Respiratory 2 Flashcards
What is bronchiolitis?
What is the mot common cause?
What are some other causes?
Bronchiolitis= inflammation of the bronchioles
Most commonly caused by RSV (respiratory syncytial virus- 80%). Others include adenovirus, mycoplasma.
Very common in winter.
What age group is bronchiolitis most common in?
- <1 year, most commonly in infants <6months
- Rarely can occur in children up to 2yrs of age (particularly in ex-premature babies with chronic lung disease)
Why does RSV not affect adults in same way as it does infants?
Same idea as for episodic viral wheeze.
Constriction due to swelling and mucus in adults is small in proportion to size of airways. In infants, the constriction due to swelling and mucus is large in proportion to size of airway hence has significant impact on ability to move air in and out of alveoli
Describe the typical presentation of bronchiolitis
- Coryzal symptoms (running or snotty nose, sneezing, mucus in throat, water eyes, cough)
- Poor feeding
- Mild fever (under 39degrees)
- Apnoea’s
- Wheeze & crackles on auscultation
- Signs of respiratory distress
- Dyspnoea
- Tachypnoea
State some signs of respiratory distress in a child
- Raised RR
- Use of accessory muscles (SCM, abdominal & intercostal)
- Intercostal & subcostal recessions
- Sternal retraction
- Nasal flaring
- Head bobbing
- Tracheal tugging
- Cyanosis
- Abnormal airway noises (wheeze, grunt, stridor)
For each of the abnormal airway noises, state why they occur:
- Wheeze
- Grunting
- Stridor
- Wheeze: air moving through narrowed airways
- Grunting: exhaling with glottis partially closed to increase positive end-expiratory pressure to keep airways open
- Stridor: obstruction of upper airway
Discuss the typical course of RSV infection in infants
- Starts an URTI with coryzal symptoms
- Around half get better spontaneously
- Other half develop chest symptoms 1-2 days following onset coryzal symptoms
- Symptoms generally worst on day 3 or 4
- Symptoms usually last 7-10 days in total
- Most infants fully recover within 2-3 weeks but could have cough for weeks
Children who have had bronchiolitis as a baby are more likely to have what in childhood?
Episodic viral induced wheeze
Most infants with bronchiolitis can be managed at home with safety netting advice; state some reasons to admit an infant with bronchiolitis
- <3 months
- Pre-existing condition (e.g. prematurity, CF, Down’s syndrome)
- 50-75% or less of their normal milk intake
- Signs of clinical dehydration
- RR >60 or 70
- Oxygen sats <92%
- Moderate to severe respiratory distress (e.g. deep recessions or head bobbing)
- Apnoeas
- Parents not confident in their ability to manage at home
- Difficulty accessing medical help from home
Discuss the management of bronchiolitis in hospital
Most infants require supportive management:
- Ensuring adequate intake: orally, via NG tube or IV fluids. Start with small feeds & gradually increase to avoid overfeeding as full stomach can restrict breathing
- Saline nasal drops & suctioning (to clear nasal secretions)
- Oxygen if sats <92%
- Ventilatory support if required
Discuss 3 options for ventilatory support
- High flow humidified oxygen via nasal cannula (e.g. vapotherm, airvo, optiflow): delivers air & oxygen continuously with added pressure to help oxygenate lungs and prevent airways from collapsing by adding positive end-expiratory pressure
- CPAP: similar to vapotherm, airvo & optiflow but can deliver much higher, controlle dpressures
- Intubation & ventilation: insertion of endotracheal tube to fully control ventilation
We don’t use ABGs in paediatrics; what other test would you use to assess ventilation in children?
Capillary blood gas. Can’t comment on pO2 but can look at:
- pCO2: rising suggest ventilation is poor as can’t clear waste CO2
- pH: falling pH suggests that CO2 may be building up causing a respiratory acidosis
What monoclonal antibody can be given to infants at risk of bronchiolitis?
How often is it given?
Who is it offered to?
How does it work?
- Palivizumab: monoclonal antibody that targets RSV
- Monthly injection
- High risk babies at risk of serious disease e.g. ex-premature (bronchopulmonary dysplasia), CF, congenital heart disease
- Not a true vaccine as doesn’t stimulate immune system but provides passive protection by circulating in body. If infant becomes infected with RSV it will work as antibody against the virus and activate immune system to fight the virus. Levels of circulating antibodies decrease over time hence why need monthly injection
Most doctors will diagnose bronchiolitis based on symptoms and signs; however, what investigation can be done to confirm?
Immunofluorescence of nasopharyngeal secretions may show RSV
State some risk factors for bronchiolitis
- Being breast fed for less than 2 months
- Smoke exposure (eg. parents’ smoke)
- Having siblings who attend nursery or school (increased risk of exposure to viruses)
- Chronic lung disease due to prematurity (5)
State some potential complications of bronchiolitis
- 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
What is pneumonia?
How does it present in children?
Infection of lung parenchyma causing inflammation resulting in sputum filling the airways and alveoli. It may cause SEPSIS; so always think about whether it could be sepsis.
Symptoms & Signs
- Cough
- High fever (>38.5)
- Increased work of breathing
- Lethargy
- Confusion
- Tachypnoea
- Tachycardia
- Hypoxia
- Hypotension
- Bronchial breath sounds (harsh breath sounds equally loud on inspiration & expiration)
- Focal coarse crackles
- Dullness to percussion
State some features of severe pneumonia in a child
According to NICE:
- Difficulty breathing
- Saturations <90%
- Tachycardia
- Grunting
- Very severe chest indrawing
- Inability to breastfeed or drink
- Lethargy
- Reduced conscious level
*image shows UHL guidance for severe pneumonia
State some common causes, bacterial and viral, of pneumonia in children; highlight the most common bacterial & viral cause
Pneumonia can be caused by bacteria (including atypical), viruses or fungi:
Bacterial
- Streptococcus pneumonia
- Group A Strep (Streptococcus pyogenes)
- Group B Strep (occurs in pre-vaccinated infants and is often contracted during birth as it colonises in vagina)
- Staphylococcus aureus
- Haemophilus influenza (occurs in pre-vaccinated or unvaccinated children)
- Mycoplasma pneumonia (atypical bacteria that causes extra-pulmonary manifestations e.g. erythema multiforme)
Viral
- RSV (respiratory syncytial virus)
- Parainfluenza
- Influenza