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Flashcards in Respiratory Deck (103):
1

describe what croup is (laryngotracheobronchitis)

usually result of a viral infection (most commonly parainfluenza type 1) causing mucosal inflammation of larynx, trachea and bronchi, increased airway secretions, and subglottic oedema-potentially dangerous in young children due to critical tracheal narrowing.
usually nose or nasopharyngeal infection initially
VC movement impaired producing barking cough and hoarseness.

2

most common cause of croup?

parainfluenza virus type 1
(also types 2,3 and 4 role in aetiology but 1 most responsible)

3

in children with a pattern of recurrent croup, what might this be related to?

atopy
*subglottal oedema may have an allergic rather than infective aetiology.

4

epidemiology of croup?

peak incidence in children of 2 years of age
but occurs from 6mnths to 6yrs (but also rarely adolescenets and adults)
boys more commonly than girls
commonest in autumn and spring

5

presenting features of croup?

onset over days with preceding corzya e.g. runny nose, sore throat, cough and fever before development of barking cough, harsh rasping stridor and hoarse voice.
hoarse cry
stridor may appear to become acutely worse with assoc. laryngeal spasm
symptoms often start and are worse at night.

6

what features in croup patient should alert you that there may be high risk of complete airway occlusion?

in a pt with previous resp distress signs including tachypnoea and intercostal recession who appears to be improving with apparent improvement in stridor and disappearance of intercostal recession, but child appears to be deteriorating.

also if there is drowsiness, lethargy and cyanosis in pt with increasing resp distress should alert to impending resp failure.

7

how long do pts tend to be unwell with croup?

illness typically lasts for about 3-7 days, but can persist for up to 2 wks.

8

croup causative organisms other than parainfluenza viruses?

RSV
adenoviruses
rhinoviruses
enteroviruses
measles
metapneumovirus
influenza A-cause of severe resp disease, and B
mycoplasma pneumoniae
coronovirus NL63

9

differing features between croup and acute epiglottitis?

onset: croup over a few days, epiglottitis over hrs
preceding coryza in croup
severe barking cough in croup, absent or slight cough in epiglottitis
hoarse voice, cry in croup and muffled voice, reluctance to speak in epiglottitis
stridor harsh and rasping in croup, soft whispering stridor in epiglottitis
drooling saliva in epiglottitis, absent in croup
unable to drink in epiglottitis
fever more than 38.5 degrees C in epiglottitis
appear toxic, very ill in epiglottitis, unwell in croup

10

how is bacterial tracheitis different from croup?

child has high fever, appears toxic and has rapidly progressive a.way obstruction with copious thick airway secretions
require IV Abx tment, and intubation and ventilation if required

11

cause of bacterial tracheitis?

staphylococcus aureus

12

how is severity of upper airways obstruction best assessed?

clinically by degree of chest retraction and degree of stridor, so looking at degree of subcostal, intercostal and sternal recession is more useful than measuring RR of pt.

13

how can croup severity be assessed?

Wesley clinical scoring system-score more than 6 indicating severe croup.
Severity assessed and graded on stridor-inspiratory and expiratory, palpable pulsus paradoxus-palpable decrease in pulse volume with abnormal BP decrease in inspiration and recession, cyanosis, confusion and drowsiness.

14

features of mild croup?

Inspiratory stridor present
Occasional barking cough, child happy to play

15

indications for hospital admission in croup?

consider if any of following present:
hx of severe obstruction, or previous severe croup, or known structural upper airways abnormalities e.g. laryngomalacia, tracheomalacia, vascular ring, or Downs which increase risk of severe croup developing
child under 6 mnths of age
immunocompromised
inadequate fluid intake, or refusing liquids
poor response to initial tment
uncertain diagnosis
significant parental anxiety, late evening or night time pres. or child's home long way from hosp. or parents have no transport.

arrange immediate admission is suspect serious disorder:
bacterial tracheitis, epiglottitis, peritonisillar abscess, retropharyngeal abscess, laryngeal diphtheria, FB, hypocalcaemic tetany, angioneurotic oedema, corrosive ingestion

and if moderate or severe croup, or impending resp failure-altered conscious level, pallor, dusky appearance, tachycardia.

16

investigations in croup?

not usually needed for diagnosis
low SpO2 (less than 95%) indicates sign resp impairment
CXR-steeple sign-narrowing underneath larynx
throat swab-rapid influenza A test, but can distress child
direct or indirect laryngoscopy if atypical course of illness or reason to suspect congenital or alternative cause for upper airway obstruction.

17

croup management?

keep child as calm and as comfortable as possible
paracetamol or ibuprofen to control discomfort from symptoms or fever
adequate fluid intake
humidified O2 if required-humidified to reduce airway irritation, maintain SpO2 above 93%.
oral dexamethasone (syrup?)-0.15mg/kg, given to all children regardless of croup severity, should be given before transfer to hosp in moderate and severe croup, in hosp can give dexamethasone (PO or IM), prednisolone 1-2mg/kg or nebulised budesonide 2mg to reduce symptoms, and can rpt dose after 12 hrs.
nebulised adrenaline if moderate to severe distress, 400micrograms/kg, max 5mg, rpt after 30mins if necessary.

18

croup complications?

significant AIRWAY OBSTRUCTION
bacterial superinfection e.g. S.aureus, group A strep, moraxella catarrhalis, causing pneumonia or bacterial tracheitis
pulmonary oedema, pneumothorax, lymphadenitis, otitis media
DEHYDRATION if can't maintain adequate fluid intake.

19

usual cause of bronchiolitis?

RSV

note RSV and human metapneumovirus dual infection assoc. with severe bronchiolitis

20

infants most at risk of severe bronchiolitis?

those born prematurely who develop BPD or with other underlying lung disease e.g. CF, or have congenital heart disease.

21

most common causes of stridor in child?

croup
inhaled FB
laryngomalacia or congenital airway abnormality
epiglottitis
bacterial tracheitis

22

presenting features of bronchiolitis?

sharp, dry cough and increasing SOB, preceded by coryzal symptoms-mild rhinorrhoea, cough, fever-many infants don't progress past initial viral URTI features
cough and dyspnoea develop over 1-2 days in those that progress to LRT features
feeding difficulty assoc. with increasing SOB
apnoeas in infants younger than 4mnths
vomiting, irritability

o/e: tachypnoea
mild conjunctivitis, pharyngitis
subcostal and intercostal recession
nasal flaring
chest hyperinflation:prominent sternum and liver displaced downwards, spleen may also be palpable
fine end-inspiratory crackles
high pitched expiratory more so than inspiratory wheeze
tachycardia
cyanosis or pallor

23

results of CXR in bronchiolitis?

unnecessary innvestigation in straight forward cases
if perfromed, typically shows lung hyperinflation: more than 8-10 posterior ribs, horizontal ribs, diaphragm flattening, increased hilar bronchial markings, due to small airway obstruction and closure, air trapping and atelectasis. also patchy infiltrates.

24

epidemiology of bronchiolitis?

disease of the very young, usually between 2 and 6 months old, uncommon after 1 year of age
peak incidence in winter mnths

25

most common cause of acute resp failure in UK paediatric ICUs?

bronchiolitis

26

RFs for bronchiolitis?

passive smoke, part. maternal
overcrowding
nursery attendance
older siblings

27

RFs for severe bronchiolitis and/or complications?

prematurity
low birth weight
age less than 12 wks
CLD-chronic lung disease
congenital heart disease
insulin dependent DM
congenital defects of airways
Downs
epilepsy
immunocompromise
neurological disease with hypotonia and pharyngeal discoordination

28

investigations in bronchiolitis?

pulse oximetry
NP aspirate-RSV rapid testing-enable isolation or cohort arrangements and prevent further unnecessary testing, viral cultures for RSV, influenza A and B, parainfluenza and adenovirus.

CXR if diagnostic uncertainty or atypical course, but should NOT be routinely performed as changes may mimic pneumonia and should not be used to determine need for Abx.
blood and urine culture if toxic appearance or fever more than 38.5 degrees C
blood gas analysis, usually capillary, only in severe disease to identify hypercarbia when additional ventilatory support is considered

29

following infection with what organism is bronchiolitis more likely to result in permanent airway damage (bronchiolitis obliterans)?

adenovirus

30

management of bronchiolitis?

most children have mild self-limiting disease that can be managed at home with supportive measures, paying attention to nutrition, fluids and temperature control, usually disease lasts 7-10 days, must ensure parents know how to spot deterioration e.g. infant feeding less and becoming lethargic.

secondary care: supportive tment still mainstay, including O2 and NG feeding where necessary, give O2 if SpO2 persistently less than 92%
can give high flow O2 with vapotherm
other tments are of uncertain benefit: bronchodilators, corticosteroids, racemic adrenaline, and are NOT recommended by NICE.

continuous CPAP can be considered if impending resp failure
perform upper airway suctioning in children presenting with apnoea, even if no obvious upper airway secretions

ensure good infection control-hand washing, aprons, infected pt isolation

31

indications for hosp r/f in bronchiolitis?

poor feeding (less than 50% usual intake over prev. 24 hrs) which is inadequate to maintain hydration
lethargy
hx of apnoea
RR more than 70 breaths/min
cyanosis
nasal flaring or grunting
severe chest wall recession
sats 94% or less
uncertainty regarding diagnosis
where home care or rapid r/v cannot be assured.

32

what do up to half of infants suffer from after episode of bronchiolitis?

recurrent episodes of cough and wheeze
bronchiolitis is assoc. with an increased risk of asthma but uncertainty whether it causes this

33

indications for immunoprophylaxis e.g. palivizumab against RSV?

children under 2yrs with CLD, who have required at least 28 days of supplemental O2 from birth or who are receiving home O2
infants under 6 mnths with L to R shunts, haemodynamically significant congenital heart disease or pulmonary HTN.
children under 2 yrs with severe congenital immunodeficiency

give 1st dose before RSV season

34

what condition do most wheezy preschool children have?

virus-associated wheeze/episodic viral wheeze/wheezy bronchitis
viruses trigger small airway narrowing due to inflammation and immune response to viral infection-release of smooth muscle constrictors e.g. histamine, and mucus production due to infectious agent.
may be decreased lung function from birth with small a.way diameter in transient early wheezers which may be assoc. with maternal smoking or prematurity.
transient early wheezing usually resolves by 5 yrs of age, probably as airway size is increased.

*vs bronchiolitis-usually onset in children in 1st 2-6mnths of life.

35

clinical features of cystic fibrosis in infancy?

meconium ileus in newborn period-intestinal obstruction with vomiting, abdo distension and failure to pass meconium in 1st 24-48hrs, tx with gastrografin enemas, but most need surgery.
prolonged neonatal jaundice*
failure to thrive
recurrent chest infections
malabsorption, steatorrhoea

36

incidence of CF?

1 in 2500 live births
carrier rate 1/25

37

investigation to diagnose pancreatic insufficiency in CF patients?

low elastase in the faeces

38

URT and LRT complications of cystic fibrosis?

sinusitis
nasal polyps-rhinorrhoea, nasal obstruction/blockage
bronchiectasis
ABPA
pneumothorax
recurrent haemoptysis-blood vessel erosion with recurrent infections?
recurrent and persistent bacterial infection-older children should have regular lung function monitoring with spirometry
persistent productive cough

39

features of CF o/e of the chest?

chest hyperinflation-?barrel deformity
scars-?pneumothorax, bilateral lung transplant, venous access port-?peripheral venous lung line for IV Abx in infection, can implant central venous catheter with SC port (e.g. portacath), to simplify access.
harrison's sulcus-horizontal groove along lower border of thorax
poor chest expansion?
palpable pulm valve closure?
RV overactivity, ?hypertropy-L parasternal heave
coarse inspiratory crepitations
expiratory wheeze
loud S2-pulmonary HTN
gallop rhythm-cor pulmonale

40

aims of management in CF?

prevent lung disease progression
maintain adequate nutrition and growth

41

how can regular flow of bile be promoted in CF patients in trying to prevent liver disease?

ursodeoxycholic acid

42

most common complication assoc. with increasing age of CF patients?

diabetes mellitus

43

what condition does wheezing perinatally suggest?

structural abnormality e.g. tracheobronchomalacia

44

episodic viral wheeze/wheezy bronchitis par. assoc. with which virus?

RSV

45

appropriate management of a child under 5 yrs of age presenting for 1st time with cough and wheeze and at low risk?

consider trial or bronchodilator tment at home-beta agonist or anticholinergic.
if with f/u deemed viral assoc. wheeze rather than asthma and child responds well then reasonable to prescribe bronchodilator for future episodes.
steroids not reccommended
if fever, recommend paracetamol or ibuprofen, can do alternate tment 4hrly if 1 alone ineffective, encourage regular fluids.

46

how does presentation of viral induced wheeze differ from that of asthma?

may be unable to differentiate in child under 5 yrs presenting for 1st time with dry cough and wheeze.
can treat with bronchodilators, and f/u to see if recurrent wheeze is only in the setting of viral infection or if occurs to other triggers e.g. HDM, pollen, exercise, cold air, suggesting asthma.
once 5 or over can do lung function testing for -look for diurnal variation peak flows and obstructive lung defect on spirometry with improvement following bronchodilator treatment.
?atopic hx, FH of asthma, that more favours asthma diagnosis.

47

what does unilateral wheeze in a toddler suggest?

foreign body

48

causes of recurrent or persistent cough in children?

rpt URTIs
asthma
post-specific resp infections e.g. pertussis, RSV, mycoplasma
suppurative lung disease e.g. CF, ciliary dyskinesia or immune deficiency
recurrent aspiration e.g. cerebral palsu=y, with or without GOR
persistent endobronch infection
inhaled FB
smoking
TB
habit cough
airway anomalies e.g. tracheo-bronchomalacia, tracheo-oesophageal fistula

49

key safety info to parents who will be managing child with bronchiolitis at home?

how to recognise developing red flag symptoms:
apnoea or cyanosis
worsening work of breathing-nasal flaring, grunting, marked chest recession
fluid intake 50-75% of normal, or no wet nappy for 12hrs
exhaustion-not responding to normal social cues, wakes only with prolonged stimulation.

50

when can diagnosis of bronchiolitis be made?

if child has coryzal prodrome lasting 1-3 days followed by:
persistent cough and
either tachypnoea or chest recession (or both) and
either wheeze or crackles on chest auscultation (or both).

but bear in mind young infants, espec. under 6 mnths, may present with apnoea without other clinical signs.

51

what can cause stridor in a child who is known to have previous intubation history?

may be subglottic stenosis

52

what should be noted in relation to cough as a symptom of FB inhalation?

cough may occur some time after choking episode has been forgotten-?FB may cause mucosal damage making more susceptible to irritation.

53

organisms likely to cause pneumonia in a child?

strep pneumoniae
mycoplasma pneumoniae-more insidious onset
H.influenzae
group B haemolytic strep-only in newborn-organisms from mother's genital tract, also gram -ve enterococci

infants and young children-resp viruses, part. RSV, but also bacterial includ strep pneumoniae or H.influenzae, also bordetella pertussis and chlamydia trachomatis, infrequently S.aureus.
children over 5-mycoplasma pneumoniae, strep pneumoniae, chalmydia pneumoniae

M.TB should be considered at all ages

RSV
influenza
parainfluenza
adenovirus
coxsackie viruses

54

predisposing factors to pneumonia in children?

congenital abnormality of tracheo-bronchial tree
inhaled FB
persistent lobar collapse
chronic aspiration
chronic L to R intracardiac shunt
immunocompromise

55

how are children protected against strep.pneumoniae pneumonia via vaccination?

receive conjugate vaccine against 13 of most common serotypes at 2 months, 4 months and 1 year.

also Hib immunisation to protect against H.influenzae type B.

56

clinical features of pneumonia in children?

usually SOB and fever preceded by URTI
also cough, lethargy, poor feeding and an 'unwell' child
if localised chest, abdo or neck pain then this suggests bacterial infection as features of pleural irritation
also consider bacterial if fever 38.5 or greater persistently or repetitively with chest recession and tachypnoea
**consider pneumonia in children with neck stiffness or acute abdo pain
o/e: tachypnoea
nasal flaring
chest indrawing
may be coarse end-inspiratory crackles over affected area, but classic consolidation signs of dull percussion note, reduced air entry and bronchial breathing often absent in young children
SpO2 may be decreased-indication for hosp admission if less than 92

57

investigations for childhood pneumonia?

CXR-can't differentiate viral and bacterial causes unless classic lobar pneumonia characteristic of strep pneumoniae
may be pleural effusion of empyema-US to differentiate, empyema needs drainage
NP aspirate in younger children useful to identify viral causes e.g. RSV

58

pneumonia f/u?

if lobar collapse, atelectasis or empyema then rpt CXR at 4-6wks

59

general management of a child with pneumonia?

if classified as mild or moderate, can be managed at home, with parental advice on managing fever, preventing dehydration and identifying deterioration
if 92% SpO2 or less when breathing air, start O2 by nasal cannulae or high flow delivery device e.g. vapotherm
avoid NGTs as can compromise breathing but if use cannot be avoided use smallest tube
measure Na+, K+ urea and/or creatinine at baseline and daily if on IV fluids

60

Abx management of childhood pneumonia?

if clear clinical pneumonia diagnosis should give Abx as can't reliably distinguish bacterial from viral
neonates need broad spec IV Abx e.g. co-amoxiclav
if under 2 and mild LRT symptoms often NOT pneumonia and don't need Abx, if had conjugate vaccine then also supports this
PO amoxicillin 1st choice
macrolides can be added at any age if no response, and should be used if mycoplasma or chlamydia suspected at any age, of if severe
if assoc. with influenza give co-amoxiclav
if signs of septicaemia, complicated pneumonia, or can't tolerate PO e.g. vomiting, then give IV e.g. amoxicillin, co-amoxiclav or cefuroxime
then switch to PO if evidence of improvement

61

what is apnoea?

cessation of breathing for at least 20 seconds

62

causes of apnoea in the neonate?

central:
apnoea of prematurity-tx with caffeine-stimulate resp centre (or aminophylline or theophylline)
hypoglycaemia
infection
IC haemorrhage
necrotising enterocolitis
convulsions

obstructive:
small jaw
thick oropharyngeal secretions
congenital blockage of posterior nares

63

recurrent apnoea is a serious complication seen in infants under 4 mnths of age with what resp infection of infancy?

bronchiolitis

64

what 2 groups are babies requiring active resuscitation divided into at birth?

primary apnoea-babies blue as failure to establish spontaneous respiration, but CVS intact with good circulation, corresponds to Apgar of 4-6 at 1 min. require lung inflation only, no cardiac support.
secondary apnoea-babies white due to failure of circulation as well as respiration, 1 min Apgar score of 0-3, will die without vigorous resuscitation. need lung inflation and cardiac support-chest compressions, may need IV sodium bicarbonate to correct met. acidosis and adrenaline IV or via trachea.

65

in a child with a persistent cough that disappears with sleep, what is the likely diagnosis?

habit cough

66

coughs which tend to be most severe on waking?

CF
bronchiectasis

67

young pt presents with suspected acute asthma attack, what should be asked about in the hx other than features related to this acute presentation?

when the pt is well, do they cough at night? SOB or chest tightness on morning before inhalers? ever wheeze? e.g. when house is vaccumed, when out in the cold, when exercising, around pets, when bed sheets being changed?
how often do they get these symptoms? how often are they using their reliever inhaler?
personal and FH of atopy
previous hosp admissions especially ITU, outcomes and tment
oral steroid courses in last year?
episode pattern-frequency of attacks, time of yr, usual precipitants? e.g. viral URTI
SH: personal or family smoking hx, impact on school-missed days?, activities, financial problems, social supports.

68

features to examine for in pt with asthma?

general impression: resp distress-colour-cyanosis, tachypnoea, nasal flaring, grunting
facial features suggestive of cushing's-moon face, flushed cheeks, atopy-swollen discoloured eyelids, transverse nasal crease
check weight and height
skin-atopic eczema?
hands-peripheral cyanosis, clubbing-CF, obliterative bronchiolitis with bronchiectasis mimicking asthma, tar staining, anaemia
tremor-beta 2 agonists
vital signs-pulse, BP-steroids, beta 2 agonists, temperature-precip. viral URTI, RR, SpO2-pulse oximetry
face-central cyanosis, anaemia
LNs, throat, ears-infection

CHEST-use of accessory muscles, chest wall recession, harrison's sulcus, hyperinflated, expansion, tracheal position, apex position, RV overactivity-L parasternal heave?
ausculate-wheeze, expiratory phase notably longer than inspiratory phase**
percuss

look at abdo for accessory muscle use and see if palpable liver pushed down with chest hyperinflation.

69

what are LK receptor antagonists e.g. montelukast part. useful for in tment of childhood asthma?

part. useful in aspirin induced asthma
protection against exercise-induced bronchoconstriction
montelukast may help with coexisting allergic rhinitis symptoms e.g. sneezing, itching and nasal congestion although intranasal corticosteroids best for this
montelukast may protect against viral-induced wheeze in children with intermittent asthma

70

ADRs of montelukast?

? behavioural issues-aggressive and depression
nightmares
abdo pain
headache

very rare-churg-strauss syndrome-usually has followed reduction or WD of corticosteroid therapy as disease was suppressed by steroids. disease=small vessel vasculitis with triad of late onset asthma, eosinophilia and granulomatous small vessel vasculitis affecting lungs, heart, nerves and skin. can get SIRS with glomerulonephritis/renal failure espec. if ANCA +ve.
be alert to development of eosinophilia, vasculitis rash, worsening pulm symptoms, cardiac complications or peripheral neuropathy.

71

role of LABAs in asthma treatment in children?

-recommended in combination with inhaled corticosteroids in those whose asthma isn't sufficiently controlled with inhaled corticosteroids alone.
-next step after SABA and ICS in children aged 5 and over
-symptom relievers, providing bronchodilation for up to 12 hrs.
-montelukast is superior for protection against exercise induced bronchoconstriction.

72

what drug may be considered in patients with allergic asthma requiring unacceptably high doses of ICS or oral CS, or those with CS-induced side effects (confirmed with eosinophilia*?)

omalizumab-monoclonal Ab that blocks IgE
SC injection 2- to 4- wkly, but expensive and dose dependent on IgE levels so if very high IgE levels then would be inpractical to use.

73

how would 5 puffs of a MDI be given through a spacer?

1 puff is loaded at a time
child told to breathe in and out, allow 30s for drug inhalation from loaded spacer, before next puff loaded
do not clean spacer until valve 'clogs up' as cleaning can cause static electricity which allows MDI medication particles to stick to spacer walls and not be inhaled.
when cleaned, use soap and water and leave to dry. should be cleaned once a mnth.
MDI with spacer can be used in children with mild-mod, or acute severe asthma*, nebuliser tment of choice in life threatening asthma.

74

definition of complete asthma control?

no daytime symptoms
no awakening at night due to asthma
no need for rescue medication
no asthma attacks
no exacerbations
no limitations on activity, including exercise
normal lung function-FEV1.0 and/or PEFR more than 80% of their predicted or best
minimal ADRs from medication

75

stepwise management of asthma in children between 5 and 12 yrs of age?

inhaled SABA
add inhaled CS 200-400 mcg/day, other preventor if this cannot be used
add inhaled LABA, if benefit but control still not adequate increase inhaled CS to 400mcg/day if not already on this, if no LABA response stop and increase inhaled CS, still poor control add LKRA or slow release theophylline-note causes N+V.
increase inhaled CS to 800mcg/day
use daily steroid tablet, maintain inhaled CS 800mcg/day and r/f to resp paediatrician.

76

what is worry if pt with acute asthma exacerbation is not having SpO2 picked up on pulse oximetry?

there is poor peripheral perfusion
may need fluid bolus (be aware of excess fluid loss associated with hyperventilation)

77

what is the importance in terms of differentials for assessing if pt with suspected asthma exacerbation has symptoms when well?

to distinguish from episodic viral wheeze/wheezy bronchitis, where pt is absent of symptoms between episodes.

78

features of acute severe asthma in children 1 year and older?

-SpO2 less than 92%, PEFR 33-50% of best or predicted
-can't complete sentences in 1 breath, or too breathless to talk or feed
-HR more than 125 (if over age of 5), more than 140 (if aged 1-5yrs)
-RR more than 30 (if over age of 5), more than 40 (if 1-5yrs)

79

features of life threatening asthma in children 1 year and older?

-SpO2 less than 92%, PEFR less than 33% of best or predited
-silent chest
-exhaustion
-poor resp effort
-confusion
-hypotension
-cyanosis

80

management of acute asthma attack in children 1-5yrs?

-if life threatening asthma, or SpO2 less than 94%, give high flow O2 via tight fitting face mask or nasal cannula sufficient rate to get 94-98% sats
-1st line: inhaled SABA, if mild to mod use pMDI and spacer, 2.5mg if under 5yrs, 5.0 mg if 5 and older
if symptoms refractory, add 250micrograms/dose ipratropium bromide mixed with neb beta 2 agonist solution
-consider adding 150mg Mg sulfate to each neb salbutamol and ipratropium in 1st hr if short duration of acute severe symptoms and present with SpO2 less than 92%.
if SABA required more than 4hrly, discontinue LABA
-give oral pred early, 10mg if under 2, 20mg if 2-5yrs, 30-40 mg if aged over 5, 2mg/kg up to 60mg if already on maintenance steroid tablets.
-rpt pred dose if vomit and consider IV hydrocortisone if can't retain
-steroid tment usually up to 3 days, no tapering unless course for more than 2wks.

-consider bolus 15 micrograms/kg over 10 mins IV salbutamol in severe attack when not responded to intial inhaled therapy
-consider aminophylline in severe or life threat
-IV Mg sulfate

81

tment of acute asthma attacks in children under 2 yrs of age?

if mild to mod, pMDI+spacer+face mask-inhaled beta 2 agonist
if more severe consider adding inhaled ipratropium
if severe, add oral steroids early-10mg soluble prednisolone for up to 3 days

82

what is laryngomalacia?

'floppy larynx'
abnormalities of laryngeal cartilages results in soft and floppy larynx that collapses during breathing
3 types:
1=aryepiglottic folds tightened or foreshortened
2=redundant soft tissue in any area of supraglottic region
3=assoc. with other disorders e.g. neuromusc, or GOR

83

presentation of laryngomalacia?

infants present within 1st few wks of life, typically at 4-6 wks and not necessarily at birth, with inspiratory stridor and noisy resiration-
these are worse lying supine (but shouldn't be worse at night due to change in pressures?**), when feeding or when agitated
may be GOR
otherwise well and happy
cry is normal-if abnormal would query abnormality at or near VCs

problems initially worsen with age, but tend to resolve by 18-24mnths
resp distress, cyanosis and failure to thrive RARE

84

indication for surgery in laryngomalacia?

usually resolves by itself within 18-24mnths
surgery e.g. laryngoplasty-may be reconstruction of aryepiglottic folds, considered if severe resp distress, can do an aryepiglottoplasty-may remove redundant mucosa over arytenoid cartilages and parts of aryepiglottic folds.

85

Define croup

Barking cough, hoarse voice and stridor.

86

Mild croup pharmacological treatment?

Inspiratory stridor present
Treat with oral dexamathasone 0.2mg/kg or oral pred 2mg/kg
Can be sent home

87

What is severity of croup if biphasic stridor is present? How is this treated?

Moderate severity
Child needs hosp admission to ward
give steroids-oral dexamethasone 6hrly, or oral pred OD
neb adrenaline-up to half hrly, call consultant if no change after 3rd.

88

What defines severe croup?

Palpable pulsus paradoxus

89

Management of severe croup?

See CICU admission for continuous monitoring
IV cannulation
Keep nil by mouth
Neb budesonide or IV dexamathasone or IV methylprednisolone
Continuous Neb adrenaline-no improvement despite 3 back to back indication for intubation.

90

what sign correlates accurately with severity in croup and should always be examined for?

palpable pulsus paradoxus

91

causes of acute upper airway obstruction in child?

INFECTIVE: croup, bacterial tracheitis, epiglottitis, RP abscess, quinsy, diphtheria
*note upper airway obstruction could be congenital structural abnormality e.g. laryngomalacia or subglottic stenosis, these would increase concern in presentation og any acute cause of upper airway obstruction as more likely to cause complete airway occlusion
TRAUMA-inhalational burns, inhaled FB, strangulation or blow to larynx-possible fracture of laryngeal cartilage.
OTHERS-anaphylaxis, tumour

92

management of very severe croup?

100% O2
continuous neb adrenaline and steroids
needs EMERGENCY INTUBATION-notify urgently consultant intensivist, anaesthetist and ENT surgeon.
preference to perform under GA: if IV, rapid fall in consciousness level which can result in sudden loss of airway patency, so pref inhaled anaesthesia.

93

what organisms can we investigate for with a nasopharyngeal aspirate?*

RSV
influenza
parainfluenza-types 1-4*
adenovirus

94

what would be a marker of severe asthma in hx of a child under 2 years who is unable to speak?

too breathless to feed

95

criteria for d/c of child in hosp with acute asthma attack?

When stable on 4 hrly inhaled bronchodilators that can be continued at home.
PEF more than 75% of best or predicted and SpO2 more than 94%.
Discharge plans should address the following:
Check inhaler technique
Consider the need for regular inhaled steroids
Provide a written asthma action plan for subsequent asthma treatment with clear instructions about the use of bronchodilators, seeking medical help and the use of oral steroids during acute exacerbations
F/U with the GP within a week. Arrange follow- up in the OPD clinic within 2-3 months( in moderate –severe asthma)
Children with severe atopy will need skin prick tests for allergy.

96

why does any child with any abnormality on CXR in investigation of pneumonia require f/u in 4-6wks?

looking for resolution to ensure diagnosis was pneumonia and no complications e.g. empyema or effusion, and radiological evidence of consolidation often takes 4-6wks to resolve.

97

clinical presentation of whooping cough?

-this is a highly contagious respiratory infection due to bordatella pertussis
-children who haven't completed their primary vaccination at 4months are part. susceptible
-1 week of coryza-child most infectious is followed by a paroxysmal or spasmodic cough, which is then followed by an inspiratory whoop-sharp inhalation
-cough spasms often worse at night, and may cause vomiting
-during paroxysm child may go red or blue in face, and mucus flows from nose and mouth
-infants-whoop may be absent, but apnoea is a feature
-vigorous coughing can cause epistaxis and subconjunctival haemorrhages
-inspiratory whoop lasts 3-6wks
-symptoms grad reduce but may persist for many mnths, the '100 day cough'
-no pyrexia or wheeze

98

complications of pertussis?

pneumonia
convulsions
encephalopathy
apnoea
otitis media
bronchiectasis
pneumothorax-due to increased intra-thoracic and/or abdo pressure with violent and/or prolonged coughing.

99

how is diagnosis of whooping cough made?

per-nasal swab-culture organism
bloods-marked lymphocytosis
antibody test-antibodies against pertussis toxin

100

whooping cough treatment?

-infants and young children suffering severe cough spasms or cyanotic attacks, or severe complications e.g. seziures, pneumonia, should be admitted to hospital and isolated from other children
-close contacts should have erythromycin prophylaxis
-unvaccinated infant contacts should be vaccinated

-although antibiotics do not alter clinical course once disease established, may curtail period of infectivity so should give as soon as possible after illness onset to eradicate organism and reduce transmission (if cough onset within the last 21 days):
-clarithromycin for babies younger than 1 month
-azithromycin or clarithromycin for children 1 month and older, and non-pregnant women
-erythromycin for pregnant women

co-trimoxazole if macrolides CI or not tolerated

-pregnant women now vaccinated against whooping cough between 20 and 32 weeks

-children should stay off school for 5 days after starting antibiotics, or 3 weeks from onset of cough

101

Why can CF cause rectal prolapse?

as a result of bulky stools that form due to malabsorption

102

when are children vaccinated against pertussis?

2 months
3 months
4 months
3 years 4 months

103

requirements for discharge of child from hospital following acute asthma attack?

-child stable on 3-4hrly inhaled bronchodilators that can be continued at home
-PEF and/or FEV1.0 is greater than 75% of their best or predicted, and SpO2 more than 94%.
arrange:
-f/u in primary care within 2 working days days
-f/u in OP paed asthma clinic within 1-2mnths
-arrange r/f to paed resp specialist if there have been life threatening features.