Respiratory system/ENT Flashcards
Definition of asthma
recurrent, reversible obstruction of the airways due to inflamed bronchi
triggers for asthma
infection - eg rhinovirus especially in the winters
allergy - dust mites etc
emotions - severe emotional upset , excitement, anxiety etc
exercise - esp. running in cold air
atmosphere - dusty air, stuffy an smoke filled rooms etc
symptoms of asthma
triad of cough, SOB and wheeze
asthma should be syspected in any child with wheezing > one occasion
wheeze - exploratory high pitch wheeze, worse at night and early morning
Cough - dry, nocturnal cough usually after midnight
Chest tightness - esp with exercise and at night
SOB - establish when in exercise normally, but in severe attacks: SOB at rest, agitation, feeding difficulties and attenuated cry (infants), drowsy and confused
symptoms usually have a clear trigger and intervals in between exacerbation
strong FHX of atopy
what are some of the questions to be asked in suspected asthmatic patient
how frequent are the symptoms
what triggers the symptoms such as sport, general activities etc
how often is sleep disturbed by asthma
how severe are the interval symptoms between exacerbations?
how much school has been missed due to the illness #
examination findings of asthma?
long-standing asthmatic patients - hyperinflation of the chest/Harrison’s solci §
generalised polyphonic expiratory wheeze and prolonged expiratory phase
widespread wheeze on auscultation
harrison’s sulci possibly
evidence of eczema - atopy
growth may be affected
investigation of asthma
Usually clinical diagnosis over the age of 5 due to the present of viral wheeze
<5 yr - Diagnostic test
- treat then diagnosis after 5 yrs old
5-16 yrs
- spirometry —> BDR —> feNO
> 17 yrs follow adult diagnostic pathway
what are some of the differentials for asthma
inhalation of foreign body allergic rhinities GORD aspiration syndrome bronchiectasis bronchiolitis bronchopulmonary dysplasia primary cillary dyskinesia
chronic management of asthma for children < 5 yrs old
PRN SABA
Step 0 - consider monitored initiation of treatment with very low to low dose ICS
Step 1 = LTRA < 5 years
Step 2 = v low dose ICS + LTRA
Step 3 = if not adequate response from LTRA, then stop LTRA, inc dose of ICS to low dose
if benefit from LTRA then continue LTRa and inc ICS to low dose
If benefit from LTRA still, can consider ICS and LABA
Step 4 - inc ICS to mediaum dose +/- theophylline + specialist input
Step 5 - daily steriod tablet in the lowest dose + medium dose ICS
what are the classification of asthma in children between 2-5yrs
moderate asthma SpO2 > 92% able to talk HR <140 RR<40
severe asthma SpO2<92% too breathless to talk HR>140 RR >40 use of accessory neck muscle
life-threatening SpO2 <92% any of the following 1) silent chest 2) poor respiratory effort 3) agitation 4) altered consciousness 5) cyanosis
what are the classification of asthma in children >5 yrs
moderate asthma SpO2 >92% PEFR>50% able to talk HR <125 RR < 30
severe asthma SpO2 <92% PEFR 33-50% too breathless to talk HR >125 RR > 30 use of accessory talk
life-threatening SpO2 <92% any of the following 1) silent chest 2) PEFʀ < 33% 3) poor resp effort 4) agitation 5) altered consciousness 6) cyanosis
acute management for moderate asthmatic attack
2-10 puffs of inhaled/nebulised salbutamol not exceeding 4 hourly
one puffs every 30/60 secs to make sure not excess
consider oral prednisolone if necessary
acute management for severe asthmatic attack
2-10 puffs of inhaled/nebulised salbutamol
oral prednisone or ɪV hydrocortisone if vomiting
assess response to treatment after 15 mins
acute management for life-threatening asthmatic attack
ɴebulised salbutamol and ipratropium bromide
ɪv hydrocortisone/ɪV salbutamol if necessary
consider ɪV aminophylline/ɪV Mg
who does inhaled foreign body most commonly occur to?
Mobile toddlers who would put objects into their mouth - objects that are small enough to pass the pharynx.
clinical features of inhaled foreign body
unilateral wheeze
resp distress
asymmetrical dull on percussion if collapse occur post obstruction
hyper-resonance on percussion around the collapse area due to compensatory emphysema
most commonly occur in the R main bronchi since it is straighter than the L one
Ix for inhaled foreign body
CXR- - segmental collapse or hyperinflation seen
bronchoscopy
management for inhaled foregin body
Bronchoscopy and removal of foreign body at the same time
if complete blockage - medical emergency - Heimlich manoeuvre
what are the prognosis of inhaled foreign body
bronchiectasis occur distal to obstruction –> dilated air sac and inefficient exchange of air –> recurrent/chronic infection –> require surgical removal
what is ottitis media
inflammation and possibly infection of the media ear
epidem of ottitis media
most frequent up to 7yrs
2.5-5yrs most common
most children will have an episode of OM but some 20% will have at least 3 episodes
Aetiology of Ottitis Media in children
children have a much shorter, more horizontal and poorly functioned Eustachian tube and so the drainage of the middle ear is not as good as in adult
causes of Ottitis media
virus - RSV, rhinoviruses
bacterial - strep pneumonae, haem. influenzae
what condition predisopse children with dysfunction Eustachian tube?
Down’s
post- common cold
adenoidal hypertrophy
cleft palate
clinical features of Ottitis Media
fever
painful ears
hearing loss
Preceded by URTI
younger children - anorexia, vomiting + diarrhoea
what examination must you carry out if a child has a fever
exam of the tympanic membrane for ottitis media
what are the exam finding of ottitis media
inflamed tympanic membrane
bulging tympanic membrane
loss of light reflex
perfusion of eardrum along with pus present
management of ottitis media
many causes are viral - supportive and should resolve in time
delayed Amoxicillin prescription - give the prescription to the parents but ask them only to get the medication after 2-3 days if not better - ABx only indicative if children >6mnths old and symptoms persist > 48 hrs
prognosis of ottitis media
most cases resolve fine
some might have recurrent infection and have ottitis media with effusion, more severe - mastoiditis, meningitis
what is ottitis media with effusion
glue ear - recurrent ottitis media leading to exudate production and and building up pushing against the eardrum and so conductive hearing loss
exam finding of OME
tympanic membrane thicken, retarted, absent light reflex
IX for OME
flat trace of tympanometry and conductive hearing loss
management of OME
if significant hearing loss - insert ventilation tube ( grammets)
if fluid still persist - insert another grammet (might be blocked) + consideration of adenoidectomy (long term benefit)
what are some of the causes of resp failure in children
lower airway obstruction Upper airway obstruction cardiac neurological toxic allergy
signs and symptoms of resp failure
dyspnoea tachypnoea cyanosis nasal flaring subcostal, intercostal recession tracheal tug grunting in baby head bobing in baby wheeze - maybe quiet if wheeze caused by asthma restless, agitation impaired consciousness and confusion
causes of lower airway obstruction RF
asthma bronchiolitis pneumonia cystic fibrosis neonatal lung disease
causes of upper airway obstruction RF
inhaled foreign body
croup
epiglottitis
causes of cardiac RF
severe HF
management of RF
If cyanosed/hypoxic, but PaCo2 normal then give O2 support aiming for 92% - be mindful of re-perfusion injury
If hypoxic and raised PaCO2, then this is a sign of lack of ability to self ventilate which means it is now time for some external ventilation support
treat underlying causes - ABx, steroids, bronchiodilator for asthma, bronchoscopy for foreign body
what is stridor
it is a symptom - loud, harsh, high pitched sound usually heard on expiatory breathing, but in severe cases of upper airway obstruction eg trachea and bronchial obstruction, it can occur in inspiratory
what are the emergency causes of stridor
inhaled foreign body
croup
epiglottitis
what are some of the common cuases of stridor
laryngomalacia subglottitis stenosis epiglottis croup inhaled of foreign body
what does biphasic stridor usually suggest in children
subglottitis/glottitic obstruction
What is the different between asthma and viral wheeler induced wheeze
Viral induced wheeze usually Preston in 1-5 yrs caused by virus - no symptoms when well
Asthma - wheeze and SOB and continue when symptoms continue even when well
what is the chronic management of asthma for a child who is > 5 yrs old
step 0 = PRN SABA
Step 1 = v.low dose of ICS
Step 2 = V.low dose of ICS + inhaled LAMA
Step 3 = if LAMA not beneficial then stop and inc dose of ICS to low dose
if LAMA beneficial then continue and inc dose of ICS to low dose
If LAMA beneficial then continue + inc dose of ICS to low dose + consider adding in LTRA
Step 4 = inc ICS dose to medium dose + inhaled LAMA + LTRA + theophylline + specialist input
Step 5 = daily oral steroid tablet + inhaled medium dose of ICS + specailist inout
What is bronchiolitis
It is a viral infection of the small bronchioles which in adults do not commonly cause any problems but in children with small bronchioles, they cause restriction too small that it will stop the breathing of the child
What is the common affected age group of bronchiolitis?
< 18 months
What are the common pathogens that cause bronchiolitis?
Respiratory syncytial virus (75%) - epidemics in winter
Parainfluenza virus, adenovirus, influenza, rhinovirus
Mycoplasma pneumoniae
Clinical features of bronchiolitis?
Wheeze, cough Rhinitis Signs of resp distress if severe - eg recession, nasal flaring, tachypnoea Overexpression of lung, fine crackles Fever
What are the investigation for bronchiolitis
Usually clinical diagnosis
Oximeter
CXR - if severe and chronic CHD and respiratory problem suspected - shows over-inflated, collapse, consolidation if severe
Management of bronchiolitis
Usually supportive
If feeding okay at home
If resp distress, hospital admission
What is bronchiolitis called after 18 months
Viral wheeze
What can be give to infant who have chronic resp problem and CHD?
Palivizumab - monoclonal antibodies against RSV
What is another name for croup?
Acute laryngotracheobronchitis
What is the most common pathogen that causes croup
Parainfluenza virus
Other also incl RSVm, adenovirus, influenza A/B
What is the most common age for croup
6 months - 2/3 years
Symptoms of croup?
Croyza Fever Stridor Seal-like barking cough Hoarseness (esp on crying) Wheeze Tachypnoea
Symptoms worse at night
IWOB
Cyanosis if severe
Restlessness
What causes the seal-like symptoms?
Caused by the inflammation of the subglottic region which causes airflow turbulence so high pitch
Investigation for croup?
Clinical diagnosis
CXR not needed (but if done, will show the steeple sign)
What is a steeple sign
Wine bottle signs which is specialised in croup (where the subglottis region is swollen)
Management of croup
Most cases will only need supportive management
However, if swelling persist then oral dexamethasone (0.15mg/kg)
Oral prednisolone is alternative
For severe cases, neb adrenaline can be used to acutely reduce inflammation
What is epiglottis
It is cellulitis of the supra-glottis region which can potentially cause airway obstruction
Can be life-threatening, considered to be emergency
What is the most common causative pathogen for epiglottis
It is haemophilia influenza B (although it should be rare nowadays due to vaccination against HIB)
Other common curative agent —> parainfluenza, Staph aureus, strep pneumoniae, MRSA, Candida (rare)
What is the most common age group that presents with epiglottitis
Age 2-4 (age group just after croup which can present just like epiglottitis)
What is the symptoms of epiglottitis
3Ds
Drooling, dysphasia, distress
Sore-throat, hot potato voice
Inability to swallow
Irritable/restless
What should you not do in epiglottitis
Do not examine the mouth/throat, you might just cause obstruction which means airway loss
What are the examination findings of epiglottitis
Stridor (inspiratory noises)
Tripod position/recession
Tachycardia
Tachypnoea
Investigation for epiglottitis?
If done at all
Gold standard - nasal laryngoscopes
Lateral neck X-ray - thrums signs (epiglottis thickening)
Throat swab (after airway secure with intubation)
Blood culture (if systemically unwell)
Management of epiglottitis
Protect airway - intubation, may need a cricothyroidectomhy
IV cefotaxime or ceftriaxone
Humidified O2
Can use dexamethasone to further reduce inflammation of the epiglottis
Can use neb adrenaline to manage acute closure
What is the prognosis of epiglottitis
If able to intubation and treat with IV cefotaxime or ceftriaxone = excellent outcome
If not, then death or severe brain injury from hypoxia
What are the most common pathogens that causes pneumonia in neonates?
Group B strep, E.coli, klebisella, staph. Aureus
What are the most common pathogens that causes pneumonia in infant?
Strep pneumonia, chlamydia
What are the most common pathogens that causes pneumonia in school age?
Strep pneumoniae, staph aureus, group A step, bordetella pertussis, mycoplasma pneumoniae
What are some of the viral causes to pneumonia?
RSV Parainfluenza Influenza Adenovirus Coxsackie virus (coxsackie A —> Hand, for, mouth disease
What predispose children to pneumonia
Chronic lung disease CF CHD Immunodeficiency Tracheotomy in situ Inhaled foreign body
Symptoms & signs of pneumonia in neonates?
Grunting Recession Cyanosis Cough poor feeding Irritable Fever
Symptoms & signs of pneumonia in infant
Cough, grunting, recession Fever Wheezy Preceded by URTI Irritable Feeding difficulties Tachypnoea
Symptoms & signs of pneumonia in pre-school/older children?
Cough
Tripod position
Fever
Preceded by URTI
Pain (chest/abdo - lower lobe infection irritates the abdo area)
Post-tussive vomiting - post cough vomiting)
Investigation of pneumonia in children
FBC - WCC raised CRP - raised Sputum culture - in older children only Blood culture - if severe CXR - focal - bacterial / diffuse - viral
Skin tuberculin test - test for TB
Cold agglutinis - mycoplasma pneumoniae (atypical pneumonia)
Management of pneumonia
Supportive
Anti-pyrexia - avoid aspirin due toe danger of Reye’s syndrome
Admission to hospital - usually okay to management in community, but if resp distress, poor feeding, tachycardia, raised CRT, chronic lung disease etc then admit
ABx - can’t differentiate between viral and bacterial if high fever then usually bacterial then consider ABx
Acute - IV penicillin
Sub-acute - PO amoxicillin
If allergic - clarithromycin, erythromycin
Prognosis/complications of pneumonia
Prognosis usually good
Complications
Lung abscess Emphysema Pneumothorax Septicaemia Bronchiectasis Pleural effusion
