Respiratory Flashcards
(48 cards)
1
Q
Abbreviations
A
SABA- Short Acting Beta Agonist
SAMA- Short Acting Muscarinic Antagonist aka anticholinergic bronchodilator
LABA- Long Acting Beta Agonist
2
Q
Describe the natural history of asthma
A
- Wheezing with resp infections, if mild and infrequent may not persist, if severe may persist
- Allergic asthma presents in second decade of life and usually persists into adulthood, if presents earlier children may “grow out” of it. Again more severe increases likelyhood of persistence
- Occupational asthma will persist after exposure ceases
- Asma patients do not have a lower life expectancy but are more likely to die of lung condition e.g. cancer
3
Q
Causes of wheeze in children
A
- Viral induced wheeze
- Atopic asthma
- non-atopic asthma
- Recurrent aspiration of feeds
- Inhaled foreign body
- CF
- Anaphylaxis
- Congenital abnormality
4
Q
History and examination findings in asma
A
Hx
- >1 occasion wheeze
- multipitch
- expiration
- Sx worse at night + early morning
- Sx have triggers e.g. exercise, pets, dust, cold air, emotions, laughter
- Interval Sx (Sx between exacerbations)
- FHx of atopy
- +ve response to asthma therapy
Exam
- Usually normal between attacks
- In chronic may have hyperinflation, generalised wheeze (polyphonic noise on expiration due to narrowed airways), Harrisons sulcus (depression of rib cage at diaphragmatic insertion)
- May have ezcema, rhinitis
5
Q
Conditions that mimic asthma (DDs) + how to differentiate
A
- GORD - Poor feeding, breathless at feeding, regurg, recurrent chest infections
- CF - finger clubbing, poor growth, chronic infection, usually picked up at newborn screening CFTR protein, also sweat test for excess chloride ions
- Viral induces wheeze - episodic, lack of interval SX, associated w/ virus, resolves at age 5
- Bronchiolotis - dry cough, tachyopnoea, signs of resp distress, tachycardia, cyanosis, fine end respiratory crackles
- Croup - 2yrs, autumn, barking cough, stridor, usually preceeded by fever and/or coryza
6
Q
Management of asthma acute exacerbation
A
Check: duration of Sx, treatment already given and course of previous exacerbations
Assess severity: RR, lung fields, HR, resp distress signs, ability to talk, cyanosis, fatigue
Management - does depend on severity see attached picture
- High flow O2
- Back to back 3x salbutamol (SABA) and/or ipratropium (SAMA) nebs
- If this fails IV salbutamol/magnesium/aminophylline
- IV steriod hydrocortisone
7
Q
Inhaler colours, what drugs they contain and their classes
A
Relievers
Blue - Salbutamol SABA
Grey - ipratropium SAMA
Preventers
Green - Salmetarol LABA
Purple - Combined fluticasone (inh steriod) + salmetarol (LABA) = seretide
Brown - Beclometasone inh steriod
Orange - Fluticazone inh steriod
Don’t give a LABA to children w/out steriod and if it doesn’t help remove (CHECK THIS)
8
Q
Asthma drugs, examples, MOA
A
See table
9
Q
CHILDREN 5-12 SIGN 5 step asthma management
A
10
Q
CHILDREN 0-5 SIGN 5 step asthma management
A
11
Q
How to asses asthma control in children
A
- Wght + Hgt
- Peak flow/spirometry (diary if applicable)
- Exercise tolerance
- Intereference with school
- Sleep
- Medication
- Technique
- Number of uses of which inhalers
- Understanding of preventer/reliever
- Chest
- hyperinflation
- Harrisons sulcus
- Wheeze
- Triggers
- Rhinits –>treatment?
- Pets/smoke etc.
- Atopy disorders
- eczema
- Other causes of wheeze
- Clubbing
- Growth failure
- Sputum
12
Q
Asthma Advice for parents
A
- What is asthma
- What the medication do + technique
- Triggers
- Have an action plan for when attacks happen
- When to seek help/hospital and consequences of not Hospital/GP/111 are always there
- Children can grow out of it
- Allow child to live normal life whilst keeping Sx under control
- Refer to information: NHS living with Asthma http://www.nhs.uk/Conditions/Asthma/Pages/living-with.aspx
13
Q
Aetioligy and natural Hx of bronchiolitis
A
Aetiology
- Respiratory syncytial virus (RSV) causes 80%
- Rest
- human metapneumovirus
- parainfluenza virus
- rhinovirus
- adenovirus
- influenza virus
- Mycoplasma pneumoniae
- (RSV+human metapneumovirus combined known to cause severe bronchiolitis)
Natural Hx
- Most common ages 1-9 months
- Coryzal Sx –> dry cough + SOB
- Reason for admission is usually difficulty feeding + dyspnoea(SOB)
- Apnoea is a serious complication
- Most at risk of sever bronchiolitis:
- Premature
- Bronchopulmonary dysplasia
- CF
- Congenital heart disease
14
Q
8 Sx of Coryzal Sx
A
- Clear/mucopurulent nasal discharge/blockage
- Fever (children)
- Soar throat
- Congestion
- Headache
- Sneezing
- Lethargy
- Anorexia
15
Q
How to differentiate viral from bacterial chest infection
A
ASK SOMEONE
16
Q
Clinical features of bronchiolitis and their relation to normal physiology
A
Clinical Features
- Sharp dry cough
- Tachyopnoea
- Subcostal/intercostal recession
- Hyperinflation of chest
- prominent sternum
- Liver displaces below rib cage
- Fine end inspiratory crackles
- High pitched wheezes exp>insp
- Tachycardia
- Cyanosis/pallor
Relate to normal physiology
Bronchiolitis is a LRTI leading to inflammation of the bronchioles (small airways preceeding alveoli). This inflammation narrows the airways (obstruction)–>Resp distress
17
Q
Treatment of acute bronchiolitis
A
Supportive
Treat only if severe e.g. low Sats
- O2 if needed
- Fluid if needed
- Ventilation if needed
18
Q
Bronchiolitis info for parents
A
- Usually viral –> no antibiotics
- Self resolving and not dangerous
- IB profen and paracetamol can be given PRN
- SX to watch out for
- Apnoea
- Severe resp distress e.g. tracheal tug, RR>70
- Central cyanosis
19
Q
Aetiology, common causative organisms and natural Hx of pneumonia
A
Aetiology
- Variety of bacteria and viruses
- 50% no causative organism identified
- See attached table
Natural Hx
- Incidence peaks in infancy and old age
- URTI–>fever difficulty breathing, usually accompanied by other general Sx lethargy, poor feeding
- Localised chest/abdo/neck pain usually sign of bacterial
20
Q
Clinical features of pneumonia and how they relate to normal physiology
A
Clinical features
- Fever
- Difficulty breathing
- Cough
- Lethargy
- Poor feeding
- “Unwell child”
- Localised chest/abdo/neck pain –> bacterial cause
- Signs of resp distress
- nasal flarring
- tachyopnoea (RR is best diagnostic feature of pneumonia so make sure to take it esp. in febrile child)
- Chest indrawing
- In affected area end resp coarse crackles, may not have any other signs o/e e.g. dullness, bronchial breathing, decreased breath sounds
- Decreased Sats
- Consolidation in C-Xray
- Virus in nasal pharyngeal aspirate
Normal physiology
Pneumonia is lung inflammation in which alveoli become filled with pus(solid) –> purulent cough, resp distress, fever, decreased Sats
21
Q
Treatment of pneumonia
A
Most children can be treated at home, criteria for admission
- Sats <92
- Recurrent apnoea
- Grunting
- Can’t eat/drink sufficiently
General supportive care
- O2 if hypoxic
- Analgesia if in pain
- IV if dehydrated/sodium inbalance
- PHYSIO HAS NO PROVEN ROLE
Antibiotics determined by age + severity
- Newborns - broad spectrum IV e.g. amox??? CHECK THIS
- Older infants - oral amox usually does the trick (co-amox if unresponsive or complicated)
- Children over 5 - oral amox or other macrolide e.g. erythromycin
- No advantage in giving IV over oral in mild/moderate pneumonia
Parapneumonic effusions
- Occur in 1/3 of children w/ pneumonia
- May resolve alone
- If fever >48 hrs depsite antibiotics suggestive pleural effusion
- Requires drainage under US
22
Q
Parental advice for chest infection
A
Treatment
- Rest
- Small + often fluids
- Prop up on pillows when sleeping if more comfortable
- If have chest pain give paracetamol
- Cough medicines do not help
- Do not smoke around them ANYTIME BUT ESPECIALLY NOW
If it is bacterial given antibiotics and should improve in 48 hrs, cough may persist wks longer, complete antibiotics
If viral antibiotics don’t help recovery takes 2-4 wks
Key Points
- Most children recover completely and quickly
- Rest + fluids small&often
- No cough medicines
- Complete antibiotics
Refer to NHS website
Hospital/GP/111 if Sx don’t improve after 4 wks, Sx get signficantly worse, your child is experiencing difficulty breathing
23
Q
Aetiology and Natural Hx of pertussis(medical word for whooping cough)
A
Aetiology
- Bordetella pertussis bacteria
Natural Hx
- 1 week coryzal Sx (catarrhal phase)
- Characteristic paroxysmal (violent attack) or spasmodic cough (paroxysmal phase)
- Worse at night
- May lead to vomiting
- May go red/blue + have mucus flowing from nose and mouth during paroxysm
- May lead to nose bleed/red eyes
- This parosymal phase lasts up to 3 months
- Sx gradualy get better (convalescent phase) but may persist for months
- Can rarely lead to complications that cause mortality esp. bad in 4 month old w/out vaccinations
- Pneumonia
- Seizures
- Bronchiectasis
24
Q
Effect of immunisation on presentation of pertussis
A
?????
Dont think there is any ????
25
Parental advice for suspected pertussis
* Highly contagious - Airbourne
* Considered contagious from Sx onset to 3/52 after coughing onset usually 4-5 wks or after 5/7 antibiotics
* Can be treated w/ antibiotics but doesn't touch the cough, OTC cough stuff doesn't help either
* Contacts may need prophylactic antibiotics
* Can be vaccinated against advice all contacts, but esp children \<6/12 or pregnant - can cause death/brain damage/kidney damage in babies
* Whoop may be abscent in adults + ppl who have been vaccinated
* Come back if Sx persist, get worse, change or your child is experiencing breathing difficulties
* Refer to NHS website
26
Clinical features TB
* Persistent productive cough
* Recurrent chest infections
* Wght loss/anorexia
* Fever
* Night sweats
* Haemoptysis
* Chest pain
* Lethargy
27
Treatment of active TB
If there are clinical features start treatment without waiting for results
* Refer to TB specialist
* Treatment
* Quadruple therapy: isoniazid (with pyridoxine), rifampicin, pyrazinamide and ethambutol for 2 months then
* isoniazid (with pyridoxine) and rifampicin for a further 4 months, 6 month for uncomplicated pulmonary or Lymph node TB, 10 months in central nervous system involved.
* For both modify drugs according to susceptability training
* After puberty give pyridoxine weekly to prevent neurpathy from isonaizid therapy
* TB meningitis give dexamethasone
28
Treatment of latent TB
* Diagnostic criteria
* Asymptomatic
* Mantoux +ve
* Test for Hep B + C before starting treatment
* 3 months of isoniazid (with pyridoxine) and rifampicin
29
Difficulties in adherence to TB treatment in children
* Sx may get better after 8/52 and therefore do not feel they need to keep taking them
* Lack of knowledge around why the length of treatment is so long
* Lack of knowledge around the serioussness of TB
* Lack of knowledge about side effect--\>parents get scared and stop giving the medication
* Lack of motivation if child doesn't like taking pills and they're better why given them?
* Stigma of having TB associated with HIV, withcraft, poverty esp. for adolescent--\>don't want ot take them incase friends find out
30
Aetiology and natural Hx of cystic fibrosis
**Aetiology**
* Autosomal recessive condition
* Caucasian disease
* Faulty cystic fibrosis transmembrane conductance regulator (CFTR)
**Natural Hx**
* Meconium ileus
* Pancreatic enzyme deficiency
* Malabsorpion
* Chronic endobronchial infections w/ specific bugs incl Pseud. aeruginosa
31
Clinical features of CF + how they relate to normal physiology
**Features**
* Preformed in new born screening heel prick and most are identified here
* Resp Sx
* Recurrent chest infections w/ specific bacteria e.g. staph. aureus, H. influenza, Pseud. aeruginosa
* Bronchiectasis
* Persistent purulent productive cough
* Hyperinflated chest w/ course insp crackles and/or exp wheeze
* Metabolic Sx
* Poor growth
* Pancreatic enzyme def.
* Malabsorption
* Failure to thrive
* Frequent large pale offensive greasy stools (steatorrhoea)
* Meconium ileus
* Intestinal obstruction + vomiting + abdo distention
**Relation to normal physiology**
Multi-system disorder from abnormal ion transport across epithelial cells
* Lungs
* Reduction in airway surface liquid layer --\> impaired ciliary function + retention of mucopurulent secretion --\> chronic infections
* Defective cystic fibrosis transmembrane conductance regulatory --\> decreased inflammation + defence against infection
* Intestines
* Thick viscus meconium is produced--\>meconium ileus
* Pancreatic duct
* Becomes blocked by thick secretions --\> pancreatic enzy def + malabsorption
* Sweat
* Abnormal function of sweat glands --\> excess sodium and chloride in sweat
32
Treatment of CF
**_General_**
* MDT approach
* Annual review in specialist center
* Aim --\> prevent disease progression in lungs, maintain nutrition + growth
* More severe CF means reg IV access --\> may need central venous catheter with subcutaneous port
**_Resp management_**
* Young children assesed w/ symptoms older children w/ spirometry
Medication
* Continuous prophylactic antibiotics usually flucloxacillin
* Rescue antio-biotics if symptoms worsen
* Persistent Sx require vigorous IV antibiotics (can be done at home if parents know how)
* Chronic pseudomonas infections are real bad for lung function use daily nebulised antipseudomonal antibiotics to help e.g. colistin
* DNAse or hypertonic saline nebulised can help w/ mucus clearance, viscosity + resp exacerbations (only hyper saline)
* Giving macrolide antibiotics like azithromycin regularly reduce the amount of resp exacerbations b/c immunomodulation effect
Physio
* From diagnosis should happen at least twice daily, done by parents or child themselves depending on age
Lung transplantation
* Only option for end stage CF
* Outcome 50% 10 yr survival
* Hardcore assessment of comorbs etc.
**_Nutrition_**
* Assessed regularly
* High calorie diet 150% normal --\> to achieve overnight gastrostomy feeding regularly used
* Meds
* Panc insufficiency --\> oral enteric coated pancreatic replacement therapy taken w/ meals + snacks
* Most also require fat soluble vit supplements
33
Clinical features of epiglottitis
* Acute onset
* High fever
* Toxic looking child (isn't that all children haha lol)
* Intense painful throat --\> child can't speak/swallow/drool saliva
* Soft insp stridor
* Resp distress Sx develop over hours
* Child usually sitting immobile w/ open mouth --\> optimise air intake
34
Causes of stridor/upper respiratory obstruction and how to differentiate them
CHECK WELLS NOTES
Possible causes of stidor/upper respiratory obstruction in children
* Croup - most common
* Preceeding coryzal Sx
* Severe barking cough
* afebrile
* Harsh rasping stridor
* Epiglottitis
* Develops over hrs
* No cough
* Not able to drink + drooling saliva + reluctant to speak
* Febrile
* Soft stridor
* Less likely in yrs 1-6 because of vaccine
* Bacterial tracheitis
* Preeceding coryzal Sx/URTI
* Develops over hrs
* Cough
* Toxic looking child
* Febrile
* Copious thick airway secretions
* Loud harsh stridor
* Inhaled foreign body
* Sudden onset resp distress
* Choking
* Recently eating peanuts/playing w/ small toys
* No fever
* No previous Sx
* Otherwise well
* Airway malacias (congenital weak bronchial cartildge)
* Recurrent/ continuous stridor since birth
* Anaphylaxis
* Recent provocative food
* Rash
* Wheeze
* Inhaled smoke/hot air from fire
* Hx of smoke inhlalation/ fire parents may smoke
* Cough
* SOB
* Irritated eyes
* Red skin
* Soot in nostrils
* Headache
* Changes in mental state
CHECK WELLS NOTES
35
Importance of otitis media, causative organisms + treatment
**Importance**
* Serious complications: mastioditis (can lead to hearing loss, brain abscess, meningitis+ blood clot) + meningitis
* Chronic infections --\> Effusion --\> Conductive hearing loss
**Causative Organisms**
* Viral
* RSV
* Rhinovirus
* Bacteria
* Pneumococcus
* H influenza
* Moraxella catarrhalis
**Treatment**
* Regular analgesia --\> paracet Ib profen
* Usually self resolving, antibiotics e.g. amox can reduce duration but are mainly given as a perscription for the parents
* Decongestants + antihistamines are not useful
36
Parental advice caring for otitis media
* Do not put oil/Q-tips/ear drops in ear
* Most caused by viruses therefore antibiotics won't help
* Give ib profen/paracetamol regularly not PRN
* Usually resolve in 3 days by themselves
* If your child has hearing loss that persists for more than 6 weeks see a doctor
* Refer to NHS website
* Hospital/GP/111 if Sx persist, change, get worse
37
Natural Hx + common causative organisms of tonsilitis
**Causative organisms**
* Group A beta-haemolytic streptococci
* Estein-Barr virus
**Natural Hx**
* Intense inflammation of tonsils --\> soar throat
* Purulent exudate
* Earache
* Temp
* Cough
* Other Sx more indicative of bacterial
* Headache
* Lethargy
* Abdo pain
* Cervical lymphadenopathy
38
Parental advice caring for tonsilitis
* Usually viral --\> antibiotics may not help (can hasten recovery in severe)
* Can give reg para + ib profen
* Usually resolves in 4 days
* Fluids
* Rest
* May need to go to hospital if can't eat/drink
* Refer to NHS website
* Hospital/GP/111 if Sx persist, change, get worse + difficulty breathing
39
What conditions does URTI infection include
Coryza
Pharyngitis
Tonsilitis
Acute otitis media
Sinusitis
40
Causative organisms + naturual Hx of UTRI
Natural Hx
* Nasal discharge/blockage
* Fever
* Painful throat
* Earache
Causative organisms
* Rhinovirus
* Coronavirus
* RSV
* Adenovirus
* Enterovirus
* Group A beta-haemolytic strep
* Epstein-Barr virus
* RSV
* Pneumococcus
* H influenzae
* Moraxella catarrhalis
41
Physiological consequences of fever, treatment + indications for/against
**Physiological consequences**
* Used to fight infection
* Frebile seizures (most important)
* Theres a lot of other effects on a variety of organs, don't think this is crazy important but if it is here's a link to a page on it https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4944485/
**Indications for treatment**
* \<3months w/ non specific clinical features
* Risk factors for infection high
* Illness in family/contacts
* Unimmunised
* Recent travel abroad
* Contact w/ animals
* Immunodeficient
* \>38 if \< 3months
* \>39 if 3-6 months
* Pale, mottled, blue
* Reduced level of conscioussnes, neck stiff, bluging fontanelle, status epilepticus, focal neuro signs/seizures
* Significant resp distress
* Bile stained vomit
* Severe dehydration/shock
* Rash? is it a nasty one?
* Focal infection signs o/e
**Treatment options**
* Manage at home w/ IB profen and paracetamol w/ instructions of when to come in. Do not give antipyrexic agents if child is otherwise well.
* Septic screen
* IV antibiotics
* \> 3months third gen cephalosporin e.g. cefotaxime, ceftriaxone
* 1-3 months cefotaxime (in case meningitis), ampicillin (in case listeria)
* Aciclovir if herpes is suspected
* Supportive - do not undress
42
Parental advice how to care for an URTI
* Most will pass w/out needing treatment in 1-2 wks
* Most are viral and therefore antibiotics won't help
* Ib profen + paracetamol will help pain
* Rest
* Fluids
* Hospital/GP/111 if Sx persist, change, get worse + difficulty breathing
43
Caustive organisms + natural Hx of viral croup (laryngotracheobronchitis)
**Causative organisms**
* Parainfluenza virus (commonest)
* Human metapneumovirus
* RSV
* Influenza virus
**Natural Hx**
* 6month-6yrs, peak 2yrs
* Most common in autumn
* Preceeded by coryzal Sx + fever
* Turns into barking cough, harsh stridor + hoarsness
* Worse at night
44
Treatment of viral croup
**When to admit**
Child can usually be managed at home if: upper airway obstruction is mild + stridor&chest recession disappear at rest.
Admit according to time of day, easr of access to hospital, low threshold for admitting \< 12 months
**Medication + Oxygen**
* Oral dexamethazone, oral prednisolone, nebulised steriod, reduce severity, duration of croup and need to admit
* Severe upper airway obstruction - nebulised adrenaline w/ oxygen via facemask --\> transient improvement
* Closely monitor w/ anaesthatist due to possible rebound Sx after adrenaline wheres off in 2hrs
Warm moist air has shown no benefit
Only a few children require intubation
45
Parental advice caring for croup
* Do not need admitting if - upper airway obstruction is mild + stridor&chest recession disappear at rest.
* Warm moist air has little effect
* Oral dexamethazone (corticosteriod), oral prednisolone, nebulised steriod, reduce severity, duration of croup and need to admit
* Sit child upright
* Comfort them --\> crying makes Sx worse
* Plenty of fluids + rest
* Refer to NHS website
* Hospital/GP/111 if Sx persist, change, get worse + child has difficulty breathing
46
Management of choking child
If they can cough
1. Encourage them to cough
2. Monitor
If they can't cough
1. Conscious
1. 5 back blows
2. 5 thrusts --\> chest for infant (like CPR), abdo if \>1 yr
2. Unconscious
1. open airway
2. 5 breaths
3. cpr
If child \<1 hold in arm angled down
47
Clinical features of bacterial tracheitis
* Fever
* Toxic appearance
* Stridor
* Tachyopnoea
* Resp distress
* Frequent non-painful cough
* Radily progressive
* Copious thick airway secretions
48
Danger of and emergency managment of burns and smoke inhalation
**Danger of**
* Children burn at a lower temp b/c thinner skin
* Smaller airways + lungs --\> easier to asphyxiate + affect a significant part
* Monoxide poisoning
* Children have a smaller surface area --\> easier to burn large areas + loose heat
**Emergency management**
* ABC
* Was there smoke inhalation?
* Yes monitor in hospital + low threshold for airway protective action
* Depth of burn?
* Full thickness reqiure hospital admission + skin graft
* Surface area of burn
* 5% full thickness or 10% partial thickness require burns specialist
* 70% any thickness poor prognosis
* Involvement of special sites
* Face --\> disfigured
* Mouth --\> obstruction from odema
* Hand/joint --\> loss of function
* Perineum
* Principles of treatment
* Analgesia
* IV fluids for shock
* Wound care (cling film)
