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Flashcards in Breathing difficulty Deck (112):
1

How to distinguish between distress caused by lung disease vs cardiac disease

Cyanosis that is not improved when given O2 is likely to be due to congenital heart disease with right to left shunting

2

Ddx for a child with breathing difficulties

URTI - viral
Pharyngitis/tonsillitis
Croup
Epiglottitis
Tracheitis
Peri tonsillar abscess
Foreign body
Asthma
whooping cough
Bronchiolitis
Pneumonia
Chronic lung disease e.g. chronic lung disease of infancy, Cystic fibrosis, Bronchiectasis, aspiration pneumonia
Cardiac failure

3

DDX for child with cough

Pneumonia
Asthma
URTI
Bronchiolitis
Croup
Whooping cough
Inhaled FB

4

DDX for child with wheeze

Bronchiolitis
Asthma
Heart failure
Inhaled FB

5

DDX for child with Acute stridor

Croup
Anaphylaxis,
Inhaled FB
Epiglottitis

6

DDX for child with Chronic stridor

Laryngomalacia
Laryngeal anomalies eg vocal cord palsy
Tracheal abnormality e.g. subglottic stenosis, vascular ring.

7

Disorders included in URTI

Rhinitis,
Tonsillitis
Pharyngitis
Epiglottitis
Laryngitis
Sinusitis

8

Common pathogens infecting nasopharynx

Rhinovirus
Parainfluenza
RSV
Adenovirus
Corona
Influenza B,C

9

Common pathogens in oropharynx

GAS, Corynebacterium, EBV, Adenovirus

10

Common pathogens in larynx and trachea

parainfluenza,
Staph aureus

11

Common pathogens in bronchi

influenza
Strep pneumonia
H influenza

12

Hx Q of viral URTI

Hx of sneezing, sore throat, cough, headache, runny or blocked nose, malaise and fever

13

who get tonsillopharyngitis

Common 5-14yr

14

Hx of pharyngitis/tonsillitis

Fever
absence cough
difficulty swallowing
foul breath

15

Examination of pharyngitis/tonsillitis

Tonsillar exudate and swelling
anterior LN - cervical

16

Modified censor criteria

1 - tonsillar exudate or erythema
1- anterior cervical adenopathy
1 - cough absent
1 - Fever present
1 if age 3-14
0 if age 15-45
-1 if >45yrs
Score 4-5 treat with ABx
Scor 2-3 preform rapid antigen test if + then ABx. if - then culture.
Score 0-1 Symptomatic relief only

17

ABx for GAS pharyngitis

Phenoxymethyl penicillin BD for 10 days or Roxithromycin if allergic

18

Mx for pharyngitis/tonsillitis

ABx if indicated
Analgesics
Corticosteroids if severe pain - dexamethasone
Admit if suspected airway obstruction or systemically unwell or signs of cx.

19

cause of Croup

RSV
Parainfluenza
Adenovirus
Metapneumonvirus
Rhino virus

20

who gets croup

6m to 5yrs

21

Hx Q for croup

Coryza +/-
Seal like barking cough
Inspiratory stridor
+/- respiratory distress
+/- fever
Worse at night and on 2or3 night

22

Characteristics of mild croup

Behaviour - normal
Stridor - barking cough and stridor only when active or upset
RR - normal
Accessory muscle use - non or minimal
O2 - none required

23

Characteristics of moderate croup

Behaviour - some/intermittent irritability
Stridor - some stridor at rest
RR - ⇑ + tracheal tug + nasal flaring
Accessory muscle use - moderate chest wall retraction
O2- none required

24

Characteristics of severe croup

Behaviour - Increasing irritability and or lethargy
Stridor - at rest
RR - Marked⇑or⇓ tracheal tug, nasal flaring
Accessory muscle use - Marked chest wall retraction
O2 - Hypoxia is a late sign of significant Upper airway obstruction

25

Examination for croup

behaviour
Resp - stridor, effort, rate, O2 stats,
ENT - mininal

26

Ix for croup

none

27

Mx of croup

Safety net
- ABCD
- Check with supervisor
- return if concerned
minimal handling
Steroid - dexamethasone once or 2 doses of prednisolone
Observe for half an hour
Fluid/ food
Discharge once stridor free at rest
Severe: Nebuliser adrenalin 1ml+3ml NS
Dexamethasone
observe for 4hr
discharge after stridor at rest and >4hr of post adrenalin.
Safety net

28

What causes epiglottitis

Haemophilus influenza
Strep pneumonia,

29

Who gets it epiglottitis

Child 1-6yr
Unimmunised or vaccine failure

30

Hx of epiglottitis

Acute high Fever
dysphagia
drooling
Lethargy
Hoarseness
Stridor - soft inspiratory stridor and rapidly increasing Resp effort
Cough- not prominent or absent

31

Examination of epiglottis

Acutely ill and anxious child
most are septicaemia, toxic and pale looking, Poor peripheral circulation
Quiet shallow breathing
Head forward
Triad position
extension of neck

32

Mx of epiglottis

Minimal handling and stay by the bed
Don’t examine, or X-ray
Resus trolley or transfer to therapy to intubate
ICU care
IV antibiotics - sepsis, IV ceftriaxone
Rifampicin prophylaxis for contacts if no contraindications if HIB.

33

DDX for child with
breathing difficulties
high fever
Hyperextension of neck
Dysphagia
Pooling of secretion in throat

Epiglottitis
Retropharyngeal/peritonsillar abscess

34

DDX for child with breathing difficulties
Toxic appearing child
Markedly tender trachea

Bacterial tracheitis

35

DDX for infant with breathing difficulties and preexisting stridor

Congenital abnormality eg floppy larynx, haemangioma/subglottic stenosis

36

Presentation of bacterial tracheitis

Toxic
Tender trachea
+/- viral prodrome eg influenza
Most commonly Stapy aureus , strep or HiB
Croupy cough
Sick child
High temperature
absence of drooling

37

Tx of bacterial tracheitis

ICU
Maintenance of airway - many require intubation
Maint - O2 and fluid balance
IV antibiotics- flucloxacillin?

38

Cause of Quinsy (retropharyngeal/peritonsillar abscess)

Polymicrobial - staph aureus and strep pyogenes

39

Who gets it Quinsy

teenagers and young adults

40

Presentation of quinsy

Starts as tonsillitis followed by difficulties swallowing with truisms (spasm of jaw = lock jaw)
High fever
Dysphagia
Odynophagia
Stridor
typical signs of respiratory distress

41

Examination of quinsy

Pooling of secretion treat
Difficulty moving or unwilling to move their neck
Hyperextension of neck - usually unilateral

42

Tx of quinsy

Admit to hospital
ABx - procaine penicillin IM or clindamycin
Surgery - aspiration or drainage

43

Hx of Foreign body in airways

Complete obstruction
- coughing, shaking, +/-Vomiting
- LOC and Cardiorespiratory arrest.
Partial obstruction
- Persistent wheeze, cough, fever or dyspnoea
- Recurrent or persistent pneumonia
- Unilateral wheeze

44

Examination of foreign body in airways

ABCD
Partial
- asymmetrical chest movement
- tracheal deviation
- Chest signs - wheeze or decrease breath sounds
May be normal

45

Mx of foreign body in airway

Complete
- ABCD - remove if you can see it
- send for help
- Prone with head down
- 5 blows to back with open hand to inter scapular area
- turn child face up
- 5 chest thrust (chest compression technique)
- Check mouth - remove if possible
- if not relieve repeat
- still not fixed try Positive pressure ventilation or surgical airway
Partial
- leave in comfortable position and arrange surgery for urgent removal (bronchoscopy)

46

Features of mild asthma

Normal mental state
Subtle or no ↑ WoB, accessory muscle use or recession
Able to talk normally

47

Features of moderate asthma

Normal mental state
Some ↑WoB with accessory muscle use/recession
Tachycardia
some limitation to talk

48

Features of severe of asthma

Agitated/distressed
Moderate/marked ↑WoB with accessory muscle use/recession
Tachycardia
Marked limitation of ability to talk

49

Features of Critical Asthma

Confused/drowsy
Maximal WoB
Exhaustion
Marked tachycardia
Unable to talk
Silent chest

50

Features of Status Asthmaticus

Severe hypoxia, hypercapnia and acidosis
done to hyperinflation and blocks airways due to excess mucous.

51

Ix for Asthma

Acute - none
Adult - PEFR, Pulse oximetry,
Blood gases (low O2, Low CO2, alkalosis. In severe it can go normal CO2)
CXR (exclude pneumothorax)
Chronic and older then 6 yr
FEV/FVC of less than 70% which does improve with inhaled bronchodilators by more than 15%

52

Mx of mild Asthma

Salbutamol by MDI/Spacer - give once and review after 20mins,
Good response - discharge on B2-agonist an needed
Poor response - treat as moderate
Oral prednisolone for acute episodes which do not respond to bronchodilator alone - 2mg/kg (max 60mg) initally, only continuing with 1mg/kg daily for1-2 days if regular salbutamol is needed.

53

Mx of moderate Asthma

O2 if sats are less then 92%
less then 6yr - 6 puffs every 20min for 1 hour.
More then 6 yrs - 12 puff
RV 10-20 min after 3rd dose to decide on timing of next dose.
Oral prednisolone - 2mg/kg (max of 60) initially, then continuing with 1mg/kg daily for 1-2 days if salbutamol is ongoing.

54

Mx of severe Asthma

O2 if less than 92%
Salbutamol 1 dose every 20mins for 1 HR
Ipratropium 4 puff if under 6, 8 puffs if over 6yr. Every 20min for 1hr
Aminophylline 10mg/kg if deteriorating
MgSO4 IV
Oral prednisolone
Involve senior staff
Arrange admission after initial assessment

55

Mx of Critical Asthma

*Involve senior staff
*O2
*Continuous nebuliser salbutamol - 2x5mg/2.5L nebules
*Nebuliser ipratropium 250mcg 3 times in 1st hour only (20minutely
*Methylprednisolone 1mg/kg IV 6 hrly
*Aminophylline as above
*MgSO4 - as above
*May consider IV Salbutamol
Beware of salbutamol toxicity = tachycardia, tachypnoea, metabolic acidosis. High lactate, might required stopping or reduces therapy if it occurs
Aminophylline, magnesium and salbutamol must be given via separate IV line
ICU for respiratory support

56

When to discharge pt after asthma attack

*Assess patient for clinical improvement 1hr following initial therapy and discharge if clinical well. if necessary reassess in 30 mins
*Adequate oxygenation - O@ sat less then 92% should not preclude discharge if patient is clinically well and has responded well to treatment.
*Adequate oral intake
*Adequate parental education and ability to administer salbutamol via spacer
* given an action plan
*observe correct inhaler use
*outpatient RV with GP within 48 hrs

57

Step wise approach to Asthma medication outside of acute attack

SABA
+ ICS
+LABA
+Higher doses and referral

58

Mx of infrequent episodic asthma

59

Mx of frequent episodic asthma

Episodes every 2-4 wk
Tx SABA then attack
Use low dose ICS

60

Mx of persistent asthma

> 3 episodes/wk with cough at night/morning
Tx SABA + LABA + ICS
May need Oral steroids or leukotriene inhibitors

61

Cause of Whooping cough

Bordetella pertussis

62

Presentation of whooping cough

Classic - cough and coryza for one week (catarrhal phase) followed by more pronounced cough in spells or paroxysms (paroxysmal phase)
Other - vomiting due to cough, apnoea, cyanosis, sick contact
Immunisation
Sever pneumonia/encephalpathy

63

Examination finding in whooping cough

Often no signs, appears well between coughs
Fever is uncommon

64

Ix whooping cough

Not needed as clinical diagnosis
Lymphocytotis
Per nasal swab PCR
Serology IgA- 2 wk after onset

65

Mx of whooping cough

Admit if 21 days or 14 days from last exposure if unimmunised
Prophylaxis - same as treatment.
Notify

66

Cx of whooping cough

Pneumonia, cyanosis, apnoea or encephalopathy

67

Cause of bronchiolitis

Viral
RSV - most common
Metapneumovirus
adenovirus
influenza
parainfluenza

68

Who gets it bronchiolitis

less then 2 years old and higher in winter

69

Risk factors for bronchiolitis

You're infant especially less than 6weeks
Ex-prem
CHD
Chronic Respiratory illness
Down’s syndrome
Neurological problems
Pulmonary hypertension
Immunological condition

70

Hx Q for bronchiolitis

Age - less then2 years
+/- hx of contact with URTI
Starts with Coryza/URTI
then Cough
then Chesty - Wheezy/crackles
then Respiratory distress
+/- Decrease feeding - ask about the feeding and urine output hydration
+/- apnoea in infants, changes in colour
Determine if fish factors for severe illness
Duration of illness
FH atopy, eczema, asthma (+exposure to smoking)
Full paed hx
Sick contacts at child care/home

71

what to examine for in bronchiolitis

General inspection - colour, apnoea, behaviour, alertness, irritability, increase work of breathing, sough, where
vital obs including oxygen saturation - +/-fever increase HR, RR, BP, CRT peripheral and central, Wt
+/- Coryza
Increased work of breathing (or tiredness)
+/- signs of dehydration
Apnoea
widespread Wheezes and fine crackles
over expansion of chest

72

Features of mild bronchiolitis

Behaviour - N
RR - N
Accessory muscle use- Nill or minimal
Feeding - N
O2 - none >95%
Apnoea episodes - none

73

Features of moderate bronchiolitis

Behaviour - some/intermittent irritability
RR - ↑RR +Tracheal tug +nasal flaring
Accessory muscle use - Moderate chest wall retraction
Feeding - Difficulty or reduced
O2 - Mild hypoxemia corrected by O2 90-93%
Apnoea episodes - may have brief.

74

Features of severe bronchiolitis

Behaviour - ↑irritability and or lethargy, fatigue
RR - Marked ↑or↓RR +tracheal tug + nasal flaring
Accessory muscle use - Marked chest wall retraction
Feeding - reluctant or unable to feed
O2 - hypoxemia, may not be corrected by O2 (

75

Ix for bronchiolitis

Not needed
NPA
CXR - hyperinflation, peribronchial thickening and patchy consolidation and collapse
BG
U&E - if IV fluids required

76

Mx of bronchiolitis

Oxygenation
fluid intake
minimal handling
Comfort oral feeds

77

Mx of mild bronchiolitis

Outpatients
Advice parent to return if any concerns or worsening
Fact sheets
Education on expected course of illness - self limiting, worse by 3-4-5 night, resolve by day 10. cough may last 4 wks.
Smaller more frequent feeds
RV with GP in 24hr or sooner

78

Mx of moderate bronchiolitis

Admit to paediatric
isolation
O2 vis nasal prongs - aim for 92-93% sats
Continue fluid either oral/NGtube/ IV (2/3 maintenance to prevent SIADH)
Paracetamol
1-2hourly observations

79

Mx of severe bronchiolitis

same as moderate plus
Cardiorespiratory monitoring
close nursing supervision
O2 and fluids
ICU and CPAP or ventilation

80

Common causes of Pneumonia

Streptococcus pneumoniae
Haemophilus influenza
Moraxella catarrhalis
Viral - most common in children
- RSV, influenza
Newborns - GBS, E.Coli, Listeria

81

Prevention of pneumonia

Pneumococcal conjugate (13vPCV)or (23vPPV) high risk. at 2, 4, 6 months (12-18 months ATSI)
Pneumococcal polysaccharide (23vPPv) for medically at risk and ATSI). 4,15, 50,65+yrs
Haemophilus influenzae type B. 2, 4, 6, 12months
Yearly influenza vaccine

82

Red flags of pneumonia in children

Signs of sepsis
Lethargic and unwell
Temp >38.5
go off their food
Signs of respiratory distress
Noisy breathing
Cough may be absence
Tachycardia especially if higher than fever should make it

83

Hx of pneumonia in children

Children with short hx of
fever, cough, or
tachypnoea, nasal flaring, lower chest indrawing or recession, consolidation or effusion, or
persistent fever or
fever and upper abdominal pain.
Grunting common in infants

84

Signs of pneumonia

↑WoB, pallor, shocked, leaning forward,
Vitals - tachypnoea, tachycardia, hyperpyrexia, reduced O2
Prolonged CRT
Cyanosis
Respiratory distress
↑tactile fremitus and reduced chest expansion
dull precision, crackles, bronchial breath sounds and increase vocal resonance

85

Mx of children with pneumonia

Pneumonia in children
almost all those 70, intermittent apnoea, not feeding
older children - RR>50, Grunting, signs of dehydration
Both groups - O2 sat 24m penicillin or roxithromycin
Severe - flucloxacillin IV + cefotaxime IV +/- roxithromycin

86

Cause of Cystic fibrosis

recessive genetic disorder - CFTR gene on Chromosome 7 causes a defect in a cellular membrane chloride channel which leads to excessively thick mucus in many body systems

87

Presentation of cystic fibrosis

Presentation
neonatal screening
Weight filtering
Diarrhoea
Chest infection

ENT - Nasal polyps, Sinusitis
Recurrent chest infections
Cough, purulent sputum, pneumonia, chronic pseudomonas infection, bronchiectasis, chest deformity, eventual respiratory failure
Finger clubbing
Liver disease - Obstructive jaundice in neonatal period (rare), Biliary stasis (may need tx with ursodeoxycholic acid). Eventually liver cirrhosis
Skin - High salt losses in sweat, salty taste to skin, risk of salt-losing crisis during very hot weather.
Development- Poor growth - Require 40% extra energy intake, Poor weight gain, short statue, malabsorption.
GIT
Pancreatic insufficiency, poor fat absorption, steatorrhoea, distended abdomen, rectal prolapse, distal intestinal obstruction syndrome (can mimic acute appendicitis), Diabetes, Meconium ileum at birth (15%).
Male infertility - Congenital absence of the vas deferent.
delayed puberty

88

Q to ask on Hx of cystic fibrosis

Failure to thrive with ravenous appetite
Cough and wheeze
Recurrent chest infections and sinusitis
Bulky. pale, offensive smelling stools, often difficult to flush away
wt loss may indicate CF
Delay puberty
FmHx
cystic fibrosis

89

Examination for cystic fibrosis

GI - Wasting, short statue, Respiratory distress, submit vascular access devices
Vital
Hands - Clubbing, pallor, Warm and well perfused
Face -
Resp - Chest wall deformity, consolidation, crackles Clubbing,
Abdo - Gastrostomy tube, Hepatosplenomegaly
genital - Delayed puberty

90

Diagnosis of CF

antenatal - chorionic villus biopsy or amniocentesis
Newborn - newborn blood spot screening
Gene testing - CFTR gene
Sweat test - collected by passing a small electric current across the skin.

91

Mx of CF

Maintenance
- Pancreatic enzymes and Vit ABDECK
- Abx prophylaxis
- Increase calorie intake
- Chest physio
- B agonist
- Mucolytic trail - Nebuliser dornase alfa
- rhGH
- Immunisation
Tune up
- Admit - eg tobramycin
- Chest physic with saline daily
- Spirometry
- Abx - based on colonisation,
- Isolation and precaution
Acute exacerbation
- Abx - Pip-taz (Piperacillin/tazobactam)

92

Defined bronchiectasis

permanent and abnormal widening of the bronchi due to walls becoming inflamed, thickened and irreversibly damage following obstruction followed by infection

93

Symptoms of bronchiectasis

Chronic cough that worse on walking
Mild disease = yellow or green sputum only after infection
advanced disease
profuse purulent offensive sputum- green, yellow
persistent halitosis (bad breath)
recurrent febrile episodes
Malaise, wt loss or suboptimal Wt gain
Sputum production related to position
PmHx - pneumonia,
Haemoptysis

94

Signs of bronchiectasis

GI - cachexia
Vitals -fever
Hands - Clubbing (severe cases)
Face - sinusitis, cyanosis
Neck - tracheal midline
Resp
Commonly affects lower lobe but may have one or more lobes at once
I - slight reduction in chest expansion
P - normal or decrease vocal femitus
P - may be resonant or dull.
A - Late inspiratory coarse crackles +/- localised wheeze. bronchial breath sounds.

95

Ix for bronchiectasis

- Sputum culture = mix of normal flora - bacteria don’t cause it they just grow once it is blocked. Done to exclude TB
Streptococcus pneumoniae, pseudomonas aeruginosa, Haemophilus influenzae (commonest)
Spirometry meter
Diagnosed = CT scan to visulise larger bronchi
CXR - normal or bronchial changes
Cytology - rule out neoplasm

96

Mx of bronchiectasis

Explanation and preventative advise
Postural drainage eg lie over side of bed with head and thorax down for 10-20 minutes 3 times a day
ABx according to organism - need to eradicate infection to halt progress of disease
Amoxycillin or roxithromycin
Bronchodilators indicated if evidence of bronchospasm.

97

Complication in a infant with cystic fibrosis

Meconium ileus
Neonatal jaundice - prolonged
Hypoproteinaemia and oedema

98

Cx in a child with Cystic fibrosis

recurrent lower respiratory tract infection
Bronchiectasis - occasionally
Poor appetite
Rectal prolapse
Nasal polyps
Sinusitis - rarely with symptoms

99

Cx in an adolescence with Cystic fibrosis

Bronchiectasis
Diabetes mellitus
Cirrhosis and portal HTN
Distal intestinal obstruction
Pneumothorax
Haemoptysis
Allergic bronchoplumonary aspergillosis
Male infertility
Arthropathy
Psychological problems

100

MDT member for mx CF

paediatric pulmonlogist
Physiotherapist
dietician
Nurse liaison or practitioner in CF
primary care team
teacher
psychologist

101

What to educate a parent who smokes around their children

research children who are exposed to passive smoking are at increased risk of croup, SIDS, bronchitis, pneumonia, ear infections, learning difficulties, behavioural difficulties and childhood asthma

102

Tx for asthma that occurs infrequently or episodic

SABA

103

Tx for frequent asthma attacks that occur more then once every 6 weeks.

SABA
Inh corticosteroid
If not improving ensure complicance and then increase dose.

104

Tx for asthma who has a daily symptoms

SABA
Inh corticosteroid
LABA
Increase doses
Ref to respiratory specialist

105

Pathogenesis of Asthma

Acute phase response- Vascular leakage and smooth muscle contraction. 1-2 hrs, Histamine, tryptase, leukotrienes, Platelet activating factor, chemokine and cytokines
Late response - eosinophilic and lymphocytic infiltration of bronchial mucosa. 6hrs post and continue for 24hr. IL5, Eosinophilia, TH2 lymphocytes.
Long term structural changes
- loss of surface epithelium
- Increased basement membrane thickness
- Marked increase in smooth muscle mass
- Marked local inflammatory cell infiltrate,
- Increase vascular permeability
- Remodelling of the airways.

106

When to ask for help when treating asthmatic

exhaustion, LOC, blood gases showing respiratory alkalosis being replaced by hypoxia, hypercarbia and acidosis .

107

Common problems is management of CF

Chest infection - mucus plug increase chronic respiratory infection especially by Pseudomonas aeruginosa or Burkholderia cepacia. Lead to rapid deterioration in lung function.
Tx involve regular bronchodilators, antibiotics (oral, nubulised or intravenously which can be delivered at home via indwelling central line). Steroid to suppress lung inflammation. Nebuliser DNase enzymes can help break down mucus in the lung.
Airway clearance
Preventive physiotherapy - exercise, autogenic drainage, positive expiratory pressure, inhalation therapy and postural awareness.
prophylactic immunisation against influenza and pneumococcus is recommended
Bronchodilators, Nebuliser dornase alfa.
Malabsorption - due to pancreatic failure
ectocrine - defect in Vit A, D, E, K. tx with pancreatic enzyme capsules and high calorie diet from infancy
Diabetes melitus - 25%-> impaired glucose tolerance. tx as optimisation of blood glucose is associated with an improvement in lung function
Salt loss - needs monitoring tx with salt tablets
Liver disease - due to sluggish bile flow = biliary disease and rarely cirrhosis - tx Ursodeoxycholic acid.
Pseudo obstruction of bowel mistaken for appendicitis tx pancreatic enzymes or osmotic laxatives.
Sub fertility - Most men have no vas deferens.

108

Signs of Respiratory distress

Intercostal recession, subcostal retraction, sternal retraction
Tachypnoea
Cough
Noisy breathing (stridor or wheeze)
Chest pain
Poor feeding
Change in colour
Poor tone
Altered conscious level

109

Difference between child and adult airways

Anatomy: tongue is larger, soft tissue, short neck, higher larynx, relatively large head, narrowest portion of the airway is at the cricoid ring and smaller airway
Compliance chest wall (decreased efficiency of breathing)
Fewer alveoli in early childhood (V/Q mismatch)
Obligatory nose breathers
Diaphragm is the principal respiratory muscle, it is flatter and has muscle fibres more vulnerable to fatigue
Increased metabolic demands
Immature immune system
Increased frequency of viral illnesses

110

Investigations for a child with respiratory distress

Pulse oximetry
May be difficult in agitated patient
May be falsely decreased in very anemic patients
Imaging
Chest X Ray: Consider in patients with focal lung findings or respiratory distress of a unknown etiology
Soft tissue radiograph of lateral neck: May identify a retropharyngeal abscess or radiopaque foreign body
Labs
ABG/VBG
Chemistry: calculate anion gap
Urine toxicology and glucose if patient has altered mental status

111

DDX for respiratory distress

Anaphylaxis
FB
Retropharyngeal abscess
Tracheitis
Asthma
pneumonia

112

prevention of asthma

No smoking in pregnancy and passive exposure
Probiotics
Food allergen avoidance
House dust mite avoidance
Breast feeding/hydrolysed formula/normal cow's milk formula, omega fatty acid