Case 2 - cough and difficulty breathing Flashcards
(31 cards)
Which features suggest bacterial cause of CAP? (rather than viral)
- Aged 2 or older
- Absence of rhinorrhoea
- Absence of wheeze
- Temp 38.5 or more
- Presence of localised pain
Viral is opposite
Assessing quality of infant CXR
- Inclusion - entire thoracic cage
- Penetration - see vertebrae behind heart
- Rotation - clavicle distance from spinous process
- Inspiration - diaphragm should be intersected by 5th-7th anterior rib at mid clavicular line
- Artefact - may obscure
Normal appearance of trachea in infant x-ray
- Often deviates to R due to displacement from L aortic arch
Standard projections in infants for CXR
- AP commonly used as too young to stand up
- = magnified heart
Presenting symptoms of CAP
- Cough - can be with vomitting in children
- Fever
- Tachypnoea - RR is best sign of severity of pneumonia
- Breathlessness or difficulty breathing - may be grunting
- Localised neck, chest or abdomen pain - pleuritic irritation and suggests bacterial
Most common pathogens causing CAP in newborns
From mothers genital tract eg:
* Group B streptococcus
* Gram negative enterococci and bacilli
Most common cause of CAP in infants
- Respiratory viruses eg RSV
- Streptococcus pneumoniae
- Haemophilus influenzae
Most common cause CAP in children over 5
- Streptococcus pneumoniae
- Mycoplasma pneumoniae
- Chlamydia pneumoniae
Mild CAP in infants - features
- RR under 50
- CRT under 2 seconds
- Mild recessions
- Taking full feeds
Moderate CAP in infants
- RR 50-70
- CRT 2 seconds
- Moderate recessions
- Reduced feeds
Severe CAP in infant features
- RR more than 70
- CRT more than 2s
- Nasal flaring
- Intermittent apnoea
- Grunting
- Unable to feed
Mild CAP in older children
- RR under 34
- CRT under 2 s
- Mild breathlessness
- Taking full feeds
Moderate CAP in older children
- RR 35-50
- CRT 2s
- Moderate recessions
- Reduced feeds
Severe CAP in older children
- RR over 50
- CRT over 2s
- Unable to complete sentences
- Severe recessions
- Nasal flaring
- Signs of dehydration
Management of mild CAP
If not needing supplemental O2 and able to tolerate oral feeds and meds:
* Managed in community
* Safety netting
* Oral antibiotics - eg amoxicillin (or clarithromycin if pen allergic)
Management of moderate CAP
- Usually need admission - may need supplemental O2 (if sats under 93%) or support with feeds
- Oral abx again
Management of severe CAP
- Admission
- Bloods - FBC, CRP, blood cultures, capillary blood gas
- Sputum culture
- CXR - only done if severe or complicated
- IV fluids - bolus if needed and maintenance
- IV abx
Bronchiolitis presentation
- Acute onset cough
- Wheeze
- Respiratory distress - tachypnoeic, intercostal recessions
- Apnoea - stopping breathing, central cyanosis, serious complication
- Following runny nose, sneezing, watery eyes coryzal prodrome
- Fine crepitations audible in all areas
Normal palpable liver in children
2cm is normal - secondary to hyperinflation
Management of bronchiolitis
- Supportive
- Supplemental O2 as needed if sats 92% or below - nasal cannula or nasal CPAP
- Help with feeds/fluids - NG or IV
- Nebulised 3% saline may improve symptoms
- Consider nasal drops and nasal suctioning
- No evidence for any other treatment
Most common cause of bronchiolitis
- RSV - MOST COMMON
- Rhinovirus
- Adenovirus
Bronchiolitis age range
- Typically under 1 yr
- Most common under 6 months
- Can be diagnosed in up to 2 yrs if premature with chronic lung disease
Signs of respiratory distress in children
- Raised RR
- Use of accessory muscles
- Intercostal recessions
- Subcostal recessions
- Nasal flaring
- Head bobbing
- Tracheal tugging
- Cyanosis
- Abnormal airway noises
Causes of stridor
- Foreign body
- Croup
- Epiglottitis
- Laryngomalacia
