RESPIRATORY PAEDS Flashcards
What is Bronchiolitis and what is usual causative agent?
Infection of the bronchioles
Usually caused by RESPIRATORY SYNCYTIAL VIRUS (RSV)
BRONCHIOLITIS: Age of presentation
Usually infants under 1 year - most common in infants under 6 months
Can rarely be diagnosed in children up to 2 years (ex-premature babies with CLD)
BRONCHIOLITIS: Presentation
- Coryzal symptoms
- Signs of resp distress
- Dyspnoea
- Tachypnoea
- Poor feeding
- Apnoeas
- Wheeze and crackles
BRONCHIOLITIS: Signs
- Raised RR
- Use of accessory muscles
- Intercostal and subcostal recessions
- Nasal flaring
- Head bobbing
- Tracheal tugging
- Cyanosis
Define WHEEZE
Whistling sound
Narrowed airways
EXPIRATION
Define GRUNTING
Caused by exhaling with the glottis partially closed due to increased positive END-EXPIRATORY pressure
Define STRIDOR
High pitched INSPIRATORY noise
Obstruction of upper airway
E.g. croup
BRONCHIOLITIS: Treatment
Most recover in 2-3 weeks, most managed at home
Supportive management:
- adequate intake
- saline nasal drops
BRONCHIOLITIS: Reasons for admission
Aged UNDER 3 MONTHS or any pre-existing condition such a prematurity, downs, CF 50-75% or less of normal milk intake Clinical dehydration RR >70 O2 sats <92% Moderate to severe respiratory distress- e.g. deep recessions, head bobbing Apnoeas Parents unable to manage at home
Blood gases in TYPE 2 respiratory distress
Rising pCO2 Falling pH (CO2 build up —> acidosis)
BRONCHIOLITIS: preventative injection
PALIVIZUMAB - monoclonal antibody against RSV
monthly injection
High risk babies
How is VIRAL INDUCED WHEEZE different to ASTHMA
Caused by: RSV or rhinovirus Prevention: Before the age of 3 No atopic history Occurs during viral infections Evidence of viral infection 1-2 days preceding onset of SOB, respiratory distress, expiration wheeze
ACUTE ALLERGIC ASTHMA type of hypersensitivity reaction
Type 1 hypersensitivity
IgE
Signs of SEVERE ACUTE ASTHMA
Peak flow <50% Sats <92% unable to complete full sentences Signs of respiratory distress RR >40 (1-5 years) RR >30 (5 years+) HR >140 (1-5 years) HR >125 (5 years+)
Signs of LIFE THREATENING ACUTE ASTHMA
Peak flow <33% predicted Sats <92% Exhaustion or poor respiratory effort Hypotension Silent chest Cyanosis Altered consciousness or confusion
Management of acute asthma (or viral induced wheeze!)
1) Supplementary oxygen if sats low
2) Bronchodilators (e.g. salbutamol, ipratropium, magnesium sulphate)
3) steroids: prednisone (oral) hydrocortisone (IV)
4) Antibiotics if bacterial infection suspected (Amoxixillin or erythromycin)
Stepped up management of bronchodilators
1) Inhaled or nebulised SALBUTAMOL (Beta-2 agonist)
2) Inhaled or nebulised IPRATROPIUM BROMIDE (anti-muscarinic)
3) IV MAGNESIUM SULPHATE
4) IV AMINOPHYLLINE
MODERATE to SEVERE acute asthma stepwise treatment
1) SALBUTAMOL inhaler via spacer device (10 puffs every 2 hours)
2) Nebulisers with SALBUTAMOL/IPRATROPIUM BROMIDE
3) oral PREDNISONE (1mg per kg weight OD for 3 days)
4) IV HYDROCORTISONE
5) IV MAGNESIUM SULPHATE
6) IV SABUTAMOL
7) IV AMINOPHYLLINE
MILD asthma
SALBUTAMOL inhaler via spacer (e.g. 4-6 puffs every 4 hours)
Side effects of Salbutamol
Hypokalaemia
Tachycardia
CHRONIC ASTHMA diagnosis
Spirometry with bronchodilator reversibility testing (FEV1 improvement by >12%)
Direct bronchial challenge test with histamine or Mehta hotline
Fractional exhaled NO (FeNO)
Peak flow variability measured by keeping a diary
Management stepwise approach CHRONIC ASTHMA in UNDER 5s
- Short acting beta-2 agonist (e.g. salbutamol) PRN
- Add low dose corticosteroid inhaler or leukotriene antagonist (ie oral monteleukast)
- Add other option from step 2
- Refer to specialist
Management CHRONIC ASTHMA in children AGED 5-12
- (Same) Salbutamol
- (Same) Low dose corticosteroid inhaler
- LONG ACTING BETA-2 AGONIST inhaler (e.g. SALMETEROL)
- Titration up the corticosteroid inhaler
- Consider adding
oral MONTELUKAST
THEOPHYLLINE - Increase corticosteroid to high dose
- Refer to specialist
CHRONIC ASTHMA management 12 years +
SAME AS ADULT
Metered dose inhaler technique WITHOUT SPACER
Remove cap
Shake inhaler
Sit or stand up straight
Lift chin slightly
Fully exhale
Make tight seal around inhaler between lips
Press canister and take steady breath in
Continue breathing for 3-4 seconds after pressing canister
Hold breath for 10 SECONDS
Wait 30 seconds before next dose
Rinse mouth after steroid inhaler
Metered dose inhaler WITH A SPACER
Assemble spacer Shake inhaler Attach inhaler Sit/stand up straight List chin slightly Make seal with lips/mask Spray dose into inhaler Take steady breaths in and out 5 times until the mist fully inhaled
Characteristic signs of PNEUMONIA
Bronchial breath sounds (harsh breath sounds equally loud on inspiration and expiration - caused by consolidation of lung tissue around airway)
Focal coarse crackles (air passing through sputum - like straw blowing into drink)
Dullness to percussion (consolidation)
Common bacterial causes of PNEUMONIA
Strep. Pneumonia Group A Strep (e.g. strep pyogenes) Group B strep (pre-vaccinated infants) Staph. Aureus H. Influenza Mycoplasma pneumonia (atypical bacteria - extra pulmonary manifestations e.g. erthyema multiforme)
Viral causes of PNEUMONIA
RSV (most common)
Parainfluenza virus
Influenza virus
Management of pneumonia
AMOXICILLIN
Add macrolide (e.g. ERYTHROMYCIN, CLARITHROMYCIN or AZITHROMYCIN ) - covers atypical bacteria
Penicillin allergy - MACROLIDES AS MONOTHERAPY
RECURRENT LRTI: Pontential underlying problems
Reflux, aspiration, neurological disease, heart disease, asthma, cystic fibrosis, primary ciliary dyskinesia, immune deficiency
CROUP: causative agents
PARAINFLUENZA
Influenza
Adenovirus
RSV
CROUP: age of presentation
6 months - 2 years
CROUP: presentation
Barking cough
Hoarse voice
STRIDOR
Low grade fever
CROUP: management
Can be managed at home - SUPPORTIVE
Oral DEXAMETHASONE - single dose, can be repeated after 12hrs if required If not improving, stepwise: - Oral Dex - Oxygen - Nebulised budesonide - Nebulised adrenaline - intubation/ventilation
EPIGLOTTITIS: Infective agents
HAEMOPHILIUS INFLUENZA TYPE B
- rare now due to vaccination
EPIGLOTTITIS: X-ray signs
Lateral X-ray of neck: THUMB SIGNS - soft tissue shakedown that looks like thumb pressed against trachea caused by oedematous swollen epiglottis
EPIGOTITTIS: management
Medical emergency!! Do not distress child Secure airway - most don’t need intubation but there is a risk of sudden airway closure, so prepare for intubation or tracheostomy IV antibiotics (e.g. CEFTRIAXONE) Steroids (DEXAMETHASONE)
Laryngomalacia characteristics
CHRONIC STRIDOR - during inspiration (larynx flops across airway as child breaths in) - harsh whistling sound
- intermittent, more prominent when feeding, upset, during URTI
Peak presentation at 6MONTHS
WHOOPING COUGH: causative agents
Bordetella Pertussis (gram neg bacteria)
WHOOPING COUGH: presentation
Initially: Coryzal symptoms, low grade fever, mild dry cough
A week +: More severe coughing fits, PAROXYSMAL cough
Loud inspiratory WHOOP when coughing ends as out of breath
Can cough so hard they faint, vomit, develop pneumothorax
+/- apnoeas
NOTIFIABLE DISEASE
WHOOPING COUGH: management
Notify public health!
Simple supportive care
Macrolide antibiotics: AZITHROMYCIN, ERYTHROMYCIN, CLARITHROMYCIN (within first 21 day)
Alternative: Co-trimoxazole
Close contacts: Prophylactic antibiotics
CYSTIC FIBROSIS: genetic mutation
Cystic fibrosis transmembrane conductance regulatory gene
Chromosome 7
Codes for a type of chloride channel
CYSTIC FIBROSIS: prevalence
1 in 2500 children have CF
1 in 25 are carriers for the mutation
CYSTIC FIBROSIS: key consequences
1) THICK PANCREATIC and BILIARY secretions - block ducts, lack of digestive enzymes such as pancreatic lipase in the digestive tract
2) Low volume THICK AIRWAY SECRETIONS - reduce airway clearance, resulting in bacterial colonisation and susceptibility to airway infections
3) Congenital bilateral absence of the VAS DEFERENS in males - male infertility as sperm have no way of getting from the testis to ejaculate
CYSTIC FIBROSIS: Diagnosis
Screening: Newborn bloodspot test (shows high immune reactive trypsinogen levels)
SWEAT TEST - gold standard for diagnosis (high conc. of chloride ions >60mmol/L)
GENETIC SCREENING - for the GFTR gene can be performed during pregnancy by amniocentesis or chorionic villous sampling or blood test after birth
CYSTIC FIBROSIS: the sweat test
PILOCARPINE applied to skin
Electrodes placed wither side of the patch and small current passed between electrodes - causing skin to sweat
Sweat absorbed by gauze/filter paper and a analysed for chloride ion concentration
CYSTIC FIBROSIS: microbial colonisers
Most common: Staph Aureus H. Influenza Pseudomonas aeruginosa (BAD - often becomes resistant and increases mortality) Other: Klebsiella pneumoniae E Coli
CYSTIC FIBROSIS: Management
Chest PHYSIOTHERAPY
Exercise
High Calorie diet
CREON tablets - to digest fats due to pancreatic insufficency
Prophylactic FLUCLOXACILLIN tablets
Bronchodilators
Nebulised DNase - can breakdown DNA material in respiratory secretions - making secretions less viscous and easier to clear
vaccinations: PNEUMOCOCCAL, INFLUENZA and VARICELLA
CYSTIC FIBROSIS: Monitoring
Follow up every 6 months
Regular monitoring for colonisation of bacteria in sputum (e.g. pseudomonas)
Screening for: diabetes, osteoporosis, VitD deficiency, liver failure
PRIMARY CILIARY DYSKINESIA: also known as?
Kartagner’s syndrome
KARTAGNER’S TRIAD
Paranasal sinusitis
Bronchiectasis
Situs Inversus
(Not all patients will have all 3)
