Breathing difficulties

Question 1

Signs of resp. distress in a child

Answer 1

· Intercostal recession

· Subcostal recession

· Tracheal tug

· Grunting

· Nasal flaring

· Tripoding

Question 2

Normal respiratory rates in children

Answer 2

Neonates: 30-60

<1 year: 30-53

1-2 years: 22-37

3-5 years: 20-28

6-11 years: 18-25

12-15 years: 12-20

Question 3

Differential diagnosis if a child has stridor

Answer 3

1. Croup: barking cough, fever
2. Foreign body aspiration: sudden onset, choking, no fever
3. Epiglottitis: drooling, very unwell/ septic, do not examine the child, ask re vaccinations
4. Bacterial tracheitis: harsh cough, chest pain, septic, no drooling, IV antibiotics and intubation needed
5. Anaphylaxis

Question 4

Varying severity of croup

Answer 4

• Mild: seal like barking cough but no stridor or sternal/ intercostal recession at rest

• Moderate: seal like barking cough with stridor and sternal recession at rest, no agitation or lethargy

• Severe: seal like barking cough with stridor and sternal/ intercostal recession associated with agitation or lethargy

• Impending respiratory failure: increasing upper airway obstruction, sternal/ intercostal recession, asynchronous chest wall and abdo movement, fatigue, pallor or cyanosis, decreased consciousness.

Degree of chest wall recession may diminish with the onset of resp failure as the child tires. Resp rate >70 indicated severe resp. distress

Question 5

How is croup managed?

Answer 5

Steroids: dexamethasone or prednisolone orally OR budesonide nebuliser

Severe croup or children with impending resp. failure may need adrenaline nebulisers and an anaesthetic/ PICU review

• Symptoms should improve in 1-3 days
• Viral so antibiotics don’t help

Question 6

What is bronchiolitis?

Answer 6

· Viral illness in children <2yrs of age causes oedema of airways with secretions +++

· Common causes: RSV, rhinovirus, adenovirus

· Causes crackles, wheeze and coryza

· Antibiotics, steroids and inhales/ nebulisers don’t work

· Treatment is supportive

· Gets worse over 5 days then improves

· Coryzal prodrome lasting 1-3 days followed by persistent cough, resp distress, wheeze/ crackles on chest

Question 7

Management of bronchiolitis

Answer 7

• Investigations: nasopharyngeal aspirate - identifies virus for cohorting purposes
• Provide oxygen to maintain sats >92%
• Support feeding with smaller more freq. feeds or NG feeds
• In severe cases use IV fluids, resp. support such as high flow oxygen, CPAP, intubation, CXR
• Who are at risk of severe bronchiolitis? <6 weeks, preterm birth, chronic lung disease, congenital heart disease, immunodeficiency

Question 8

What % of paeds admissions are due to resp. conditions?

Answer 8

Respiratory conditions responsible for 50% of all acute paeds admissions

Question 9

Why do children aged 1-6 tend to vomit when they cough?

Answer 9

Increased intra-abdo pressure when coughing and immaturity of the lower oesophageal sphincter

Question 10

Choanal atresia

Answer 10

Nasal passages blocked by bone or tissue

• 1/10,000 births
• Bilateral atresia presents with respiratory distress or cyanosis at birth
• Improves on crying because mouth is open
• Early surgery is needed to open the blockage with nasal stents inserted until the nasal passage heals

Question 11

Epidemiology of asthma in children

Answer 11

• Most common cause of wheeze in children
• Affects 1/10 children aged >5
• Boys affected more than girls
• Children can grow out of it

Question 12

What is Harrison’s sulci?

Answer 12

Question 13

Why do admissions for acute asthma exacerbations increase in stormy weather?

Answer 13

Thunderstorms cause large amounts of pollen to be released into the air

Question 14

Diagnosis af childhood asthma

Answer 14

• Diagnosis made on clinical information
• Symptom diaries can be helpful to ascertain the triggers
• Children too young to undergo lung function tests are given a trial of medication and asthma can be diagnosed if the medication relieves symptoms

Question 15

Overview of asthma management in children

Answer 15

• Medication given follows the pathway used for adults
• Relievers: reverse bronchoconstriction, short acting
• Preventers: inhaled steroids, reduce inflammation and reduce likelihood of bronchoconstriction
• MABs rarely used when symptoms are hard to control
• Inhaler technique checked at every appmt
• Younger children given medication through mask and spacer
• Parents advised to stop smoking

Question 16

Stepwise management of asthma in children

Answer 16

1. Short acting B agonist
2. SABA + low dose inhaled CS
3. SABA + CS + leukotriene receptor antagonist
4. SABA + CS + long acting B agonist (stop leukotriene if not helping - contrast to adult guidelines)
5. SABA + mild maintenance and reliever therapy (CS + LABA)
6. SABA + moderate dose maintenance and reliever therapy
7. SABA + increased ICS to high dose / trial of additional drug e.g. theophylline / refer to specialist

In children <5 years, refer to specialist when trial of leukotriene not successful

Question 17

Definitions of moderate - severe asthma attacks

Answer 17

2-5 years:

Moderate = >92% sats + no features of severe asthma

Severe = <92%, too breathless to talk, HR >140, RR >40, use of accessory muscles

Life-threatening = <92%, silent chest, poor resp effort, agitation, altered consciousness, cyanosis

>5 years

Moderate: >92% sats, PEF >50%, no features of severe asthma

Severe: <92%, PEF 33-50%, can’t complete sentence, HR >125, RR>30, use of accessory muscles

Life threatening: <92%, <33% PEF, silent chest, poor resp. effort, altered consciousness, cyanosis

Question 18

Management of mild - moderate acute asthma

Answer 18

Bronchodilator therapy

• give a beta-2 agonist via a spacer (for a child < 3 years use a close-fitting mask)
• give 1 puff every 30-60 seconds up to a maximum of 10 puffs
• if symptoms are not controlled repeat beta-2 agonist and refer to hospital

Steroid therapy

• should be given to all children with an asthma exacerbation
• treatment should be given for 3-5 days

Question 19

What is cystic fibrosis?

Answer 19

Inherited genetic disorder affecting the lungs and digestive tract

Associated with shortened life expectancy

1 in 25 Caucasian Europeans are carriers of a CF gene with approximately 1 in 2500 live births having CF

Question 20

Pathophysiology of cystic fibrosis

Answer 20

Mutation in a gene that codes for Cl- channel

Disruption in Cl- movement results in:

• thick mucous in airway
• blocked pancreatic duct >> pancreati insufficiency
• thick mucous in GI tract >> obstruction >> meconium ileus
• thick mucous in biliary tree >> cholestasis
• 98% males are infertile due to congenital absence of vas def

Question 21

What should be suspected in a child presenting with nasal polyps?

Answer 21

Cystic fibrosis

Question 22

Investigations for cystic fibrosis

Answer 22

• Chest radiograph: to assess for hyperinflation, there may be evidence of bronchial thickening (undertaken annually as part of annual assessment) Some units undertake CT scanning.
• Chloride sweat test (at diagnosis and annually if in receipt of CFTR potentiator/corrector therapy)
• Microbiological assessment e.g. cough swab/sputum sample (at every clinical encounter)
• Glucose tolerance test (at annual assessment at teenage and beyond)
• Liver function test and coagulation (at annual assessment)
• Bone profile (at annual assessment)
• Lung function testing – spirometry / lung clearance index

Question 23

Epidemiology and aetiology of cystic fibrosis

Answer 23

• Affects 1/2500-3000 live births
• Rare in Africans and Asians
• Autosomal recessive
• Result from defects in the cystic fibrosis conductance membrane regulator (CFTR) gene - this gene encodes a protein that regulates chloride movement (along with water) across epithelial surfaces
• Defects in the gene cause mucous, sweat and pancreatic cells to produce thick and sticky secretions that damage the lungs and affect the GI tract
• 1/25 people carry one mutation so two people with the recessive allele need to produce an individual with CF

Question 24

Clinical features of cystic fibrosis

Answer 24

• Respiratory problems
• Persistent wheeze
• Persistent mucous and resulting bronchiectasis
• Bowel problems from birth
• 20% of babies have meconium ileus - bowel obstruction as a result of thickened meconium that cannot be passed
• Thick secretions from the pancreas prevent absorption of fat-soluble vitamins leading to malnourishment and failure to thrive
• Loose-offensive smelling stools
• Usually detected following newborn screening

Question 25

What is measured during newborn screening for cystic fibrosis?

Answer 25

Cystic fibrosis blocks pancreatic enzyme ducts and prevents trypsinogen from draining effectively and this causes its concentration to increase in the blood So, serum concentration of immunoreactive trypsinogen is measured If levels are high, in combination with CF DNA mutations a sweat test is carried out, **the sweat test is the gold standard test for CF.** CF is diagnosed when a high chloride concentration (\>60mmol/L) is detected in the sweat

Question 26

Complications of cystic fibrosis

Answer 26

General: failure to thrive, salty taste to skin, clubbing Respiratory: persistent wheeze, bronchiectasis, nasal polyps GI and nutritional: meconium ileus, loose stools, bloating and pain, rectal prolapse, pancreatitis, cholestasis, fat soluble vitamin deficiency Metabolic: hyponatraemic and hypochloremic dehydration, DM

Question 27

Management of cystic fibrosis

Answer 27

* MDT approach * Aims to prevent bacterial colonisation of the airways, prevent chest infections, preserve pulmonary function, prevent non-pulmonary complications of CF * Genetic counselling helps patients understand condition, inheritance pattern and help family adjust to living with the condition or risk **Physiotherapy** * Exercise to clear the secretions and prevent chest infections * Chest physio is given daily, usually by parents * Mucolytics to break down the mucous * Inhaled hypertonic saline * Bronchodilators **Nutrition** * Weight gain and good nutrition correlate with good lung function and improved survival * Children with CF have malabsorption and abnormal pancreatic secretions so they need a high fat and high calorie diet with pancreatic enzyme replacement * Impaired pancreatic function can also lead to diabetes, this is treated with insulin **Antibiotics** * When CF is diagnosed children are started on prophylactic flucloxacillin to prevent a staph chest infection * Patients with CF need antibiotics for long periods of time in high doses to ensure their sputum is infiltrated with the antimicrobial * Chronic pseudomonas aeruginosa infection is associated with deterioration of lung function and poor prognosis so is treated aggressively * Chronic pseudomonas is treated with nebulised daily antibiotics **Gene therapy** * Area of research, aim is to replace the abnormal gene with a normal one

Question 28

Prognosis of cystic fibrosis

Answer 28

* Median lifespan is 40yrs * Lung transplant can prolong survival and QoL

Question 29

What is bronchiolitis?

Answer 29

Viral infection of the lower resp tract that affects bronchioles and alveoli * **_Respiratory syncytial virus causes 80% of cases_** * Other causes: adenovirus, influenza and parainfluenza

Question 30

Symptoms of bronchiolitis

Answer 30

* Dry cough progressing to productive * Difficulty breathing * Poor feeding * Audible wheeze * Apnoea can occur in small babies * Head and neck: nasal flaring, nasal discharge, tracheal tug * Chest: tachypnoea, tachycardia, widespread crepitation, prolonged expiratory phase with wheeze, intercostal recession, subcostal recession * Abdo: palpable liver edge due to lung hyperinflation * Fever

Question 31

Risk factors for development of severe bronchiolitis

Answer 31

* Age \<6 weeks * Preterm * Other lung conditions * Congenital heart disease * Immunocompromised * Neuromuscular problems

Question 32

What is the natural hx of bronchiolitis?

Answer 32

Worsening symptoms up to day 5-7 and resolution by day 10

Question 33

Management of bronchiolitis

Answer 33

* Supportive unless children aren't able to take 50% of their normal feeds in which case they are sent to hospital * Oxygen given if hypoxic * Babies given feeds via NG tube to reduce feeding effort * Feeding stopped if children are in significant resp. distress because of risk of aspiration * CPAP for children with worsening hypoxia, exhaustion or apnoeas

Question 34

Prognosis of bronchiolitis

Answer 34

* Children recover well * Cough can continue for weeks * Obliterative bronchiolitis is a rare form of the condition caused by an adenovirus infection - it causes chronic inflammation and scarring of the bronchioles and ongoing oxygen is needed, often for years

Question 35

Epidemiology of bronchiolitis

Answer 35

* Most common cause of a serious lower respiratory tract infection in \< 1yr olds (90% are 1-9 months, with a peak incidence of 3-6 months). Maternal IgG provides protection to newborns against RSV * higher incidence in winter

Question 36

When to immediately refer a patient with bronchiolitis?

Answer 36

NICE recommend immediate referral (usually by 999 ambulance) if they have any of the following: * apnoea (observed or reported) * child looks seriously unwell to a healthcare professional * severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute * central cyanosis * persistent oxygen saturation of less than 92% when breathing air.

Question 37

Epidemiology of pneumonia in children

Answer 37

* 40/1000 children under the age of 5 in Europe

Question 38

Most common organisms responsible for pneumonia in children

Answer 38

* Strep pneumoniae most commonly causes CAP * Viruses: respiratory syncytial virus, parainfluenza * Bacteria: strep pneumoniae, mycoplasma, haem influenzae, staph aureus

Question 39

Clinical feataures of pneumonia

Answer 39

* Tachypnoea * Fever * Cough * Difficulty breathing * Crepitations over the site of pneumonia * Abdo pain can sometimes be the only sign of pneumonia

Question 40

How is pneumonia diagnosed?

Answer 40

Clinical signs usually CXR nit often needed

Question 41

Management of pneumonia

Answer 41

* Home treatment with antibiotics, antipyretics and analgesics * Children with severe symptoms admitted for IV antibiotics and oxygen * If continuing beyond 48hrs a chest x-ray is needed to exclude parapneumonic effusion because it could become infected and cause empyema

Question 42

What is pertussis?

Answer 42

AKA whooping cough * Bacterial respiratory tract infection causes by Bordetella pertussis * Pertussis vaccine has reduced incidence * Occurs in older children as vaccine wears off * Droplet transmission

Question 43

Clinical features of pertussis

Answer 43

* 100 day cough - cough persisting past 3 months * Deep inspiration at end of coughing spree sounds like a whoop Stages of the illness: * Catarrhal stage: cough and runny nose 1 week * Paroxysmal stage: cough, whoop, face congestion, cyanosis, apnoea, vomiting 2 weeks * Convalescent stage: cough gradually subsides 3-12 weeks

Question 44

Management of whooping cough

Answer 44

* Supportive, with oxygen if needed * **Clarithromycin can be given to prevent spread** * **No medication improves symptoms** * infants under 6 months with suspect pertussis should be admitted * in the UK pertussis is a notifiable disease * an oral macrolide (e.g. clarithromycin, azithromycin or erythromycin) is indicated if the onset of the cough is within the previous 21 days to eradicate the organism and reduce the spread * household contacts should be offered antibiotic prophylaxis * antibiotic therapy has not been shown to alter the course of the illness * **school exclusion: 48 hours after commencing antibiotics (or 21 days from onset of symptoms if no antibiotics)**

Question 45

Complications of whooping cough

Answer 45

* subconjunctival haemorrhage * pneumonia * bronchiectasis * seizures

Question 46

Prognosis of whooping cough

Answer 46

Major complications and death can occur mainly in those \<6months * Bronchopneumonia * Weight loss due to vomiting * Cerebral hypoxia and haemorrhage * Pneumothorax due to coughing * Around 10 deaths per year in the UK

Question 47

Transient tachypnoea of the newborn

Answer 47

* Commonest cause of respiratory distress in the newborn period. It is caused by delayed resorption of fluid in the lungs * It is more common following Caesarean sections, possibly due to the lung fluid not being 'squeezed out' during the passage through the birth canal * Chest x-ray may show hyperinflation of the lungs and fluid in the horizontal fissure

Question 48

Acute epiglottitis

Answer 48

Acute epiglottitis is rare but serious infection caused by *Haemophilus influenzae* type B. Prompt recognition and treatment is essential as airway obstruction may develop. Epiglottitis generally occurs in children between the ages of 2 and 6 years. The incidence of epiglottitis has decreased since the introduction of the Hib vaccine **Features** * rapid onset * unwell, toxic child * stridor * drooling of saliva Diagnosis is made by direct visualisation (only by senior/airway trained staff, see below). X-rays may be done, particularly if there is concern about a foreign body: * A lateral view in acute epiglottis will show swelling of the epiglottis - the 'thumb sign' * A posterior-anterior view in croup will show subglottic narrowing, commonly called the 'steeple sign' **Management** * immediate senior involvement, including those able to provide emergency airway support (e.g. anaesthetics, ENT) * endotracheal intubation may be necessary to protect the airway * if suspected do NOT examine the throat due to the risk of acute airway obstruction * the diagnosis is made by direct visualisation but this should only be done by senior staff who are able to intubate if necessary * oxygen * intravenous antibiotics