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Paediatric Respiratory Week 2s Teaching Series Made by:Felicia Chiu PaediatricRespiratoryConditions URT LRT Other • Anaphylaxis • CysticFibrosis • Asthma • Croup • Bronchiectasis • Kartagener’s Syndrome • Epiglottitis • Bronchiolitis • Respiratory distress syndrome • Laryngomalacia • Pneumonia • Obstructivesleep apnoea • Inhaled foreign body • Pertussis Wheezevs Stridor vsStertor Stertor– Nasal/PharyngealAirway Wheeze – LowerAirway • Obstructivesleep apnoea • Asthma • Bronchiectasis Stridor – UpperAirway • Bronchiolitis • Anaphylaxis • Pneumonia • Croup • Epiglottitis • Laryngomalacia • Pertussis Anaphylaxis KEY FACTS • Most commoncause inchildren isfood(nuts) DEFINITION CLINICAL SIGNS • Suddenandrapidprogressionofsymptoms in • Airwayproblems- Swelling ofthe throat Airway,BreathingorCirculation andtongue→ Hoarsevoice andStridor • Medical emergencycausedbya severetype 1 • Breathingproblems- Respiratorywheeze, (IgE) hypersensitivityreaction Dyspnoea • Circulationproblems–Hypotension, Tachycardia • Pruritis MANAGEMENT • Widespreaderythematous/ urticarial rash • IM Adrenalineevery5mins in anterolateralaspectofmiddlethird ofthigh COMPLICATIONS Afterstabilisation • Nonsedating oralantihistamines INVESTIGATIONS • despite2 doses ofadrenalinetoms persist • Adrenalineautoinjector • Clinical • IV fluids + IVadrenaline • Specialistallergy clinic • Serumtryptase sometimes taken–they remainelevatedforupto12 hrs followan • Beforedischargekeep biphasic acuteepisodeofanaphylaxis reactions inmind! Croup KEYFACTS • Peak incidence 6 months –3 years CLINICAL SIGNS DEFINITION • More commoninautumn • Barking cough(Seal like) • Stridor • URTI usually causedby parainfluenza virusesleading to oedema in thelarynx • Worse at night and trachea • Fever • Othercauses areRSV, adenovirus, • Coryzalsymptoms influenza • Increased work ofbreathing MANAGEMENT st • 1 line- Singledose ofOral Dexamethasone(0.15mg/kg) regardless ofseverity • 2 line–Prednisolone INVESTIGATIONS EmergencyMx for severe croup • Clinicaldiagnosisusually • High-flowoxygen • CXR: • Nebulisedadrenaline Steeple sign–Subglottic narrowing Epiglottitis KEYFACTS • Do NOT examine the throat due to the risk CLINICAL SIGNS of acuteairway obstruction → get senior help • Rapidonset DEFINITION • Pyrexia • Inflammationand swelling of epiglottis andadjacent • Generallyunwell supraglottic structures caused • Stridor byHaemophilusinfluenzae typeB • Drooling ofsaliva • ‘Tripod'position MANAGEMENT • Immediateseniorinvolvement (anaesthetics,ENT)- Endotracheal intubation to protectthe airway • Oxygen • IV Ceftriaxone + Vancomycin INVESTIGATIONS • Directvisualisation(onlybyseniortrainedstaff) via nasopharyngoscopy/ laryngoscopy • X-rays- lateralshows swelling ofthe epiglottis - 'thumbsign'Questiontime!A 10-year-old girlisbroughttoA&Eafter attendinga picnicata friends’house. She developedswellingofhis tongue andthroat aftereating andwas brought tothe hospitalvia ambulance. Onexamination, she presents withwidespreadurticaria, stridor anda bloodpressure of93/55mmHg withaheart rateof129/min. Hersymptomsimproveafter receiving intramuscular adrenalineand is currently being observed What is themostappropriate investigationtoconfirm the suspecteddiagnosis? • SkinPrickTest • PathergyTest • CXR • Serummastcelltryptase • IgE bloodtestA 10-year-old girlisbroughttoA&Eafter attendinga picnicata friends’house. She developedswellingofhis tongue andthroat aftereating andwas brought tothe hospitalvia ambulance. Onexamination, she presents withwidespreadurticaria, stridor anda bloodpressure of93/55mmHg withaheart rateof129/min. Hersymptomsimproveafter receiving intramuscular adrenalineand is currently being observed What is themostappropriate investigationtoconfirm the suspecteddiagnosis? • SkinPrickTest • PathergyTest • CXR • Serummast cell tryptase • IgE bloodtestA 7-month-old boy presentstoA&Eaccompaniedby hisgrandadwithaweekhistory ofcoughandlow- grade fever.Thegrandaddescribes thecoughas aseal sound. Hehas completedallthevaccinationstodate. Onexamination, you observesuprasternalwall retractionat rest,but thechildlooks alert andreactive. You canhear stridor atrest. What is themostappropriate managementplan? • Admit topaediatricward • Dischargewithdexamethasone • Dischargewithprednisolone • Dischargewithsafetynetting • Urgent referraltoanaestheticsA 7-month-old boy presentstoA&Eaccompaniedby hisgrandadwithaweekhistory ofcoughandlow- grade fever.Thegrandaddescribes thecoughas aseal sound. Hehas completedallthevaccinationstodate. Onexamination, you observesuprasternalwall retractionat rest,but thechildlooks alert andreactive. You canhear stridor atrest. What is themostappropriate managementplan? • Admitto paediatricward • Dischargewithdexamethasone • Dischargewithprednisolone • Dischargewithsafetynetting • Urgent referraltoanaestheticsA 12-year-old is brought intotheEmergency Departmentvia ambulanceaftersuddenly feeling very unwellwitha highfever anddifficulty breathing. Onexaminationyounotice shehas stridor, isdrooling andsitting forwards withher handsonher knees. What is themostcommoncauseofthis diagnosis? • Parainfluenzavirus • Haemophilus influenzae • Bordetella pertussis • Respiratory syncytialvirus • Adenovirus • RhinovirusA 12-year-old is brought intotheEmergency Departmentvia ambulanceaftersuddenly feeling very unwellwitha highfever anddifficulty breathing. Onexaminationyounotice shehas stridor, isdrooling andsitting forwards withher handsonher knees. What is themostcommoncauseofthis diagnosis? • Parainfluenzavirus • Haemophilusinfluenzae • Bordetella pertussis • Respiratory syncytialvirus • Adenovirus • Rhinovirus Laryngomalacia KEY FACTS CLINICAL SIGNS • Intermittentinspiratory stridor • Typically presentsat 4 weeks of DEFINITION agewith stridor • Worsenswhen supine,sleeping,orin presenceof URTI • Congenital abnormality of the larynx where the aryepiglotticfolds are • Severecases can presentwith acute shorter than normal – characteristic respiratory distress omega shape • Arytenoid cartilage areenlarged and softerthan usual MANAGEMENT • Usually resolves spontaneously by 2years old as muscles strengthen • Ifhypoxemic → Supplemental INVESTIGATIONS O2 • Flexiblefibreopticlaryngoscopy/ • Iflaryngomalacia persists bronchoscopy tracheotomy or supraglottoplasty may be neededPertussis(Whoopingcough) KEYFACTS CLINICAL SIGNS • Infantsareroutinelyimmunisedat 2, • Catarrhal phase → URTI 3,4 months and3-5 yearsfor symptoms DEFINITION whooping cough • Paroxysmalphase → Persistent • Pregnant women(16-32 weeks)are coughing, inspiratorywhoop, • Infectiousdiseasecausedby the offeredthe vaccine apnoea Gram-negativebacterium Bordetella • Convalescentphase→ Cough pertussis subsides Diagnostic Criteria • Cough≥14dayswithoutanother of:arentcause,andone ormore • Paroxysmalcough MANAGEMENT • Inspiratorywhoop • <6 monthsshouldbe admitted • Post-tussivevomiting • OralMacrolide if onset within 21 • Undiagnosed apnoeic attacksin days young infants • Abxprophylaxis forhousehold contacts COMPLICATIONS • School exclusion – 48hrs after • Subconjunctival haemorrhage Abx, or 21 daysfromonsetof Sx INVESTIGATIONS • Notifiable disease • Pneumonia • Nasal swabculture • Bronchiectasis • PCR andserology • Seizures InhaledForeignBody KEY FACTS CLINICAL SIGNS • Mostlikelytobe foundinthe right main • Signsofrespiratorydistress - bronchus asit iswider, shorter andmore tachypnea, nasalflaring, and DEFINITION vertical thanthe left retractions • CanaffecteitherURTor LRT,usuallyit affects theLRT • Cough • Stridoror wheeze • Usually<3 years • Dyspnoea • Choking • Vomiting MANAGEMENT COMPLICATIONS • If choking- 5 back blows oninfantor Heimlich manoeuvreonolder child INVESTIGATIONS • Button batteries(lithium) → rapid mucosaldamage, necrosisand • Endoscopy + IV antibioticsifabove • A-E perforation pylorus for extraction • X-ray • Magnets → perforation, necrosis, • Spontaneous passing if post pylorus fistulas • Bronchoscopy Bronchiolitis KEYFACTS • More severewithBronchopulmonary CLINICAL SIGNS DEFINITION dysplasia, Congenitalheart disease, or Cysticfibrosis • Coryzal symptoms first • Infection andinflammation of bronchioles • Peak incidence3-6 months andin Then • Mostly causedby Respiratory syncytial Winter • Dry cough virus • increasing breathlessness • Othercauses :mycoplasma, adenoviruses • Wheezing • Fineinspiratory cracklesmay be present • Feeding difficulties associated MANAGEMENT with increasing • Immediate hospital referral if childlooks seriously unwell (RR >60,cyanosis, apnoea,respiratory distress symptoms) • Supportive Management – HumidifiedO if sats <92%,feedingtube if needed,suction for excessive secretions INVESTIGATIONS • Immunofluorescenceof nasopharyngeal secretionsQuestiontime!A 4-year-old child is diagnosed withwhoopingcough. Thecoughstarted around10 daysago. What is the most appropriate antibiotictherapy? • Noantibiotics needed,dischargewithsupportive therapy • OralAmoxicillin • OralClarithromycin • OralLevofloxacin • OralCo-Amoxiclav • IV Vancomycin • IV GentamicinA 4-year-old child is diagnosed withwhoopingcough. Thecoughstarted around10 daysago. What is the most appropriate antibiotictherapy? • Noantibiotics needed,dischargewithsupportive therapy • OralAmoxicillin • Oral Clarithromycin • OralLevofloxacin • OralCo-Amoxiclav • IV Vancomycin • IV GentamicinWhichofthe followingstatementsregarding Bronchiolitisisfalse? • Peak incidence occurs at 3-6 months • Bronchiolitisismoresevere withcongenitalheart disease • Peak incidence occurs inAutumn • Bronchiolitisiscaused byRespiratorysyncytial virus • Coryzalsymptomsoccur firstWhichofthe followingstatementsregarding Bronchiolitisisfalse? • Peak incidence occurs at 3-6 months • Bronchiolitisismoresevere withcongenitalheart disease • Peak incidenceoccursinAutumn • Bronchiolitisiscaused byRespiratorysyncytial virus • Coryzalsymptomsoccur firstA mother arrivestoA&Ecryingsaying that her 17-month- old girlisbreathing funny.Inyour history takingyou discover that shehadleftthe child alone playingwith Polly pocket dollsfor 3 minutestogotothe bathroomand returned toher childcoughingand lookingredintheface. Onexaminationthechildhas ceased coughing buthas an audible wheeze. Whereis thePolly pocket doll’sshoe most likely tobe found? • Left lowerlobe • Left mainbronchus • Right lowerlobe • Right mainbronchus • Trachea • LarynxA mother arrivestoA&Ecryingsaying that her 17-month- old girlisbreathing funny.Inyour history takingyou discover that shehadleftthe child alone playingwith Polly pocket dollsfor 3 minutestogotothe bathroomand returned toher childcoughingand lookingredintheface. Onexaminationthechildhas ceased coughing buthas an audible wheeze. Whereis thePolly pocket doll’sshoe most likely tobe found? • Left lowerlobe • Left mainbronchus • Right lowerlobe • Rightmain bronchus • Trachea • Larynx Summary • Covered commonpaediatricrespiratoryconditions including Anaphylaxis, Croup, Epiglottitis, Laryngomalacia,Pertussis, Bronchiolitis, andInhaledforeignbodies • Stertor vs Stridor vsWheeze • Ifyouhaveany questions, please letusknowand fill in thefeedback formto receivethe attendancecertificateand accessto thePowerPointon Medall • Followour Medall pagehttps://app.medall.org/c/university-of-nottingham-paediatric-societyThankY ou! Feedback Form + Certificateof attendance: