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Respiratory Flashcards

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1
Q

Upper respiratory tract infections (URTI)

Examples

A
  • Common Cold (coryza)
  • Sore throat (Pharyngitis, including tonsilitis)
  • Acute otitis Media
  • Sinusitis (Relatively uncommon) - Headache, Facial pain
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2
Q

Upper respiratory tract infections (URTI)

Commonest Presentation

A
  • Nasal Discharge and blockage
  • Fever
  • Painful throat
  • Earache

May cause -
* Difficulty in feeding in infants, as their noses are blocked and this obstructs breathing.
* FEbrile convulsions
* Acute exacerbations of asthma

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3
Q

Sore throat (Pharyngitis)

Causes

A
  • Usually due to viral infections with respiratory viruses - Mostly adenovirus, enterovirus, rhinovirus. EBV, Corona
  • In older children, group A beta-hemolytic streptococcus is a common pathogen.
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4
Q

Tonsilitis

Causes

A

A form of pharyngitis where there is intense inflammation of the tonsils, often with a purulent exudate.
Common Pathogens:
* Group A beta- hemolytic streptococci
* EBV
Often difficult to distinguish between the two.
If bacterial - High fever, exudates

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5
Q

Tonsilitis

Mx

A
  • Antibiotics - Often prescribed for severe pharyngitis and tonsilitis
    Penicillin - 6hrly, dose depends on weight for children, 500mg for adults.
    Erythromycin if penicillin allergy.
  • In order to eradicate the organisms to prevent rheumatic fever, 10days of Rx is required.
  • Amoxicillin is best avoided.
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6
Q

Tonsilitis

Why is Amoxicillin best avoided?

A

It may cause a widespread maculopapular rash if the tonsilitis is due to infectious mononucleiosis.

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7
Q

Infectious Mononucleiosis (IMN)

Cause and C/F

A

Caused by EBV. Also known as kissing disease.
C/F:
* Fever
* Tonsilitis (Pharyngitis + generalised lymphadenopathy)
* May be associated with splenomegaly and less commonly hepatomegaly.
* Palletal petechiae - red spots in mouth

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8
Q

Infectious Mononucleiosis (IMN)

Ix

A
  • Increased Lymphocytes (atypical lymphocytes)
  • Positive Monospot test - Antibodies against EBV
  • Ab against EBV & heterophil Ab
  • Bone marrow biopsy - Normal
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9
Q

Infectious Mononucleiosis (IMN)

What is often similar to IMN?

A

ALL

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10
Q

Infectious Mononucleiosis (IMN)

Similarities & Differences between IMN and ALL

A

Similarities -
* Atypical lymphocytes
* Generalised lymphadenopathy
* Tonsilitis
* Hepatomegaly

Differences -
* Bone marrow biopsy is normal in IMN, abnormal in ALL, Blast cells present.
* LN are tender and soft in IMN, LN are non-tender and firm/ hard in ALL.
* ESR is normal in IMN, ESR high in ALL

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11
Q

Infectious Mononucleiosis (IMN)

Indications for tonsillectomy

A

Children with recurrent tonsilitis are often refferred for removal of their tonsils, one of the commonest operations performed in children.
* Recurrent severe tonsilitis (as opposed to recurrent URTIs - atleast 4/year or >3times/year
* Peritonsilar abscess (quinsy)
* Obstructive sleep apnea (the adenoids will also normally be removed) - snoring

Generally tonsillectomy is avoided until 5yrs.
Many children have large tonsils but this in itself is not an indication for tonsillectomy, as they shrink spontaneously in childhood.
The adneoids increase in size until about the age of 8yrs and then gradually regress.

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12
Q

Infectious Mononucleiosis (IMN)

Indications for the removal of adenoids

A
  • Recurrent otitis media with effusion and hearing loss
  • Obstructive sleep apnea (an absolute indication)
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13
Q

Infectious Mononucleiosis (IMN)

Mx

A

Supportive care - PCM for pain, Salt H20 gargling.

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14
Q

Acute Otitis Media (OM)

Causes

A

Most common at 6-12M of age.
* Infants and young children are prone to acute OM because their eustachian tubes are short, horizontal and function poorly.
* Causative Organisms:
Viruses - Respiratory Syncytyl Virus (RSV), rhinovirus
Bacteria - pneumococcus (Strep. pneumoniae), H. influenza, Moraxella catarrhalis.

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15
Q

Acute Otitis Media (OM)

C/F

A
  • Fever and Ear pain (Every child with fever should have their ear examined)
  • Tympanic membrane is seen to be bright red and bulging with loss of the normal light reflection (Shiny appearance)
  • Occasionally, there maybe acute perforation of the ear drum with pus visible in the external canal.
  • There maybe ear discharge and even hearing loss due to conductive deafness.
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16
Q

Acute Otitis Media (OM)

Rx

A
  • Most cases of acute OM resolve spontaneously (Commonly when viral)
  • Pain should be treated with analgesics such as PCM or ibuprofen (NSAID, can cause peptic ulcers, Should be given with an antacid/PPI)
  • Antibiotics - Amoxicillin, Co-amoxiclav - 8hrly for 7days.
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17
Q

Acute Otitis Media (OM)

Complications

A
  • If recurrent, may result in otitis media with effusion (Glue ear), which may cause speech and learning difficulties from hearing loss.
  • Recurrent OM can also lead to chronic OM.
  • Serious complications are mastoiditis and meningitis (brain abcesses), but are now uncommon.
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18
Q

What is the most common chronic respiratory disorder in childhood?

A

Asthma

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19
Q

Childhood Asthma

Pathophysiology

A

A chronic condition caused by airway hyper-responsiveness to various stimuli, leading to reversible narrowing of the airway.
* Genetic predisposition, Atopy, enviormental triggers/ stimuli causes Bronchial inflammation.
* Bronchial inflammation leads to mucosal edema, excessive muscus production, infiltration with cells (eosinophils, mast cells, neutrophils, lymphocytes) and bronchial smooth muscle constriction.
* Results in bronchial hyper-responsiveness - Exaggerated ‘twitchiness’ to inhaled stimuli.
* Reversible airway narrowing leading to Sx:
Wheeze
Cough - Occurs in the morning or at night, non-productive cough.
Breathlessness
Chest tightness

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20
Q

Childhood Asthma

Enviormental triggers

A
  • URTI - Simple cough and cold
  • Allergens - house dust mite, grass pollen, pets
  • Smoking - active or passive
  • Cold air
  • Exercise
  • Emotional upset or anxiety
  • Chemical irritants - paint, aerosols
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21
Q

Childhood Asthma

Atopic Asthma

A

Recurrent asthma associated with evidence of allergy to one or more inhaled allergens.
Skin rash + asthma
It is stronglt associated with other atopic diseases such as eczema, rhinoconjunctivitis and food allergy, and is more common in those with a FHx of such diseases.

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22
Q

Childhood Asthma

C/F

A
  • Wheeze - Due to bronchoconstriction. A polyphonic (multiple pitch) noise coming from the airways believed to represent many airways of different dimensions vibrating from abnormal narrowing. It is an expiratory sound. It can be due to other causes other than asthma too.
  • Chronic cough, SOB, chest tightness, Diurnal pattern.
  • In long standing asthma there maybe hyperinflation of the chest, generalized polyphonic.
  • Onset of the disease in early childhood may result in Harrison sulci.
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23
Q

Childhood Asthma

Harrison Sulci

A
  • Due to early childhood onset of asthma
  • Abnormality of chest
  • Abdomen may invaginate into thorax.
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24
Q

Childhood Asthma

Features associated with a high probability of a child having asthma

A
  • Sx worsen at night and in the early morning.
  • Sx that have triggers - exercise, pets, dust, cold air, emotions, laughter
  • Interval Sx - Sx between acute exacerbations
  • Personal or FHx of an atopic disease
  • Positive response to asthma therapy.
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25
# Childhood Asthma Ix
A clinical Dx Usually Ixs are not needed but Ix are done to exclude D/d or see the severity of Asthma. * CXR - to rule out the presence of a pneumothorax or a Foreign body. * PEFR - peak expiratory flow rate. * FBC - may show eosinophilia * Arterial Blood Gas (ABG) - Done in acute or severe asthma.
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# Childhood Asthma How is PEFR carried out?
In standing position. Take a deep breath, lips sealed on peak flowmeter and blow, **Forcefully & Fast**. Done 3 times. Highest value is taken. Done for children >5yrs. Normal value depends on age, weight, sex, height. It is important to Dx asthma and check response to Rx.
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# Childhood Asthma Mx
Aim of management is to allow the child to lead as normal a life as possible, by controlling Sx and preventing exacerbations, optimizing pulmonary function, while minimizing Rx and side-effects. Mx of asthma involves mx of acute episodes and long term Mx. **Acute Mx:** * Identify whether it is acute severe asthma or life threatening asthma. * Start O2 via face mask * Start nebulisation with salbutamol (2.5mg if <2yrs. 5mg if 2-5yrs) * If no response, add ipratropium bromide with salbutamol. * Corticosteroids should be given Prednisolone 1-2mg/kg if the child can swallow or IV hydrocortisone 4mg/kg if not. * If still no improvement - IV MgSO4 50mg/kg (+ monitor for S/E). * If still no improvement, Start IV bronchodilators - IV aminophylline/ IV salbutamol Aminophylline 10mg/kg bolus over 1hr followed by 5mg/kg/hr infusion (bolus not given if the patient is already on theophylline) * If the child is going in to respiratory arrest - Intubation **Long-term Mx:** * Depends on the severity * Is with reliever medications and preventive medication.
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# Childhood Asthma Acute Severe Asthma C/F
* Too breathless to talk or feed * Can't complete sentences in one breath * Use of accessory neck muscles * RR: 2-5yrs - >50/min, >5yrs - >30/min * Pulse: 2-5yrs - >130/min, >5yrs - 120/min * Peak flow <50% predicted or best value. * Is type 1 respiratory failure.
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# Childhood Asthma Life threatening Asthma C/F
* Silent chest * Cyanosis * Poor respiratory effort * Decreased RR * Bradycardia and hypotension * Peak flow <33% predicted or best value * Altered conciousness * Oxygen saturation <92% * Is type 2 respiratory failure
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# Childhood Asthma Reliever Medication types
Relieve Sx (bronchodialators) * Short acting beta 2 agonists (SABA) - salbutamol, terbulaline * Anti-cholinergics - ipratropium bromide * Corticosteroids - hydrocortisone
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# Childhood Asthma Preventive Medication types
Prevents attacks * Inhaled steroids - budesonide, beclomethasone, fluticasone * Long acting b2 agonists - salmeterol * Methylxanthines - theophylline * Leukotriene inhibitors/ receptor modulaor- Montelukast, Sodium chromoglycate
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# Childhood Asthma Mild intermittent asthma, C/F and Mx
Frequency of signs and Sx during day <=2 per week Frequency of signs and Sx at night: <=2 per month Mx: Inhaled SABA (salbutamol) as and when needed - Blue color inhaler
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# Childhood Asthma Mild persistent asthma, C/F and Mx
Frequency of Sx and signs during day: >2 per week but not every day Frequency of Sx and signs at night: >2 per month Mx: Inhaled SABA (salbutamol) as and when needed - Blue color inhaler + Low dose inhaled steroids for prevention - Brown color inhaler (Eg: Beclomethasone)
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# Childhood Asthma Moderate Persistent Astma, C/F and MX
Frequency of Sx and signs during day: Once a day Frequency of Sx and signs at night: >1 per week Mx: Inhaled SABA (salbutamol) as and when needed - Blue color inhaler + Medium dose inhaled steroids or Low dose inhaled steroids & LABA (salmeterol) - Eg: Salmeterol and Fluticasone - Purple color inhaler
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# Childhood Asthma Severe persistent asthma, C/F and Mx
Frequency of Sx and signs during day: Continual Frequency of Sx and signs at night: Frequent Mx: Inhaled SABA (salbutamol) as and when needed - Blue color inhaler + High dose inhaled steroids and LABA (salmeterol)
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# Childhood Asthma Complications
**Medical Complications:** *Acute - * * Respiratory Distress, which lead to respiratoy arrest * Pneumothorax * Respiratory alkalosis *Long term -* * Growth Failure, due to chronic disease * Reduced capacity to withstand respiratory tract infections * Adverse effects of medication (steroid inhalation) - Oral candidiasis - Wash mouth thoroghly after using. **Social complications:** * Social stigma and stress of having a chronic disease * Cost of medication, hospital visits * Psychological
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# Childhood Asthma Types of inhaler devices and care
* <2yrs - Metered dose inhaler (MDI) + baby haler * 2-5yrs - MDI + Spacer device (with face mask until 3yrs) * 5-8yrs - MDI alone * >8yrs - Dry powder inhaler (DPI) In MDI, mother should keep count of doses, cannot wait until there is no more spray from inhaler. Because there is another chemical that facilitates delivery of the medication which may remain even after medication is over, which itself can trigger asthma. Spacers are replaced - generally 6monthly, maximum 1yearly Washing is done under running water and air dried - No scrubbing
38
What is the most common serious respiratory infection of infancy (<1yr)?
Bronchiolitis Rare after 1yr of age, but can occur upto 2yrs.
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# Bronchiolitis Causes
* Respiratory syncytial virus (RSV) - 80% of cases. * Others - Human metapneumovirus, parainfluenza virus, rhinovirus, adenovirus, influenza virus, *Mycoplasma pneumoniae*
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# Bronchiolitis C/F
* Sharp, dry cough, No sputum * Tachypnea * Subcoastal and intercostal recessions - features of difficulty in breathing * Hyperinflation of chest - due to air trapping Prominent sternum Liver displaced downwards * Fine end-inspiratory crackles (crepitations) * High-pitched wheezes (Rhonchi) - expiratory>inspiratory * Tachycardia * Cyanosis or pallor * Apnea in infants <4M * Coryzal Sx (URTI) may precede bronchiolitis - Cough, cold, runny nose.
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# Bronchiolitis Risk fators for severe bronchiolitis
* Prematurity - Bronchopulmonary dysplasia * Underlying lung diseases (Eg: Cystic fibrosis) * Congenital heart disease
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Differences on auscultation between pneumonia, asthma and bronchiolitis
Pneumonia - Crepitations only Asthma - Rhonchi only Bronchiolitis - Both
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# Bronchiolitis Dx
Clinical Xray changes: * Hyperlucent blackish lung fields * Horizontal ribs * Flat diaphragm
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# Bronchiolitis Mx
Supportive * Humidified O2 * Monitor for apnea * Fluids - IV or via NG tube * Antibiotics - given if child has gotten secondary bacterial infection. * Steroids and nebulized bronchodilators such as salbutamol or ipratropium - Not proven to be effective, can be given, May work for some, may not for others. * There is a place for hypertonic (3%) saline nebulization.
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# Bronchiolitis Prognosis
Most recover from the acute infection within 2W. However, as many as half will have recurrent episodes of cough and wheeze.
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# Bronchiolitis Prevention
A monoclonal antibody to RSV for high risk infants, but is costly - IM palivizumab. Not given in SL
47
# Croup Pathophysiology of Croup
* mucosal inflammation * increased secretions affecting the airway * edema of the subglottis area
48
# Croup MOs causing Croup
* Viruses- parainfluenza, RSV, influenza, human metapneumovirus
49
# Croup Most common MO causing croup
Parainfluenza virus
50
# Croup Age group
6 months to 6 years. Most common in the second year of life
51
# Croup Clinical features
* Barking cough * harsh stridor * mild fever * followed by coryza
52
# Croup Croup Sx may worsen during.....
night time
53
# Croup Mx
* Usually managed at home but monitored for acute severity * Steam inhalation * PO dexa, nebulized budesonide * severe croup- nebulized epinephrine w oxygen facemask * croup complicated w secondary bacterial infections- antibiotics
54
# Croup what measures can reduce the need for hospitalization
* PO dexa * nebulized budesonide (Pulmicort) Giving steroids can reduce the need for hospitalization
55
# Croup how is adrenaline given during severe croup
nebulized w oxygen facemask in hospital
56
# Croup What needs to be done while giving nebulized adrenaline during severe croup
monitor for adverse effects
57
# Pseudomembranous croup Pseudomembranous croup is also known as
bacterial tracheitis
58
# Bacterial tracheitis Sx
* high fever * appears toxic/ very ill * copious thick airway secretions * rapidly progressive airway obstruction
59
# Bacterial tracheitis MO
Staph aureus
60
# Bacterial tracheitis Mx
* IV ABx- flucloxacillin, cloxacillin, vancomycin * If needed intubate and ventilate
61
# Epiglottitis MO
Haemophilus influenzae type B
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# Epiglottitis major reason for >99% reduction in epiglottitis
Universal Hib immunization in infancy
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# Epiglottitis Pathophysiology
intense swelling of the epiglottis and sorrounding tissues w septicemia
64
# Epiglottitis age group
1-6 years commonly but can affect any age group
65
# Epiglottitis Sx
* **acute onset very high fever** * ill, toxic- looking child * very painful throat that prevents the child from speaking or swallowing-** drooling of saliva** * **soft **inspiratory stridor * rapidly increasing respi difficulty * child in tripod possition to optimize the airway
66
# Epiglottitis Mx
**Pediatric emergency** * urgent hospital admission * **do not examine the throat** * call ENT surgeon, anesthetist, pediatrician * transfer child immediately to the ICU or anesthetist room * intubate or if it fails urgent tracheostomy * once the airway is secured, take a blood culture,iv ABx (cefuroxime)
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# Epiglottitis Prophylaxis to family members
Rifampicin
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Difference between epiglottitis and croup
Croup * Onset - over days * Preceding coryza- yes * cough- severe, barking * able to drink- yes * Drooling of saliva - no * appearance- unwell * fever- <38.5 * Stridor- harsh, rasping * voice cry- hoarse Epiglottitis * Onset- over hours * Preceding coryza- no * Cough- absent/ slight * able to drink- no * Drooling of saliva- yes * appearance- toxic/ very ill * fever- >38.5 * stridor- soft, whsipering * voice cry- muffled, reluctant to speak
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