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Child and Adolescent Health (CAH) > Respiratory Presentations > Flashcards

Respiratory Presentations Flashcards

Stridor, wheeze and cough.

1
Q

Define STRIDOR.

A

Stridor is typically an inspiratory noise caused by obstruction of the upper airways.

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2
Q

Outline some differentials for acute versus chronic stridor.

A

ACUTE STRIDOR
✔️acute laryngotracheobronchitis (acute croup)
✔️ acute epiglottis
✔️ anaphylaxis
✔️ foreign body aspiration
✔️ acute bacterial tracheitis
✔️ peritonsillar abscess (i.e. Quinsy)
✔️ tonsillar enlargement from EBV infection
✔️ transient altered consciousness leading to reduced respiratory tone

CHRONIC STRIDOUR
✔️ laryngomalacia
✔️ significant micrognathy
✔️ pharyngeal cysts
✔️ vascular ring
✔️ haemangioma
✔️ vocal cord paralysis
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3
Q 
ACUTE LARYNGOTRACHEOBRONCHITIS (CROUP)
✔️ epidemiology
✔️ aetiology
✔️ risk factors
✔️ clinical symptoms
✔️ general management
A

EPIDEMIOLOGY
Children 6 months to 6 years (most commonly 2 to 3 years of age).

AETIOLOGY
Any respiratory virus (e.g. rhinovirus, RSV, parainfluenza, influenza).

RISK FACTORS
✔️ young age
✔️ narrowed airways (e.g. laryngomalacia, Pierre Robin's Sequence)
✔️ previous hospital admission for croup
✔️ neurological anomalies 
✔️ Down's Syndrome

CLINICAL FEATRES
✔️ prodromal coryzal symptoms (e.g. watery eyes, runny nose, sore throat)
✔️ “barking seal” cough which is worse at night
✔️ loud inspiratory stridour
✔️ does not appear toxic; low-grade fever
✔️ signs of respiratory distress (e.g. nasal flaring, subcostal recessions, tachyponea, cyanosis)

GENERAL MANAGEMENT
✔️ do NOT handle the child
✔️ do NOT examine the throat / collect swab
✔️ do NOT change the child’s position
✔️ mild and moderate croup can be treated with oral corticosteroids (e.g. dexamethasone or prednisolone)
✔️ severe croup may require IM / IV corticosteroids + nebulised adrenaline

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4
Q

Outline the management of mild and moderate croup.

A

Dexamethasone 0.15mg per kg PO

Prednisolone 1.0mg / kg PO plus additional dose that night.

Discharge is appropriate when child does NOT have stridor at rest. If deterioration occurs, treat for severe croup.

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5
Q

Outline the management of severe croup.

A

Nebulised adrenaline PLUS dexamethasone 0.6mg/kg IM or IM.

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6
Q

What are some conditions where observation for a child with croup may be extended to beyond 4 hours?

A

✔️ family lives far away from medical care
✔️ patient presents in the evening
✔️ multiple episodes of stridor within the single disease
✔️ child has risk factors for severe croup

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7
Q 
ACUTE EPIGLOTITIS
✔️ epidemiology
✔️ aetiology
✔️ risk factors
✔️ clinical symptoms
✔️ general management
A

EPIDEMIOLOGY
Children aged 3 to 4 years.

AETIOLOGY
Haemophilus influenza B (HiB) bacteria
Note that Strep. and Staph. are becoming more common causes.

RISK FACTORS
✔️ unvaccinated child
✔️ partially immunised
✔️ failed immunisation
✔️ immunocompromised child
CLINICAL FEATURES
✔️ acute onset fever and lethargy (4 to 6 hours) 
✔️ cough is NOT a prominent symptom
✔️ stridor is soft and expiratory 
✔️ child appears toxic / septic 
✔️ drooling
✔️ tripod position

GENERAL MANAGEMENT

  1. consider / think of the diagnosis
  2. one-on-one medical observation
  3. do NOT handle the child; do NOT collect throat swab; do NOT send to X-Ray
  4. immediate / urgent escalation to senior clinician
  5. medical escort to surgery for emergency intubation
  6. collect swabs and bloods in theatre
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8
Q 
FOREIGN BODY INHALATION
✔️ epidemiology
✔️ aetiology
✔️ risk factors
✔️ clinical symptoms
✔️ general management
A

EPIDEMIOLOGY
Most common in children < 4 years of age; may present in older children with neurodevelopmental issues.

AETIOLOGY
Nuts, seeds, raw fruit / vegetables, coins, small toys etc.

CLINICAL SYMPTOMS
✔️events are usually unwitnessed
✔️ acute onset coughing, spluttering, choking
✔️ stridor
✔️ wheeze (polyphonic, unilateral)
✔️ cyanosis
✔️ cardiopulmonary arrest

MANAGEMENT
If partial obstruction of airways, encourage coughing to try and dislodge the item.

If signs of complete or near-complete obstruction are present, immediate referral to anaesthetic / ENT to secure airways.

Bronchoscopy or laryngoscopy to visualise and remove the object.

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9
Q

Define ANAPHYLAXIS.

A

Anaphylaxis is a multi-system disorder in which there is acute onset of cardiovascular, respiratory, gastrointestinal or neurological symptoms in response to exposure to an allergen against which the immune system has been sensitised to. Typical dermatological features include angioedema and urticarial rash.

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10
Q

What is the clinical diagnosis of anaphylaxis?

A
  1. Acute onset skin features plus involvement of at least ONE other organ system OR
  2. Hypotension, bronchospasm or respiratory distress in a child in which anaphylaxis is likely.
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11
Q

What are some risk factors for severe anaphylaxis?

A

✔️ adolescent
✔️ poorly controlled asthma
✔️ known allergy to treenuts, peanuts, shellfish, dairy etc.
✔️ delayed response to adrenaline or emergency management of anaphylaxis in the past
✔️ underlying cardiovascular or respiratory conditions

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12
Q

Describe the emergency management of ANAPHYLAXIS.

A
  1. Primary survey (ABCDE)
  2. IM adrenaline 0.01mL per kg of 1:1000 OR 10microg / kg –> administer every 5 minutes if child is not responding until IV access is gained
  3. Oxygen if required
  4. Consider salbutamol in a child with a wheeze
  5. Consider antihistamines for relief of rash / itch
  6. Do NOT use corticosteroids
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13
Q

What are some differentials for ACUTE versus CHRONIC cough?

A 
ACUTE COUGH
✔️ exacerbation of asthma
✔️ croup (laryngotracheobronchitis)
✔️ acute pneumonia
✔️ reactive airway disease
✔️ viral induced wheeze
✔️ bronchiolitis
CHRONIC COUGH
✔️ asthma (poorly controlled)
✔️ bronchiolitis 
✔️ chronic bronchitis
✔️ bronchiectasis
✔️ cystic fibrosis
✔️ gastro-oesophageal reflux
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14
Q

What are cardinal features of RESPIRATORY DISTRESS?

A 
✔️ tachyponea
✔️ tachycardia
✔️ nasal flaring
✔️ intercostal / substernal recessions
 ✔️ head bobbing
✔️ expiratory grunting
✔️ cyanosis
✔️ tripod position
✔️ tracheal tug / deviation
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15
Q

Identify INFECTIOUS and NON-INFECTIOUS causes of respiratory distress.

A 
INFECTIOUS CAUSES
✔️ croup
✔️ bronchiolitis
✔️ viral-induced wheeze
✔️ viral exacerbation of asthma
✔️ pneumonia
✔️ acute epiglottis 
✔️ bacterial trachietits 
NON INFECTIOUS CAUSES
✔️ foreign body inhalation
✔️ anaphylaxis 
✔️ asthma (non-infectious cause)
✔️ hyperventilation
✔️ metabolic acidosis
✔️ pneumothorax
 ✔️ dehydration
✔️ congestive cardiac failure
✔️ severe anaemia
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16
Q

What are some risk factors for SEVERE ASTHMA?

A

✔️ poor adherence to medications
✔️ previous hospital admission requiring ICU
✔️ previous severe asthma attack
✔️ history of anaphylaxis
✔️ significant / frequent interval symptoms

17
Q

What are some RED FLAGS suggestive severe / life-threatening asthma?

A 
✔️ reduced consciousness / lethargy
✔️ fatigue
✔️ silent chest
✔️ pulsus paradoxus
✔️ unable to speak in full sentences
✔️ look of fear / dread
✔️ cyanosis
18
Q

Identify appropriate investigations in ACUTE ASTHMA.

A

✔️ CXR is NOT indicated
✔️ ABG will cause further distress and so is NOT indicated
✔️ UECs may be indicated if significant risk of hypokalaemia
✔️ spirometry is NOT to be performed in the acute setting / in a child < 6 years of age

19
Q

Outline the principles of management of an acute ASTHMA attack.

A

SALBUTAMOL (100microg / puff)
If < 6 years, give 6 puffs every 20 mins via MDI + spacer
If > 6 years, give 12 puffs every 20 mins via MDI + spacer

If non-responsive to inhaled salbutamol, consider 5mg nebulised.

IPATROPIUM BROMIDE (21 microg / puff)
If < 6 years, give 4 puffs every 20 mins via MDI + spacer
If > 6 years, give 8 puffs every 20 mins via MDI + spacer

Oral corticosteroids should be given as prednisolone 2mg / kg (maximum 60mg) and then 1mg / kg per day for 1 to 2 days.

Consider O2 if saturation < 90%.

20
Q

What are the risks of salbutamol?

A
  1. hypokalaemia

2. salbutamol toxicity –> tachycardia, tachyponea, tremour, metabolic acidosis

21
Q

Outline the principles of ongoing asthma management in children.

A

CHILD < 5 YEARS

  1. SABA via spacer, PRN (e.g. salbutamol)
  2. ICS via spacer, two puffs, twice daily (e.g. fluticasone) OR leukotriene antagonists if ICS not tolerated
  3. ADD eukotriene antagonist (e.g. monteleuklast)
  4. Referral to specialist

CHILD 5 TO 12 YEARS

  1. SABA via spacer, PRN (e.g. salbutamol)
  2. ICS via spacer, two puffs, twice daily (e.g. fluticasone)
  3. Add LAMA / LABA or consider leukotriene antagonist
  4. Consider increasing dose of ICS or add oral corticosteroids OR refer to specialist
22
Q 
BRONCHIOLITIS
✔️ epidemiology
✔️ aetiology
✔️ risk factors
✔️ clinical symptoms
✔️ general management
A

EPIDEMIOLOGY
Children between 2 months to 2 years (most commonly < 12 months of age).

AETIOLOGY
Respiratory syncytial virus (RSV)

RISK FACTORS FOR SEVERE DISEASE
✔️ Indigenous 
✔️ immunocompromised 
✔️ < 10 weeks gestational age
✔️ neuromuscular disorder
✔️ Trisomy 21
✔️ chronic lung disease
✔️ congenital heart disease

CLINICAL SYMPTOMS
Clinical symptoms tend to peak around day 2 to 3. The total duration of symptoms is 7 to 10 days. Cough can persist for 4 to 6 weeks.

Clinical symptoms include: 
✔️ prodromal coryzal symptoms
✔️ productive / "chesty" cough
✔️ wheeze or stridor
✔️ low grade fever
✔️ apnoea
✔️ reduced feeding and oral intake

GENERAL MANAGEMENT
✔️ oxygen if < 90%
✔️ fluids (deficit, maintenance) via enteric route, NG or IV
✔️do NOT give salbutamol, corticosteroids, adrenaline, antibiotics, antivirals and nebulised hypertonic solution

Discharge when: 
✔️ no respiratory distress / increased WOB
✔️ feeding appropriately 
✔️ no apnoea episodes
✔️ parents comfortable to care at home
23
Q

Define VIRAL INDUCED WHEEZE.

A

Viral induced wheeze is defined as an expiratory wheeze that occurs in children > 12 months of age but < school age who have recently recovered from, or been infected by, a viral infection.

Children’s airways are innately narrow compared to adults, meaning that inflammation and oedema associated with viral infection can cause significant lumen narrowing, and wheeze.

24
Q

How is viral induced wheeze managed?

A

Trial of SALBUTAMOL.

Child and Adolescent Health (CAH) (6 decks)

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