used in asthma?
Systemic side-effects, including impaired growth, adrenal suppression and altered bone metabolism, when high doses are used.
What is the most common add-on therapy used in asthma in young children?
Leukotriene receptor agonist such as montelukast
What is another therapy that is only used in severe cases of asthma, administered by a specialist?
Anti-IgE therapy (omalizumab), an injectable monoclonal antibody that acts against IgE
How do you treat exercise-induced asthma?
For most, a short-acting beta2-agonist bronchodilator taken immediately before exercise is sufficient, but if there are more marked symptoms a LABA taken in conjunction with an inhaled steroid will give greater protection
What are the clinical features of an acute asthma attack?
Wheeze and tachypnoea
Increasing tachycardia
The use of accessory muscles and chest recession
The presence of marked pulse paradoxus
If breathlessness interferes with talking it is very serious
Cyanosis, fatigue and drowsiness are late signs
What are the criteria for admission to hospital in asthma attacks?
They have not responded adequately clinically
Are exhausted
Still have a marked reduction in their predicted peak flow rate
Have a reduced oxygen saturation
How would you manage a acute asthma attack?
High dose inhaled bronchodilators, steroids and oxygen form the foundation of therapy of severe acute asthma. In severe cases, high dose bronchodilators should be given and repeated every 20-30 minutes or with a nebuliser ad oxygen.
What are the causes of recurrent or persistent cough?
Recurrent respiratory infections Post-specific respiratory infections (pertussis, RSV, mycoplasma) Asthma Suppurative lung disease (CF) Recurrent aspiration (gastro-oesophageal reflux, esp. in cerebral palsy and neuro disorders) Persistent endobronchial infection TB Parental smoking
Is it more concerning if a child has a wet or dry cough?
Wet, any child with a persistent cough that wounds wet or is productive should be investigated
What is bronchiectasis?
Permanent dilation of the bronchi
Is bronchiectasis in one lobe or both?
It can be generalised or restricted to a single lobe
What are the causes of generalised bronchiectasis?
CF, primary ciliary dyskinesia, immunodeficiency or chronic aspiration
What are the causes of focal bronchiectasis?
Previous severe pneumonia, congenital lung abnormality or obstruction by a foreign body
What is primary ciliary dyskinesia?
Congenital abnormality in the structure or function of the cilia, which leads to impaired mucociliary clearance
What are the clinical features of primary ciliary dyskinesia?
They characteristically have a recurrent productive cough, purulent nasal discharge and chronic ear infections; 50% also have dextrocardia and situs inversus
What is Kartagener syndrome?
Dextrocardia and situs inversus
How would you manage primary ciliary dyskinesia?
Daily physiotherapy to clear secretions, proactive treatment of infections with antibiotics and appropriate ENT follow up
What lymphadenopathy is highly suggestive of TB?
Marked hilar or paratracheal lymphadenopathy
What imaging best shows bronchiectasis?
CT, X-rays may show it but CT is better
What is the pathology of CF?
Defective protein called the cystic fibrosis transmembrane conductance receptor (CFTR), which is a chloride channel found in the membrane of the cells.
Where if the chromosomal abnormality in CF?
delta F508 on Chromosome 7
How does the pathology of CF affect the function of the lungs?
Reduction in airways surface liquid layer and consequent impaired ciliary function and retention of mucopurulent secretions.
What organism commonly causes endobronchial infection in CF?
Pseudomonas aeruginosa
Why are there more common infections in children with CF?
CFTR (the receptor) causes dysregulation of inflammation and defence against infection
How does CF affect the intestines in infants?
Thick meconium is produced, leading to meconium ileus
How does CF affect the pancreas?
The pancreatic ducts become blocked by thick secretion, leading to pancreatic enzyme deficiency (lipase, amylase and proteases) and malabsorption.
How does CF affect the sweat glands?
Abnormal function of the sweat glands results in excessive concentrations of sodium and chloride in the sweat
What test is performed on newborns to screen for CF?
Guthrie test
What would you find on examination of a child with CF?
Hyperinflation of the best due to air trapping, coarse inspiratory crepitations and/or expiratory wheeze. With established disease, there is clubbing
What are the clinical features of CF in infants?
Meconium ileus in newborn period Prolonged neonatal jaundice Failure to thrive Recurrent chest infections Malabsorption, steatorrhoea
What are the clinical features of CF in young children?
Bronchiectasis
Rectal prolapse
Nasal polyp
Sinusitis
What are the clinical features of CF in older children and adolescents?
Allergic bronchopulmonary aspergillosis (ABPA) Diabetes mellitus Cirrhosis and portal hypertension Distal intestinal obstruction (DIOS) Pneumothorax or recurrent haemoptysis Sterility in males
How does pancreatic enzyme insufficiency in CF affect the bowels?
It can lead to passing frequent large, pale, very offensive and greasy stools (steatorrhoea)
How can pancreatic insufficiency be diagnosed?
Demonstrating low elastase in faeces
What is the essential diagnostic tool in CF?
The sweat test, to confirm that the concentration of chloride in sweat is markedly elevated. Confirmation can be made with testing for gene abnormalities in the CFTR protein
What respiratory test would you measure regularly in older children?
Spirometry to measure FEV1 and lung function, it will decline as the disease progresses
What physio is used in children with CF?
Parents are taught to perform airway clearance at home using chest percussion and postural drainage. Older patients perform controlled deep breathing exercises. Physical exercise is beneficial and is encouraged
Do children with CF have to take regular antibiotics?
Yes, many specialists recommend continuous prophylactic oral antibiotics (usually flucloxacillin)
What happens if a child with CF gets a respiratory infection?
Persisting symptoms require prompt and vigorous IV therapy to limit lung damage. Parents are taught to administer these at home
What can be nebuliser to decrease the viscosity of sputum and therefore increase its clearance?
Nebulised DNAse or hypertonic saline
What is the only option for end-stage CF?
Bilateral sequential lung transplantation
How is pancreatic enzyme insufficiency treated in CF?
Oral enteric-coated pancreatic replacement therapy taken with all meals and snacks.
How does CF affect nutrition?
A high calorie diet is essential and dietary intake is recommended at 150% of normal. To achieve this, overnight feeding via a gastrostomy is often used
How can you treat the liver damage caused by CF?
Regular ursodeoxycholine acid improve the flow of bile
Why are males with CF virtually always infertile?
Due to the absence of the vas deferens, although they can father children through ICSI
What does the Guthrie test actually measure?
Immunoreactive trypsinogen
What are the clinical features of obstructive sleep apnoea?
Loud snoring, witnesses pauses in breathing, restlessness and disturbed sleep.
What are the complications of obstructive sleep apnoea?
Excessive daytime sleepiness, learning and behaviour problems, acute life-threatening cardiorespiratory events and in severe cases, pulmonary hypertension.
What are the causes of obstructive sleep apnoea?
Upper airway obstruction secondary to adenotonsillar hypertrophy. Hypotonia, muscle weakness and anatomical problems (Down syndrome, neuromuscular disease)
What investigations are performed during obstructive sleep apnoea?
Overnight pulse oximetry.
How would you manage obstructive sleep apnoea?
If possible, treat cause. If not, CPAP or BIPAP may be required
