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Respiratory Paediatrics Dara O’Donoghue RBHSC/QUBRespiratory Paediatrics • Bronchiolitis • Croup • Asthma • Chronic Productive cough • Cystic Fibrosis • Obstructive sleep apneaBronchiolitisReferral • Apnoea • RR>60/min • Looks seriously unwell • Severe respiratory distress • Reduced oral fluid intake (50-75% of usual) - Grunting, marked chest • Clinical dehydration recession or RR>70/min • Persistent oxygen saturation <925 in • Central cyanosis room airCroupCroup • Treatment 0.15 mg/kg of dexamethasone • Budesonide nebuliser • Adrenaline nebuliser 2.5-5ml 1:1000 • Differential Diagnosis - Foreign body - Anaphylaxis - Tracheitis - Epiglottitishttps://what0-18.nhs.ukAsthmaERS Clinical Practice Guidelines for the diagnosis of asthma in children aged 5-16 years April 2021 • Asthma is a disease that includes the symptoms of wheeze, cough and breathing difficulty together with reversible airways obstruction, airway inflammation and bronchial hyperresponsiveness.Asthma therapyNational Review of Asthma Related Deaths • 1 Uk wide investigation of asthma deaths • Multiprofessional panel • 1 Feb 2012-31 Jan 2013 • 195 deaths • 14% <19 years The National Review of Asthma Deaths in the UK • Prescribing data in the year preceding death Prescriptions for ICS and/or ICS-combination inhalers • 14% of patients had not been prescribed an ICS inhaler Prescriptions for SABA inhalers (n=165) • 4% (6 patients) prescribed >50 inhalers Most patients were undertreated (n=128) 38% of patients had been issued <4 preventer inhalerss • Royal College of Physicians. Why asthma still kills: The National Review of Asthma Deaths (NRAD) 2014. AvailableBTS/SIGN 16Intervention – reminder electronic messages to collect preventer refillsCompliance • Repeat prescriptions • Smarthalers • Direct Observed therapy- schools • Remote direct observed therapy 18 Use of de • RBHSC uses dexamethasone 0.3 mg stat for acute asthma attacks • However no evidence that one has superior efficacy 1 1 • Dexamethsone is better tolerated ( less vomiting) • Dexamethosne is difficult to store in primary care children: a meta-analysis. Pediatrics. 2014 Mar;133(3):493-9ons inChronic Productive CoughChronic cough • Cough lasting > 4 weeks • Dry or productiveHistory • 4 ½ year old girl • Problematic cough for 1 year • Other noises? No – no wheeze or stridor • Audible loose cough throughout the consultation • Treatments tried • Clenil modulite and montelukast for 1 month • No improvement. Stopped and no deterioration • No oral steroids • Antibiotics x2 courses – no improvementPossible Diagnosis • Asthma – why not? • No wheeze • No response to treatment • Audible loose productive coughInvestigations • Spirometry normal • FeNO = 7ppbPossible Diagnosis • Asthma – why not? • No wheeze • No response to treatment • Audible loose productive cough • Diagnosis: Persistent bacterial bronchitis • Treatment: 4 week course Augmentin Duo • Review: excellent response!Persistent bacterial bronchitis • Wet cough in the absence of other diagnoses responds to antibiotic and recurs • Often treated with asthma therapy • Sputum/BAL • Haemophilus inf and Moraxella catarrhalis common • CXR –patchy/ bronchial wall thickeningSlides re PBBPersistent bacterial bronchitis • 2 -4 week course of antibiotics – 50% resolution • 15% will require 6 or more courses of antiobiotics • Strong association with large airway malacia • Can co-exist with asthma • Recurs- referPersistent bacterial bronchitis • ? Pre- bronchiectatic condition • Immune profile • Sweat test • Flexible bronchoscopy • Nasal Nitric Oxide- Primary Ciliary Dyskinesia • CT = ? bronchiectasisCystic Fibrosis Personalised medicine in CF • IVACAFTOR (KALYDECO) acts on transmembrane conductance regulator (CFTR) • Patients > 6 years old • At least 1 G551D mutation in the CFTR gene • LUMACAFTOR/IVACAFTOR ( ORKAMBI) • Patients >2 years • 2 copies of delta F508 mutationObstructive Sleep ApneaOSA • Snoring and restlessness at night a cause of ‘backwardness and stupidity in children’ • First case series published 1982 1 Hill 1889. On some causes of backwardness in children BMJ 2 : 771-2Who is at risk? Normal airway Normal airway Small airway Normal T+A Large T+A Normal T+A Examples of the oxygen saturation trend graphs from overnight oximetry tests: from top to bottom, categories 1 to 4 Nixon, G. M. et al. Pediatrics 2004;113:e19-e25 Copyright ©2004 American Academy of PediatricsTreatment of OSA in children • Adenotonsillectomy • Weight loss • Positional therapy • Nasal steroids, decongestants/ antihistamines, Montelukast • Nasal CPAPRespiratory Paediatrics Dara O’Donoghue RBHSC/QUB