Respiratory Flashcards
List 5 causes of airway compromise in kids?
- Anaphylaxis → oedema, urticaria, shock, diarrhoea
- Epiglotittis → need immediate anaesthetics and ENT support → give ceftriaxone + adrenaline – don’t upset the
child - FB
- Diphtheria
- Croup → viral infection → dexamethasone, if severe, give adrenaline nebs
What do the following suggest:
- Wheeze alone →
- Creps alone →
- Wheeze and Creps →
- Wheeze alone → asthma
- Creps alone → pneumonia
- Wheeze and Creps → Bronchiolitis
What are the most common causes of tonsillitis? How do you distinguish
.
commonly group A β haemolytic streptococcus and EBV.
More likely to be bacterial if → there is constitutional disturbance (headache, apathy, abdo pain), white exudate, cervical lymphadenopathy
o Not possible to clinically distinguish between the two
What are the first line ivx for tonsillitis?
- Throat culture
- Rapid strep antigen test -
This test should be ordered in children over 3 years old and adults with high probability of group A beta-haemolytic streptococci (GABHS) infection, as assessed by at least three Centor criteria.
Lower sensitivity than culture. So confirm with culture. But faster result
If suspecting ebv: Blood film - Atypical activated lymphocytosis - ebv Serology- ebv IgM FBC - Anaemia, low platelets Mono spot test - positive
How do you treat tonsillitis? What must be avoided n why?
If not due to alpha haemolytic strep. - pain killers
Give ABX if severe / alpha strep→ Phenoxymethylpenicillin
or erythromycin/clarithromycin if pen allergic
- Avoid Amoxicillin as can cause maculopapular rash if infectious mononucleosis (EBV)
- Low threshold to give ABX in infants, immunosuppressed
If not severe but:
o If group A streptococcus (GAS) has been confirmed → after rapid antigen testing or strongly suspected after applying a FeverPAIN score (4 or 5) or Centor score (3 or 4) and results of throat cultures are pending → consider prescribing ABX
severe recurrent tonsillitis → more than 7 in 1 year or more than 5 per year for 2 years, with no clear explanation → refer to ENT to consider tonsillectomy
• Advise adequate fluid intake, ibuprofen/paracetamol, salt water gargling/lozenges with LA for pain relief
How does otitis media present? What would you see on otoscopy?
May present with otalgia, irritability, decreased hearing, anorexia, vomiting, or fever, usually in the presence of an ongoing viral respiratory infection.
NO DISCHARGE
Otoscope:
Bright red bulging tympanic membranes - can be white, yellow, pink or red, loss of normal light reaction ± perforation and pus
What are the most common causes of acute otitis media?
The most common bacteria responsible for AOM are
Streptococcus pneumoniae (approximately 40%),
non-typable Haemophilus influenzae (25% to 30%),
Moraxella catarrhalis (10% to 15%)
Remember these follow, respiratory viral infections - URT
o RSV
o Rhinovirus
What is the pathophysiology of acute otitis media?
Viral and bacterial co infection:
Kids get an URT, this affects nasal passages. Exudates forms in middle ear and becomes infected with nasopharyngeal bacteria
What is the admission criteria in otitis media?
: <3 months with temperature 38+ (suspected meningitis); 3-6 months with temperature 39+ or systemically unwell
How is otitis media managed?
Paracetemol or NSAID for pain and fever
• Ideally NO ABX or delayed ABX prescribing
o Can give a 5 day course of
amoxicillin PO to parents to give if no improvement in symptoms after 4 days of onset of symptoms or if there is significant worsening → if pen allergic
give clarithromycin or erythromycin
Give immediate ABX if systemically unwell
or other co-existing condition which may increase risk of serious complications
2nd line → Co-Amoxiclav
Recurrent - ENT referral. Don’t swab chronic OM
Dull retracted eardrum with fluid meniscus, flat trace on tympanometry, conductive loss on audiometry is indicative of?
The result of recurrent AOM infection :
otitis media with effusions (glue ear) with decreased hearing (eustachian tube dysfunction)
What is chronic supprapurative otitis media? presentation. and ivx? treatment?
Chronic suppurative otitis media (CSOM) is defined as ‘a chronic inflammation of the middle ear and mastoid cavity, which presents with recurrent ear discharges (otorrhoea) through a tympanic perforation’. CSOM is assumed to be a complication of acute otitis media (AOM).
not the same as glue ear!
-> will NOT have fever or pain!!
Otoscope: perforated eardrum
Weber’s test: lateralises to that ear. hearing loss (difficulty in school).
Refer to ent don’t swab
Rex; abx, steroid - TOPICAL
What is a Grommet?
indications?
Grommets are tubes used for treating glue ear - otitis media with effusions.
OM/Effusion mx: arrange hearing test, leave for 3 months
Named grommets due to shape. Aka Tympanostomy tube.
It drains fluid away from the middle ear and keeps the eardrum open/airated.
Indications;
Chronic otitis media with effusions for 6months (1 ear)
- for 3 months (both ears)
What presents as :
- Barking cough, harsh stridor, hoarse voice
- Preceded by fever and coryza, onset is over days
- No drooling
Cause?
Croup - Viral laryngotracheobronchitis
Most commonly due to parainfluenza virus
(also RSV, human metapneumovirus, influenza*)
eg HiB - haemophilus influenza B
How do the different levels of croup present?
Mild croup: barking cough
Moderate: + stridor/sternal recession at rest
Severe: + agitation/lethargy, sternal/intercostal recession
stirdor - is on inspiration
0-2pts (mild); 3-7pts (mod); 8-11pts (severe); Westley croup severity score.
What are the signs of Impending respiratory failure - in croup ?
Admission criteria?
12-17 pts on Westley croup severity score.
↑ obstruction, asynchronous chest wall and abdominal movement, ↑RR of 70, pallor, cyanosis, ↓ consciousness
Admit if: moderate or severe illness; RR>60; other co-existing conditions, < 3 months, concern regarding carer’s ability to cope.
How is croup managed?
PO Dex OR nebulised budesonide,
Nebulised adrenaline if more serious
If severe → supplementary O2
• If respiratory compromise → oral dexamethasone (0.15mg/kg)
• If too unwell → consider IM dexamethasone or inhaled budesonide to reduce severity and duration
• If moderate → adrenaline nebs can provide transient improvement
o Risk of rebound 2h later so needs close monitoring
o Observe on day unit until respiratory distress settles
• If mild → oral dex, advise that symptoms usually resolve within 48h, encourage fluid intake and check on child
regularly (overnight)
What are the complications of UPPER RESPIRATORY TRACT INFECTIONS in kids?
Complications
• Difficulty in feeding in infants as their noses are blocked, obstructing breathing
• Febrile seizures
• Acute exacerbation of asthma
What is the Most common infection of childhood? Pathophysiology?
Rhinitis / common cold:
inflammation of URT mucosa, involving nose, throat, sinuses or larynx
Rhinoviruses (50%); coronaviruses (10%);
influenza (5%); parainfluenza (5%); respiratory syncytial virus, RSV (5%)
What is the management of rhinitis? Complications?
Health education → Self-limiting, no specific treatment → may reduce anxiety and unnecessary visits to Dr
• Pain → paracetamol or ibuprofen
• Potentially decongestants or antihistamines
Cough may last 4 weeks after cold
Complications - otitis media, acute sinusitis
How does acute sinusitis present ? Rx?
Majority of cases in adults and children are of viral aetiology.
Duration of symptoms more than 10 days often indicates bacterial cause.
Purulent nasal discharge (brown, yellow etc), nasal obstruction/ stuffiness
If they get a 2ndary bacterial infection due to the viral infection → pain, swelling, tenderness over cheek due to infection of maxillary sinus
Frontal sinuses NOT involved / developed
Rex: pain relief, abx (if immunocompromised or severe)
- saw in GP; dont get ent referall unless >7 in 1yr
Which condition presents as follows:
Hoarseness, dysphagia, sore throat, odynophagia, cough, GORD, rhinitis, fever, lethargy, fatigue
• Lymphadenopathy (ant cervical chain), post- nasal drip, SOB
Risk factors and ivx?
Laryngitis
Risks:
incomplete or absent Haemophilus influenzae type B (Hib) vaccination or Diphtheria, contact and travel,
preceded by urti !!!
Ivx:
clinical Dx mostly, BUT laryngoscopy (± biopsy)
List causes of laryngitis? Rx?
Causes may be infectious or non-infectious (e.g., vocal strain, reflux laryngitis, chronic irritative laryngitis).
Haemophilus influenzae is one of the most frequently isolated bacteria. Other causes include tuberculosis, diphtheria, syphilis, and fungi
Viral o Supportive care – voice rest and hydration o Paracetemol o Guaifenesin – expectorant o Codeine sulphate – antitussive
• Bacterial
o Same as above, with Abx – phenoxymethylpenicillin
What is acute epiglottitis? How does it present?
It is an URTI
Life-threatening emergency – high risk of AIRWAY obstruction.
Caused by haemophilus influenzae type B (universal Hib imm has led to a 99% reduction).
Very acute onset (over hours)- so may be well in the morning and shortly afterwards is unwell
no preceding coryza
high fever in ill or TOXIC looking child, absent cough
- Subcostal, intercostal recession or sternal retraction (pic)
- Unable to drink, speak, swallow, drooling saliva (due to pain in throat)
soft INSPIRATORY stridor
• Child sitting immobile, upright, mouth open, tripod positioning (they do this to open airway)
Pertinent diagnostic criteria include the classic ‘tripod’ seating position of the patient, drooling, high fever, and a toxic appearance.
How do we ivx acute epiglottitis?
: Laryngoscopy (Dx and therapeutic - because can establish airway - do in theatre);
Lateral neck X-ray - thumbprint sign
cultures; - neutrophilia/ left shift
oximetry and monitoring; gases
How do we manage acute epiglottitis?
Urgent hospital admission – senior anaesthetist, ENT, paeds
• Secure airway, then supplementary O2 → visualise & intubate with GA
- Then, blood cultures and IV ABX (ceftriaxone/cefuroxime or local guidelines)
- ± dexamethasone
What causes whooping cough?
gram negative bacterial, Bordetella pertussis.
How does whooping cough present? Risk factors?
An URTI with severe cough
Initial symptoms may be similar to a cold, with rhinorrhoea and lacrimation, or a dry cough followed by episodes of severe coughing. Fever may be absent or low-grade.
Week long coryza (catarrhal phase), then paroxysmal cough followed by inspiratory whoop ± vomiting (post gussied vomiting) ± epistaxis
Early phase - Rhinorrhea
1-2wks later - cough
3wks+ - inspiratory whoop
- Symptoms worse at night, child may go red/blue in face
- Infants may have apnoea rather than a whoop
Inspiratory whooping is a characteristic symptom in children but may be absent in infants, adolescents, and adults.
- Symptoms gradually decrease (covalescent phase) but can persist for months
- RF: not vaccinated (should have DTaP at 2, 3 and 4 months), contact with infected
Admission threshold in whooping cough?
• Admit if <6 months and acutely unwell,
significant breathing difficulties (severe paroxysms, apnoea episodes, cyanosis)
o Need isolation on ward - remain culture positive 3-4 weeks even with vaccine / rx. can affect adults
What are the ivx for whooping cough?
- per-nasal swab/ nasopharyngeal swab AND culture
Culture of the bacterium Bordetella pertussis from nasal secretions can confirm the diagnosis, especially early in the course of the disease. A negative culture does not exclude the diagnosis
- Pcr of above
More sensitive - Can consider serology
List some Other Bordetella species that may rarely cause pertussis or pertussis-like cough
include B parapertussis, B bronchiseptica, or B holmesii; these species are not vaccine-preventable
What are the Three identifiable stages typical in childhood pertussis? How do they present?
catarrhal, paroxysmal, and convalescent
-> *
How do we manage pertussis?
• Macrolides - Azithromycin or Clarithromycin if started in catarrhal phase, onset of cough within previous 21 days
- Give prophylaxis to close contacts, advise rest/fluids/paracetamol
- Avoid school or nursery until 48 hours of ABX
• Inform that even with ABX, whooping cough is likely to cause a protracted non-infectious
cough that may take several weeks to resolve completely
What are the most common causes of pneumonia by age group?
- Viruses are more common in younger children, and bacteria in older children
- Newborn eg <1month (group B strep),
- Infants (mainly RSV, but also Strep pneumoniae, pertussis, H influenzae) - but note viral causes more common that bacterial (until age 5) so rsv> strep p
- 5y+ (mycoplasma pneumoniae, streptococcus pneumoniae, chlamydia pneumonia
How does pneumonia present in kids?
- Fever, difficulty breathing, preceding URTI, cough, lethargy, poor feeding, ↑ RR, nasal flaring, chest indrawing
- Consolidation → dull percussion, ↓ breath sounds, bronchial breathing
How do we manage paeds pneumonia?
what is the admission criteria?
Supportive care → fluids, O2, analgesia
Community acquired:
Non-severe (based on clinical judgement - no scores)
Kids 1 month +
1st line - Amoxicillin TDS 5 days
Clarithromycin - if mild / pen allergic / atypicals
Severe
Co-amoxiclav TDS 5 days
o Broad spectrum IV ABX for infants – cannot be sure if viral or bacterial? Admit if o O2 sats <93% o Severe tachypnoea o Grunting o Apnoea o Not feeding o Increased drowsiness o Severe chest recessions o RR > 60 o Age <3 months o Temp 38+
How do we ivx pneumonia in a child?
Cxray
Your response exam and it’s components eg cyanosis etc
Do we do sputum etc? *
Causes and epidemiology of RSV?
Bronchiolitis is the leading cause of hospital admission in infants under 1 year of age.
Affects children <1yo; 30% of infants will get it → age from 0 months to 24 months
• 80% are respiratory syncytial virus → RSV
How does bronchiolitis present ? Main differentiators from others?
Coryzal symptoms preceding a dry cough and increased breathlessness, feeding difficulty ± recurrent apnoea
• ↑ RR, subcostal/intercostal recession,
Differentiators:
hyperinflation of chest (prominent sternum, displaced liver)
- Fine end-expiratory crackles, high pitched wheeze, exp > insp, cyanosis or pallor
- Worse on day 4-5 then starts getting better, lasts 10-14 days
Who is particularly at risk of bronchiolitis?
Premature borne,
bronchopulmonary dysplasia, underlying lung disease, CF, CHD (congenital heart disease)
How do we ivx bronchiolitis? Admission criteria?
Resp stuff- Degree of agitation, signs of cyanosis/accessory muscles, RR, HR, BP, hydration status, O2 sats
• Admit if → agitation, severe respiratory distress, RR > 70, central cyanosis, sats <92
Not necessary but can do:
• Virus can be identified by PCR of nasopharyngeal aspirate
• CXR not indicated in straightforward cases but would show hyperinflation and air trapping
How do we manage bronchiolitis?
prognosis?
Most cases are mild and self-limiting, and supportive care is the only indicated therapy.
if very young and struggling with breathing :
-> Give O2 (nasal cannula, can be humidified)
(target sats above 92) . note if sats are high enough - dont need to give this!
-> ± fluids (give orally if not tolerated - nasogastric, then IV)
see bronchiolotic podium -> next card
if older:
o ± paracetamol or ibuprofen
o May need oral steroids - if prior hx of wheeze
o Don’t smoke in the house
Prophylaxis:
Palivizumab IM- humanised monoclonal antibody that binds to the F protein of respiratory syncytial virus (RSV) and inhibits viral infection and replication.
- for the <1y/o & predisposed. Or <2 and immunosuppresed
• Prognosis → most recover in 2 weeks – largely self-limiting
What is the bronchiolitic podium?
Escalation steps in regards to breathing and feeding
Breathing
- No support
- O2
- CPAP
a. To open up heavy mucus airways closing at end of expiration
b. CPAP will hold these open when max breath out
c. Preopens airway – give when child is grunting (this is child self-creating CPAP) - Intubate and ventilate
Feeding
- Little and often
- NG tube
a. Still risk of vomiting and aspiration - IV fluids
a. Completely removes pressure of having to feed on top of breathing - Intubate and ventilate
