ILA- resp + cardio Flashcards
A two year old girl called Emily is brought in with a barking cough, noisy breathing and a hoarse cry. Her mother says that she has been unwell for a few days with coryza. Generally, Emily is a healthy child and she is up to date with her immunisations. Her weight is 12 kg. On examination, Emily has a harsh stridor at rest with an intermittent barking cough. She has a lowgrade fever of 37.8°C. Her oxygen saturations are 94% in air. What is the differential diagnosis? - whats most likely?
Croup aka viral laryngotracheobronchitis!! - most likely Epiglottitis Bacterial trachetitis – bad one Foreign body Diphtheria Laryngemalacia Subglotic stenosis Allergic laryngeal angioedema – seen in anaphylaxis and recurrent croup- quite common, floppy, Inhalation smoke/fumes
What is stridor? How is it different from wheeze?
Stridor is an upper respiratory problem caused by extra thoracic obstruction in upper airway. It is an inspiration sound. Sounds harsh and musical.
wheeze high pitched, on exhalation, obstuctive cause in lower airways
What is the diagnositic features of croup?
6 months to 6 years
Has mild fever, harsh stridor, difficulty breathing, hoarse voice (due to inflamm of vocal cords) and barking cough (due to trachel odema and collapse) which fits with croup
Followed an event of coryza
What are the sx of croup?
Over days Coryza procedes Barking cough, severe Can drink Unwell Low grade fever Harsh stridor Hoarse voice
What are the sx of epiglottitis?
Over hours Bacterial Cough slight/absent Drools saliva tripod position - lean foward and extend neck when seated Very unwell High grade fever Soft stridor Muffled voice with reluctance to speak
When examining child with stridor, what must you not do and why?
Must avoid doing an exam of the throat using a spatula as can lead to total airway obstruction, (laryngospasm) unless resuss equipment is on hand
What is the usual cause of croup, and when is it most prevalent (age and time of year and day)?
Cause – viral usually – parainfluenza most common, then rhinovirus, RSV and influenza
Most prevalent age is 2 yrs
Most common in autumn – when go back after holidays to school
Symptoms are worse at night
What is the first-line treatment for croup?
Steroids - cortico - dexqa or pred - PO if poss but otherwise IM/ budesonide by nebs
Child with croup deteriorates and saturations drop to 86%. How should she be managed now?
Nebulised adrenaline (epinephrine) is usually reserved for patients in moderate-to-severe distress. Crash call. Can give burnside nebs as well mixed. If dropping sats with stridor means obstruction is indicated (dropping sats for wheeze is normal) - May need emergency tracheotomy if don’t recover
Jake is a six month old child who has been referred by his GP with difficulty in feeding and breathing and a dry cough with coryza. He has been unwell for the past two days but has become worse overnight. He was born at term with no difficulties. His birth weight was 3.2kg. On examination, Jake has a low grade fever of 37.8o C and peripheral cyanosis, with oxygen saturations of 88% in air. He has a hyper-inflated chest with tachypnoea and intercostal recession. There are widespread crepitations and wheeze bilaterally on auscultation. What is the most likely diagnosis?
Bronchiolitis – infant, dry cough, tachypnoea, recession, hyperinflated chest, crackles, wheeze
Difficulty feeding due to coryzal – indicates viral
Bronchiolitis indicated by crepitations rather than viral induced wheeze
What is the differential diagnosis of wheezy child?
Bronchiolitis
Viral induced wheeze
Atypical pneumonia
More acute – anaphylaxis or foreign body
What are the most common causative organisms of bronchiolitis? What is the most common?
RSV - most common
Parainfluenza
Rhinovirus
adenovirus
What risk factors for bronchiolitis?
CF Premature – bronchopulmonary dysplasia CHD Any other underlying lung condition – chronic lung disease Immunodeficiency Parents smoking
Which investigation would you order for bronchiolitis?
Pulse oximetry
Viral throat swabs for respiratory viruses ! – confirm RSV- associated bronchiolitis obliterates and want to keep RSV patients separate from non RSV patients (RSV very infectious)
How is bronchiolitis treated?
supportive Oxygen Fluids NGT if still cant feed Anti pyrexials CPAP if severe Ribavarin – anti RSV monoclonal antibody if very severe
How can bronchiolitis be prevented and in what categories of patients would this be done?
How can bronchiolitis be prevented and in what categories of patients would this be done?
Airborne spread, prevented by palavizumab in IM over winter – for those with CLD or BPD or pulmonary hypophysis or congenital heart disease or immunodeficiency
child with bronchiolitis was diagnosed with cystic fibrosis (CF) by the neonatal screening test taken on day six of life. Does this change the diagnosis or the management of bronchiolitis?
Might need PT and abx
More likely to need IV as can’t clear their excretions
What test confirms CF?
Newborn blood spot test – IRT levels (immunoreactibe trypsin)
In older do sweat test for sodium and chloride - will be an excess of both
What conditions are picked up on the newborn screening test?
CF
Congenital hypothyroidism
SCD
Metabolic inherited eg PKU – don’t need to learn their names just be aware we test for some metabolic conditions
What is the pattern of inheritance for CF?
Autosomal recessive
What is the pathophysiology behind CF and which organ systems are affected?
CFTR defect –> cAMP chloride channel found in membrane of epithelial cells.
Prevents absorption of chloride –> so less sodium is absorbed
Dehydrated pancreas, biliary, reproductive, liver, bowel and lungs
Dehydration of the airway surfaces reduces mucociliary clearance and favours bacterial colonisation, local bacterial defences are impaired by local salt concentrations and bacterial adherence is increased by changes in cell surface glycoproteins.
Increased bacterial colonisation and reduced clearance produce inflammatory lung damage due to an exuberant neutrophilic response involving mediators such as IL8 and neutrophil elastase.
How does CF present clinically at different ages?
Newborn: screening, meconium ileus (thick meconium – delay in passing stool due to obstruction- distension, comit, constipated)
Infancy: Prolonged jaundice neonate, poor growth, recurrent chest infections, malabsorption – due to pancreatic enzyme insufficiency
Young child : bronchiectasis, rectal prolapse, nasal polyp, sinusitis
Older child: DM, portal htn and cirrhosis, distal obstruction, pneumothorax, sterility
Management of CF?
PT for mucus clearance
Continuous prophylactic abx for resp infections eg flucloxacillin – chronic psuedomnoas infection
Nebs saline to increase sputum clearance
May have portacath for easier IV access
Lung transplant for end stage CF disease
Pancreatic replacement enzymes and high calories meal
Ursodeoxycholic acid to help bile movement
A six-week-old infant is referred to hospital with a three-week history of progressive wheeze, poor feeding, and poor weight gain. She now appears short of breath especially towards the end of feeds. She was born at term with no difficulties. Her routine neonatal examination was normal. What is the differential diagnosis?
VSD Asd Pda Bronchiolitis Reflux Immunodeficiency Tracheo/laryngomalacia
On examination, six week old who is progressive FTT, SOB, appear coryzal, is apyrexial and her oxygen saturations are 96% in air. Her femoral pulses are normal. There is a palpable thrill on the chest wall and on auscultation, there is a harsh pansystolic murmur, loudest at the left sternal edge. Jessie is tachypnoeic with some intercostal and sternal recession. There are fine crepitations audible in both lung fields. The liver is just palpable at 3cm below the costal margin. What is the most likely diagnosis and why?
VSD – progressive SOB, faltering growth after 1 week old; tachyponea; nsystolic murmur on L sternal edge; hepatomegaly and crackles and SOB (heart failure) ; No fever ; femoral pulses fine – indicates PDA unlikely
What investigations would you request for VSD and what would they show?
CXR – cardiomegaly, enlarged pulmonary arteries, increased pulmonary vascular markings, pulmonary oedema, Kelley b lines
ECG – biventricular hypertrophy
Echo – shows anatomy, hemodynamic effects, pulmonary htn
Management of VSD?
Diuretics combined with captopril - Furosemide for heart failure
Surgery between 3-6 months to prevent eisenmengers
Manage faltering growth with high calorie meal
What are other causes of heart failure in neonates and infants and older children?
Neonates –hypoplastic L heart syndrome, severe aortic stenosis, severe coarction of the aorta, interruption of the aortic arch
Infants – VSD, AVSD, persistent ductus arteriosus
Older- eisenmengers, rheumatic heart disease, cardiomyopathy
any age- increased free or pre load and anaemia and sepsis
How does a left to right shunt present and what are the types?
SOB
Eg ASD, VSD, PDA
How does a right to left shunt present and what are the types?
Cyanosis
Eg tetrology of fallot, TGA
How does common mixing present and what are the types?
SOB and cyanosis
Eg AVSD, complex congenital heart disease
What are differentials in a child with a wheeze?
viral episodic wheeze, asthma, bronhciolitis, foreign body aspiration, cystic fibrosis, pneumonia
How does bronchiolitis present?
<18 m
Coryzal symptoms precede a dry cough, SOB, recession crackles, hyperinflated chest, fever, wheeze, WONT feed due to coryzal sx will be mouh breathing and therefore cannot breastfeed
ix and mx for bronchiolitis?
Do pulse oximetry. Only do more if in resp failure.
Give oxygen, fluids, NGT feed
describe the presentation of a viral induced wheeze
Under 5s
Thought to be due to smaller airways eg RF include second hand smoke or prematurity
Episodic in nature, occurs each time have viral infection eg common cold
No interval symptoms
mx of VIW
No benefit from inhaled steroids but may use PO
Use bronchodilators, if that doesn’t work add ipratropium, then add montelukast. Give oxyegn.
What are the sx of asthma?
wheeze, dry cough, SOB, chest tight, worse at night and early morning, Fhx or person hs atopy
What ix are done for asthma?
PEFR or spirometry. Usually variability shown. Diagnosis shown by improvement on values with bronchodilator. - 12% improvement shows variability and is typical of asthma
pathophysiology of asthma
Bronchial inflammation, hypersensitivity, airway narrowing -pathophysiology
signs of moderate vs severe vs life threatening asthma attack?
mod:Able to talk in sentences;
Arterial oxygen saturation (SpO2) ≥ 92%;
Peak flow ≥ 50% best or predicted;
Heart rate ≤ 140/minute in children aged 1–5 years; heart rate ≤ 125/minute in children aged over 5 years;
Respiratory rate ≤ 40/minute in children aged 1–5 years; respiratory rate ≤ 30/minute in children aged over 5 years.
severe: Can’t complete sentences in one breath or too breathless to talk or feed;
SpO2 140/minute in children aged 1–5 years; heart rate > 125/minute in children aged over 5 years;
Respiratory rate > 40/minute in children aged 1–5 years; respiratory rate > 30/minute in children aged over 5 years.
life threatening:
Peak flow
mx of acute asthma attack?
- Supplementary high flow oxygen- 1 puff every 30-60 s of salbutamol up to a max of 10 puffs 4 hrly
- nebulised salbutamol (add on MgSO4)
- nebulised ipratropium bromide (add on MgSo4)
- Oral prednisone (1mg per kg for 3 days)/ IV hydrocortisone if not swallowing
SECOND LINE - send to PICU (already do this if its life-threatening)
5. IV magnesium sulphate
- IV Salbutamol
- IV aminophylline
What is the mx of chronic asthma?
Mild step 1: SABA
Step 2: preventor: ICS 200mcg starting dose
Step 3: add on: over 5- LTRA then LABA -less than 5 – LTRA only (montelukast)
OVER 5:
step 4: MART regime
Step 5: increase inhaled steroid dose to 800mcg/ day or consider theophylline or referral
If fail to respond – consider adherence, choice drugs, environment, diagnosis
what are examples of the asthma preventer drugs?
Inhaled steroids: beclamethasone, budesonide, fluticasone, mometason
Inhaled cromones: sodium cromoglycate
