Paediatrics: Respiratory and ENT Flashcards by Anish Chandrasekar

What is the general management pathway for acute asthma attack?

Inhaled salbutamol - 10 puffs max
Seek urgent medical attention
Salbutmol nebs in ambulance (2.5 mg)
High flow oxygen (15L/mins via NRBM)
Salbutamol and Ipratopium bromide (250mcg) nebs
Consider magnesium sulphate (150mg) with each salbutamol + ipratropium bromide nebs
PO prednisolone early (all pts) - continue for at least 3 days post
Consider IV salbutamol nebs (15mcg/kg over 10mins)
Aminophylline
Consider IV magnesium sulphate

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What is the discharge criteria for an acute asthma patient?

Sats > 94% on air
Inhaled salbutamol 4-6hrly that can be continued at home
PEF/FEV1 > 70% predicted

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What are the follow up appointments for paediatric acute asthma attacks?

Primary care in 2 d
Paeds clinic in 2 months
Paeds respiratory referral if life threatening symptoms occurred

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When are most cases of asthma diagnosed?

50% diagnosed before age 10

Asthma can be diagnosed in children age > 2 yo

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What are the pulmonary function test results for asthma?

Spirometry
- FEV1 significantly reduced
- FVC normal or reduced
- FEV1/FVC < 80% (0.8)
- FEV1 increases by >15% post-B2 agonist inhaler
PEFR
- Reduced (often can be < 70% predicted)
- improves by > 15% post-B2 agonist inhaler

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What are the features of acute severe asthma in children?

Sats < 92% 
PEFR 33-50% of predicted 
HR > 140 if <5yo or >125 if > 5yo 
RR > 40 if < 5yo or >30 if > 5yo 
Inability to complete sentences or feed due to breathlessness

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What are the features of life threatening asthma in children?

Sats < 92%
PEFR < 33% 
Silent chest
Cyanosis 
Exhaustion 
Poor respiratory effort 
Hypotension 
Confusion

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What is step 1 of asthma control

Very low dose ICS AND

B2-agonist (or LTRA if < 5yo)

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What is step 2 of asthma control

Add a LABA OR

LTRA if < 5yo (Montelukast)

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What is step 3 of asthma control

LABA works?

Low dose ICS or
Trial of LTRA (Montelukast)

LABA does not work?
- Low dose ICS

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What is step 4 of asthma control

Refer to specialist

Medium dose ICS or
Trial with 4th drug usually SR Theophylline

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What is step 5 of asthma control

Refer to specialist

PO Steroid tablet (minimum dose to gain control)
Addition of other drugs to reduce steroid

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When do you decide to go up the asthma management ladder?

If child is using B2-agonist inhaler > 3 times per week

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What is the typical presenting age of bronchiolitis and what is the causative organism?

1-9 months (90%)

Respiratory syncytial virus (RSV)

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What is the clinical presentation of bronchiolitis?

Prodrome:
- Coryza (typically 3d before)

Presentation (respiratory distress):

Mild fever
Dyspnoea + Tachypnoea
Persistent dry cough
Wheeze
Fine-end inspiratory crepitations
IC/SC recession, tracheal tug, accessory muscle use,
grunting, nasal flaring, head bobbing (rare + severe)

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How would you manage a patient with bronchiolitis?

ABCDE - rule out other causes

Reassure parents
Supportive therapy
- Humidified oxygen with nasal cannula if sats are < 94% (vapotherm provides oxygen and flow)
- Paracetamol to control fever

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What is the criteria for hospital admission with bronchiolitis?

Age < 3 months with fever (must rule out other causes)
Sats < 94%
Signs of severe respiratory distress: severe recession, nasal flaring, grunting, RR > 70
Reduced oral fluid intake < 50%
Apnoea - observed or reported
Diagnosis unclear

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What is croup, its causative organism and the age range it affects?

Laryngo-tracheo-bronchitis
Parainfluenza virus
6 months - 3/6years (peak at 2 years)

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What is the presentation of a patient with croup?

Classic (symptoms are worse nocturnal)

Prodrome: Coryza
Barking cough - seal or crow like
Harsh stridor
Hoarseness
Dyspnoea
Can drink, Cant eat
Respiratory distress (if severe)

How would you manage a patient with croup?

ABCDE

Reassure parents
Manage from home - keep child upright, minimise distress, steroids, observe for signs of resp distress
Dexamethasone to all patients (0.15mg/kg) regardless of severity
- Prednisolone as alternative
Humidified oxygen if sats <92%
Adrenaline if airway is threatened
Intubation if airway is compromised

What is the typical age range of epiglottis and the causative organism?

1-6 years

Haemophilus influenza type B (HiB)

What is the typical presentation of a child with epiglottis?

HIGH Fever 
Toxic child 
Soft stridor 
Cant eat or drink 
Drooling 
Increased respiratory distress and HR 
Anxiety

What is the management of a child with epiglottis?

ABCDE

Manage airway
- do not examine throat, can compromise
- call anaesthetist
- Intubate and consider tracheostomy if required
Provide 100% oxygen and prevent desaturation
IV Cefuroxime or Cefotaxime (3-5d post tube removal)
Rifampacin for household

What are the causative organisms of pneumonia in neonates, children < 5yo and children >5yo

Neonates - Group B strep (from mother GU tract)
Infants + children < 5yo - S.Pneumonia, Chlamydia, RSV, HiB
Children > 5yo - S.Pneumonia, M.Pneumonia, S.Aureus (rare + severe)

What are the clinical symptoms and signs of pneumonia?

``` Productive cough - green + purulent Dyspnoea + tachypnoea (most sensitive sign) Fever End-inspiratory coarse crepitations Dull percussion - localised Decreased expansion Decreased air entry Respiratory distress if young ```

What is the investigative ladder for pneumonia in children?

1. CXR - Consolidation patchy and localised or generalised - Bronchograms 2. Sats may be reduced 3. Nasopharyngeal aspirate - culture

What is the management of Pneumonia for children < 5yo and those > 5yo?

< 5yo 1st line = amoxicillin 2nd line = co-amoxiclav (complicated typical) 1st line = erythromycin, clarithromycin, azithromycin (if atypical) > 5yo 1st line = amoxicillin 1st line = erythromycin, clarithryomycin (if M.pneumo, Chlamydia or S.Aureus)

What are the signs and symptoms of atypical pneumonia .e.g mycoplasma pneumonia? how is it treated?

``` Fever > 38 Headache Vomiting Vague upper abdominal pain Non-productive cough Miserable and lused ``` Erythromycin or clarithrymycin (macrolides)

What is the criteria for bacterial tonsillitis?

Centor - Age: <3yo (0), 3-14 (1), >48 (-1) - Fever > 38 (1) - Cough absent (1) present (0) - White exudate on tonsils or furry tongue (1) - Cervical lymphadenopathy tender and swollen (1) Score ≥ 3 = group B strep, treat accordingly

What are the red flag viruses causing pharyngitis?

EBV (can also cause white exudate)

What is the management of tonsillitis?

1. Paracetamol - reduce temperature 2a. Viral (common) - Reassure and provide supportive therapy - Self-limiting, it will resolve in 1 week 2b. Bacterial - Pencillin V or erythromycin - Clarithromycin if pen allergic - avoid amoxicillin as if EBV can cause rash 3. tonsillectomy if recurrent

What is the presentation of an infant with CF?

``` FTT and malabsorption Meconium ileus Steatorrhoea Prolonged neonatal jaundice Recurrent chest infections ```

What are the features of bronchiectasis in a child with CF?

``` Fine end inspiratory crackles Productive cough Recession Recurrent chest infections Finger clubbing and rectal prolapse Nasal polyps ```

What is causative mutation in CF?

ΔF508 on chromosome 7 (CFTR gene)

how is CF diagnosed?

Blood spot analysis via Guthrie card (day 5 of life) - Increase IRT (immunoreactive trypsinogen) - CFTR gene mutation reactions Sweat test - Cl- count > 60ml FISH - ΔF508 mutation

What is the chronic management for CF?

1. Manage in tertiary centre 2. Physiotherapy - daily breathing exercises and acapella/flutter device 3. Prophylactic Abx when well - flucloxacillin (protect against staph.aureus) may be given IV through porta-cath 4. Annual influenza vaccination 5. Saline nebs 6. Regular sputum samples 7. Regular r/v every 6-8 wks in outpatients 8. High calorie and fat diet

What is the typical age range of otitis media? What are the causative organisms?

3-6 years Viral - RSV, rhinovirus Bacterial - pneumococcus, group B strep, HiB,

What are the differences in presentation between acute and secretory OM?

Acute - Sudden onset pain - Fever + irritable - TM bursts eventually --> visible purulent pus in external canal (resolves in 48hrs) - Drum is bright red, bulging and loses natural light reflection Secretory - Middle ear effusion - No pain - Hearing loss - Behavioural issues in class - Dull retracted TM

What is the treatment for OM?

1. Abx if bacterial - Amoxicillin or Co-Amoxiclav 2. Analgesia (ibuprofen) and paracetamol 3. Myringotomy with tympanovstomy insertion - i.e. grommets

What are the features of pertussis infection?

``` Prodrome phase (1-2 weeks) - Cough, coryza, fever ``` Paroxysmal phase (2-6 week) - Coughing fits followed by inspiratory whoop - Causes vomiting - Cough and vomit worse nocturnally - Facial erythema or cyanosis - Rhinorrhoea

What are the investigative findings of pertussis infection?

1. Subconjunctival haemorrhage in eyes 2. Pernasal swab (Diagnostic) - pertussis culture 3. Bloods - Leuko/lymphocytosis

What is the treatment for pertussis infection?

Antibiotics - Erythromycin (14 d) or Clarithromycin (7d) - Erythromycin for close contracts

what is the clinical presentation of TB?

``` Weight loss Fever Night sweats Cough absent or present with haemoptysis Focal signs of infection Anorexia Malaise ```

What are the investigative findings for TB?

1. Mantoux test - +ve 2. CXR - Focal opacification (coin lesions) - Consolidation - Effusion - Hilar lymphadenopathy - Cavitation 3. Sputum sample - Acid fast bacilli (will resist ZN stain)

What is the treatment for TB?

``` RIPE: - Rifampacin - Isoniazid - Pyrazinamide ± Ethambutol ```