Respiratory System Paeds Flashcards
(131 cards)
1
Q
Major differences between infants and adults in anatomy
A
Neonates obligatory nasal breathers
Ribs more horizontal
Lungs less compliance
Chest wall more compliant
Bronchioles no cartilage, more vascular
Higher metabolic rates
2
Q
definition: pneumonia
A
Cough OR Difficulty breathing
AND
Tachypnoea
3
Q
Severe pneumonia
A
Chest indrawing or recession (respiratory distress)
4
Q
Very severe pneumonia
A
Cyanosis
Inability to drink, vomiting ++
Lethargy, convulsions, reduced LOC
Severe respiratory distress
5
Q
Respiratory distress
A
Nasal Flaring
Accessory muscle use
- Sternocleidomastoid
- Scalene
- The head bobs forward during inspiration and falls back during exhalation
Recession
Grunting: Exhaling against a closed glottis
CYANOSIS
6
Q
Recession
A
Subcostal
Hyperinflation – diaphragm flattened
Intercostal
Sternal
Supraclavicular
Suprasternal (tracheal tug)
7
Q
Grunting
A
Exhaling against a closed glottis
Attempts to prevent smaller airway/alveolar collapse during expiratory phase
Increase end expiratory pressure
8
Q
Bronchovesicular Breathing
A
- Higher pitched on inspiration, early low pitch in expiration
- Inspiratory phase is equal in length to the expiratory phase
- No pause inbetween inhale and exhale
- Normal in children
9
Q
Vesicular Breathing
A
Soft, low-pitched, fade away in inspiration
Normal in axilla & lung bases
Inspiration>Expiration 2:1
No pause
10
Q
Bronchial Breathing
A
“blowing” harsh howwlow
Consolidation
Lung/lobar collapse with bronchi patent
Large superficial cavity
Lung compressed by pleural fluid
Distinct pause between inhale and exhale
11
Q
Diminished/Absent Breath sounds
A
“associated with dull or resonant percussion”
Pleural effusion
Pleural thickening
Collapsed lung/lobe with bronchi occluded
Pneumothorax
12
Q
Stertor Breath sounds
A
”snoring sound”
Obstruction of the nasal turbinates/nasopharynx/ oropharynx/hypopharynx
13
Q
Causes of Stertor Breath sounds
A
(Rhinitis Infective/Allergic)
Adenoidal hypertrophy
Midface hypoplasie/Choanal atresia
Foreign body
14
Q
Stridor
A
Harsh, high pitched
Narrowing of the extra-thoracic large airways – mostly on inspiration
Severe – both phases
15
Q
Causes of Stridor
A
Acute laryngotracheo-bronchitis
Epiglottitis
Retropharyngeal abscess
Anaphylaxis
Foreign body
Laryngomalacia
Vocal cord paralysis
Subglottic stenosis
16
Q
Wheeze
A
Continuous musical sound during expiration
Air forced through a partially obstructed lower airway
Mild – only in expiratory phase
Severe – Inspiratory and expiratory
“silent chest”
17
Q
Causes of a wheeze
A
Intrathoracic large airways
Foreign body
TB nodal compression
Small airways
Bronchiolitis
Viral induced wheezing
Asthma
18
Q
Crackles/Crepitations
A
Fine inspiratory – collapse of the distal airways
(rub hair in front of your ear)
Coarse insp/exp – air bubbling through mucous/fluid in larger airways
19
Q
Causes of crackles
A
Pneumonia/Bronchiolitis
Atelectasis
Bronchiectasis
20
Q
Nosocomial Pneumonia
A
LRTI in hospitalised patient acquired between 48-72 hrs after admission or within 2 weks of discharge
21
Q
Ventilator-associated Pneumonia
A
LRTI acquired 48 hours or more after intubation & ventilation, that wasnt present before.
22
Q
Investigations and Diagnosis of pneumonia
A
6 in total
- Diagnosis is clinical
- Pulse oximetry in all
- CXR : if child requires hospital admission AP, lateral if suspicion of possible TB
- Blood cultures – not routine. If fail to improve in 24-48 hrs or complication
- Arterial blood gas if severely distressed
- Other investigations: FBC, HIV, TB work-up, U&E, inflammatory markers
23
Q
Most common causative organisms pneumonia
A
Bacterial pneumonia(Community Acquired) - Streptococcus pneumoniae
Viral pneumonia – up to 80% under 2 years of age – esp RSV
24
Q
causative organisms pneumonia <2yrs
A
- Bacterial: Gram negative, Group B Strep, Staphyloccus aureus, Chlamydia trachomatis, TB
- Viral: RSV, human metapneumovirus, parainfluenza, adenovirus, influenza, rhinovirus.
- Suspect Staphylococcus if breakdown, effusions, lung abscess, empyaema, remain pyrexial >48 hrs
25
causative organisms pneumonia 2-5yrs
Bacterial: Streptococcus pneumoniae, Haemophilus influenza, S. aureus, TB
Viral: RSV, human metapneumovirus, parainfluenza, adenovirus, influenza, rhinovirus
26
causative organisms pneumonia >5yrs
Bacterial: same as 2mo-5yrs; also atypicals: Mycoplasma, Chlamydia
(no viral on the slides eish)
27
causative organisms pneumonia immunocompromised
Usual organisms AND
Bacteria:
- TB, other Mycobacteria eg MAI,
- Gram positive: Staph, Strep;
- Gram negative: non-typhoid Salmonella, E.coli, Klebsiella,
Viral: CMV, VZV, other
Fungal: Pneumocystis jiroveci, Candida
28
Indications for hospital admission:
pneumonia
<2 months of age
Cyanosis
Hypoxaemic (O2 sats <92%)
Respiratory distress
Grunting
Stridor
Decreased LOC
Severe malnutrition
Caregiver unable to provide care or to return if deteriorates
29
Antibiotics Pneumonia
High dose amoxicillin – 30mg/kg/dose 8hrly
Due to increasing pneumococcal resistance to beta-lactam antibiotics
>5 years: azithromycin for atypical
Duration of therapy: 5-7 days uncomplicated CAP, 3-5 days atypical pneumonia, 14-21 days for complicated pneumonia
30
Antibiotic therapy: CAP
*Table
<3 months: Ampicillin & Gentamycin ± Cloxacillin
>3 months: Ampicillin, Add Cloxacillin if not improved in 24–48 hrs
>5 years: Ampicillin ± Azithromycin
Immunocompromised: Ampicillin & Gentamycin ± Cloxacillin; Consider PJP (high dose Bactrim), CMV (ganciclovir), fungal (antifungal
31
Supportive therapy in pneumonia
Oxygen: nasal cannulae, face mask, high flow, CPAP, ventilation
Fluids: restrict to two-thirds maintenance – may have SIADH
32
What supportive therapy has no role in pneumonia
chest physiotherapy
cough syrups
nebulisations
steroids
33
Simple pneumonia
lobar pneumonia or bronchopneumonia
34
Complicated pneumonia
Parapneumonic effusion
Multilobar
Lung abscess/cavity
Necrotising pneumonia
Empyaema
Pneumothorax
Bronchopleural fistula
35
Mx Complicated pneumonia
Prolonged course of antibiotics often 14-21 days
Chest drain or pig-tail catheter
Surgery
Follow-up CXR – persistent symptoms, collapse, round pneumonia, any complication present
36
CXR findings of PARAPNEUMONIC PLEURAL EFFUSION/EMPYEMA
NO LUNG MARKINGS
DENSE OPACIFICATION
NO VOLUME LOSS
MEDIASTINUM PUSHED OVER
Clinical sx = Absent breath sounds
Dull percussion
37
Upper Respiratory Tract Infections plus causative organisms
- Rhinitis – Viral
- Otitis media – Bacterial (S. pneumoniae, H. influenzae)
- Tonsillitis – Bacterial (β-haemolytic streptococcus)
- Pharyngitis – Bacterial (Streptococcus)
- Sinusitis – Viral / Bacterial (S. pneumoniae, H. influenzae)
38
Lower Respiratory Tract Infections plus causative organisms
- Laryngotracheobronchitis – Viral (parainfluenza, measles)
- Tracheobronchitis – Viral
- Bronchiolitis – Viral (RSV)
- Pneumonia – Bacterial (H. influenzae, S. pneumoniae)
39
Acute Otitis Media what is it
painful infection of the middle ear that most commonly results from a bacterial superinfection with
Streptococcus pneumoniae, Haemophilus influenza, or Moraxella catarrhalis following a viral upper respiratory tract
infection.
under the age of 2 years acute onset sx
40
Sx of Acute Otitis Media
otalgia, fever, anorexia
* Otalgia/earache, commonly described as throbbing pain
* Hearing loss in the affected ear
* Fever
* Otorrhea in the case of a ruptured tympanic membrane (TM)
Typical presentation in infants
* Irritability
* Incessant crying
* Refusal to feed (anorexia)
* Repeatedly touching the affected ear
* Fever and febrile seizures
* Vomiting
41
signs of middle ear inflammation
bulging tympanic membrane,
erythema
42
Summarize the Mx of AOM
Mild unilateral infections can be managed without antibiotics, as they are often self-limiting.
Infections in
children under 6 months, bilateral AOM, or severe symptoms are usually treated with oral antibiotics.
43
Complications AOM
The most common complication is acute mastoiditis
- facial palsy
- labyrinthitis
- intracranial abscesses
- venous sinus thrombosis.
44
Diagnosis of AOM
Clinical
Pneumatic otoscopy or
tympanometry should be used to confirm the presence of an effusion.
Rule out other causes of hearing loss and otalgia
* Gram stain and culture of middle ear fluid
o Indication: patients who do not respond to initial therapy, acutely ill patients, and patients with immune
deficiencies
o Typically acquired through tympanocentesis: the extraction of middle ear fluid through a small-gauge needle.
45
Differential AOM
otitis media with effusion
chronic otitis media
foreign bodies
trauma
46
Indications for treatment of AOM
* Symptoms do not improve after 48–72 hours.
* Severe AOM
* Signs of severe illness in children
* Children ≤ 6 months
* Bilateral AOM in children < 24 months
* AOM with otorrhea not due to otitis externa
* All AOM in children with cochlear implants
47
Chronic Otitis Media
Chronic otitis media (OM) refers to a group of chronic inflammatory diseases of the middle ear, which often affects
children.
48
Chronic suppurative otitis media CSOM
persistent drainage from the middle ear through a perforated tympanic membrane lasting > 6–12
weeks
through a perforated tympanic membrane (TM)
< 15 years old
49
Presentation of CSOM
The condition is often seen in patients with a history of acute otitis
media with TM rupture and presents with painless otorrhea and conductive hearing loss.
o Painless, recurrent otorrhea (usually odorless; mucoid or serous)
o Conductive hearing loss → Weber test lateralizes to the affected ear
o Possibly development of concurrent cholesteatoma
o Fever is not typical and indicative of complications if it occurs.
50
Etiology CSOM
- bacterial infection following perforation of the tympanic membrane due to
o (Recurrent) acute otitis media
o Placement of ventilation tube
o Trauma
51
Pathophysiology of CSOM
infection secondary to translocation of bacteria of the external ear canal into the middle
ear through the perforated tympanic membrane
52
Dx CSOM
o Clinical diagnosis
o Otoscopy: visible defect of the tympanic membrane → confirmation of diagnosis
o Cranial CT or MRI: if complications are suspected
53
Rx CSOM
o Goal: restore integrity of the tympanic membrane, prevent permanent hearing loss
o Conservative treatment: rinsing of the ear; topical antibiotic (e.g., ciprofloxacin)
and steroid drops (e.g., dexamethasone)
o Surgical treatment: tympanoplasty with insertion of a graft
54
Complications of CSOM
Possibly life-threatening spread of infection
(e.g., meningitis, intracranial abscess, facial paralysis);
rarely occurs with adequate treatment
Tympanosclerosis
55
Tympanosclerosis
§ Scarring of the tympanic membrane due to recurrent ear infections or otitis media with
effusion
§ May be asymptomatic or lead to conductive hearing loss
§ White calcified plaques in the tympanic membrane seen on otoscopy
56
Otitis media with effusion effusion (glue ear)
chronic mucoid or serous effusion in the tympanic cavity in the absence of infection lasting for > 3
months
in toddlers after an episode of acute OM
eustachian tube dysfunction
57
OM with Effusion clinical fx
o May be asymptomatic
o Typically painless sensation of pressure in the affected ear
o Conductive hearing loss
o Speech and language impairment
58
Dx OM with effusion
o Best initial test: pneumatic otoscopy to assess the tympanic membrane
§ Intact TM
§ TM is opaque, yellow-colored, may be retracted
§ Air-fluid level behind the TM
§ Impaired mobility of the TM
o If pneumatic otoscopy is inconclusive: impedance tympanometry
o Persistent OME for > 3 months or speech impairment: audiometry
§ Conductive hearing loss of 20–40 dB
59
Rx OM with effusion
o Patients without speech impairment at the time of diagnosis: monitor for 3 months
o Patients with speech impairment or persistent OME at follow-up
§ Age < 4 years: placement of tympanostomy tubes
§ Age ≥ 4 years: placement of tympanostomy tubes and/or adenoidectomy
60
Rhinitis is the irritation and swelling of the mucous membrane of the nose. There are two main types: allergic rhinitis and nonallergic rhinitis.
61
allergic rhinitis
Allergic rhinitis is caused by a type 1 hypersensitivity reaction (IgE mediated) that leads
to inflammation of the nasal mucous membranes. Acute or chronic rhinitis caused by exposure to an inhaled allergen (e.g., dust, animal dander, mold
spores, plant pollen)
62
nonallergic rhinitis
Nonallergic rhinitis does not always involve an inflammatory
process, and it includes infectious rhinitis, atrophic rhinitis, vasomotor rhinitis, drug-induced rhinitis, occupational
rhinitis, gustatory rhinitis, hormonal rhinitis, and nonallergic rhinitis with eosinophilia syndrome (NARES). Infectious
rhinitis is most often secondary to an upper respiratory tract infection that manifests as rhinosinusitis.
63
Infectious rhinitis
Infectious
rhinitis is most often secondary to an upper respiratory tract infection that manifests as rhinosinusitis.
64
Atrophic rhinitis
Chronic rhinitis associated with atrophy and sclerosis of the nasal mucosa.
primary (idiopathic) or secondary (e.g., due to granulomatous diseases like syphilis, leprosy, SLE)
This form of rhinitis commonly manifests with a foulsmelling,
crust-filled nasal cavity and anosmia.
65
Presentation of NARES
nasal polyposis and hyposmia
66
o Recurrent episodes of sneezing, nasal congestion, rhinorrhea, and postnasal drip
o Itchy nose and throat
o Pale, boggy nasal mucosa with hypertrophic turbinates
o Nasal polyps are seen in 25–30%
o Cobblestone appearance of the posterior pharyngeal wall
o Allergic shiners: hyperpigmentation and edema of the lower eyelid as a result of venous congestion
o Allergic salute: a habit of wiping the nose with a transverse or upward movement of the hand
o Allergic nasal crease: a transverse hyperpigmented or hypopigmented line that is seen at the junction
of the lower third and the middle third of the nasal bridge, which is the natural crease formed when the
nose is pushed upwards by the allergic salute
o Adenoid facies
o Chronic allergic rhinitis can predispose the patient to recurrent sinusitis and/or otitis media.
67
Diagnostics in Rhinitis
o RAST (radioallergosorbent test): measures serum concentrations of IgE antibodies against a
specific allergen
o Prick test and intradermal test to identify the causative allergen
68
Mx of allergic rhinitis
§ Avoidance of allergen
§ Corticosteroid nasal spray (e.g., budesonide, fluticasone) first line Rx
§ Antihistamines
§ Intranasal (e.g., azelastine)
§ Oral (e.g., cetirizine, levocetirizine, loratadine)
§ Decongestants
§ Intranasal (α1-sympathomimetics such as phenylephrine, oxymetazoline,
xylometazoline, and naphazoline)
§ Oral (α1-sympathomimetics such as phenylephrine and pseudoephedrine)
§ Mast cell stabilizers (e.g., cromolyn sodium)
§ Intranasal anticholinergics (e.g., ipratropium bromide)
§ Leukotriene receptor antagonists (e.g., montelukast)
§ Immunotherapy
§ Surgical treatment: resection
of hypertrophic nasal turbinates to relieve
nasal obstruction in treatment-resistant rhinitis
69
Complications of long term corticosteroid nasal spray use
§ Increased risk of mucosal atrophy, nosebleeding, and septal perforation with longterm
use [8]
70
Gustatory Rhinitis
Episodic rhinitis with diffuse watery rhinorrhea associated with certain foods
71
Vasomotor Rhinitis
A type of nonallergic rhinitis caused by an increase in blood flow to the nasal mucosa
- Mostly idiopathic
- Irritant odors (e.g., cigarette smoke, perfumes, car exhaust)
- Temperature changes (e.g., cold and dry air, humidity changes)
- Certain drugs (e.g., aspirin, NSAIDs, alpha-1 blockers, beta blockers, OCPs)
- Emotional stimuli (e.g., anxiety, excitement
72
Nonallergic Rhinitis with Eosinophilia Syndrome (NARES)
Most common type of inflammatory nonallergic rhinitis.
Chronic eosinophilic rhinitis with development of nasal polyposis and hyposmia.
Most commonly occurs in middle-aged individuals.
Increased eosinophils in the nasal mucosa confirm the diagnosis.
Causes: Unknown.
73
Drug-Induced Rhinitis
Recurrent, nonallergic inflammation of the nasal mucosa associated with certain medications.
Causes:
Aspirin and other NSAIDs.
Antihypertensives (e.g., ACE inhibitors, clonidine, guanethidine, hydralazine, methyldopa).
Phosphodiesterase inhibitors (e.g., sildenafil, tadalafil, vardenafil).
Oral contraceptives.
Antipsychotics (e.g., risperidone, chlorpromazine).
Antidepressants (e.g., amitriptyline).
74
Rhinitis Medicamentosa
Rebound nasal congestion seen upon discontinuing intranasal sympathomimetics.
Occurs 5–7 days after use of topical decongestants
75
Hormonal Rhinitis
Rhinitis associated with hormonal imbalance.
Rhinitis of pregnancy usually starts during the second month and stops after delivery
76
Occupational Rhinitis
Rhinitis caused by exposure to irritants in the workplace.
77
Rhinosinusitis
Rhinosinusitis is a mucosal inflammation of both the paranasal sinuses and adjacent nasal cavities. Viral infections
are the most common cause of acute rhinosinusitis, with bacterial and fungal infections occurring less often.
78
Sinusitis Sx
purulent rhinorrhea, nasal obstruction, and facial pain.
79
Pansinusitis
inflammation of all sinuses on one or both sides
80
Acute sinusitis
inflammation of the sinuses for < 4 weeks
81
Subacute sinusitis
progressive symptoms of sinus inflammation occurring over 4–12 weeks; represents a
transition from acute to chronic infection
82
Chronic sinusitis
persistent symptoms of sinus inflammation > 12 weeks
83
Recurrent acute sinusitis:
four or more separate episodes of acute sinusitis that occur within 1 year, with at
least 8 weeks of symptom resolution between episodes
84
Rhinosinusitis
simultaneous inflammation of the nasal mucosa and sinuses
85
Rx rhinosinusitis
Acute rhinosinusitis: typically managed in an outpatient setting
o Uncomplicated viral rhinosinusitis is usually self-limiting.
o Uncomplicated acute bacterial rhinosinusitis (ABRS)
§ Treat with antibiotics or observe for up to 7 days before initiating antibiotics if follow-up is
assured.
* Acute invasive fungal rhinosinusitis: antifungal therapy (e.g., amphotericin B) and surgery
* Symptomatic treatmenr – nasal saline irrigation, oral analgesics, intranasal steroids and decongestants
86
Tonsilitis
Acute tonsillitis is an inflammation of the tonsils that frequently occurs in combination with an inflammation of
the pharynx (tonsillopharyngitis). The terms tonsillitis and pharyngitis are often used interchangeably, but they refer to
distinct sites of inflammation
Caused by viruses or group A streptococci (GAS).
They are characterized by the sudden onset of fever, sore throat, and painful swallowing.
87
Rx of Tonsilitis
normally self-limited. However, if GAS infection is confirmed via rapid antigen detection test and/or throat culture, treatment with antibiotics (most often penicillin) should be initiated to prevent rheumatic fever.
Tonsillectomy is a treatment option for recurrent and chronic tonsillitis
88
Complications of Tonsillitis
Peritonsillar abscess and parapharyngeal abscess are serious suppurative complications of acute bacterial tonsillitis and require
immediate treatment.
89
Clinical Fx of tonsilitis
Bacterial Tonsillopharyngitis
o Sudden onset of symptoms: fever, sore throat, dysphagia
o Significantly inflamed pharynx
§ Pharyngeal and/or tonsillar erythema and edema
§ Pharyngeal and/or tonsillar exudates (rare in children < 3 years)
§ Palatal petechiae
§ Excoriation of skin around the nostrils (more common in children < 3 years)
§ Scarlatiniform rash
o Cervical lymphadenitis
o Absence of cough
Acute viral tonsillopharyngitis
o Cough
o Coryza
o Rhinorrhea
o Oral ulcers, anterior stomatitis
o Conjunctivitis
o Diarrhea
o Absence of fever
90
Diagnosis of Tonsilitis
scoring systems (e.g., the modified Centor score) can be used to
estimate the likelihood of acute GAS tonsillopharyngitis based on clinical
features.
RADT Rapid Antigen Detection Testing
91
Rx of tonsilitis
self-limited; antibiotic therapy for acute GAS
pharyngitis recommended to prevent rheumatic fever.
Delay antibiotics if RADT is negative until receiving a positive throat culture result.
Viral is self limited symptomatic care
92
Causative organisms for Pneumonia
Bacteria
- Strep pneumoniae
- Haemophilus influenzae
- Staph aureus
- M TB
- Moraxella catarrhalis
Atypical bacteria
- Mycoplasma pneumonia
- Chlamydia trachomatis
- Chlamydia pneumoniae
Viruses
- Respiratory Syncytial Virus
- Human metapneumovirus
- Parainfluenza virus type 1 and 3
- Adenovirus
- Influenza A or B
- Rhinovirus
- Measles Virus
93
Causative organisms of pneumonia in HIV children
Bacteria
- non-typhoid salmonella
- klebsiella pneumo
- strep milleri
- E coli
- Methicillin resistant staph aureus
Fungi
- PJP
- Candida species
Viral
- CMV
- Varicella Zoster
94
<3 mo Pneumonia organisms
– Gram negative organisms
– Group B streptococcus
– Staphylococcus aureus
– Haemophilus influenzae
– Other atypical
* chlamydia, ureoplasma
95
3mo - 5yrs pneumonia organisms
– Streptococcus pneumoniae
– Haemophilus influenzae
– Staphylococcus aureus
96
>5yrs pneumonia organisms
– Streptococcus pneumoniae
– Mycoplasma pneumoniae
– Staphylococcus aureus
97
PJP in HIV children and pneumonia
Clinical signs of CAP are similar in HIV-infected
PCP is the most common and serious infection causing CAP commonly at 6 weeks - 6 months of age
PCP is frequently (20 - 40%) the initial presenting feature of AIDS in HIV-infected children not taking cotrimoxazole
prophylaxis.
98
Tetrad PJP sx
tetrad of features:
- tachypnoea
- dyspnoea
- fever
- cough
Hypoxia may be prominent and rapidly progressive.
99
Complications of Pneumonia
* Empyema
* Lung abscess
* Necrotising pneumonia
100
Exudative stage of Parapneumonic effusion in pneumonia
Simple, sterile, uncomplicated parapneumonic effusion. Pleural fluid have normal glucose
concentration, normal pH and a low cellular count.
101
Fibrinopurulent stage of Parapneumonic effusion
Bacterial invasion and fibrin deposition on the pleural surfaces. Pleural fluid pH and
glucose concentration decrease and LDH concentration increases. This progresses further and leads to
thickening of the exudate and pleura, with the formation of loculations.
102
Organizational stage of Parapneumonic effusion
A thick pleural membrane forms with a persistent pleural space with ongoing potential
for infection. Thoracentesis may yield a dry tap. This stage typically occurs two to four weeks after initial
development of the empyema.
103
Necrotising pneumonia
* Also termed cavitary pneumonia or cavitatory necrosis. Massive pulmonary gangrene, tissue liquefaction and
necrosis
* Diagnosis of NP can be suspected on CXR
– dense lobar consolidation and pleural effusion
* Chest CT is needed for a more definitive diagnosis.
104
Organisms of Necrotising pneumonia
* Streptococcus pneumoniae
* Staphylococcus aureus
* Mycoplasma pneumoniae,
105
Transfer and PICU admission Pneumonia
* Failure to maintain a saturation of > 90% on an FIO2 of > 70%
* If the partial pressure of arterial oxygen (PaO2):FIO2 ratio is < 100
* Apnoea
* Hypercarbia with resulting acidaemia (Ph < 7.25)
* Exhaustion
106
Croup
Acute Viral Laryngotracheobronchitis)
Age 6mo - 2 years of age, previously well child, fully immunised, with preceding upper
respiratory tract infection, develops mild fever, BARKING COUGH and gradually progressive inspiratory obstruction and is
otherwise well.
107
Diagnosis when all the symptoms look like croup but age is <4mo
Underlying congenital abnormality
108
Diagnosis when all the symptoms look like croup but sudden onset severe obstruction
Foreign body
109
Diagnosis when all the symptoms look like croup but incomplete immunization
diphtheria
110
Diagnosis when all the symptoms look like croup but dysphagia or sitting forwards
epiglottitis, retropharyngeal abscess
111
Diagnosis when all the symptoms look like croup but systemic toxicity, pyrexial, fever
epiglottitis, peritonsillar or retropharyngeal abscess, staph aureus bacterial tracheitis
112
Diagnosis when all the symptoms look like croup but oral ulcers or severe oral thrush
herpes or candida infection
113
Diagnosis when all the symptoms look like croup but aphonia and preceding hoarse voice
Laryngeal papillomatosis
114
Diagnosis when all the symptoms look like croup but history of previous intubation
post intubation injury with stenosis
115
Diagnosis when all the symptoms look like croup but repeated episodes
Spasmodic croup, anatomical/ functional abnormality, gastro-oesophageal reflux
116
Grading of Croup severity
The grading implies a predictable course/prognosis
1 = inspiratory obstruction
2 = " and passive expiration
3 = " and active expiration acces mm use
4 = cyanosis, apathy, retractions, impending apnoea
117
SUPPORTIVE MEASURES Croup
* Monitor oxygen saturation, heart rate and respiratory rate.
* Monitor the nutritional status and fluid requirements.
* Avoid arterial blood gas estimations, clinical criteria are more effective in determining severity.
* Depending on severity, admit child to high care or intensive care ward.
* Keep child as happy as possible as crying aggravates airway obstruction. Encourage parents to stay with
child at all times. Avoid suctioning or chest physiotherapy.
118
Medical treatment of croup ****Go chatgpt that table
119
child is less than 5 years old and the contact has Isoniazid mono resistant TB
Rifampicin 15mg/kg daily for 4 months may be
given
120
Indications for the evaluation of children for TB include:
o Exposure to a smear or culture positive case of PTB. TB contact
o Indication of TB infection (Mantoux 10mm in HIV-negative or 5mm in HIV positive children).
o Symptoms or signs suggestive of TB. *Chronic cough in children is NB sign of TB
121
Diagnostic test for TB
- Sputum should always be obtained in children presenting with a chronic cough
- Gastric
aspirations should be done in young children who are unable to expectorate sputum
- Culture: GeneXpert
122
Sx of TB in children
- chronic cough unresponsive to AB
- Fever of greater than 38°C for 14 days after excluding common causes such as malaria or
- weight loss
- failure to thrive
- lethargic abnormal behaviour
123
Signs that would require further investigations to exclude TB
* Painless enlarged lymph glands, most commonly in the neck, that do not respond to a course of antibiotics.
* Gibbus, especially if it is of recent onset
* Pleural effusions
* Pericardial effusions
* Abdominal ascites
* Non painful joint swelling or painful limbs and joints
* Meningitis not resolving on antibiotic treatment
* Other non-specific signs: night sweats, breathlessness, peripheral oedema
124
DANGER SIGNS IN LIFE THREATENING FORMS OF TB:
* Headache (especially if accompanied by vomiting), irritability, drowsiness, neck stiffness and convulsions
(signs of TB meningitis).
* Meningitis not responding to treatment, with a sub-acute onset or raised intracranial pressure.
* Big liver and spleen (signs of disseminated TB)
* Distended abdomen with ascites
* Breathlessness and peripheral oedema (signs of pericardial effusion)
* Severe wheezing not responding to bronchodilators (signs of severe bronchial compression)
* Acute onset of angulation of the spine (TB gibbus).
125
CXR of TB lungs
* Enlarged hilar region of the lung or a widened mediastinum due to enlarged hilar or mediastinal glands. These enlarged lymph
glands can occlude the airway resulting in collapse of a lobe.
* A parenchymal lesion can enlarge causing widespread opacification in a segment or lobe of the lung.
* Acute dissemination causes widespread fine millet-sized (1-2 mm) lesions (miliary TB).
* Pleural effusions
126
TB treatment failure
same in both HIV-infected and HIV-uninfected children noncompliance
with therapy, poor drug absorption, drug resistance
127
Oral steroids should be added to the treatment in children with the following forms of TB
* TB meningitis
* TB pericarditis
* Mediastinal lymph glands obstructing the airways.
* Severely ill children with disseminated TB (miliary)
128
Steroids in TB children name & dose
Prednisone 2 mg/kg orally, daily for 4 weeks
129
Role of Pyridoxine in treatment of TB in children
In children who are malnourished or HIV positive
to prevent and manage isoniazid (INH)-induced peripheral neuropathy
130
Presentation of CMV or PJP in HIV children
severe pneumonia requiring high concentrations of supplemental oxygen or ventilation. It is clinically and
radiologically not possible to differentiate between these two forms
Rx: co-trimoxazole and gancyclovir to which parenteral steroids are added
131
