Paediatric Respiratory Flashcards
Outline the most common cause of bronchiolitis
- Viral infection
- Specifically, respiratory syncytial virus (RSV)
Bronchiolitis - state the following:
- Pathophysiology
- Most common age
- Presentation (including any red flags)
- Differential diagnosis
- Investigations
- Management
Pathophysiology:
- Inflammation and infection of the bronchioles
(excess mucus production, IgE-mediated type 1 allergic reaction causing inflammation, bronchiolar constriction and oedema)
- Usually caused by viruses, specifically respiratory syncytial virus (RSV)
Most common age:
- Under 1 year (up to 2 years if previously premature and chronic lung disease)
Presentation:
- Coryzal symptoms e.g. snotty nose, sneezing
- Signs of respiratory distress
- Dyspnoea
- Tachypnoea
- Poor feeding
- Mild fever
- Wheeze on auscultation
- Crackles on auscultation
RED FLAG: Signs of respiratory distress
Investigations:
- Pulse oximetry = KEY
- ABG if severely unwell
- Blood and urine culture if child is pyrexic
- Consider chest x-ray
- Consider ELISA (test for RSV)
Management:
Mainly supportive
- Adequate intake (oral, NG tube, IV fluids)
- Controlled O2 if < 92%
- Saline nasal drops / suctioning
- Ventilatory support if required
Describe the following abnormal airway noises
- Wheezing
- Grunting
- Stridor
Wheezing - whistling sound typically during expiration, caused by narrowed airways
Grunting - caused by exhaling with glottis partially closed, to increased positive end-expiratory pressure
Stridor - high pitched inspiratory noise, caused by obstruction of the upper airway (commonly heard in croup)
State signs of respiratory distress in children = IMPORTANT!
Head and neck:
- Head bobbing
- Nasal flaring
- Tracheal tug
- Abnormal airway noises e.g. grunting
Chest:
- Tachypnoea
- Intercostal and subcostal recessions
- Use of accessory muscles
Body:
- Cyanosis
Outline the typical course of respiratory syncytial virus (RSV)
Often causes bronchiolitis
- Starts as an URTI with coryzal symptoms (of which 50% get better spontaneously)
- Other 50% develop chest symptoms in following 2 days
- Symptoms worse on days 3-4, lasting 7-10 days in total
- Most recover by 2-3 weeks
State some reasons for admission in infants with bronchiolitis
Non-modifiable:
- Under 3 months
- Pre-existing condition e.g. pre-maturity, Down’s or cystic fibrosis
Modifiable:
- Tachypnoea > 70
- O2 sats < 92%
- Moderate-severe respiratory distress
- Apnoea (episodes of stopping breathing)
- Clinical dehydration/ significantly less intake of milk (50-75% less)
- Parents not confident in managing at home
State the 3 types of ventilatory support which can be used for children
- High flow humidified oxygen via tight nasal cannula (air and oxygen continuously with pressure to prevent airways collapsing)
- CPAP - similar to previous but can deliver more high pressure / controlled pressure
- Intubation and ventilation
Can use capillary blood gases to monitor in ventilatory support
State some risk factors for bronchiolitis
- Chronic lung disease due to prematurity
- Siblings who attend nursery or school (increased risk of exposure to viruses)
- Smoke exposure (eg. parents’ smoke)
- Being breast fed for less than 2 months
State some differentials for bronchiolitis
- Heart failure – VERY IMPORTANT not to miss this
- Pneumonia
- Asthma / viral induced wheeze
- Bronchitis
- Croup
- Cystic fibrosis
State 2 complications of bronchiolitis (once infection has resolved)
- Persistent cough or wheeze (very common)
- Bronchiolitis obliterans (airways become permanently damaged due to inflammation and fibrosis)
Acute asthma attack - state the following:
- Pathophysiology
- Presentation (including any red flags)
- Investigations
- Management
Pathophysiology:
- Acute worsening of symptoms of asthma
- Usually caused by any of the typical triggers of asthma
Presentation:
- SOB
- Expiratory wheeze (throughout chest)
- Signs of respiratory distress
- Tachypnoea
- Reduced air entry
RED FLAG: silent chest
Investigations - investigate severity:
- PEFR
- O2 sats
- Listen to chest
- Count RR and HR
Management:
Mild: manage in community with regular Salbutamol inhaler in spacer
Moderate-severe - stepwise approach:
- Salbutamol inhaler / nebuliser
- Ipratropium Bromide nebuliser
- Oral Prednisolone / IV Hydrocortisone
- IV Salbutamol
- IV Magnesium
- IV Aminophylline
Chronic (ongoing) asthma - state the following:
- Pathophysiology
- Presentation
- Investigations
Pathophysiology:
- Chronic inflammatory disease with variable reversible airway obstruction
Presentation:
- Intermittent episodes with evidence of triggers
- Dry cough, worse at night (diurnal variability)
- Wheeze
- SOB
- Family history of atopy (asthma, hayfever, eczema)
+ improvement of symptoms with bronchodilators
Investigations:
No single diagnostic test, based on typical history and examination. If doubt, can do following options
- Monitor PEFR twice daily, 2-4 weeks
- FeNO
- Spirometry (if > 5)
- Direct bronchial challenge with histamine
State which factors need to be met for a child to be discharged after an acute asthma attack
- Inhaler technique assessed/taught
- Written asthma management plan given and explained to parents
- SaO2 >94% in air
- GP should review the child 2 days after discharge
- Regular bronchodilator use, 6 puffs every 4 hours
State some differential diagnoses for asthma
- Viral wheeze
- Bronchiolitis
- Inhaled foreign body
- Cardiac failure
- Cystic fibrosis (CF)
- Primary ciliary dyskinesia
State how asthma is managed long term for the following age groups:
Under 5
5-12+ (same as adults)
Under 5:
- SABA e.g. Salbutamol
- Low dose ICS or Montelukast
- Low dose ICS AND Montelukast
- Refer to specialist
5-12+:
- SABA e.g. Salbutamol
- Low dose ICS
- LABA e.g. Salmeterol
- Increase dose ICS
- Consider adding Montelukast or theophylline
- High dose ICS
- Refer to specialist
Outline the impact of inhaled corticosteroids on growth when used in children (as if explaining to a parent)
- Some evidence to show that use of ICS can slightly reduce growth velocity and reduction in final adult height of up to 1cm
- However, this is dose dependent (small dose, less impact)
- The impact of poorly controlled asthma can have a greater impact on growth than ICS
Regular asthma reviews will monitor growth velocity
Pneumonia - state the following:
- Pathophysiology
- Presentation (signs and symptoms, including any red flags)
- Investigations
- Management
Pathophysiology:
- Infection of lung parenchyma
- Leads to inflammation of parenchyma and increased mucus production in airways and alveoli
- Can be caused by: bacterial, virus and atypical bacteria e.g. mycoplasma
Presentation - symptoms:
- Productive cough (yellow green)
- Fever
- SOB / increased work of breathing
- Chest pain
Presentation - signs:
- Tachypnoea
- Tachycardia
- Hypoxia
- Delirium
- Bronchial breath sounds
- Dullness to percussion
- Focal coarse crackles
Investigations:
- Chest x-ray is investigation of choice, although not always required (used if doubt or complicated)
- Consider sputum culture or viral PCR to guide treatment if needed
Management:
- Controlled O2 therapy if < 92%
- Oral antibiotics (commonly Amoxicillin)
- Can add Macrolide e.g. Erythromycin to cover atypical or if penicillin allergy
- Consider IV antibiotics if sepsis or intestinal absorption issues
State differential diagnoses for pneumonia in children
- COVID-19
- Acute bronchitis
- Asthma exacerbation
- Heart failure
- Bronchiectasis
- TB
- Empyema
- PE
- Pneumothorax
- Hypersensitivity pneumonitis
State the most common causes of pneumonia in children (bacterial and viral)
Bacterial:
- Streptococcus pneumonia = most common
- Group strep A
- Group strep B (GBS in vagina after birth)
- Staph aureus
- Haemophilus influenzae
- Mycoplasma pneumonia
Viral:
- Respiratory syncytial virus (RSV) = most common
- Parainfluenza
- Influenza
Suggest some underlying conditions to consider for a child presenting with recurrent chest infections (and the test to check)
- Low WCC (FBC)
- Scarred lungs (chest x-ray)
- Antibody deficiency (serum immunoglobulins)
- Cystic fibrosis (sweat test)
- HIV (HIV testing)
Croup - state the following:
- Pathophysiology
- Most common age
- Presentation (including any red flags)
- Investigations
- Management
Pathophysiology:
- Acute upper respiratory tract infection (also known as acute laryngotracheitis)
- Causes oedema in the larynx
- Generally caused by viruses, mainly parainfluenza virus
Most common age:
- 6 months to 3 years (can be older)
- Peak incidence at 2 years
Presentation:
- Barking cough (clusters of coughing fits)
- Increased work of breathing
- Hoarse voice
- Stridor
- Low grade fever
RED FLAGS: signs of respiratory failure, drowsiness, lethargy
Investigations:
- Not generally needed
- Chest x-ray and lateral neck if suspicion of foreign body ingestion
Management:
- Supportive at home if mild with fluids and rest
- Consider admission if high risk
- Single dose of oral Dexamethasone (allowed 2nd dose 12 hrs later) or Prednisolone
- Further care: oxygen, nebulised Budesonide, nebulised Adrenaline
State differential diagnoses for croup
Anything that causes upper airway obstruction!!
- Inhaled foreign body / noxious substance
- Epiglottitis
- Acute anaphylaxis
- Bacterial tracheitis
- Laryngomalacia
- Peritonsillar abscess (quinsy) / retropharyngeal abscess
- Diphtheria
