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He's like confirmed that you can hear and see me now and see the slides. Um My name is Kristen. I am a current PS ST one. And today we're gonna be talking about some peds, rest conditions. These are the things we're gonna talk about. Um, we'll talk about them for about an hour or so. Um And then if there's time at the end, I've got some like extra questions and stuff. Thank you for the thumbs up in the chat. I appreciate it. Um So today we're gonna talk about generally the approach to respiratory distress in Children. We're then gonna talk about like the three main respiratory conditions that we see in Children. So that's bronchiolitis, viral induced wheeze and asthma. Um And then we'll talk about croup a little bit and very little bit about whooping cough as well. Um So throughout I've put a few SBA S to kind of test key learning points. Um So I'll give you a couple of minutes if you can go to vox.com and then put in this nice long number and I'll just give you a minute and why don't I also put this number in the chat. Cool. So if everyone is ready, we're gonna just start with that first question. Uh which is what are the signs of respiratory distress in Children? And I'll just wait for a couple of want us to come through. Cool, good. We're getting some good answers for you. If anyone can't access monster to wait it in the chat, then they're welcome to. Cool, great. I'm gonna stop it there. Uh You should be able to see the results in a second and we're getting some good answers. So main signs of respiratory to stress in Children, just as in adults. So tack it near a fast breathing rate. Um and then subcostal and intercostal recessions as well. Um And we'll look at some videos of that in a second. Um And then a few that are kind of more specific to Children um which are grunting, nasal flaring and head bobbing, which someone did say so well done. Great. Ok. So just want to show you some videos quickly. Um The Children who are experiencing difficulty breathing may sometimes suck the skin into their chest. So what you can see here is some like subcostal recessions and you can see a little bit of intercostal recessions as well. And then here you can see some tracheal tug and then here um I'll play the sound for a little bit. Um Just so you get an idea of what we're talking about. So this child is grunting. Um and I think that can be a difficult, it's, it's, it's a question you'll like often see, you'll often see grunting mentioned in questions and stuff like that. But actually working out what it is in real life is quite difficult. It is an expiratory noise and it means that um the child is having to work harder to get their air out and that's why they're making that like grunt noise. Um Just to say someone puts stride or as a first question as like an answer to the first question, it is a specific sign of respiratory distress in certain conditions, which we will talk about in a little bit, but it's not like a generic sign. Um Cool. And then when we're generally talking about an approach to an unwell child as well, um it's really important to be aware of this like um the nice guidelines for approaching fever in under five year olds. Um We're not going to talk about this in detail, but if you like Google the guideline or have a look at this table, um we can kind of risk stratify Children to like low, medium and high risk. Cool. So first thing we're gonna talk about is bronchiolitis and I have a question for you. Um So it should be open on vox and I'll give you about a minute. Um I can read it out as well if you like. Uh So we've got a five month old who's brought to A&E with our parents who are concerned about reduced feeding, a runny nose and a cough. What single feature most indicates the need for an inpatient admission. A, a respiratory rate of 50 b oxygen saturations of 92%. C mild intercostal recessions. D wheeze and crackles on auscultation or e having around 50% of their usual feeds. And I'll wait for a few more answers to come through. Ok. Just a few more seconds. All right, we're gonna stop it then. So the answer is e, having 50% of usual feeds. Um, and we will talk through why. Um, as we, like, go through the next slides, um, it's maybe like a bit of a controversial one. But, um, yeah, we'll talk about it generally. Um, in bronchiolitis, the acceptable oxygen saturation target is greater than 90%. Um, this is for a number of reasons. Some of them is kind of like practicality. Some of it is actually we, we over treat lots of people with too much oxygen anyway. Um, greater than 90 is specific for bronchiolitis. Although just a note that if you look at nice guidelines, er, they say that sats should be greater than 92% if a baby is less than six weeks old. Um, then looking at the other ones. So, respirator rate of 50 depending on the age, this is a five month old. It's a little bit high but it's, it's fine. It's, um, doesn't it's not the single feature that indicates the need for an inpatient admission, mild intercostal recessions. Again, it's kind of mild respiratory distress. It's not a clear cut. You would admit this patient, uh wheezing crackles on auscultation. You'd expect we'll talk about that in a second. Um, but having around 50% of usual feeds indicates that this child is at risk of getting dehydrated. So you would need to admit them um for some support with the feeding. So bronchiolitis, bronchiolitis is something we only really see in Children and small babies. Um It is unlike bronchitis, which is like inflammation of the bronchi or pneumonia where we've got um infection, inflammation of the lung, like the parenchyma, bronchiolitis is inflammation of the like small bronchioles in the lungs. And remember that those are much, much smaller when people are babies or toddlers. It is almost always caused by RSV sa respiratory syncytial virus. And actually bronchitis kind of follows these seasonal peaks where RSV is much more common in the population. It affects one third of Children in the first year of life. And it's a really common cause of being admitted to hospital as well. Typically see it between the ages of six weeks and two years old. It's a viral infection. It's, it's a bad cold basically and it affects Children and can be really serious because they're small. They have small airways and they basically just get filled with like mucus and they constrict because of the inflammation from that. But it kind of follows a period of about a week, two weeks and classically gets worse between days, three and days. Five. The key thing with bronchitis, it's a cold. We manage it conservatively. We just step in when we need to if babies need support with either feeding or breathing. So, clinical features of bronchitis is a cold. So you cough, you got a really blocked nose and a really runny nose fevers. These are generally low grade fevers, um difficulty feeding because babies are filled with snot and they can't like coordinate their breathing and their swallowing because they're so snotty. Um and subsequently, they've come dehydrated, uh also apnea. So episodes where they stop breathing and then obviously, like we talked about respiratory distress on examination, you get wheeze and crackles. So the crackles are kind of um because of all the mucus and the wheeze is because the airways are constricted um from the like inflammation. Um It is important to note here that this is not the same process that causes a wheeze as you see in asthma. So another question, um let's open it and then I'll read it out and we'll talk through each of these. Um I'm sorry for all the text here. So we've got a four month old child who presents to A&E with three days of cough and runny nose today. They have been struggling to feed and have only had around half of their usual water amounts on examination. They have moderate subcostal and intercostal recessions with some mild tricky or tug. Their saturations in air are 88% and they have a temperature of 38.2. What is the most appropriate plan for investigation and management? Um, I'll read through these answers but look at the differences between them and then you don't have to read them all. Er, so a start oxygen do a chest X ray. Consider opta flow. If that's a new word for you, don't worry, we'll talk about that in a second. Take bloods and start IV fluids and IV antibiotics. B start oxygen. Consider optic flow, insert an NG tube and place on two thirds maintenance via N GC. Start oxygen. Do a chest X ray. Consider C PAP, take bloods, give a 20 mil per kilo fluid bolus and start IV fluids. Uh start oxygen. Consider OPFL in certain NG tube and place on 100 and 50% maintenance via NG. Take bloods including a blood culture and have a low threshold for lumbar puncture. E start oxygen, consider nebulized salbutamol, insert an NG tube and place on two thirds maintenance via NG. Uh I appreciate that is me like a lot of words. So I'll give you maybe about 30 seconds and remember it's anonymous. So if you aren't sure, just click something and it doesn't matter. And if you have any questions about these, uh as we go, um, please just write them in the chart. Cool. Ok, 10 more seconds and then I'll stop. Ok, can stop there. So the correct answer is B start oxygen. Consider opt flow, insert an NG and place on 2000 maintenance via NG. Um, we'll talk about the management and then we'll come back to this question and we'll go through each one. So, investigations for bronchiolitis, like I said, it's a cold, it's a bad cold. Um, and it's serious. That doesn't mean it's not serious, but it's essentially a cold. We do not routinely do any investigations other than a swab. Uh, so an NPA A nasopharyngeal aspirate a nose swab, a throat swab, whatever for respiratory viruses. Sometimes. Um, if babies are in kind of respiratory distress, you would do a capillary blood gas in pediatrics. We do not do arterial blood gasses. Um, they are painful and horrible in adults. We do not do them in Children except for very, very rare circumstances. Um, you will some sometimes do a venous if you're getting venous access. But, um, most of the time you're doing capillary blood gas, that's just like you use a big version of a, the finger prick thing that you use for a glucose test and you do it on a heel in a baby or on a finger in a bigger child and you just get a tiny bit of blood and run it through the blood gas machine. You interpret it in a similar way, but obviously, the oxygen like a venous gas is uninterpretable. Um So we can do that in babies who might have a bit of respiratory distress. A high CO2 would indicate um that they're not effectively um like they're not having effect of gas exchange. Um And then you can also look at parameters of dehydration as well. So, like the sodium, you'd look at the lactate and also at the glucose. If you're really, really worried that they haven't fed very well. Um You would investigate a child with bronchiolitis if you thought they might have an alternative diagnosis. And if you did, then you would do your standard bloods, maybe a blood culture, maybe a chest X ray, you shouldn't routinely do a chest X ray for bronchiolitis. If you did, it would probably look like this. So it's a little bit streaky. There's not really like focal consolidation, but it's kind of like patchy both sides, maybe a bit more on the right side than this one. But that's not specific. It's kind of this nonspecific streaky x-ray. OK. Management. So it's symptomatic. Um it's supportive management. The main issues that babies have are with feeding or breathing. So, feeding, we support with an NG tube that would be preferable because it's more physiological. They can have breast milk or formula through the NG tube or they can have diorite sometimes or the other way you can support feeding if they are in need of resuscitation or they're really not tolerating anything into their stomach. You would give them IV fluids. Um And then we can support breathing. So that is if oxygen saturations are low, remember, less than 90% is when we give oxygen, um then we give oxygen. Um and often what we give is humidified oxygen. So that's op to flow. Um I recognize that maybe not everyone will have come across what that is. Um But um opt to flow is essentially like warm, humidified oxygen. It's warm and it's comfortable and it goes up the nose and it pushes the oxygen in a little bit. So it's similar to CPAP in that sense, but it's not, it's not CPAP, but it pushes it in with a bit of pressure. So it supports with work of breathing and it's also more comfortable than like nasal cannula oxygen. In really bad case of bronchitis, babies might be put on babies and Children might be put on CPAP or they might be intubated. This does happen. Um But it's rare m the vast vast majority of Children with bronchiolitis are OK. They just have a bit of oxygen when you're managing. Bronchiolitis do not give salbutamol, do not give steroids. These were both like previously used for bronchiolitis. They are not used anymore. And then the vast majority of bronchitis is managed at home. Um You tend to admit Children if they're having apneas because uh you need to monitor them for if they stop breathing, er, if their saturations are low in real life, if they were kind of borderline, you might observe them for a little bit. Um, but strictly, it sats less than 90 if their fluid intake is low. So generally, generally we say kind of if they're having less than half to two thirds of their normal fluid intake or like, because you can't always tell what intake someone is having, you look at output. So less than half to two thirds of their normal wett nappies, you would also make a child if they're in severe respiratory distress um because they are going to get tired. Um and then they're at risk of de decompensating basically. Uh so I talked about this a little bit but ox flow or other forms of high flow, nasal oxygen are used quite a lot in pediatrics. They are used um like sometimes in kind of itu settings in adults. Er but we use them all the time like on the normal pediatric ward, um warm, comfortable, humidified oxygen and it's at high flow. So it pushes air into the lungs and it helps support work of breathing. Sometimes if babies don't even have an oxygen requirement, like they don't require additional oxygen, they might just have optic flow put on them. But with air going through, so with like 21% oxygen and that can help their work of breathing basically. Ok. So when we go back to this one. We can see that with our principles of don't investigate and don't do things you don't need to do unless you're worried. This is a classic presentation of bronchitis, cough, runny nose. Um, they're struggling to feed because they're snotty. Probably. They've got a bit of subcostal intercostal recessions. They've got a low grade fever, they've got low sats. This sounds like bronchiolitis. So we're not going to chest X ray. So any answer that references a chest X ray is wrong, um You're not going to do blood or um give antibiotics because this is a viral infection. It follows a kind of standard course, you can obviously do those things if there's any doubt. So if this child didn't get better or started to have really high fevers, um or had a kind of decompensation, that meant you did a chest X ray and there was clearly a massive empyema or something. Um Then sure you'd get out IV antibiotics. And then um just when we look through the other options, so the kind of optic flow versus CPAP thing is like CPAP is, is much more invasive. Um So you would do opti flow first. This could easily also just say nasal cannula oxygen. And then this one that mentions like 100 and 50% maintenance fluids versus two thirds maintenance when you have bronchiolitis, uh or when you have anything that makes it difficult for you to breathe. Um having a really full stomach presses on the diaphragm, presses on the lungs and can make things really, really uncomfortable. Often you'll see babies and Children vomit a lot when they're having difficulty breathing. Um, so often we use kind of two thirds of their maintenance calculations. Um, and that's what they'll have while they're unwell. Um, just a note. So obviously we say bronchiolitis, you can have it from six weeks old. Um, and you don't investigate it, you just leave it alone and, and support them to get better. This, the caveat to this is if a child is under three months old. So these are the nice guidelines um for fevers in those less than three months, these are really important to know. Um babies who are less than three months who have a fever are really vulnerable to like a severe bacterial infection, especially those that are very young and still um with thinking about like a late onset neonatal sepsis in the kind of 34 week old ones. So any fever under three months should be seen by a pediatrician and just a sign that we define fever as 38 and above, they should all have bloods um and a urine culture. Um If there are signs, a chest X ray and a stool culture, and then you tend to do a lumbar puncture because these babies can get um meningitis only if they are less than a month or they're 1 to 3 months and they look unwell or they're 1 to 3 months and they have a higher or low white cell count. Um And then you also give them antibiotics. Um It's really important and I think, helpful to know these. So if you had a question whether the baby was less than three months, you just need to be aware that that exists and then just a mention of palivizumab. Um So, like I said at the start, bronchitis is almost always caused by R SV. Um babies, Children who have certain health conditions are really, really vulnerable to getting bronchiolitis and it can be really devastating for them. Um Palivizumab is a monoclonal antibody um that is given to Children who are vulnerable, um who are at risk of getting seriously unwell from bronchiolitis and they're given it during RSV season. These are the criteria for getting it, don't worry about it. Um Like memorizing them, but essentially, it's chronic lung disease, hemodynamically significant, uh congenital heart disease and then a few kind of niche situations. And then palivizumab is not used in people beyond that because uh it's quite like intensive, you have five injections like one a month, five months. Um But there have been some recent studies into other monoclonal antibodies um that in some places have been given to all Children. Um And they cut bronchiolitis admissions really drastically, which is great. Um OK, we're now gonna talk about asthma and wheeze for those of you who haven't done like your peds placement yet. Um Wheeze in Children does not necessarily indicate asthma. Um but their management is, is broadly quite similar. Um So we'll talk about viral induced wheeze. This is kind of a specific syndrome or like presentation, I guess you'll see in young Children. Um It is the combination of bronchospasm. So the same kind of um like mechanism of wheeze, you see in asthma, a bronchospasm plus a viral illness, that viral illness is normally an upper respiratory tract infection. They tend to present a few days of cough and runny nose and then drastically some difficulty in breathing. Um It often overlaps with bronchiolitis. So Children from kind of 18 months to six years are the typical group to get a viral induced wheeze. Um when it overlaps bronchiolitis, um you kind of look clinically. Um and we can talk when we talk about management, we can mention kind of what you do if you weren't sure if it was a bronchitis or a wheeze, that's not something you would have to like address in exams, I don't think. Um But when you're working in A&E or in GP or in Pedes, um it's something you have to think about. It's really common to get viral induced wheeze and lots of Children who have viral induced wheeze, just stop getting these wheezy episodes and don't go on to have asthma. Um broadly, there are kind of like two phenotypes for these young Children who get viral induced wheeze. There are those who have like episodic wheeze only with a viral illness. And then there are those who have what's called multi trigger wheeze. So they also do get a bit wheezy with exercise or allergen exposure. That's a kind of similar kind of presentation to asthmatics, I guess. Um that group might benefit from steroids in both acute in the acute setting. Um So that's why it's important to ask about when we're thinking it's this viral induced wheeze or asthma. Generally, as I said, with bronchitis, Children have small airways, so they're more susceptible to wheeze because the airway is smaller, it's more likely to make that wheezy noise when you've got like pressure, like high pressures going through it. Um if you're kind of seeing an older child. Um and you're not sure if this is generally like Children under five are not diagnosed with asthma, um sometimes they are, but generally they're not. Um if you're seeing an older child and it's not clear if it's kind of a viral induced wheeze or asthma, you think about things like, do they have an atopic history? So at p is um like those allergy illnesses that people get. So, asthma, eczema, hay fever and food allergies, um like those I ge mediated um things and then also in asthma, you tend to see a diurnal variability. So, symptoms are better um or like worse at night or worse in the morning. Um, Children with asthma also tend to get these episodic sy symptoms, um, where they're triggered by exercise and cold air. They're not just triggered by being unwell with virus. And then Children with asthma also have interval sy symptoms. So they cough at night, they get exercise induced wheeze and they get shortness of breath. Um, and they need to use their salbutamol inhaler more than a couple of times a week. Like I said, the acute management of a viral induced wheeze is similar um in lots and lots of ways. Um And, but the chronic management differs, we'll talk about both. Um Just really brief recap. You could talk for a very long time about um like the path of physiology of asthma. Um But essentially you've got kind of chronic inflammation of the airways and then a trigger causes the release of all these inflammatory mediators. And then you get airway narrowing that's caused by like edema secretions and constriction of the airway, smooth muscle. And remember that constriction of the airway, smooth muscle is what salbutamol is acting on. That's why like the kind of um beta agonist effect of salbutamol makes that smooth muscle, er, relax and open the airway. So we have a question. Um A 14 year old girl comes to A&E with difficulty in breathing. I thought I opened the pole. There we go. Um A 14 year old girl comes to A&E with difficulty in breathing she takes regular inhalers at home on examination. She's wheezy and tachypneic, which of the following signs is most concerning. So, a moderate subcluster recessions ba respiratory rate of 45 C A heart rate of 100 and 50 D quiet air entry on auscultation e being too breathless to complete sentences. So, I'm not saying that any of these are not concerning in a 14 year old with difficulty breathing, but which is the most concerning and think about how you might kind of stratify your concerning features. Cool. I'll give you about 10 more seconds. All right, we'll stop that. So the answer is quiet air entry on auscultation. Is it? Yes, it is my next slide. Cool. So we'll talk about these, like I said, um these are all scary respirate 45. That's scary. That's high for a 14 year old being too breathless, complete sentences. That's also concerning. But the most concerning is quiet air entry. So this question is asking you to think about the way you kind of stratify um like a moderate versus a severe versus a life threatening asthma attack or wheeze attack in this question. Um The patient had asthma, she was 14, she took inhalers at home, she's got asthma. Um you kind of approach it really similarly. So these are taken from the BT S guidelines on management of asthma. Um And this is for the kind of like pediatric um acute management. So a moderate asthma attack. We'd say you're keeping your saturations high and your peak flow is decent, a severe asthma attack. Your SATS are low, you're too breathless to talk. So the main, the kind of phrase uses too breathless to complete a sentence. Your tachycardia you attack at me and you're using your accessory muscles. So all those other criteria in the question were part like indicators of a severe asthma attack, but indicators of a life threatening asthma attack also low sat a silent chest. So that not kind of that quiet air entry on auscultation, it means that they are not getting air into their lungs basically because their airways are so brittle and so constricted and so inflamed, they just can't aerate their lungs. That's terrifying. Um And like when you see it in a patient, it's very scary. Um and similarly poor respiratory effort that like when patients just got so tired that they can't breathe properly, they can't even like put the effort in to breathe. They don't have recessions cos they're not even their body's not trying to breathe, they're tired, agitation, cyanosis, confusion, altered consciousness. So this is kind of um yeah, also signs of a life threatening asthma attack. So, acute management. So remember this is both viral induced wheezing asthma. Um The most like kind of important approach for you guys is probably asthma. Um generally it goes bronchodilators, steroids, repeat bronchodilators and then your second line managements, we can talk about those in more detail. So bronchodilators throw salbutamol at patients who are wheezing. Um whether it's inhalers or nebulizers depends on their oxygen requirement. Generally in pediatrics, especially in smaller Children, it's felt that inhalers are just as effective at getting sub one into the lungs as nebulizers are as long as you're using a spacer ipratropium. Um So a muscarinic antagonist um is often used in life threatening asthma attacks. Again, this is, I think this is from the BT S guidelines. Hospitals you work in will have different guidelines. Um But Ipratropium generally using life mattering attacks and in kids, what we tend to do is burst um inhaler therapy. So that means you give kind of back to back inhalers or nebs um three times over 10 to 20 minutes each. So, in an hour, you're giving three lots of salbutamol and three lots of ipratropium if they need it. Um If a child has asthma, you give them steroids as soon as possible. Normally that's prednisoLONE and you normally do like a 3 to 5 day course during their um asthma attack. Um If they're not tolerating if they're vomiting, um or they like can't coordinate swallow cos they're working so hard to breathe, I guess. Um they need to give them IV hydrocortisone. If a child is young, they don't have a diagnosis of asthma. You think this is a viral induced wheeze. You do give them steroids if it's a severe wheeze or if you think they're like that asthma kind of phenotype that we mentioned earlier, then you can repeat your bronchodilators. Um The BT S guidelines go into this in more detail, but it is a bit confusing to kind of put on a slide. Um So you can kind of do another burst. Um Generally people will have like two lots of bursts before you think about other things and then you see when they next need their inhalers or their nebs. So if they finish that kind of hour of having lots of salut or lots of ipratropium and they're feeling a bit better. You see how long they go without kind of becoming really wheezy, really tight in that chest again. Um You tend to give it kind of, you can give it every hour, you can give it every two hours. It depends how long they kind of stretch is the word we would use. Um And then if they're needing a lot of inhalers or they're not improving, you think about your second line treatments? Er, so IV magnesium sulfate IV salbutamol, which can be a sorry, that's meant to say bolus or infusion for the salbutamol. Um IV Aminophylline is another option that is a bolus and an infusion. So you give a loading dose of aminophylline. Um Just a note on the side. BT S guidelines for the first step suggest adding like magnesium sulfate to nebulizers. I've not seen that used my hospital that I work at now doesn't um use it for Children. Um, but it's in the kind of national guideline. So these IV therapies, you might be familiar with these from your adult um respiratory medicine. But magnesium sulfate is used a lot. It's generally kind of first line IV therapy you'd use for asthma or wheeze, you give it as a bolus. Um, but you have to kind of monitor BP. It can cause hypotension and you have to monitor heart rate as well. I think um if you can often give it kind of twice in a 24 hour period, sometimes more, it depends. Um but it generally is pretty well tolerated. Um And is the first one you'd use, then IV Aminophylline at least where I work at the moment. That's the one we would tend to use next. Um So aminophylline is a like phosphodiesterase inhibitor. It works as a bronchodilator as well. Um You give a loading dose and then you give an infusion. The only caveat to the loading dose is if Children are on oral theophylline, again, you might be familiar from adult re um then they don't need a loading dose. I guess they've already kind of got that in their system, right. Um You have to take levels when someone's on an aminophylline infusion, they tend to be on the infusion for like can be 24 hours can be longer. Um It's not quite as well tolerated. Um And it's obviously like more intensive to give because it's an infusion over a long time. Um, side effects can be tachycardia, arrhythmias and vomiting. Uh I think it's the BT S guidelines recommend an antiemetic cover and then IB salbutamol is also given. Um you can give it as a bonus or as an infusion when you're treating Children who have asthma or wheeze or anyone like anyone with lots of salbutamol, it's really common to get a bit what we like would call salbutamol toxic. You can get this from inhaled salbutamol, from nebulized salbutamol or from IV salbutamol. Um signs and symptoms of salbutamol toxicity are tachycardia tremor and typically like a lactic lactic acidosis after the kind of first rounds of burst, you can see Children in A&E have really high lactates of like 56 from the salbutamol. Um, salbutamol also causes hypokalemia. So that's an important thing to look at as well. Um, rarely it can cause urticaria or a paroxysmal bronchospasm, um which would be very unhelpful, er, because that's the thing you're trying to treat. Um, but that's where when people are starting to show signs of salut more toxicity, that's where things like um magnesium sulfate and aminophylline are really helpful because they work in a different way and they kind of don't contribute to toxicity. Uh Cool. So, yeah, I didn't s skip a slide. Good. Um Another question, you've got an eight year old who's been admitted to the pediatric ward following an asthma exacerbation, they're flu a positive, they're feeling better and they're ready to be, be discharged. They'll be discharged with an inhaled corticosteroid and a salbutamol inhaler. What is the most important advice to give the family on discharge a to return to hospital if needed to give sub more inhalers more than every six hours B to use a spacer device whenever they give either of the inhalers C to stop in sub more inhalers completely at home and to come back if they become wheezy again or d to ensure the child, the child has a GP review within a week to check if they are improving or e to stay off school until asymptomatic for 48 hours. I'll give you about 10 more seconds. Ok, I'll stop with that. So the correct answer is B to use a spacer device whenever they give either of the inhalers. So pediatrics, you are always giving a spacer with any inhaler you are giving. Um, it makes the delivery of the medication into the lungs so much better. Um Even in adults, if you're using like a meter dose inhaler, the ones where you press the button and you have to coordinate your breath. Actually, the delivery of like salbutamol with those inhalers is really quite rubbish. Um How are you getting an eight year old to coordinate their or like a parent pressing the button and then breathing in? It's not gonna happen. Whereas if you've got a spacer, they're breathing in and out over 10 seconds and they're getting way more of the puff into their lungs. Always use a spacer. Um, always, always, always, um, let's go through the other ones. So to return to hospital if needing to give ea small inhalers more than every six hours when people with asthma or Children with asthma or wheeze are discharged from hospital. Um, there's a bit of controversy about what they do with their inhalers when they go home. So it used to be that people were given like um a weaning plan of salbutamol because at the point, you're being discharged from hospital. Um You're normally on four hourly salbutamol inhalers, that's normally the threshold at which we say someone is well enough to go home. Um There's this idea that they, they will obviously still have ongoing symptoms and you want parents to be giving um that it the inhalers when they need to. And so often there would be like a people would be giving a wheezing plan saying give this many puffs this many hours on day one, this many puffs every this many hours on day two. And you continue like that increasingly, it's turning to a system of like give it when you need it. Um because there's concern that like if you wean salbutamol over several days, it masks symptoms of a kind of relapse of the exacerbation. Um It's a bit controversial. It's kind of changing in different places. Um, but the key thing is the main bit of safety netting you give is that if a child needs salbutamol more than every four hours is when they come back to hospital, that was a really roundabout way of saying a is not the right answer. C I've talked about you, you don't, um, you, you can stop the salbutamol inhalers at home if they don't need it, but you wouldn't come back if they're wheezy, you would try the salbutamol at home. If they need it on there. Four hours, you'd bring them back in terms of d we generally say that Children should have a GP review within 48 hours uh to make sure they're improving, how often that happens. I don't really know. Um But that's the kind of accepted advice. It's in all the guidelines and then e to stay off school. Uh That's not correct. Uh So that was meant to kind of trick you into thinking with flu. You need to stay off school. You don't. Um There's normally like a list somewhere on the internet of like all the kind of isolation guidelines for certain common pediatric conditions. So like, um what to do if your kids got chicken pox and do you send them to school or stuff like that flu? You can send them to school uh if they're well in themselves. Um Whether the school would appreciate that is probably not. Uh It's a baseball but you don't need to stay out of school. Uh So whenever you discharge a patient from the ward or from hospital after episodes of wheeze, um these are kind of like common things that could come up in a osk, you're checking inhaler technique. Um Inhaler technique is like a common OSK station. We'll talk about it on, I think the next slide um you review their preventer therapy, you're kind of thinking if they have asthma, why have they come in? Is it that their preventer isn't um working for them? Are they not taking it? Um Are they not doing their inhaler? Right? Why has this happened or have they got a viral illness that's triggered this, you discuss smoking. So you ask parents if they smoke, do they smoke in the home? Do they smoke outside the home? A lot of parents think that if they smoke in the garden or the balcony and they come back into the house, then it's fine. It doesn't affect their children's breathing it unfor it does. Um So it's really important to talk to the parents about smoking cessation. Um obviously in a like gentle um in a gentle way that like prioritizes the health of their child and then wheeze plan that I spoke about and a review of the GP um inhaler technique, really common question. Um I won't go through it in detail. This screenshot is from a website called Healthy Together. It's got lots of like patient information, leaflets and stuff and it's really, really helpful um for like working pediatrics, but also probably helpful to read when you're learning pediatrics. Um I want to, there are a few more slides on like aspirin wheeze and I will maybe go a little bit quickly. Um, so we can get to croup before we finish. Asthma is often a clinical diagnosis you're looking at like, do they improve with Bronchodil? Basically, um in Children, the kind of typical things you do in adults aren't feasible because they can't comply with the investigations. So like your spirometry, um but you would see as an adult, an obstructive spirometry pattern and reversibility with a bronchodilator. Um The nice guidelines love to mention this fraction of exhaled nitric oxide. I've never seen this in clinical practice. Maybe I'm not working in the right areas, but I've not seen it mentioned anywhere. Um Essentially people with asthma have high levels um of eo of nitric oxide in their like exhaled gas. Um and that's because their epithelial cells are inflamed and they produce more nitric oxide. Um So that's an important investigation to be aware of cos it is in the national guidelines. Um Generally your chronic management of asthma in Children. This is from BT S guidelines. Um You've got your salbutamol, you add a low dose of steroid because it can affect growth in Children. Then you add something like a laba or a leukotriene receptor antagonist like Um Montelukast. Um So yeah, you follow these steps. Um And an important thing to say here, essentially learn the guideline, often the guidelines contradict each other. So like BT S and nice, contradict each other. Um The principles of treatment are more important. So the principles in pediatric management of asthma are that you tend to start with very low doses of steroids and you gradually build them up, you try other agents. If they don't work, you stop them. Um And once you've tried kind of those three agents, so the I CS, the laba and the LTR A, if things aren't working, you do a specialist referral and that's where they think about things like theophylline, um chronic management of viral induced wheeze. So those under six year olds who aren't really asthmatic but who get lots of wheeze with their viral illnesses, which they always have uh some guidelines suggest you can use oral Montelukast. I don't think I've seen that used again. Maybe I've just not seen enough. Um And those with multi trigger wheeze that more asthmatic phenotype, you can try a low dose uh steroid. This just goes into a bit more detail about some of the treatments. These are all similar to what you see in adults. The main thing with corticosteroids is that um they affect, they can affect growth and that's the kind of concern of using them long term in Children. Ok. Cool. So we're gonna talk about upper airway obstruction, um, that involves croup and a couple of other things. Um, these are all quite, these are all kind of like, uh, illnesses that you only really see in kids. Um, so they're really important to know about. Um, and they've all got quite classic presentations. So, um, a two year old child presents with a barking cough and stridor. They respond well to oral dexamethasone. What is the single most likely causative organism? I'll say all those words weirdly. So I'm not gonna read them out. That'll give you about 20 seconds. Ok, I'm gonna stop that. So this is croup. Any time you see barking cough, stridor. Um It's croup, croup is again, almost always caused by parainfluenza virus. In reality, you don't really test kids for it. Um But that's the kind of learnt wisdom. It's caused by parainfluenza virus. That's the thing you should learn. Um barking cough, Stridor. So, Stridor is like a harsh inspiratory noise. So it's that the upper airway is obstructed. Um Oh, let me go onto the next page. Um So croup is laryngotracheal bronchitis. So it's like your upper airway, your larynx and your trachea are inflamed because of the viral infection that you have. Um And that's what causes that Stridor noise. So you can't get the air in and it causes um like an inspiratory noise called Stridor. Um Look up videos. I always think it's helpful to see like videos of what it looks like but I didn't put one in, sorry. Um, often affects Children between six months and three years old. They can get like recurrent episodes of croup, um, and come into A&E all the time with it. Um, generally kind of a few days cough, runny nose as with everything. And then they develop a barking cough. It can really sound like a bark. It always says like in questions anywhere you read about it, a barking cough, it can really, really sound like a dog barking. Um They become hoarse in their voice and they develop this Stridor. Um It is helpful to know about something called the Wesley system, um which helps you assess Children with croup. Um Don't worry about remembering the numbers, but it's just kind of how you risk assess your Children with croup and what you do about it essentially croup, like most things gets better. Um But sometimes we treat it and I'll talk about that in a couple of slides. Um Sometimes we treat it if um, patients are like gonna decompensate, that's normally if they've got Stridor. Um your se scoring system takes into account recessions, cyanosis level of consciousness and stridor. I won't go through it in that much detail, management of group uh dexamethasone. Uh So just like liquid steroid. Um and it cools down the information you observe kids for a couple of hours. If they get better, they go home, that's generally given if they've got stride or if they've just got the cough, maybe not. Um, you can give small doses. If you're worried you can give big doses. Again. We are cautious with stories in Children but do still tend to give it a lot. Um, you can repeat doses if you've not got up to that maximum dose of naught 0.6 mi milligrams per kilogram if Children are vomiting, er, or they won't tolerate the dexamethasone for whatever reason. So often, er, Children with autism might not tolerate kind of liquid, um, like medications. Um, and they can taste funny as well. Um, then you could give inhaled budesonide. So a different steroid, um, like as an inhaler, um, then you observe them if they get better, they go home. Um, your kind of second line is nebulized adrenaline. Um, nebulizer adrenaline treats the symptoms. They say you've got a child who's come in, they've got really bad barking cough and a bad stride or you give them dexamethasone, they don't get better. You can give them adrenaline because it will make the stridor better, but it doesn't stop the stridor from coming back whereas the dexamethasone does if that makes sense. Um, but it kind of buys time in these really severe cases of croup which by the way, are very rare. Um, and then your kind of last line management of croup is to intubate. Um, the main thing about croup is that you keep Children very calm. There's not even a slide on investigations for C group because you don't investigate it. Um, you clinically diagnose it and you leave them alone unless you're giving them a treatment because if they become onset then the Stridor is gonna get worse. Their worker breathing's gonna get worse and they're gonna decompensate. Um, after every treatment you give and I should have mentioned this earlier with wheeze, but you always kind of recategorise the severity. Ok. Um, another question, a two year old presents to A&E with a barking cough and Inspiratory Stridor. They're given oral dex methadone as treatment while being observed, their breathing comes labored and noisy and their oxygen saturations drop, but they're crying when the saturations probe is placed on their finger. What is the single most important? Next step? A obtain bloods including a blood gas. B, contact an anesthetist. C give nebulized adrenaline. D give a further dose of oral dexamethasone or E obtain IV access and give IV hydrocortisone. So think about what I was saying on the previous slide. So we've got a child who's been treated for creep. They've had treatment, but then they've not really responded and they're becoming a bit unwell, but they're also very angry and they don't want you to touch them. I'll give you a few more seconds cool. I'll stop that. So contact an anesthetist. Um like I said, don't touch them, don't do bloods, don't do a blood gas, don't get IV access, you'll make them. So angry that they're scary when they're angry, they'll get worse. Um, you can give nebulizer adrenaline. Um, and that would definitely be part of your management. It is not the single most important next step. Um, again, you could give a further, further dose of oral dexamethasone, but the question does not specify how much they were given. And if they were given the maximum dose, you wouldn't give them another dose. Uh, that's maybe a bit of a mean like vague answer. But here you'd contact your niece test, you'd probably call them, then give the nebulizer adrenaline. And what happens in these really severe cases of croup is that um like if it's really bad and they're really decompensating, they tend to be intubated, but in a very calm elective manner, like you want everything to be as calm as possible. Uh Yeah, that's basically what I've said. Cool. Um This is a chest X ray of a child with croup. And what you see here is something called the stele sign. So you see how like the trachea has that little point at the top. Um This is in a couple of conditions, croup and tracheitis where the trachea is inflamed and you see that kind of narrowing on the chest X ray, you wouldn't routinely be doing a chest X ray and croup again, only if there was diagnostic uncertainty. Um But that's what you would see if you got one and it sometimes comes up in exams. Um, so stridor that scary, harsh inhaled noise, um, often croup, if it's in combination with a barking cough, a bit of a fever, a bit of, kind of crier. Um, but it can be a few other things. Um, and the important ones to know about are inhaled foreign body. Children love to swallow things or like put things in their mouths and then they can go in their clear. Um, so you need to always think about that, especially if it's a child who you think might have. Croup doesn't get better with steroids. Um And I guess they could work that into questions in certain ways. And then you've got bacterial tracheitis and then epiglottitis, which are kind of not um not the same thing, but often kind of at least in my head overlap. Um But bacterial tracheitis is the child looks really unwell. They look what we say is like toxic. The same with titi but bacterial tracheitis, it's like um a bacterial superinfection normally following an NTI um they look bad, they look unwell. Um The same with epiglottitis. The important thing with epiglottitis is that it's often caused by haemophilus influenza B. And it's really rare since hip was introduced uh since the hip vaccine. But maybe if you had a question that asked you about a child who wasn't vaccinated. Um They were and then the, also the other classic things they will say is they're drooling. Um So they can't even kind of manage their secretions because their upper airway is so inflamed and this tripod position. So they're kind of like sat forward really working to breathe and this toxic looking just means they look really unwell. Um And then also like a retro fungal or Periton labs that comes up less often than questions. The main things to think about are inhaled foreign body and hepatitis. Um super quickly, we'll talk about weeping cough because it's increasing in incidence. So it's helpful to know about clinically but also always comes up in exams caused by border tele pertussis, which is a gram negative organism spread by aerosol, really contagious and can be really dangerous to little babies. You give a vaccine in pregnancy, I think at like 20 or 30 weeks, but don't quote me on that. Um And that protects infants less than two months because of passive, passive immunity via the placenta. Um And also in breastfeeding. Um And then it's also given to 23 and four month olds. Um If the cough has been present for less than 21 days, you treat with a macrolide like Erythromycin, Clarithromycin, Azithromycin, I think normally it's Erythromycin, it has these several phases. Um But the main one we know about is the whoop. And again, I've got a video because I think um it's helpful here we go. So that's the kind of thing you see in whooping cough, those really bad coughing fits babies turning pink, sometimes babies will turn blue and they have that in like that harsh whoop at the end of it. I did not mean to pay that again. Ok. Uh So it's about eight o'clock. Um We can do some feedback. Um Here is the QR code. I have a few more SBA S but I know people are gonna get sent the slides. So I wonder if the best thing is to like the size can be sent round and I'll just write some explanations in the notes. Um That's probably like, it's, it's like it's probably nicer than doing it now for you guys. Um, but then you can still see them. Um Yeah, and if you've got any questions, please let them in the chat.