Respiratory Paeds

Question 1

Hospital managemnet of bronchiolitis

Answer 1

Give oxygen if sats < 92% in room air
Give fluids via nasogastric or orogastric tube if inadequate oral intake
Consider CPAP if there is impending respiratory failure
Perform upper airway suctioning if there are upper airway secretions or apnoea

Question 2

When can a child with brinchiolitius be dishcarged?

Answer 2

Discharge can be considered when the child is:

• Clinically stable
• Taking adequate oral fluids
• Maintaining sats > 92% for more than 4 hours

Question 3

What are the complications with bronchiolitis?

Answer 3

Hypoxia
Dehydration
Fatigue
Respiratory failure
Persistent cough or wheeze (very common and parents should be counselled that their child may cough for several weeks)
Bronchiolitis obliterans – Airways become permanently damaged due to inflammation and fibrosis

Question 4

What will you see on hx and examination with bronchiolitis?

Answer 4

The typical history is one of increasing symptoms over 2-5 days, usually consisting of:

Low-grade fever
Nasal congestion
Rhinorrhoea
Cough
Feeding difficulty

On examination

Tachypnoea
Grunting
Nasal flaring
Intercostal, subcostal or supraclavicular recessions
Inspiratory crackles
Expiratory wheeze
Hyperinflated chest
Cyanosis or pallor (6)

Question 5

Ix for bronchiolits

Answer 5

Laboratory tests

Nasopharyngeal aspirate or throat swab – RSV rapid testing and viral cultures
Blood and urine culture if child is pyrexic
FBC
Blood gas (ABG) if severely unwell – this may detect respiratory failure and the need for respiratory support, but should not be done routinely

Imaging

CXR (only if diagnostic uncertainty or atypical course) – features seen are:
Hyperinflation
Focal atelectasis
Air trapping
Flattened diaphragm
Peribronchial cuffing (8)

Question 7

What is wheeze, grunting and stridor

Answer 7

Wheezing is a whistling sound caused by narrowed airways, typically heard during expiration
Grunting is caused by exhaling with the glottis partially closed to increase positive end-expiratory pressure
Stridor is a high pitched inspiratory noise caused by obstruction of the upper airway, for example in croup

Question 8

What is the management for children with mild to moderate acuet asthma?

Answer 8

Bronchodilator therapy
give a beta-2 agonist via a spacer (for a child < 3 years use a close-fitting mask)
give 1 puff every 30-60 seconds up to a maximum of 10 puffs
if symptoms are not controlled repeat beta-2 agonist and refer to hospital

Steroid therapy
should be given to all children with an asthma exacerbation
treatment should be given for 3-5 days

Question 9

When can a patient with acuet asthma exacerbtion be discharged?

Answer 9

Generally, discharge can be considered when the child well on 6 puffs 4 hourly of salbutamol. They can be prescribed a reducing regime of salbutamol to continue at home, for example 6 puffs 4 hourly for 48 hours then 4 puffs 6 hourly for 48 hours then 2-4 puffs as required.

A few other steps to consider:

Finish the course of steroids if these were started (typically 3 days total)
Provide safety-net information about when to return to hospital or seek help
Provide an individualised written asthma action plan

Question 10

What is the presentation of viral induced wheeze?

Answer 10

Evidence of a viral illness (fever, cough and coryzal symptoms) for 1-2 days preceding the onset of:

Shortness of breath
Signs of respiratory distress
Expiratory wheeze throughout the chest