Common Respiratory Problems Flashcards

1
Q

Commonest cause of admission to hospital in small children

A

-Viruses and bacteria:
=Strep pneumonia
=RSV
=Mycoplasma
=Human metapneumovirus
=Pertussis
=Influenza/parainfluenza

-Asthma
-Bronchiolitis
-Pneumonia
-Croup
-CF

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2
Q

How many resp infections are normal?

A

-8-10 viral RTIs/year
-Cough for up to 3 weeks with each
-3-4 LRTIs/year
-Most resolve without treatment

Abnormal: multiple episodes or continuous symptoms, failure to thrive, focal signs, other infections, unusual organisms

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3
Q

Differentials of recurrent chest infections

A

-Normal
-Asthma
-CF
-GORD
-Congenital abnormality of lung
-Inhaled FB
-Muco-ciliary clearance problem
-Immune deficiency

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4
Q

Differential of wheeze

A

-High pitched, music, predominantly expiratory, chest. Associated with cough, difficulty breathing, chest tightness
-Bronchiolitis (20% of infants): resolving viral illness continue to cough for 4 weeks
-Asthma 11% Scottish children
-33% pre-schoolers gets wheeze at some point

-Reflux
-Rhinitis
-CF, immunodeficiency

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5
Q

History

A

-Age:
=different illnesses at different ages
=small babies get more ill more quickly (under 3 months): history of apnoea

-Past medical history:
=Prematurity: low threshold for admission, can deteriorate quickly
=Cardiac/respiratory disease

-Fast/noisy breathing? Cough? Until vomiting?

-Eating and drinking? Indication for admission if dehydrated

-Level of activity? Tiredness, quiet and clingy

-Fever? Bacterial/ pneumonia

-Characteristic stories:
=Baby with snuffly nose, wet cough, wheeze – Bronchiolitis (apnoea if few weeks old)
=Pre-schooler with runny nose then dry cough and wheeze – Viral induced wheeze
=Older child with recurrent wheezy episodes, atopy in family - Asthma, pattern and family history

-Ability to sleep without disturbance
-Admission to ICU
-Course of previous steroids
-How unwell have they become in the past

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6
Q

Examination

A

-General:
=Level of alertness
=Interested in surroundings
=Posture
=Ability to speak

-Do as much as possible from a distance to keep child calm
-Noisy breathing
-Respiratory rate: increases with severity then until decompensation, adjust for age, prolonged expiration (asthma, bronchiolitis)
-Work of breathing: recession (tracheal tug, supraclavicular, sternal if severe, intercostal, subcostal), younger children show more frequently as softer walls
-Accessory muscles: head bobbing, abdominal breathing, nasal flaring
-Oxygen saturations and heart rate: supplemental if <94, tachycardia ill, bradycardia pre-arrest
-Auscultation: limitations (often hear without stethoscope, may not relate to how ill small chests transmit sounds all over, crying), wheeze, creps, bronchial, silent chest
-Peak flow: best in children who have done it before and old enough to understand, compare with PB or predicted for height
-Beware children who have little work of breathing may be tired and about to decompensate

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7
Q

Why are children more vulnerable to respiratory disease?

A

-Airway calibre: small airways
-Dynamic airway collapse
-Compliant chest well
-Predominantly diaphragmatic breathing (as horizontal ribs, muscle gets tired)
-Greater ventilation: perfusion mismatch
-Naïve immunity (less exposure to infections, no acquired immunity)
-More vulnerable to environmental effects (smoking)

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8
Q

Differentials of noisy breathing

A

-Coryza (runny nose) – common in URTIs, bronchiolitis and well infants!

-Wheeze – lower airway narrowing – asthma (constricted), bronchiolitis (secretions), viral-induced wheeze

-Stridor – upper airway narrowing larynx– croup, other rarer infections foreign body aspiration, epiglottitis, anaphylaxis, bacterial tracheitis

-Grunting – infants with severe respiratory distress, close glottis to increase pressure, bronchiolitis

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9
Q

Asthma diagnosis

A

-History (diurnal variation, wheeze, cough, triggers, atopy, chronic, seasonal variability, responds to appropriate treatment)
-Wheeze heard by health professional
=Distinguish wheeze from upper airway noise or rattles
-Tests: skin prick, FeNO, high eosinophils, PEF, BD response, exercise test, test for bronchodilator reversibility
-Trial of therapy
-Repeated reassessment
-Record basis of diagnosis
-Probability

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10
Q

Clues to alternative diagnosis

A

-Symptoms present since birth or perinatal lung problem: CF, chronic lung disease of prematurity, ciliary dyskinesia, developmental anomaly
-FH of unusual chest disease: CF, neuromuscular
-Severe URT disease: defect of host defence, ciliary dyskinesia

-Persistent moist cough: CF, bronchiectasis, protracted bronchitis, recurrent aspiration, CD
-Excessive vomiting: GORD, aspiration
-Dysphagia: aspiration, swallowing problems
-Light-headedness and tingling: panic attack
-Inspiratory stridor: tracheal/ laryngeal
-Abnormal voice or cry: laryngeal
-Focal signs in chest: developmental, post-infective syndrome, bronchiectasis, tuberculosis
-Finger clubbing: CF, bronchiectasis
-Failure to thrive: CF, GORD, host defence disorder

-Radiological changes

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11
Q

Asthma management

A
  1. Newly-diagnosed asthma: SABA 100mcg/puff 2-4 puffs (4 puff, QDS for 4 days for escalation). Non atopic, no FH: try Montelukast for entire season (side effects). Clenil modulite 100mcg/puff 1 puff BD, spacers
  2. Not controlled with symptoms >= 3/week or night time waking: SABA + 8 week trial of paediatric moderate dose inhaled corticosteroid
    =After 8 weeks stop ICS and monitor: no resolution than review diagnosis/ resolved then reoccurred within 4 weeks restart ICS at low dose/ reoccurred beyond 4 weeks repeat ICS trial. Oral steroids not recommended unless rationale, conscious of repeat prescribing
  3. SABA + paediatric low dose ICS + LTRA (leukotriene)
  4. Stop LTRA and refer to paediatric asthma specialist

-Maintenance and reliever therapy (MART)
=A form of combined ICS and LABA treatment in which a single inhaler, containing both ICS and a fast-acting LABA, is used for both daily maintenance therapy and the relief of symptoms as required
=MART is only available for ICS and LABA combinations in which the LABA has a fast-acting component (for example, formoterol)

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12
Q

-Overview of asthma exacerbation

A

-Hyper-reactive airways causing coughing and wheezing bronchi constrict and produce mucous)
-“Viral-induced wheeze” in pre-schoolers – not necessarily asthma
-Asthma triggers: smoke, exercise, excitement, dust, pollen, allergies. 10% children

-I: Attempt to measure PEF in all children aged > 5 years. Assess severity

-M: Beta-2 agonist inhaler via MDI + spacer +/- mask if child less than 3 (salbutamol, less effective under age 1, give 1 puff every 30-60 seconds up to a maximum of 10 puffs). Prednisolone therapy 3-5 days, high flow oxygen maintain >92. Combination salbutamol, ipratropium, magnesium sulphate if poor response, IV aminophylline, IV magnesium sulphate, steroid IV if vomiting

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13
Q

Severe vs life-threatening attack

A

-Severe
=SpO2 < 92% (unlike in adults, SpO2 < 92% may be consistent with a ‘severe’ attack in children)
=PEF 33-50% best or predicted
=Too breathless to talk or feed
=HR >125 (>5 years), >140 (1-5 years)
=RR: >30 (>5), >40 (1-5)
-Use of accessory neck muscles

-Life-threatening
=SpO2 <92%
=PEF <33% best or predicted
=Silent chest
=Poor resp effort
=Agitation
=Altered consciousness
=Cyanosis

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14
Q

Overview of Croup

A

-Virus causing upper airway inflammation/obstruction in toddlers. It is characterised by stridor which is caused by a combination of laryngeal oedema and secretions. Parainfluenza viruses account for the majority of cases
-More common in autumn peak incidence 6 months-3 years

-P: Barking seal-like cough worse at night, hoarse voice +/- stridor (insp or exp) and shortness of breath, fever, coryzal symptoms, intercostal recession, subcostal recession, sternal recession, tracheal tug, tiring

-I: clinical, CXR (steeple sign subglottic narrowing, thumb sign of epiglottis swelling

-M: Try not to distress a child with croup as this can worsen obstruction so do not examine airway. Steroids (oral dex single 0.15mg/kg, pred is dex not available, budesonide) +/- adrenaline nebuliser, high-flow oxygen. Admit if moderate or severe, <3 months, known upper airway abnormalities, uncertainty of diagnosis

-Differentials: acute epiglottitis (quiet stridor, toxic looking), bacterial tracheitis, peritonsillar abscess foreign body inhalation, anaphylaxis

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15
Q

Mild, moderate vs severe croup

A

-Mild
=Occasional barking cough
=No audible stridor at rest
=No or mild suprasternal and/or intercostal recession
=The child is happy and is prepared to eat, drink, and play

-Moderate
=Frequent barking cough
=Easily audible stridor at rest
=Suprasternal and sternal wall retraction at rest
=No or little distress or agitation
=The child can be placated and is interested in its surroundings

-Severe
=Frequent barking cough
=Prominent inspiratory (and occasionally, expiratory) stridor at rest
=Marked sternal wall retractions
=Significant distress and agitation, or lethargy or restlessness (a sign of hypoxaemia)
=Tachycardia occurs with more severe obstructive symptoms and hypoxaemia

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16
Q

Overview of Bronchiolitis

A

-Acute bronchiolar inflammation, RSV 75-80%
-Most common cause of a serious lower respiratory tract infection in < 1yr olds (90% are 1-9 months, with a peak incidence of 3-6 months). Maternal IgG provides protection to newborns against RSV
-Winter

-P: Shortness of breath, wheezy cough, mild fever, runny nose, lower airway secretions, wet sounding cough, Coryzal symptoms precede dry cough, increasing breathlessness, wheezing with fine inspiratory crackles not always present, feeding difficulties with dyspnoea

-I: immunofluorescence of nasopharyngeal secretions, clinical

-M: at home or admit for feeding support, oxygen (humidified via head box, recommended if stats <92), suction, nasogastric feed if inadequate. Palivizumab in selected high risk infants for passive immunisation, RSV vaccines?

=Immediate referral if apnoea, seriously unwell, severe resp distress, central cyanosis persistent stats <92, dehydrated, high RR, difficulty breastfeeding

17
Q

Overview of Pneumonia

A

-Clinical signs often subtle in children
-Generally unwell, febrile (38.5+), lethargy, tachypnoeic, refuse to feed, high HR out of proportion to degree of fever, tach dyspnoea
-May not have a cough

-Check O2 saturations and look for signs of respiratory distress. Severe: oxy <92, RR >50/70, tachycardia, difficulty breathing, poor feeding, dehydration, chronic conditions, absent breath sounds + dull percussion note: parapneumonic effusion
=X ray

-Virus, strep pneumoniae, mycoplasma haemophilus, Group A strep, staph A

-M: manage fever, prevent dehydration, abx amoxicillin and macrolide

18
Q

Red flag signs Resp

A

-Choking
-Apnoea
Status Asthamticus

19
Q

Overview of choking

A

-Foreign bodies
=Upper airway (larynx) – life-threatening
=Bronchi – wheeze, chest infection
=Oesophagus – discomfort, drooling (talk or cry)
=Bang on back upside down or chest thrusts/ Heimlich 4/5

-Stuck in larynx:
=Spontaneous cough? – encourage coughing
=No/ineffective cough? – back blows, abdominal thrust (>1 yr) or chest thrusts (<1 yr)
=Unconscious? – standard CPR
=In hospital – contact ENT and anaesthetics urgently. Forceps removal

-Stuck in main bronchus:
=Wheezing or chest infection some time after the event which may not be recalled
=Chest X-ray may be helpful; ball valve effect, unilateral hyperinflation

-Stuck in oesophagus:
=No respiratory compromise
=Drooling
=Refer to surgery/anaesthetics

20
Q

Overview of apnoea

A

-Pause in breathing/stopping breathing
-Occur in infants with bronchiolitis, Pertussis, sepsis, meningitis, fits
-Apparent life-threatening event (ALTE): Brief Resolved Unresolved Events
=Floppiness, cyanosis, and/or apnoea
=Many possible causes

21
Q

Overview of Status Asthmaticus

A

-Classify attack as moderate, severe or life-threatening
-Acute severe: requires repeated nebulisers +/- IV treatment
=History of severe attacks in the past
=Increased work or breathing
=Fatigue
=Hypoxia
=Tachycardia
=PICU involvement
=Marked improvement after treatment

22
Q

Congenital abnormalities of airway

A

-Present with noisy breathing +/- difficulty breathing

-Laryngomalacia
=Floppy larynx: usually benign and self-limiting

-Pierre Robin sequence
=Retrognathia, cleft palate, upper airway obstruction

-Airway malacia
=Vocal cord paralysis / web/ stenosis
=Tracheal stenosis
=Cysts
=Haemangiomas
=Vascular rings and slings
=Choanal atresia

23
Q

Congenital abnormalities of lung

A

-Presentation: antenatal scans, infection, difficulty breathing, incidental CXR
-Congenital pulmonary adenomatoid malformation
-Congenita lobar overinflation (emphysema)
-Bronchogenic cyst
-Pulmonary sequestration
-Pulmonary hypoplasia/ agenesis
-Diaphragmatic hernia