Common Respiratory Problems Flashcards
Commonest cause of admission to hospital in small children
-Viruses and bacteria:
=Strep pneumonia
=RSV
=Mycoplasma
=Human metapneumovirus
=Pertussis
=Influenza/parainfluenza
-Asthma
-Bronchiolitis
-Pneumonia
-Croup
-CF
How many resp infections are normal?
-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
Differentials of recurrent chest infections
-Normal
-Asthma
-CF
-GORD
-Congenital abnormality of lung
-Inhaled FB
-Muco-ciliary clearance problem
-Immune deficiency
Differential of wheeze
-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
History
-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
Examination
-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
Why are children more vulnerable to respiratory disease?
-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)
Differentials of noisy breathing
-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
Asthma diagnosis
-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
Clues to alternative diagnosis
-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
Asthma management
- 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
- 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 - SABA + paediatric low dose ICS + LTRA (leukotriene)
- 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)
-Overview of asthma exacerbation
-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
Severe vs life-threatening attack
-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
Overview of Croup
-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
Mild, moderate vs severe croup
-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
