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Paediatric Respiratory Crash Course Isis Hill + Oliver Biggs Increased respiratory rate Use of accessory muscles Subcostalrecessions Signs of Intercostalrecessions Respiratory Tracheal tug Distress in Head bobbing Children Nasalflaring Grunting Cyanosis • Starts as an URTI with coryzal Bronchiolitis symptoms • Half getbetter.Half get worse • Very commonconditionin babies • Chestsymptomslast7-10 days under 1. Particularly in Winter • Mostcommonlycausedby • Mostrecoverin 2-3 weeks respiratory syncytial virus (RSV) • Children who had bronchiolitis are • Causes inflammation and infection morelikely to have viral induced in the bronchioles. wheezein future. • Inflammation→ Mucus secretion → Narrowing → Reduced gasexchange Management • Why doesn’tit affectadults? • Conservative management • than adultslly much smaller airways • Saline nasal drops (WHY?) • Oxygen (Optiflow) • reduced lumen size → poorly babyto • CPAP Palivizumab - Monoclonal antibody to RSV • ICU Given to ex-prem + congential heart diseaseCroup • Very commoncondition in young children 6 months– 2 years. • Mostcommonlycaused by parainfluenza virus • Causesinflammationand oedemain the larynx. • Presents with respiratorydistress, barking cough,hoarse voice, stridor(BAD) Management • Usuallyimprovesin a couple of days • Conservative management • Oral dexamethasone is very effective.This is usually a single dose if required after12 hours.repeated • Acute wheezyillnessoften ViralInduced caused by aviral infection Wheeze • Viral Induced Wheeze • In children UNDER3 or Asthma? • Same pathophysiologyof bronchiolitis • Presentingbefore3 • Leads to anexpiratory yearsof age wheeze • No atopic history • Only occurs during • FH of asthma= chance of viral infections VIWin child and chance of asthmain later life Management • Acute asthmapathway • Cantrial a relieverinhalerif happeningwith every URTI Pneumonia Main Causes Infectionof lung tissue • Strep Presentswith: pneumonia • Unwell • Group B strep S • RSV E • Cough (wet + productive) P • Fever • Tachypnoea S • Tachycardia I • Increased WoB Management S • Confusion • SEPSIS7 • Abxoften amoxicillin • IV Abxmaybe needed • Oxygenis essential Anaphylaxis Trigger → IgE mediated→ Mastcell degranulation→ Histaminerelease→ A/B/C compromise AdrenalineDoses Anaphylaxisis a life-threateningmedical 1:1000 IM emergency.It iscaused by aseveretype1 0-6years = 150ug hypersensitivityreaction. Anaphylacticsymptoms 6-12years = 300ug Allergicsymptoms • Urticaria ANAPHYLAXIS CAN • SoB >12years= 500ug CAUSE DEATH IN • Wheeze • Itching • Stridor(laryngealoedema) • Angio-oedema LESS THAN 15 • Tongueswelling • Abdopain MINUTES • Tachycardia • Collapse Immediatemanagement Delayed management A– E approach toestablishdiagnosis Re-assess IMadrenaline Watchfor biphasic reactions Antihistamines Perform serum tryptaseblood test Steroids Education+ EpiPenOSCEstation You are an FY2 in the paediatric emergency department. Karen has brought her 6-month-old baby in as she is ‘very sniffly. On examination the baby is apyrexial, saturating well on room air, has a slightly elevated respiratory rate and very mild subcostal recession. Please take a focussed history and explain your management plan to Karen.Congenitalheartdisease • What is it? • a fault or problem with the heart that’s there from birth. This means it develops in the womb, before a baby is born. • Increased risk of developingif • Family history of CHD • Maternal diabetes • Maternal infection e.g. rubella during pregnancy • Alcohol use during pregnancy • Chormosomal abnormalities e.g. Down Syndrome, Turners Cyanoticdefects • Rightto leftshunt: de- oxygentatedblood goes intosystemic circulation (cyanosis) • Examples(5Ts) • TetralogyofFallot • Transpositionof greatarteries • Truncus arteriosus • Tricuspid atresia • Totalanomalous pulmonary vascularreturn AcyanoticDefects Left toright shunts: oxygenatedblood flows throughpulmonary circulation (no cyanosis) • Examples • Ventricular septal defect • Atrial septal • Patent ductus arteriosus • Coarctation of aortaPresentation Symptoms • Asymptomatic • Cyanosis - 'does you baby ever turn blue' • Poor feeding/ poor weight gain • SOB/breathing difficulties • Lethargic Clinical signs • Murmur • Thrills • Radiofemoral delay (coarctation of aorta)DiagnosisandManagement • Beforebirth • May be detected on USS during anomaly scan (20 wks) • Afterbirth • Symptoms may present immediately after birth e.g. turning blue (TGA) • Murmur may be detected during neonatal check • Echocardiogram • CXR • Management(dependson type) • Definitive: SurgeryOSCEstations • Cardiovascular examination with questions about CHD • Poor feeding hx • Lethargic/ SOB hx • Child turning blue hxAsthma <12 years Historyandpresentation Questionsto ask • Ageat onsetof symptoms:usually>3 years • Frequency of symptoms:symptomsshouldbeepisodic • Does the child have anyallergies? • Whattriggers the symptoms?(exercise,cold air, pets,damp,smoke) • Are there any risk factors? (family historyatopy,smokersin house) Symptoms • Expiratory wheeze? • Diurnal variation: aretheysymptomsworseatnightor early in themorning? • SOBon exertion: can theyrunas far as their friendswithout gettingsymptoms? • Severity: havetheymissedanyschool?Anyprevioushospitaladmissions?Examination • Look for inhalers/spacer/peak flow around beside? • Check observations e.g. O2sat,HR,RR • Is the child comfortable at rest? • Anyfeatures of atopic disease e.g.eczema? • Mostchildren haveno signs when they do not havean exacerbation • Dothey have anysigns of respiratory distress? • Tracheal tug,intercostalrecession, nasalflaring • Look at chest shape(hyperinflation in poorly controlled asthma),is there symmetricalchest expansion? • Is there equal bilateral air entry? Anywheeze? Silent chest?Diagnosis • In children <5, diagnosis is based off clinical judgement • Tests to help confirm asthma diagnosis in children >5 include- • Spirometrywithbronchodilatorreversibility:improvementin FEV1 by 12%is considered positive • FeNO:consider in children aged5-16if there is diagnostic uncertainty and they have normal spirometry or obstructive spirometrywith negativereversibility: FeNO of 35ppbispositive • Variablepeak expiratoryflowAll childrenwill receive anasthma plandetailinghowto use their inhalerand whattodo ifthey havean asthma attackMDItechniquewithouta spacer(revision) • Remove the cap • Shake the inhaler (depending on the type) In OSCE, demonstrate • Sit or stand up straight technique and then ask to • Liftthe chin slightly watch them do it • Fully exhale • Make a tight seal around the inhaler between the lips Poorinhaler technique leads to poorly • Take asteady breath in whilst pressing the canister controlledasthma! • Continue breathing for 3 - 4 seconds after pressing the canister • Hold the breath for 10 seconds or as long as comfortably possible • Wait 30 seconds before giving a further dose • Rinse the mouth after using a steroid inhalerMDItechniquewitha spacer(revision) • Assemble the spacer • Shake the inhaler (depending on the type) • Attachthe inhaler to the correct end • Sit or stand up straight • Lift the chin slightly • Make a seal around the spacer mouthpiece or place the mask over the face • Spray the dose intothe spacer • Take steady breaths in and out 5 times until the mist isfully inhaled • Extra points: mentionthey will have a personalised asthmaplan to refer to,safety net about signs of asthma attackAcuteAsthma Exacerbation Can't completesentences in one breath or toobreathless to talk/feed O2 sats <92% Severeasthma Peak flow 33-50% best exacerbation RR:> 40 (1-5years)or>30 (>5 years) HR: >140 (1-5years),>125(>5years) PEF <33%, O2 <92% Cyanosis Life-threatening asthma Hypotension exacerbation Exhaustion/confusion 33,92CHESP Silentchest(nowheeze) Poorrespiratoryeffort O – HighflowO2.Aimto achieve sats 94-98% S – Salbutamol NEB(5mg > 5 years, 2.5mg 2-5 years) H – POprednisolone.10 mg prednisolone (<2 years), 20 mg (2–5 years) and 30–40 mg (>5 years). Treatment for up to 3 days sufficient. I – IpratropiumbromideNEB(250 micrograms 2-12 years).Add this if symptomsrefractory to SABA Management T – Aminophylline.Onlyconsider in severe or lifethreatening asthma unresponsive to max doses of SABAand steroid. M – IVmagnesiumsulphate(40mg/kg/day) E - EscalatetoICUOSCEstations • Asthma hx • Explain asthma diagnosis to parent • Explain how to use an inhaler (MDI technique withand without a spacer) • Counsel parents who are concerned about giving their child a steroid due to side effect • Worried steroids reduce growth • Put intocontext that small doses reduce asthma exacerbations which would require high doses to treat • Poorl controlled asthma can also have a significant impact on growthCysticFibrosis What is it • an inherited(autosomalrecessive) diseasecaused by mutationsin genes thatproduce CFTR protein How this affects the body • CFTR normally allows the body to make thin and watery mucus • In CF, this protein is defective which results inthe production of thick, sticky mucus • This thick mucus clogs up the lungs and digestive tract. This also creates a place where bacteria caneasily grow- causing infections.Presentation • Chroniccough/wheezing/SOB • Thicksputumproduction • Recurrent respiratoryinfections(key colonisers staphaureusandpseudomonas) • Loose, greasy stools(due to a lack oflipase) • Abdominalpain andbloating • Jaundice • Poorweight andheight gain(failureto thrive) • (meconiumileus)--> alwaysasked ifthey passed a stoolafterbirth!Diagnosis • All babies are screened for CF as part of the newborn bloods spot test • If screening suggests the child may have CF, then they need confirmatory tests: • Sweattest:measuresthe amountof saltin sweat which is high in CF • Genetictest:blood or salivachecked for faulty geneT reatment • Currentlythere is nocure for CF there are manydifferent treatmentscurrentlyavailable. • Lifestyle • Exerciseimprovesrespiratoryfunctionand reserve, andhelpsclearsputum • vitamins.riediet to helpwith malabsorptionandinputfrom dietician.Supplementationoffat-soluble • Medical • Chestphysiotherapyseveraltimesa dayis essentialto clearmucusand reduce the risk of infectionand colonisation • missing lipase enzymes)atsin patientswith pancreaticinsufficiency(these replace the • Prophylacticflucloxacillintabletsto reduce the risk of bacterialinfections(particularlystaphaureus) • Bronchodilatorssuch assalbutamolinhalerscan helptreat bronchoconstriction • Vaccinationsincludingpneumococcal,influenzaandvaricella