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Paediatric Respiratory Medicine Presented by Ashwitha Karnati FY1 DoctorContents Overview of Common Respiratory Conditions • Bronchiolitis • Croup • Bacterial Tracheitis • Acute Epiglottitis • Acute Asthma • Whooping Cough • Foreign Body Inhalation • Cystic FibrosisIntroduction • Respiratory conditions are extremely common • Typically present with some form of noisy breathing, including 1. Wheeze – expiratory, lower airway obstruction (asthma, bronchiolitis) 2. Stridor – inspiratory, upper airway obstruction (croup, epiglottitis, laryngomalacia) 3. Grunting – due to expiration against partially closed epiglottis (pneumonia) 4. Coughing (asthma, bronchiolitis, pneumonia) 5. Snoring (sleep apnoea)Signs of Respiratory Distress • Lower respiratory tract infection • Causes: Respiratory Syncytial Virus (RSV) during winter months (most common), mycoplasma, parainfluenza, adenoviruses Bronchiolitis • Infants < 12 months, typically 1- 6 months. • Signs: coryza precedes cough, low fever, tachypnoea, wheeze, inspiratory crackles, apnoea, intercostal recession ± cyanosis.Management: supportive treatment – oxygen to maintain saturations, limiting oral feeds to avoid tiring (? NGT), saline nasal drops for clearing secretions, bronchodilators for wheeze, antibiotics (? secondary bacterial infection, consider only if admitted - not routinely given) Prophylaxis: Palivizumab (monoclonal antibody to RSV) given to preterm babies and oxygen-dependent infants as a monthly IM injection to reduce risk of hospitalization and the need for mechanical ventilationCroup (aka laryngotracheal bronchitis) • Upper Respiratory Tract Infection, causing oedema in the larynx • Typically aged 6 months to 2 years, spring and autumn • Starts with runny nose, then barking cough, hoarse voice, often in early AM acute stridor • Causes: Parainfluenza virus, RSV, Influenza, Adenovirus • Croup used to be caused by diphtheria. Croup caused by diphtheria leads to epiglottitis and has a high mortality. Rare in developed countries due to During attacks it can help to sit the child up and vaccination programmes. comfort them. Measures should be taken to avoid • Croup is classified into mild/moderate and severe – Determines management spreading infection, for example hand washing and staying off school.Most cases can be managed at home with simple supportive treatment (fluids and rest). Oral dexamethasone is very effective (single dose of 150 mcg/kg, which can be repeated if required after 12 hours) Alternative is Prednisolone where dexamethasone in not available Stepwise options in severe croup to get control of symptoms: Oral dexamethasone Oxygen Nebulised budesonide Nebulised adrenalin Intubation and ventilationBacterial Tracheitis • Failure to improve with steroids/nebulized adrenaline should prompt the consideration of Bacterial tracheitis. • Caused by Staph Aureus • Presents similar to croup (with barking cough and stridor) but child will appear SEPTIC with high grade fever • Dtracheal mucosal sloughing that is not cleared byate and coughing, and risks occluding the airway. Pronounced tracheal tenderness may be present. • Call anaesthetist ASAP  benefits from early intubation, allowing pulmonary toilet and improved ventilation, broad spectrum abx (i.e. flucloxacillin for Staph infection)Acute Epiglottitis • Life threatening emergency – acute stridor • Caused by Haemophilus Influenzae B, less common now due to the vaccination programme • Will rapidly lead to airway obstruction • Presentation Suggesting Possible Epiglottitis - Patient presenting with a sore throat and stridor, Drooling, Tripod position, sat forward Muffled voice, Scared and quiet child, Septic and unwell appearanceing, • CALL THE ANAESTHETIST RIGHT AWAY – DO NOT EXAMINE treatment once the airway is secure: IV antibiotics (e.g. ceftriaxone), Steroids (i.e. dexamethasone) • development of an epiglottic abscess, which is a collection of pus around the epiglottis. This also threatens the airway, making it a life- threatening emergency. Treatment is similar to epiglottitis.If the patient is acutely unwell and epiglottitis is suspected, then investigations should not be performed. Acute Asthma • Combination of Bronchial inflammation, Bronchial hyperresponsiveness, Bronchoconstriction • Chronic Inflammatory disorder • Associated with stimuli – cold weather, dust, pollen, exercise (Important to take a detailed history to avoid future asthma attacks) • Ask about other atopic conditions – hay fever and eczema • Clinical Features: wheezing, dyspnea, cough, and chest tightness.**Do NOT be reassured by absence of a wheeze on ausculatation**Near Fatal Asthma •Acute asthma leads to tachypnoea and patients blow off CO2, leading to low PaCO2 on ABG •When patients become exhausted, their ventilation becomes so poor that CO2 begins to build up and their PaCO2 normalises again or even rises •This is a pre-terminal sign •Do NOT be reassured by normal CO2 on ABGAcute Asthma- Management (OHSHITME) Oxygen- 15L high flow oxygen through NRBM Help- call for senior help Salbutamol - back to back nebs (dosing according to age) Hydrocortisone IV/Prednisolone PO (if not life threatening) Ipratropium bromide - 4-6h nebs (dosing according to age) Theophylline  IV aminophylline or IV salbutamol Magnesium IV Escalate (anaesthetics) Common OSCE station – Counselling for InhalersViral Induced Wheeze or Asthma • Viral-induced wheeze describes is an acute wheezy illness caused by a viral infection. • Encounter a virus (RSV or rhinovirus)  inflammation and oedema of the airway walls  constriction of airway muscles  swelling and constriction of the airway caused by a virus has little noticeable effect on the larger airways of an older child or adult, however due to the small diameter of a child’s airway, the slight narrowing leads to a proportionally larger restriction in airflow. • Typical features of viral-induced wheeze (as opposed to asthma) are: Presenting before 3 years of age, No atopic history, Only occurs during viral infections • Asthma is historically a clinical diagnosis, and the diagnosis is based on the presence of typical signs and symptoms along with variable and reversible airflow obstruction. • Presentation Evidence of a viral illness (fever, cough and coryzal symptoms) for 1-2 days preceding the onset of: Shortness of breath, Signs of respiratory distress, Expiratory wheeze throughout the chest • Management of viral-induced wheeze is the same as acute asthma in children.Foreign Body Inhalation • Suspect in any child with sudden onset coughing, with history saying he/she was ‘playing with friends/family’ • An isolated sudden cough with normal other observations should make you suspect FB • Management: Rigid bronchoscopy (ENT) followed by prophylactic antibiotics for secondary pneumonia **Neither viral-induced wheeze or asthma cause a focal wheeze. If you hear a focal wheeze be very cautious and investigate further for a focal airway obstruction such as an inhaled foreign Right bronchi – more vertical and shorter – body or tumour. These patients will require an more likely to get foreign body lodged here urgent senior review.Whooping Cough CAUSE: Bordetella Pertussis (cases should be rare due to vaccination) vomiting, 100 day coughping sound between coughs, cough-induced INVESTIGATIONS: nasopharyngeal PCR test/anti-pertussis toxin TREATMENT: • Macrolide antibiotics: clarithromycin/erythromycin/azithromycin** NOTIFIABLE DISEASE- CONTACT PUBLIC HEALTH** • Prophylactic antibiotics for close contactsCystic Fibrosis • Autosomal recessive genetic condition affecting mucus glands. It is caused by a genetic mutation of the CFTR gene on chromosome 7.  • Screened for at birth with the newborn bloodspot test. Gold standard is the sweat test. by amniocentesis or chorionic villous sampling, or as a blood test after birth. • and obstruct the bowel)leus (in CF, meconium is thick and sticky, causing it to get stuck The key consequences of the cystic fibrosis mutation are: • Thick pancreatic and biliary secretions that cause blockage of the ducts, resulting in a lack of digestive enzymes such as pancreatic lipase in the digestive tract • Low volume thick airway secretions that reduce airway clearance, resulting in bacterial colonisation and susceptibility to airway infections • Congenital bilateral absence of the vas deferens in males. Patients generally have healthy sperm, but the sperm have no way of getting from the testes to the ejaculate, resulting in male infertilityStruggling to clear airway secretions  Perfect environment for bacterial colonization The key colonisers  Staph aureus and Pseudomonas. Patients with cystic fibrosis take long term prophylactic flucloxacillin to prevent staph aureus infection. Pseudomonas should be remembered as a particularly troublesome coloniser that is hard to treat and worsens the prognosis of patients with cystic fibrosis. Management  MDT approach (Chest physiotherapy, Exercise, High calorie diet, CREON tablets to digest fats in patients with pancreatic insufficiency (these replace the missing lipase enzymes), Prophylactic antibiotics, VaccinationsThank You Any questions?Resources for Finals •Passmed textbook •Geeky medics •Zero to Finals • Teach Me PaediatricsChronic Asthma Management