Respiratory Learning Objectives Flashcards
Understand the natural history of asthma during childhood
airway inflammation, bronchial hyper-reactivity and reversible airway obstruction
Clinical triad = cough, wheeze and shortness of breath
<5 & viral prodrome = viral induced wheeze
ddx for wheeze
Bronchiolitis • Foreign body in the airway • Allergic rhinitis • Croup inspiratory stridor and wheeze • Infection aspergillosis, viral or bacterial • Vocal cord dysfunction mimics steroid refractory asthma
• Bronchiectasis focal signs • Post-nasal drip cough at night • Gastroesophageal reflux accompanied by vomiting • Ciliary dyskinesia • Sinonasal manifestation of CF especially if present since birth
SIGN guidelines for management
- SABA
- low-dose ICS
- LABA / LTRA (for <5)
- increasing ICS dose or + LTRA / LABA
- specialist care
management of severe / life-threatening asthma
severe = Sp02 <92%, can't talk, accessory mm use, PEFR 33-50% - oxygen 8L/min - salbutamol neb - prednisolone
life-threatening
= exhaustion, agitation, altered consciousness, cyanosis, silent chest, PEFR <33%
- oxygen 8L/min
- salbutamol nebs + ipatropium
Understand the aetiology and natural history of bronchiolitis
- Respiratory syncytial virus (RSV) is cause in 80% of cases
- other 20% are accounted for by
o Human metapneumovirus
o Parainfluenza virus
o Rhinovirus
o Adenovirus
o Influenza virus
o Mycoplasma pneumoniae
Recognise and be able to describe the clinical features of bronchiolitis and be able to relate these to normal physiology
Normal symptoms of a viral URTI is 1st symptom (mild rhinorrhea, cough and fever) followed by dry cough and increasing breathlessness
• Feeding difficulties are associated with increasing dyspnea
• Apnoea may occur, especially in young infants
• Characteristic findings
o Sharp, dry cough
o Tachypnoea
o Subcostal and intercostal recession
o Hyperinflation of the chest = prominent sternum or liver displaced downwards
o Fine end-inspiratory crackles or prolonged expiration
o High-pitched wheezes = expiratory > inspiratory
o Tachycardia
o Cyanosis or pallor
Know how to treat acute bronchiolitis
- supportive care
- Children should be referred to hospital where there is
o Poor feeding
o Lethargy
o History of apnoea
o Respiratory rate >70 breaths/min
o Nasal flaring or grunting
o Severe chest wall recession
o Cyanosis
o Saturations <94%
Know and understand the aetiology and natural history of pneumonia including knowledge of the common causative organisms
Infection of the lower respiratory tract and lung parenchyma that leads to consolidation
common bacterial agents:
o Neonates = organisms from mother’s genital tract - group B streptococcus, E.coli, Klebsiella, Staph. Aureus (Gram –ve enterococci)
o Infants = Strep. pneumoniae, Chlamydia trachomatics, Haemophilus influenzae - more commonly respiratory viruses (RSV)
o School age = Strep pneumoniae, Staph aureus, group A streptococcus, Bordetella pertussis, Mycoplasma pneumoniae
Recognise and be able to describe the clinical features of pneumonia and be able to relate these to normal physiology
- May have had a recent URTI with fevers & difficulty breathing
- other symptoms may include cough, lethargy, poor feeding and an ‘unwell child’
- Localised chest pain, abdominal or neck pain are a feature of pleuritic irritation - suggests bacterial infection
hx:
o Temperature >38.5oC
o Shortness of breath
o Cough with sputum production in >7yrs old
Have knowledge of the treatments available to children with pneumonia
Most can be managed at home
= indication for admission
o SpO2 <93%
o Severe tachypnoea
o Difficulty breathing, grunting or apnoea
o Not feeding or family unable to provide appropriate care
General supportive care = O2 for hypoxia and analgesia for pain, IV fluids if dehydrates or correct electrolytes
abx:
Newborns = broad spectrum IV Abx
<5yrs = Strep. Pneumoniae is most common
▪ 1st line - oral amoxicillin
▪ 2nd line
• Co-amoxiclav or Cefaclor for typical cases
• Erythromycin, clarithromycin or azithromycin for atypical cases
>5 yrs = Mycoplasma pneumoniae is most common ▪ ▪ 1st line - oral Amoxicillin or macrolide (Erythromycin) if mycoplasma or chlamydia is suspected
▪ 2nd line - if Staph. Aureus is suspected consider using macrolide or combination of Flucloxacillin with Amoxicillin
Severe pneumonia = Co-amoxiclav, Cefotaxime or Cefuroxime IV
Know the aetiology and natural history of pertussis
Caused by Bordetella parapertussis - causes epidemics every 3-4yrs
- Other causes = Mycoplasma pneumoniae, Chlamydia or adenovirus
• Catarrhal phase (1-2 weeks) = mild symptoms with fever, cough and coryza
• Paroxysmal phase (2-6 weeks) = develops characteristic paroxysmal or spasmodic cough followed by a inspiratory whoop
• Convalescent phase (2-4 weeks) = symptoms gradually decrease, but may persist for many months
- Spasms of cough are often worse at night - may culminate in vomiting and child may go red or blue in the face, with mucus from nose & mouth
- Whoop may be absent in infants but there may be apnoea
Understand the effect of immunisation on presentation of clinical features and advice to contacts
Immunisation reduces the risk of developing pertussis and the severity of disease in those affected but does not guarantee protection - level of protection declines steadily during childhood
• If erythromycin is started in the catarrhal phase it can reduce symptoms and eradicate pertussis organisms
contacts:
- Close contacts should receive prophylactic Erythromycin and unvaccinated infants should be vaccinated
- Symptoms will eventually resolve: advise about common symptoms and explain symptoms that may be worrying
Be able to recognise the clinical features of tuberculosis in children
Caused by Mycobacterium tuberculosis and is spread via droplet infection and infect site of entry & regional lymph nodes
ASYMPTOMATIC:
= mantoux test may be positive (5-15mm)= sufficient to start treatment
SYMPTOMATIC:
gohn focus / primary complex: lung lesion & enlarged LN
o Fever
o Anorexia and weight loss
o Cough
o CXR changes
Post-primary TB may present as local disease or widely disseminated miliary TB to bones, joints, kidneys, pericardium and CNS (can cause meningitis)
Have a knowledge of treatment options required and the difficulties in ensuring adherence in children
2 months = rifampicin, isoniazid, pyrazinamide & ethambutol
4 months = rifampicin & isonazid
- After puberty = pyridoxine is given weekly to prevent the peripheral neuropathy associated with isoniazid therapy (this complication does not occur in young children)
- Tuberculous meningitis = dexamethasone is given for 1st month to decrease the risk of long-term sequelae
- Asymptomatic children with a +ve Mantoux test are seen to be latently infected - treated with rifampicin & isoniazid for 3 months (decreases the risk of reactivation of infection later in life)
Know and understand the aetiology and natural history of cystic fibrosis
Autosomal recessive genetic condition - 1/2500 live births and 1/25 carriers every year
CFTR gene located on chromosome 7 = most common defect is F508
lungs = excessive mucus production & recurrent chest infections
intestine = thick meconium - meconuim ileus in 10-20%
pancreatic ducts = enzyme deficiency & malabsorption
sweat glands = salty sweat (=sweat test)
Recognise and be able to describe the clinical features of cystic fibrosis and be able to relate these to normal physiology
newborn = heel-prick test diagnosis
infancy = meconium ileus (obstruction), prolonged neonatal jaundice, failure to thrive, recurrent chest infections, malabsorption steatorrhoea, hypoproteinaemia & oedema
young child = bronchiectasis, rectal prolpase, nasal polyp, sinusitis, anorexia
adolescent = ABPA, DM, cirrhosis & portal HTN, distal intestinal obstruction, pneumothorax / recurrent haemoptysis, sterility in males
Be aware of the treatments available to children with cystic fibrosis including medications, physiotherapy and nutrition
FEV1 is an indicator of clinical severity and declines with disease progression
PULMONARY CARE:
- All children with CF should have physiotherapy twice a day:
o chest percussion
o Postural drainage
o Self-percussion
o Deep breathing exercises
o Use of flutter or acapello device
- Antibiotic therapy
o When well = oral Abx (flucloxacillin) against Staphylococcus aureus & Haemophilus influenzae
o Acute exaccerbations = 14 day course of IV Abx through an indwelling long-line that should last several weeks
o Pseudomonas aeruginosa = nebuliser for those chronically infected
- Other therapies = annual flu vaccine, bronchodilators, mucolytics (before physio) and oral azithromycin
GI CARE:
- laxatives
- creon (PO pancreatic supplement)
- high calorie diet
- salt supplement
- fat soluble vitamin supplements
Be able to recognise the clinical features of epiglottitis
Acute epiglottitis = life-threatening swelling of the epiglottis and septicaemia due to Haemophilus influenzae type B infection
- most commonly in children 1-6yrs but now rare due to routine HiB immunisation
= There is intense swelling of the epiglottis and surrounding tissue associated with septicaemia - it is important to distinguish clinically between epiglottitis and croup, as they require different treatment
- very acute onset
- pyrexic, toxic-looking child
- intensely sore throat w/ drooling
- soft inspiratory stridor
- sat upright w/ open mouth
management:
- ICU admission for andothracheal intubation
- blood cultures & IV abx
o 2nd or 3rd generation Cephalosporin IV for 7-10 days: Cefuroxime, Ceftriaxome or Cefotaxime
o Rifampicin prophylaxis to close contacts
Be able to distinguish epiglottitis from other causes of upper airway obstruction
time course = E: hours; C: days prodrome = C: coryza cough = E: slight if any; C: barking feeding = E: no C: can drink Mouth = E: open & drooling; C: closed toxic = E: yes; C: no stridor = E: soft; C: rasping voice = E: weak / silent; C: hoarse
Recognise the importance of otitis media, be aware of causative organisms and the treatment options available
infection of the middle ear associated with pain, fever and irritability
= red bulging tympanic membrane w/ loss of normal light reflex
caused by:
o Viruses = RSV and rhinovirus
o Pneumococcus
o Group A haemolytic streptococcus
o Haemophilus influenza
complications inc. mastoiditis & meningitis (uncommon)
manage w/ broad spectrum abx (amoxicillin) if not clear in 2-3/7 & analgesia
recurrent = secretory otitis media
= middle ear effusion w/out sx of acute otitis media
Know and understand the aetiology and natural history of tonsillitis including knowledge of the common causative organisms
a form of pharyngitis
w/ purulent exudate = often due to group A -haemolytic streptococcus or EBV
(not possible to distinguish viral or bacterial clinically)
bacterial might inc: headache, apathy, abdo pain, white tonsillar exudate, cervical lymphadenopathy
manage severe tonsilitis w/ 10 day course of penicillin or erythromycin
avoid amoxicillin as it can cause a widespread rash if infection is caused by EBV)
surgery only indicated if >5 a year and:
- recurrent otitis media w/ effusion
- peritonsillar abscess (quinsy)
- obstructive sleep apnoea
Know and understand the aetiology and natural history of URTI including knowledge of the common causative organisms
Commonest presentation = combination of nasal discharge/blockage, fever, painful throat and earache cough may also be present
URTIs can cause:
o Difficulty in feeding (infants are obligate nasal breathers)
o Febrile convulsions
o Acute exaccerbations of asthma
common cold (coryza) = rhinovirus, coronavirus & RSV sore throat (pharyngitis) = adenovirus, enterovirus, rhinoviris & group A B-haemolytic streptococcus sinusitis = viral (paranasal) or secondary bacterial (maxillary)
Know the physiological consequences of fever and the therapeutic options and indications for treatment of fever during childhood
red flags:
fever >38 <3 month or >39 if 3-6 months
bile stained vomit (obstruction)
rash (meningococcal septicaemia)
septic screen incs: o Blood culture o FBC - including differential WCC o Acute phase proteins - CRP o Urine sample o Consider: CXR, LP, rapid antigen screening (blood/urine/CSF), meningococcal/pneumococcal PCR (blood/CSF) or virus PCR for HSV or enterovirus (CSF)
Parental antibiotics given immediately in seriously unwell children = 3rd-generation cephalosporin (cefotaxime or ceftriaxone) and ampicillin
Know and understand the aetiology and natural history of viral croup including knowledge of the common causative organisms
laryngotracheobronchitis
causes: parainfluenza (also metapneumovirus, RSV & influenza)
features: o barking cough o harsh stridor o hoarseness o preceeded by fever & coryzal sx o start & worse at night
Know the management options available for viral croup
Oral dexamethasone, oral prednisolone and nebulised steroids (budesonide)
Severe cases with severe upper airway obstruction = nebulised adrenaline with oxygen provides transient improvement but rebound symptoms may occur after 2hrs
Be able to recognise the clinical features of bacterial tracheitis
Rare, but dangerous condition = similar to severe croup except child has high fever, appears toxic and has rapidly progressive airway obstruction due to thick airway secretions
• Caused by Staphylococcus aureus
• Management = IV antibiotics and intubuation/ventilation if required
Understand the immediate danger posed by burns and smoke inhalation in relation to the anatomy of the airway and be familiar with emergency protocols for their management
sx: o Cough o Shortness of breath o Sore throat o Headache o Confusions o Mucosal oedema = caused by burning of the mouth and throat o Blue or cyanosed - asphyxia due to deposition of smoke in the lower lungs o Increased RR accordingly
management = high flow humidified oxygen (100% o2 to remove CO from blood quickly)
