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Yr4: Child Health > Respiratory 2 > Flashcards

Respiratory 2 Flashcards

1
Q

What is bronchiolitis?

What is the mot common cause?

What are some other causes?

A

Bronchiolitis= inflammation of the bronchioles

Most commonly caused by RSV (respiratory syncytial virus- 80%). Others include adenovirus, mycoplasma.

Very common in winter.

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2
Q

What age group is bronchiolitis most common in?

A
  • <1 year, most commonly in infants <6months
  • Rarely can occur in children up to 2yrs of age (particularly in ex-premature babies with chronic lung disease)
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3
Q

Why does RSV not affect adults in same way as it does infants?

A

Same idea as for episodic viral wheeze.

Constriction due to swelling and mucus in adults is small in proportion to size of airways. In infants, the constriction due to swelling and mucus is large in proportion to size of airway hence has significant impact on ability to move air in and out of alveoli

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4
Q

Describe the typical presentation of bronchiolitis

A
  • Coryzal symptoms (running or snotty nose, sneezing, mucus in throat, water eyes, cough)
  • Poor feeding
  • Mild fever (under 39degrees)
  • Apnoea’s
  • Wheeze & crackles on auscultation
  • Signs of respiratory distress
  • Dyspnoea
  • Tachypnoea
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5
Q

State some signs of respiratory distress in a child

A
  • Raised RR
  • Use of accessory muscles (SCM, abdominal & intercostal)
  • Intercostal & subcostal recessions
  • Sternal retraction
  • Nasal flaring
  • Head bobbing
  • Tracheal tugging
  • Cyanosis
  • Abnormal airway noises (wheeze, grunt, stridor)
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6
Q

For each of the abnormal airway noises, state why they occur:

  • Wheeze
  • Grunting
  • Stridor
A
  • Wheeze: air moving through narrowed airways
  • Grunting: exhaling with glottis partially closed to increase positive end-expiratory pressure to keep airways open
  • Stridor: obstruction of upper airway
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7
Q

Discuss the typical course of RSV infection in infants

A
  • Starts an URTI with coryzal symptoms
  • Around half get better spontaneously
  • Other half develop chest symptoms 1-2 days following onset coryzal symptoms
  • Symptoms generally worst on day 3 or 4
  • Symptoms usually last 7-10 days in total
  • Most infants fully recover within 2-3 weeks but could have cough for weeks
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8
Q

Children who have had bronchiolitis as a baby are more likely to have what in childhood?

A

Episodic viral induced wheeze

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9
Q

Most infants with bronchiolitis can be managed at home with safety netting advice; state some reasons to admit an infant with bronchiolitis

A
  • <3 months
  • Pre-existing condition (e.g. prematurity, CF, Down’s syndrome)
  • 50-75% or less of their normal milk intake
  • Signs of clinical dehydration
  • RR >60 or 70
  • Oxygen sats <92%
  • Moderate to severe respiratory distress (e.g. deep recessions or head bobbing)
  • Apnoeas
  • Parents not confident in their ability to manage at home
  • Difficulty accessing medical help from home
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10
Q

Discuss the management of bronchiolitis in hospital

A

Most infants require supportive management:

  • Ensuring adequate intake: orally, via NG tube or IV fluids. Start with small feeds & gradually increase to avoid overfeeding as full stomach can restrict breathing
  • Saline nasal drops & suctioning (to clear nasal secretions)
  • Oxygen if sats <92%
  • Ventilatory support if required
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11
Q

Discuss 3 options for ventilatory support

A
  1. High flow humidified oxygen via nasal cannula (e.g. vapotherm, airvo, optiflow): delivers air & oxygen continuously with added pressure to help oxygenate lungs and prevent airways from collapsing by adding positive end-expiratory pressure
  2. CPAP: similar to vapotherm, airvo & optiflow but can deliver much higher, controlle dpressures
  3. Intubation & ventilation: insertion of endotracheal tube to fully control ventilation
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12
Q

We don’t use ABGs in paediatrics; what other test would you use to assess ventilation in children?

A

Capillary blood gas. Can’t comment on pO2 but can look at:

  • pCO2: rising suggest ventilation is poor as can’t clear waste CO2
  • pH: falling pH suggests that CO2 may be building up causing a respiratory acidosis
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13
Q

What monoclonal antibody can be given to infants at risk of bronchiolitis?

How often is it given?

Who is it offered to?

How does it work?

A
  • Palivizumab: monoclonal antibody that targets RSV
  • Monthly injection
  • High risk babies at risk of serious disease e.g. ex-premature (bronchopulmonary dysplasia), CF, congenital heart disease
  • Not a true vaccine as doesn’t stimulate immune system but provides passive protection by circulating in body. If infant becomes infected with RSV it will work as antibody against the virus and activate immune system to fight the virus. Levels of circulating antibodies decrease over time hence why need monthly injection
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14
Q

Most doctors will diagnose bronchiolitis based on symptoms and signs; however, what investigation can be done to confirm?

A

Immunofluorescence of nasopharyngeal secretions may show RSV

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15
Q

State some risk factors for bronchiolitis

A
  • Being breast fed for less than 2 months
  • Smoke exposure (eg. parents’ smoke)
  • Having siblings who attend nursery or school (increased risk of exposure to viruses)
  • Chronic lung disease due to prematurity (5)
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16
Q

State some potential complications of bronchiolitis

A
  • Hypoxia
  • Dehydration
  • Fatigue
  • Respiratory failure
  • Persistent cough or wheeze (very common and parents should be counselled that their child may cough for several weeks)
  • Bronchiolitis obliterans – Airways become permanently damaged due to inflammation and fibrosis
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17
Q

What is pneumonia?

How does it present in children?

A

Infection of lung parenchyma causing inflammation resulting in sputum filling the airways and alveoli. It may cause SEPSIS; so always think about whether it could be sepsis.

Symptoms & Signs

  • Cough
  • High fever (>38.5)
  • Increased work of breathing
  • Lethargy
  • Confusion
  • Tachypnoea
  • Tachycardia
  • Hypoxia
  • Hypotension
  • Bronchial breath sounds (harsh breath sounds equally loud on inspiration & expiration)
  • Focal coarse crackles
  • Dullness to percussion
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18
Q

State some features of severe pneumonia in a child

A

According to NICE:

  • Difficulty breathing
  • Saturations <90%
  • Tachycardia
  • Grunting
  • Very severe chest indrawing
  • Inability to breastfeed or drink
  • Lethargy
  • Reduced conscious level

*image shows UHL guidance for severe pneumonia

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19
Q

State some common causes, bacterial and viral, of pneumonia in children; highlight the most common bacterial & viral cause

A

Pneumonia can be caused by bacteria (including atypical), viruses or fungi:

Bacterial

  • Streptococcus pneumonia
  • Group A Strep (Streptococcus pyogenes)
  • Group B Strep (occurs in pre-vaccinated infants and is often contracted during birth as it colonises in vagina)
  • Staphylococcus aureus
  • Haemophilus influenza (occurs in pre-vaccinated or unvaccinated children)
  • Mycoplasma pneumonia (atypical bacteria that causes extra-pulmonary manifestations e.g. erythema multiforme)

Viral

  • RSV (respiratory syncytial virus)
  • Parainfluenza
  • Influenza
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20
Q

What investigations are done in children with suspected pneumonia?

A
  • Sputum culture for M,C&S and viral PCR
  • CXR (investigation of choice but not routinely required; may be useful if uncertain or it is a complicated or severe case)
  • Capillary blood gas to assess for acidosis/alkalosis and blood lactate in unwell pts
21
Q

Discuss the management of pneumonia in children

A
  • Oxygen if saturations <92%

Use local guidelines when deciding antibiotic choice; usually the following applies:

Non-severe signs or symptoms

  • First line= PO amoxicillin
  • If atypical bacteria suspected, penicillin allergic or no response to amoxicillin = PO macrolide
  • Pneumonia associated with influenza= co-amoxiclav
  • ****atypical bacteria (e.g. Mycoplasma pneumoniae, Chlamydophila pneumoniae*)
  • Children with moderate CAP will usually require admission but can have oral abx.*

Severe signs or symptoms or associated with influenza

  • First line= IV co-amoxiclav
22
Q

If a child is having recurrent antibiotics for LRTIs what investigations may you consider?

A

Investigations to determine if there is an underlying lung or immune system disease:

  • FBC: check levels of white cells
  • CXR: screen for structural abnormalities in chest or scarring from infections
  • Serum immunoglobulins: test for antibody deficiencies
  • Immunoglobulin G to previous vaccines: test if there have been any problems responding to vaccine (e.g. can’t convert IgM to IgG so no long term immunity as in immunoglobulin class-switch recombination deficiency)
  • Chloride sweat test: test for CF
  • HIV test: in particular if mum is positive or status unknown
23
Q

What is croup?

State some common causative organisms; highlighting the most common

A

Croup, also known as laryngotracheobronchitis, is a common respiratory disease of childhood, characterised by the sudden onset of a seal-like barky cough, often accompanied by stridor, voice hoarseness, and respiratory distress. The symptoms are a result of upper-airway obstruction due to generalised inflammation of the airways, as a result of viral infection. The characteristic signs & symptoms are due to laryngeal oedema and secretions.

*Is it an URTI? Sources say it is but trachea & bronchi are LRT.

24
Q

State some common causative organisms of croup; highlighting the most common

A
  • Parainfluenza (types 1 or 3)
  • RSV
  • Adenovirus
  • Influenza A or B
  • Meta pneumovirus

*NOTE: croup used to be caused by diphtheria but this is rare in developed countries due to vaccination. Croup caused by diphtheria leads to epiglottitis therefore has high mortality.

25
Q

What age group does croup commonly affect?

When in year is it most common?

A
  • Commonly affects children aged 6 months to 3yrs; peak incidence is 2yrs
  • More common in autumn
  • Affects boys > girls (1.43:1)
26
Q

Describe the clinical features of croup

A

Typically 1-4 day history of non-specific cough & other coryzal symptoms progressing to:

  • Barking cough (worse at night)
  • Increased work of breathing
  • Stridor
  • Hoarse voice
  • Low grade fever
  • May be reduced breath sounds on auscultation due to airflow obstruction
  • Signs of respiratory distress e.g. tachypnoea, intercostal recessions, tachycardia
  • Altered level of consciousness
27
Q

We can grade the severity of croup into mild, moderate and severe; discuss the criteria for each

Also state the scoring system you can use to help you determine severity (saves you remembering the criteria)

A

Westley croup score: mild = 1, moderate 2-4, severe =/> 5

28
Q

State some differential diagnoses for croup

A
  • Epiglottitis
  • Bacterial tracheitis
  • Laryngomalacia
  • Peritonsillar abscess (quinsy)
  • Inhaled foreign body
29
Q

Majority of children are diagnosed clinically; however, state some investigations that may be considered if deemed necesary

A
  • Bloods: FBCs, CRP, U&Es
  • CXR: rule out other possible causes e.g. inhaled foreign body
  • Laryngoscopy: if suspect alternative cause
30
Q

There are two characteristics signs you may see on CXR of a child with croup; one is seen in PA view and the other in lateral view. State these signs

A
  • PA view: steeple sign (subglottic narrowing)
  • Lateral: thumb sign (swelling of epiglottis)
31
Q

Discuss which children with croup would require admission

A

NICE suggest admitting any child with:

  • Moderate or severe croup
  • Who is <6 months of age
  • Inadequate fluid intake (50-75% or less of normal volume or no wet nappy for 12hrs)
  • Has known upper airway abnormalities (e.g. Laryngomalacia, Down’s syndrome)
  • Uncertainty about diagnosis
  • Concerns about whether carer can look after child at home or if it is difficult for them to access healthcare from home

Have lower threshold for admission for children with other medical conditions e.g. chronic lung disease, congenital heart disease, neuromuscular disorders, immunodeficiency

32
Q

Most cases of croup can be managed at home with supportive treatment; discuss how you would treat children who are being managed at home and what advice you would give the parents

A

If child has been to GP/A&E, they will be prescribed a single dose of oral dexamethasone 0.15mg/kg (prednisolone 1-2mg/kg is alternative is dexamethasone not available) and then given the following advice:

  • Explain symptoms usually resolve after 48hrs but may last up to 1 week
  • Explain that is a viral illness so abx not needed
  • They should ensure child has adequate fluid intake
  • Use paracetamol or ibuprofen to control pain & fever
  • Advise to check on child regularly including through the night
  • Safety net: seek urgent medical advice if symptoms worsen. Look out for stridor at rest, high fever, high heart rate, signs of respiratory distress. If child is cyanotic, lethargic/not responding, really struggling to breath call ambulance.
33
Q

Discuss the management of croup if a child is admitted to hospital

A
  • Keep child as calm as possible (crying increased oxygen demand & causes respiratory muscle fatigue)
  • Oral dexamethasone (0.15mg/kg): this can be repeated after 12hrs. Prednisolone (1-2mg/kg) can be used if dexamethasone not available.
  • Budesonide neb is alternative to PO dexamethasone
  • Oxygen
  • Nebulised adrenaline
  • Contact ENT and an anaesthetist if you think may be need for airway support- intubation & ventilation or emergency tracheostomy
34
Q

Nebulised adrenaline offers temporary relief in croup; the effects usually last at least an hour but subside after 2 hours. Explain how nebulised adrenaline offers temporary relief

A

Causes vasoconstriction which temporarily reduces the oedema in airways

35
Q

Stridor can be inspiratory, expiratory or biphasic; what does each indicate?

A
  • Inspiratory: obstruction in pharynx, supraglottic or glottic area
  • Expiratory: lower down tachea (rarer)
  • Biphasic: subglottic area
36
Q

What is whooping cough?

Why is it called whooping cough?

A

URTI caused by Bordetella pertussis

*called whooping cough because coughing fits so severe that child unable to take in any air between coughs so makes a loud whooping noise as they forcefully suck in air after the cough

37
Q

What gram stain is Bordetella pertussis?

What shape is it?

A

Gram -ve coccobacilli

38
Q

Whooping cough is highly contagious; true or false?

A

True (up to 90% household contacts catch it)

39
Q

Who is vaccinated against Bordetella pertussis?

A
  • Pregnant women (between 16 & 32 weeks. Introduced as new-born infants are particularly vulnerable)
  • Infants at 2, 3 & 4 months and again at 3-5yrs

*NOTE: neither the vaccine or infection results in lifelong protection so adolescents & adults may develop whooping cough despite being vaccinated but infection is much milder when older

40
Q

Describe clinical features of whooping cough

A

1-2 week history of mild coryzal symptoms including:

  • Rhinitis
  • Conjunctivitis
  • Sore throat
  • Low grade fever
  • Dry cough
  • Irritability

… then develop more severe coughing fits with ‘whooping cough’. May be sick, faint and/or be cyanotic after coughing fits. Infants may have apnoea’s rather than coughing. This stage can last for 2-8 weeks.

Cough gradually decreases in frequency and severity; this can take weeks-months.

Symptoms last 10-14 weeks

41
Q

When should you suspect whooping cough?

A

Person has acute cough that has lasted for 14 days or more without other apparent cause and has one of more of the following:

  • Paroxysmal cough
  • Inspiratory whoop
  • Post-tussive vomiting
  • Undiagnosed apnoeic attacks in young infants
42
Q

Discuss how you diagnose whooping cough

A
  • Within 2-3 weeks of onset of symptoms: nasopharyngeal or nasal swab with bacterial culture or PCR testing
  • If cough present >2 weeks can test for anti-pertussis toxin immunoglobulin G
    • Aged 5-16yrs: oral fluid
    • Aged 17yrs & over: blood test
43
Q

Discuss the management of whooping cough

A
  • Notify Public Health (notifiable disease)
  • Admit infants under 6 months, infants with significant apnoea’s, feeding difficulties
  • Oral macrolide beneficial within first 21 days of cough (e.g. clarithromycin, azithromycin, erythromycin). Co-trimoxazole is alternative.
  • Close contacts are given prophylactic antibiotics for vulnerable groups: pregnant women, infants <1yr, underlying health conditions
  • Supportive management e.g. paracetamol, ibuprofen, fluids
  • Educate: may take months to resolve, highly contagious, need to avoid nursery school until had cough for 21 days or have had antibiotics for 5 days
44
Q

Do antibiotics improve symptoms of whooping cough?

A

Don’t alter clinical course once disease established but help to reduce periof of infectivity when given early on in illness

45
Q

State some potential complications of whooping cough

A
  • Seizures
  • Subconjunctival haemorrhages
  • Secondary bacterial pneumonia
  • Bronchiectasis!! *Key one to remember
46
Q

Explain the pathophysiology of whooping cough

A
  • Spread via respiratory droplets
  • Attach to respiratory epithelium
  • Produce toxins that paralyse cilia and promote inflammation
  • Above leads to impaired clearance of secretions
  • … Which leads to cough
47
Q

Why is it it difficult to diagnose TB in children?

A

In children, there are far fewer TB bacteria than in adults. It’s also harder for children to cough up mucus; therefore more difficult to get a sample and detect bacteria in sample.

*See Yr3 medicine for full TB notes

48
Q

Describe presentation of TB in:

  • Younger children
  • Older children
A

Younger children

  • Fever
  • Weight loss
  • Poor growth
  • Cough
  • Swollen glands
  • Chills

Older children (similar to adults)

  • Cough that lasts longer than 3 weeks
  • Pain in the chest
  • Blood in sputum
  • Weakness
  • Tiredness
  • Swollen glands
  • Weight loss
  • Decrease in appetite
  • Fever
  • Sweating at night
  • Chills

*management same as adults just diff doses

  • Active: Rifampicin, isoniazid, pyridoxine (6 months) and pyrazinamide, ethambutol (for 2 months)
  • Latent: rifampicin & isoniazid & pyridoxine for 3 months or 6 months of isoniazid & pyridoxine

Yr4: Child Health (21 decks)

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