Respiratory Flashcards
(88 cards)
1
Q
What is bronchiolitis?
A
Inflam and infection in the bronchioles, usually caused by virus. Most commonly resp syncytical virus. Usually in <6m but can be rarely dx in children up to 2 years, esp ex premie w chronic lung disease.
2
Q
What is the presentation of bronchiolitis?
A
- Coryzal sx - runny nose, sneeze, mucus in throat, watery eyes
- Signs of resp distress - dyspnoea, tachypnoea
- Poor feeding
- Mild fever
- Apnoea
- Wheeze (airway narrowing, not bronchoconstriction) and crackles
- Sx worst on day 3-4
3
Q
What are the signs of resp distress?
A
- Raised RR
- Use of accessory muscles
- Intercostal and subcostal recessions
- Nasal flaring
- Head bobbing
- Tracheal tug
- Cyanosis
- Abnormal airway noises
4
Q
What are the abnormal airway noises?
A
- Wheezing - caused by narrowed airways, normally during expiration
- Grunting
- Stridor - inspiratory, obstruction of upper airway
5
Q
What are reasons for admission in bronchiolitis?
A
- <3m
- Pre existing condition - premature, Down’s, CF
- 50-75% less feeding
- Dehydrated
- RR >70 and O2 sats <92%
- Signs of resp distress
- Apnoea
6
Q
What is the management of bronchiolitis?
A
Normally supportive:
- Ensure adequate intake - orally, NG tube or IV fluids - small freq feeds and increase grad as tolerated
- Saline nasal drops and nasal suctioning
- Supplementary O2
- Ventilation
- NOT SABA AS NO BRONCHOCONSTRICTION
7
Q
What are the stages of ventilatory support?
A
- High flow humidified O2 via nasal cannula = positive end expiratory pressure PEEP
- Cont +ve airway pressure CPAP
- Intubation and ventilation
8
Q
How do you measure resp distress in children?
A
Capillary blood gases: rising pCO2 and falling pH
9
Q
How can you try and prevent RSV?
A
Palivizumab given monthly to prevent in high risk babies - ex premature, congenital heart disease, chronic lung disease, immunodef.
Provides passive protection until virus is encountered.
9
Q
What is CF?
A
Autosomal recessive mutation of CF transmembrane conductance reg gene making an abnormal Cl channel.
10
Q
What the main consequences of CF?
A
- Thick pancreatic and biliary secretions = duct blockage = no digestive enzymes
- Thick airway secretions = reduced airway clearance = bacterial colonisation = susceptible to airway infections
- Congenital bilateral absence of vas deferens = male infertility
- Also female infertility
11
Q
What is the presentation of CF?
A
Newborn: most CF found when screened for w newborn blood spot test. Meconium ileus is often the first sign = bowel obstruction in newborn baby.
Later on: recurrent LRTI, failure to thrive, pancreatitis.
12
Q
What are the signs and sx of CF?
A
Sx - chronic cough, thick sputum production, recurrent RTIs, steatorrhoea, abdo pain and bloat, salty sweat (high in Na), failure to thrive
Signs - low weight or height on growth charts, nasal polyps, finger clubbing, crackles and wheezes, abdo distension
13
Q
What are some of the causes of clubbing in children?
A
- Hereditary clubbing
- Cyanotic heart disease
- Infective endocarditis
- CF
- TB
- IBD
- Liver cirrhosis
14
Q
What are the ix into CF?
A
- Sweat test
- Molecular genetic testing for CFTR gene
- Sinus XR or CT scan - opacification of sinuses
- CXR or CT thorax
- LFT - but unreliable before 6 years
- Sputum microbiology
15
Q
What is the sweat test?
A
Chloride conc >60mmol/L w Na conc lower than that of the Cl on 2 separate occasions. Is the gold standard.
16
Q
What are the common pathogens in CF?
A
- H.influenzae
- Staph aureus
- Pseudomonas aeruginosa
- E.coli
17
Q
Why is pseudomonas so troublesome?
A
Difficult to get rid of - bacteria resistant to multiple Abx. Children w CF and pseudomonas to stay away from others w CF to prevent spread.
Treat - long term neb abx eg. tobramycin
18
Q
What is the management of resp CF?
A
- Chest physio - several times a day to clear mucus and exercise to improve resp function
- Prophylactic fluclox against S.aureus
- Treat chest infections aggressively
- Bronchodilators
- NEBS - DNase to break down resp secretions and hypertonic saline and tobramycin
- Vaccines - pneumococcal, influenza, varicella
19
Q
What is the management of pancreatic insufficiency?
A
- High calorie diet - treat malabsorption, increased resp effort, coughing and infections
- CREON - pancreatic enzyme replacement
(confirmed w stool elastase) - Screen for diabetes, insulin replacement will be required if have
20
Q
What are other treatment options of CF? These are more adulthood treatments
A
- Lung transplantation in end stage resp failure
- Liver transplant in liver failure
- Fertility treatment = testicular sperm extraction
- Genetic counselling
21
Q
What monitoring is done of CF patients?
A
- Sputum monitoring for colonisation
- Screen - diabetes, OP, Vit D def and liver failure
- Seen every 6 months in specialist centre
- PFTs, CXR, DXA, blood glucose, USS liver
22
Q
What is the prognosis of CF?
A
~50 years old life expectancy.
- 90% will get pancreatic insufficiency
- 50% develop CF diabetes and need insulin
- 30% of adults get liver disease
- Most males are infertile
23
Q
What is bronchiectasis? When would children get it?
A
Abnormal dilation of airways w associated destruction of bronchial tissue. Is potentially reversible, esp in children. Children are likely to get it if they have CF but other pathologies can lead to it.
24
How is bronchiectasis caused?
Inflam response to severe infection = structural damage within bronchial walls = dilation. Scarring = reduced cilia = predisposed to further infections.
25
What are the causes of bronchiectasis?
Post infection - Strep pneumonia, Staph aureus, adenovirus, measles, influenza virus, TB
Immunodef - IgA/IgG def, HIV infection, ataxia telangiectasia
Primary ciliary dyskinesia - autosomal recessive genetic defect = inaction of cilia = reduced mucus clearances
Post obstructive - foreign body aspiration
Congenital syndromes - Young's and Yellow nail syndrome
26
What are the CF of bronchiectasis?
Chronic productive cough !!
- Purulent sputum
- Chest pain
- Wheeze
- Breathlessness on exertion
- Haemoptysis
- Recurrent LRTIs
- Finger clubbing
- Inspiratory crackles
27
What are the ix into bronchiectasis?
Imaging - CXR, high resolution CT
Bronchoscopy - not required but for those w focal bronchiectasis on HRCT or airway abnormality
LFTs - obstructive
Microbiological assessment - indicates underlying cause
Ix for underlying cause - Cl sweat test, FBC, immunoglobulin panel (IgA and IgG), HIV test
28
What are the signs of bronchiectasis on imaging?
CXR - bronchial wall thickening or airway dilation, tram tracks?
HRCT - bronchial wall thickening, signet ring sign, bilat upper lobe bronchiectasis = CF, unitlat upper lobe bronchiectasis = TB, focal bronchiectasis = foreign body inhalation
29
What is the management of bronchiectasis?
- Chest PT
- Bronchodilators for pt w wheeze
- Abx and exacerbations - dep on causative organism, normally need 10-14 days
- Long term abx - 3+ exacerbations a year should be considered
30
What are the signs of an acute exacerbation of bronchiectasis?
- Acute deterioration
- Worsening cough
- Increased sputum vol, viscosity or purulence
- Increased wheeze, breathlessness or haemopytsis
- Feeling systemically unwell
31
What are the complications of bronchiectasis?
- Recurrent infection
- Life threatening haemopytsis
- Lung abscess - empyema
- Pneumothorax
- Poor growth and development
32
What are the signs of acute severe asthma attack in children >2 years old?
- O2 sats <92%
- Too breathless to talk
- Pulse >125 >5 or >140 2-5
- RR >30 >5 or >40 2-5
- PEFR <50%
- Signs of resp distress
33
What are the signs of a life threatening asthma attack in children >2 years old?
O2 sats <92% plus:
- Silent chest
- Cyanosis
- Poor resp effort
- Agitation and confusion
- Coma
- Hypotension
PEFR 33-50%
34
What are the signs of a moderate asthma attack in children <2 years?
>92%
- Audible wheeze
- Using accessory muscles
- Still feeding
35
What are the signs of a severe asthma attack in children <2 years old?
- <92% O2 sats
- Cyanosis
- Marked resp distress
- Too breathless to feed
36
What are the hospital admission options in the case of acute asthma?
Life threatening asthma - admit
Severe asthma - admit if bronchodilator doesn't help
Mod asthma - admit if sx worsen despite bronchodilator or have comorbidity, poor adherence, prev hx of hospital admission, nocturnal sx
37
What is the immediate management of acute asthma?
- Supplemental O2 if <92%
- Inhaled salbutamol or NEB
- Ipatropium - inhaled or NEB added if no response to SABA
- Corticosteroids - 3 days, oral prednisolone or IV hydrocortisone
- IV salbutamol if no response to inhaled bronchodilators
- IV Mg Sulphate can be considered
- IV aminophylline
38
What is a step down regime of inhaled salbutamol?
10 puffs 2 hourly - 10 puffs 4 hourly - 6 puffs 4 hourly - 4 puffs 6 hourly
39
What are the SEs of salbutamol?
- Hypokalaemia
- Tachycardia
- Tremor
40
What are the safe discharge criteria of acute asthma?
- Child is well on 6 puffs 4 hourly of salbutamol
- Sats >94% on air
- Inhaler technique assessed or taught
- Written asthma management plan
- GP review child 2 days after discharge
41
What are the triggers of asthma?
- Cold air and exercise
- Pollution
- NSAIDs and B blockers
- Exposure to allergens
42
What is preschool wheeze?
50% of children have at least one episode of wheeze by their 5th bday - most commonly a viral wheeze.
1. Episodic viral wheeze, only wheeze when have virus, most commonly caused by rhinovirus
2. Multiple trigger wheeze
43
What are the ix into asthma?
Spirometry, <80% is obstructive in children, different from in adults. Then bronchodilator reversibility testing to see if theres an improvement.
Other tests - PEFR, bronchial provocation tests, exercise testing, skin prick testing, exhaled nitric oxide, CXR
44
What is the definition of good asthma sx control in children?
Full school attendance
No sleep disturb
<2x/week daytime sx
Use salbutamol <2x/week
No limitation on daily activities
Normal lung func
45
What is the stepwise management of chronic asthma aged 5-12?
1. PRN SABA eg. salbutamol
2. Inhaled corticosteroids - reg, eg. at night and in morning
3. Montelukast
4. LABA
5. Increase steroid dose
6. Reg oral steroids = refer
Always use inhalers w spacer
46
What are the drugs that can be used in chronic asthma in secondary care?
Omalizumab - reduces IgE to reduce inflam response
47
What is the management of chronic asthma in <5?
1. SABA PRN
2. Low dose ICS or leukotriene antagonist
3. Add the other option from step 2
4. Specialist
48
What is the management of chronic asthma in >12?
Same as adults:
1. SABA
2. Reg low dose inhaled corticosteroid
3. LABA
4. Titrate up corticosteroid inhaler, consider leukotriene R antagonist
5. Titrate up corticosteroid inhaled, can try oral theophylline or LAMA
6. Oral steroids at lowest dose possible
49
Can inhaled corticosteroids affect growth?
Yes but small reduction - 1cm less than what final height would be without inhaler, less of a problem w smaller doses.
But! poorly controlled asthma can lead to a more significant impact on growth and development, child will have reg asthma reviews to check growth.
50
What is the inhaler technique in children?
Spacer in children!
1. Assemble spacer
2. Shake the inhaler and attach spacer
3. Sit or stand up straight, lift chin slightly
4. Make a seal around the spacer mouthpiece
5. Spray dose into spacer
6. Take steady breaths in and out 5 times until the mist is fully inhaled or exhale fully before making the seal and then spray the dose and take 1 deep breath and then hold for 10 secs
51
What is the presentation of whooping cough?
- Mild coryzal sx
- Coughing attacks where child can't catch their breath = inspiratory whoop when the coughing ends
- Pt can cough so hard they faint, vomit or pneumothorax
- Can present w apnoeas
52
What causes whooping cough?
Bordetella pertussis - children and pregnant women vaccinated against it but less effective after each dose
53
What are the ix into whooping cough?
Nasopharyngeal or nasal swab w PCR test or bacterial culture if less than 3 weeks
>2 weeks = anti pertussis toxin immunoglobulin G from oral fluid if <16
54
What is the management of whooping cough?
- Notifiable disease
- Supportive care
- w/i first 21 days = macrolide abx eg. azithromycin or clarithromycin
- Close contacts = prophylactic abx if they are vulnerable eg. HCW, unvaccinated infants or pregnant women
- Sx resolve w/i 8 weeks but can last several months
55
What are some LRTI?
- Pneumonia
- Bronchitis
- Acute exacerbation of bronchiectasis
56
What is the presentation of pneumonia?
- Cough, typically productive
- High fever >38.5
- Tachypnoea and tachycardia
- Increased work of breathing
- Lethargy
- Delirium
- Hypotension
57
What are the chest signs of pneumonia?
- Bronchial breath sound - loud breath sounds inspiration and expiration, caused by consolidation of lung tissue
- Focal coarse crackles - air passes through sputum
- Dullness to percussion - lung collapse or consolidation
58
What are the ix into pneumonia?
- CXR
- Sputum cultures
- Throat swabs - culture and PCR
- Blood cultures if septic
- CBG
59
What are some of the organisms that cause pneumonia?
Bacterial - S.pneumonia, group A strep, group B strep, Staph aureus, H.influenzae, TB
Viral - RSV, influenza virus
60
What is the management of pneumonia?
Abx according to local guidelines, IV when septic
Supplemental O2 if <92%
61
Preschool wheeze vs asthma
Preschool wheeze = reversible obstruction of airways that responds to bronchodilators (is basically asthma!) but children are too young to do spirometry required to diagnose asthma, are basically the same thing. Will be treated w asthma medication.
62
What are the differentials for a wheezing child?
- Asthma/preschool wheeze
- Foreign body aspiration
- Allergy
- Neonatal wheeze in extremely pre term babies
- Bronchomalacia, gets worse w SABA
63
Why do you use spacers in children?
- Better lung deposition
- Reduces side effects of oral thrush and a hoarse thrush
eg. volumatic spacer
64
How do you administer inhalers to children?
- Baby = spacer and a mask!!!!! w a metered dose inhaler, need to TILT the volumatic spacer to open the valve, need to have a seal w the mask, shake inhaler and press down once for a min of 10 secs then shake it again and give another puff, don't need to tilt an aerochamber
- Exhale first all the way out and then inhale the drugs and hold breath for 10 secs
65
How do you look after spacers?
Clean the spacer with soap and warm water and AIR DRY it, change spacer every 6 months
Types:
- Volumatic
- Aerochamber w mask or mouthpiece in school age children
66
What are the different types of inhalers?
- Aerosol
- Dry powder inhalers, not aerosol - clicks when its ready to inhale (school age+)
- Easibreath, breath activated inhaler
- Accuhaler, powder inhaler
67
Viral vs bacterial CAP
Viral - younger, lower fever, wheeze and runny nose, no chest pain
Bacteria - older, higher fever, no wheeze or runny nose, chest pain
68
What are some causes for chronic cough?
- Recurrent viral bronchitis
- Post infectious cough, post nasal drip
- GORD
- PBB
- CF
- Immune fed
- Recurrent pulm aspiration
- Retained inhaled foreign body
- Chronic bronchitis
69
How do you treat post nasal drip?
Steroid nasal spray and antihistamines
70
What is PBB?
Is a diagnosis of exclusion. Protracted bacterial bronchitis:
1. Presence of wet cough >4w
2. Absence of sx or signs suggestive of other causes
3. Cough resolves following 2-4w abx
71
What are specific cough pointers?
Sx - chest pain, dyspnoea, haemoplysis, failuret o thrive. feeding difficulty, cardiac abnormality, immunodef, RF for TB
Signs - resp distress, clubbing, crackles, chest wall deformity
72
What are the ix into chronic cough?
1. Sweat test
2. Bronchoscopy - malacia
3. ph/impedance study
4. HRCT - bronchiectasis
5. Nasal brushings/ciliary studies - primary ciliary dyskinesia
73
What is tracheobronchomalacia? How is it managed?
Flaccidity of supporting cartilage of the trachea.
No cure but can manage sx - physio, prophylactic abx, may need CPAP if severe
Normally improves over time as muscles strengthen.
74
What are the CF of PCD?
Primary ciliary dyskinesia
- Chronic wet cough
- Sinusitis/rhinitis - persistent nasal discharge
- Situs inversus - organs in thorax switch side
Associated w congenital heart lesions, asplenia, hydrocephalus, renal disease
75
What is long term ventilation?
If need ventilation for >3 months.
Can be done by tracheostomy or NIV mask to be worn for part of the day.
76
What are the reasons for needing LTV?
- Neuromuscular eg. muscular dystrophy
- Upper airway obstruction
- Prader Willi syndrome
Either a bridge to recovery or used for ever, can prolong life expectancy for up to 10 years.
77
Differentials for apnoea
78
Differentials for SOB
Asthma
Congenital heart disease - heart failure
Croup
Epiglottitis
Bronchiolitis
Foreign body aspiration
Allergic rhinitis
79
Differentials for cough
URTI
LRTI - pneumonia, bronchitis, whooping cough
Bronchiectasis
Bronchiolitis
Otitis media
Pharyngitis
Croup
Cystic fibrosis
Foreign body aspiration
80
Differentials for stridor
Resp distress
Foreign body
Croup
Epiglottitis
Anaphylaxis
Tracheomalacia
Head and neck abscess
81
Differentials for cyanosis
Congenital heart disease - cyanotic, RtoL shunt
Aphyxia
Polycythaemia
Cold exposure
Raynaud's
Sepsis
82
Differentials for wheeze
Asthma
Viral wheeze
Allergic reaction/anaphylaxis
Airway foreign body
GORD
OSA
83
What are the sx of OSA in children?
Snoring
Pauses in breathing
Restless sleep
Mouth breathing
Nighttime sweating and bed wetting
Sleep terrors
Daytime - trouble w school and paying attention, hyperactive, sleepy, behaviour probs
84
What are some RF of sleep apnoea in children?
- Down's syndrome
- Birth defects in skull or face
- CP
- Sickle cell
- Neuromuscular disease
Most common cause in children - enlarged tonsils or adenoids
85
What is the management of OSA?
- Remove tonsils/adenoid
- CPAP machine while sleep keeps airway open
- Weight loss if overweight
86
What is high in CF?
Immunoreactive trypsinogen
87
What is the management of croup?
1. Oral dex, single dose
2. O2 and NEB adrenaline if severe resp distress
