The Child with Cough, Respiratory Distress or Noisy Breathing Flashcards
A sick child needs inhaled salbutamol. What is the dosage?
- Salbutamol dosage - 6 puffs under 6, 12 over 6
A sick child needs inhaled ipratropium. What is the dosage?
- Ipratropium dosage - 4 puffs under 6, 8 puffs over 6
What are the signs that asthma is mild?
- Normal mental state
- Subtle WOB
- Talking normally
- No limitation of speech
What is the management for mild asthma?
- Salbutamol, 1 dose (6 puffs under 6, 12 over 6) via spacer, reassess 20/60
- Oral prednisolone if no response
What is the management for moderate asthma?
- Oxygen if < 92%
- Salbutamol, 1 dose (6 puffs under 6, 12 over 6) via spacer 20/60ly for 1 hour
- Oral prednisolone
What are the signs of moderate asthma?
- Normal mental state
- Some WOB
- Tachycardia
- Some limitation of talking
What are the signs of severe asthma?
- Agitated
- Mod-marked WOB
- Tachycardia
- Marked talking limitation
What is the management for severe (not critical) asthma?
- Oxygen if < 92%
- Salbutamol, 1 dose (6 under 6, 12 over 6) via spacer 20/60ly for 1 hour
- Ipratropium, 1 dose (4 under 6, 8 over 6) via spacer 20/60ly for 1 hour
- MgSO4
- Oral prednisolone
- Consider aminophylline
What are the signs of a child with critical asthma?
- Drowsy
- Maximal WOB
- Exhaustion
- Marked tachycardia
- Unable to talk
- Silent chest
What is the management for critical asthma?
- Oxygen
- Continuous nebulised salbutamol
- Nebulised ipratropium
- Methylprednisolone IV
- Aminophylline
- MgSO4
How might a child with bronchiolitis present?
- Prodrome: URTI with cough and fever - 1-3 days
- Symptoms: wheeze, cough (wet, non-productive), poor feeding, fever, peaking at 3-5 days
- Signs: wheeze, respiratory distress, tachypnoea, tachycardia, retractions, poor air entry
How might you grade the severity of bronchiolitis in a child?
- Severe - increased WOB, SaO2 <92% on FiO2 > 0.5, apnoeic episode
- Moderate - Some increased WOB, SaO2 < 92% on room air, decreased feeding
- Mild - no increased WOB
How is bronchiolitis managed?
- Severe - O2 to 92%, supportive fluids, ICU monitoring, CPAP or intubation
- Moderate - admit, O2 to 90%, supportive fluids
- Mild - home treatment, early review
How does a child with croup present?
- Prodrome: coryzal
- Barking cough, inspiratory stridor, hoarse voice, worsens at night
- DDx: epiglottitis (acute, high fever, dysphagia, drooling, lymphadenopathy), foreign body (Hx, no prodrome)
How might you decide the severity of croup in a child?
- Cough only: supportive at home, return if worsening
- Mild (minimal accessory muscle use and rest stridor)
- Moderate (accessory muscle use and recession/stridor at rest)
- Severe (hypoxia < 92%, distress, marked accessory muscle use)
How might you manage croup in a child?
- Cough only: supportive at home, return if worsening
- Mild (minimal accessory muscle use and rest stridor): prednisolone, monitor 1-2 hours
- Moderate (accessory muscle use and recession/stridor at rest): prednisolone, nebulised adrenaline if no improvement by 30 minutes, monitor 3 hours
- Severe (hypoxia < 92%, distress, marked accessory muscle use): prednisolone, neb adrenaline, admit +/- ICU
How might a child with epiglottitis present? What treatment do they urgently need?
- Presentation
- Toxic child - fever, flushing, tachycardia
- Stridor, drooling, increased work of breathing
- Treatment
- ICU admission
- IV cefuroxime
How might you manage a child with croup?
- Antibiotics (do not improve clinical course but limit transmission)
- Clarithromycin/azithromycin (GN bacteria) for child and contacts
- Continue with routine immunisations
- Admit if: systemically unwell, <6/12, severe respiratory distress, feeding poorly
How might a child who has inhaled a foreign body present?
- Choking or coughing while eating solids or chewing on a toy
- Unwitnessed
- Persistent wheeze and cough, unilateral breath sounds and hyperinflation in unaffected side
What are some of the complications associated with cystic fibrosis?
- Respiratory: bronchiectasis, pneumothorax, aspergillosis, pulmonary fibrosis/cor pulmonale
- Gastrointestinal: pancreatic insufficiency, chronic liver disease (CBD atresia), biliary disease, intussusception
- Cardiovascular: cor pulmonale (secondary to pulmonary fibrosis/HT)
- Misc: infertility (males), subfertility (females), diabetes mellitus, clubbing (hypertrophic osteoarthropathy)
What are some of the issues that may arise in the management of a patient with cystic fibrosis?
- Genetic counselling
- Nutrition: high-fat, high calorie diet
- Pancreatic enzyme replacement
- Vitamin supplementation (A, E, D) and salt
- Pulmonary care
- Chest physiotherapy (daily)
- Bronchoalveolar lavage (after diagnosis and annually until expectoration occurs)
- Antibiotic therapy based on colonisation
- Acute respiratory infection treatment
- Distal intestinal obstruction syndrome
- Infertility
