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Uh For us, if you're struggling with, uh you know the presentations and you can rejoin again. Sometimes, yeah I might switch to chrome because I think it's just not working on safari uh No it is um the other option is you can send me your presentation and I'll um then do it for you. I'll share it for you. Basically, you can present, but okay, cool, you guys can see my screen, yeah yes, we can see now, sound nice, cool, so sorry for the delay again guys. Um All five of you guys are waiting well done for waiting for a while uh so my name is for us. I'm currently we an f. Y. To working in the Northwest England. I've just come off a rotation on pediatrics, so I thought it would be quite fitting for me to do that. I've only got my slides in front of me, so I can't see your questions or anything that you guys might put in the chat. I feel free to just shout out at any point if there are any questions. Uh Frazzle send you the uh for the chat and you can open it on your phone and then you'll be able to see the messages that you get. Thank you is that all right yeah right, so we'll just go through basically some acute conditions that you'll commonly come across. If you ever do a pediatric placement or if you do in any placement and you're working in the pediatric section and um yeah we'll just go through some acute presentations essentially in conditions I've not really gone with the case based presentation, which is how I normally like to do things, but hopefully it kind of all makes sense as we go through, so especially this time of year like one of the most common conditions that we come across as uh bronchiolitis, so bronchiolitis is basically um inflammation or infection of your the terminal ends inside your lungs of your bronchi, olds. We tend most commonly to see it in babies up to a year old or in re situations that can go up to even two years old, and it can be seen with more severe presentations in babies who have chronic lung disease. Um There's loads of viruses that can cause bronchiolitis, the most common of those viruses is RsV and at the end, it doesn't really make a huge difference what virus is really causing bronchial isis, but it helps when you're admitting patient's in the hospital because then you can separate babies into into different days based on what viruses they have rather than spreading it amongst themselves. Um diagnosis of bronchiolitis or what most commonly you'll tend to see um what like as the presentation will essentially be 123 days of being Coryza Lso essentially being a little bit snotty, potentially having a cough. It's usually a little bit of a wet cough and usually they'll end up being referred to pediatrics, if any doctors feel that they're working quite hard for their breathing, so we'll go through the signs of increased work of breathing in a second, actually just bring the next load up and we can have a look at it then, so these are the signs that you kind of look for for for increased work of breathing and babies, so the most common ones would be recessions, so you can get various different types of recessions. You can get subcostal recessions so that's underneath your ribs, you can get sternal recessions, so just the sternum kind of going in and you can get intercostal recessions, so essentially it looks like you're sucking in between your ribs aside from that. The other common things to look out for are trivial tug, so it just looks like you're sucking in around where your trachea is you've got nasal flaring which is babies just kind of increasing the size of your nostrils at their breathing and in severe respiratory distress. You can get head bobbing as well. If you go and have a look on youtube. You can find pretty good examples of all of these as well, and aside from that, you look out for things such as an increased respiratory rates, a tachypnea, and also things like you can check you know for signs of their central or peripheral cyanosis and and finally with bronchiolitis. In particular, you'll expect them to just be quite congested up over here, so just sound very snotty. Um The main things to ask for when you're assessing for bronchiolitis, so first of all you wanna find out what symptoms the baby has so what we've been through already with coffin Coryza you can have a low grade temperature as well generally. So with bronchiolitis, you expect temperatures to be 11 39 above 38 duration. So you want to establish how long it's going on for it, and the reason why that's important is because with bronchiolitis generally tends to be worse between days two and five of the infection, so normally we would expect babies to kind of get worse over the course of a few days and then hopefully after day five. As you're going on to day six day seven, they'll get better and that can kind of be reassuring for parents as well um with the temperatures that we mentioned already, you expected to be kind of a low grade temp, um The main thing you want to establish or the main thing that's reassuring in terms of the baby's head of hospital is our parents able to control the temperature with regular parity to pollen, ibuprofen, so essentially that every time that baby does have a fever. If they're giving paracetamol or ibuprofen, are they able to knock it down below 38 it might eventually come back up, but as long as they're able to initially knock it down, it's fine. Um you want to establish feeding and a lot of these things will end up being quite common theme throughout all the respiratory conditions Because essentially their your criteria for looking at what requires admission and what doesn't require admission, so with feeding, you want to see how much they normally feed with babies were generally trying to work out, most of them will be bottle pled, you're trying to work out how many bottles they're having how much is in each bottle and in terms of what is their normal and then you kind of compared against what they're currently having um and generally, it's reassuring for us if they're having more than 50% of what they normally have. Um aside from that with bronchial ISIS, because babies can get like quite easily congested, It kind of sometimes exacerbate their work of breathing when they're when they're feeding orally, because obviously if they're feeding orally and they're already blocked up over here, then it's not gonna work out too well, So you essentially need to assess whether they potentially need some sort of feeding support and with bronchiolitis being a viral illness um It's kind of good to establish as well whether there's been any recent ill, close contacts, so either whether there's somebody in the house that's currently ill or are they part of like a play group or going to nursery or something like that where they could have easily picked up viral illnesses from and normally it's more just to kind of like solidify the picture that you painted in your head of this being a viral illness because you know know someone else's else but probably it's just that. Um Past medical history is you're going to ask in any assessment anyways, um and this will be to do kind of well. The reason why it could be helpful is you can essentially establish whether they've had any previous admission's for a similar condition, um what's the maximum level of treatment that they needed and essentially you can see whether it has gone really downhill before have needed something like h. D. You admission, which would kind of oversleep, lower your threshold for you know for treating or even for keeping them in for a period of observation. Um You obviously want to keep an eye out for whether they've got any underlying conditions, so any underlying respiratory conditions, for example like cystic fibrosis or any underlying or chronic lung disease or any underlying um immune immunological deficiencies, which might potentially um increase their risk of having severe infection um and then obviously as we're going through a pediatric history, we like to get a good history about the pregnancy and birth history find out a bit about you know whether they've had their immunizations or not that kind of stuff work. Other risk factors um fine, so a lot going on in the slide. Um Nothing really one second all right uh behavior you're still on here yes for us. Yeah are you guys are seeing my present, my presentation can screen being like the whole slide, Yeah, I can see through two slides basically bronchiolitis pathway and assessment in primary care and the management section experiences, I'm guessing not able to read it early. Uh No uh this one's a bit bloody but about your now. Um uh It's like if you'll you'll teach, then we'll be able to gather it yeah uh um sorry, my laptop just playing up a little bit uh someone is reading the chat box that day and yeah now we can need it properly okay, fine, so, anyways there's a lot going on on the slide. Not expecting you guys to read all of it. This is basically kind of your primary care assessing assessment for bronchiolitis, so kind of like pathways to follow. Um main things to take away from it is essentially you're looking out for things like you know, basically their observations, seeing how to technique they are if they're psych apneic uh checking what their oxygen saturations are then on the left, especially on this box on the left over, here to the left of the green up, you've got your chest possession, nasal flaring and grunting, which are all your signs of increased work of breathing. You've got feeding hydration over there, which you've already talked about. Apnea's another thing you can look out for us, so if parents say that you know, they've noticed that baby at any point stopped while they thought that maybe stopped breathing, so that's obviously not a good sign and it could be a sign of someone who's high risk with their bronchial artiss, um at the top of their you've got behavior, so essentially seeing whether a baby seems okay or not are they drowsy or are they a bit lethargic and on the high risk side, you've got things like you're unable to rouse them so obviously we're talking about extremes there um and essentially this is just to help you kind of categorize, are they safe to just send him right away with an amber one do you potentially want to have them follow it up or do you want to potentially refer them to hospital and red is obviously you want to immediately have them seen a hospital cool, so management of bronchiolitis because bronchiolitis is generally just viral illness. Um The management is normally just supportive in terms of investigations that you may want to do you do not need loads, imaging not routinely done um in babies that were suspecting have bronculitis at most, what you want to do is you when I get a set of labs when they come in, you can consider doing nasal swab like essentially now what virus it is causing all of this cb g, so it's just like a little field correct blood gas that we can get again not routinely recommended routinely warrant it can be like if you're kind of borderline about whether a baby needs admission or not more from like potentially dehydration point of view you can use it to look at the laC taped or um if you're concerned that babies working hard their breathing and you're potentially considering considering putting them on some kind of mental a tory support um doing a blood gas early on kind of, give you a good indication to compare them against after you've initiated some sort of treatment, so with most babies that we see even if they have some slight work of breathing. Um we tend to send them home. I'll talk about, we'll we'll go a bit further down and we'll talk about what make you want to bring them in, but mostly we'll let them go home well. Tell parents like I said before bronchitis tends to be worse between days three and five. Since the onset of symptoms, uh the cough may go on a little bit longer. So babies tend to kind of still have their bronchiolitis cough for about three weeks after and then it should self resolve. Um The other things that you can consider doing so. We can consider giving parents saline nasal drops, or sometimes they can even get a second while they're in any, and that's the essentially help, ease up a little bit of the congestion that they've got going on, uh which can then make it easy for babies to feed, and the flonase spray is another thing that we routinely give that can help and so babies help old kids and it's essentially kind of a spray. Almost the parents can spray it on the back of their throat about 15 20 minutes before feeds um and and if babies obviously have like a viral upper respiratory tract infection, Kind of picture, they might have a little bit of sore throat and that's why they're not feeding as much so giving them a little bit of the phlegm spray beforehand can kind of help with their feeding. Um Another thing which I found out only after starting working is that we've got some a safety net uh in a way of uh community nurses, so we can normally organize for babies for community nurses to go out the next day or in the next two days and just review them see how they're getting on with their work of breathing and then it's kind of reassuring for the parents as well because they know, they've got some kind of medical professional coming and seeing their baby again um at home and just making sure that they're fine at home and that they don't need to be seen again um by a doctor um So with bronchiolitis, um the kind of things that would make you want to admit a patient you've got and firstly whether or not they need support, they're feeding, So as I mentioned if they've got, if they're feeding less than 50% of what they normally do that would probably be a reason to consider bringing um one thing that we do in a need to test with that is, we can do something called a fluid challenge. So essentially what they do is they get a little bit of fluid in a syringe and slowly feed it to baby and see whether baby can tolerate fluid while they sat in a any and if if they can pass their fluid challenge, we can normally look at getting them home right away um. And if they don't pass the fluid challenge, then we can consider doing the fluid challenge again with something like the different spray. For example, if they don't pass their flu challenge with diff lump or say a baby comes in just looking shopping, just looks dehydrated, has als signs of dehydrated like a depressed fontanel or dry mucous membranes and a race cap refill, then you're like fine okay, we need to do something more for this baby. Um The mainstay of actually supporting them with their feeding, so ideally we're meant to actually replace it with n. G. Tube feeds so that's most commonly what done with bronchi babies. Um. Part of the reason behind that is that if we continue giving them feed through an n. G. T. Ag, then it helps kind of still fill up their stomachs, they still feel full um and essentially they don't tend to get as angry as us as when we're for example giving them fluids. Because if we're just giving them fluids and through a cannula, they're not satisfied, and if they get angry, kind of exacerbate their breathing as well, another reason to bring them in, so they have an oxygen requirement, so with babies we have lower uh with oxygen, so for babies underneath under six weeks or with any underlying lung conditions. We aim sat 22% or above babies above the age of six weeks. We tend to aim sats 90% plus fine and fine. The last couple of things that we would admit them for. We mentioned apneas before and then obviously any signs of sphere respiratory distress or any like or extreme tachypnea, so for example a respirator above 70 um we could consider admission for it and essentially why we would be admitting them is to potentially give them high like oxygen through a high flow nasal cannula or through machines that include er both or opt to flow and that can be escalated to seep up and essentially what arrow and optic flow are is. There are two machines that use high flow nasal cannula to essentially pump air into the baby's lungs, So if baby's lungs are like or bronchioles are kind of constricted with mucus around them. You're kind of pumping air to them to kind of increase the pressure and help them expand by themselves uh and we know that sometimes that can help with babies work of breathing, so they might especially this time of year are word was like 50% full of bronchiolitis, babies on opta flow and you give them that little bit of support for a couple of days, give them that support with what they're feeding and then you gradually wean them off it and getting them home yeah fine so that's bronchi lighted yes, um so just a couple of things that we got from the guidelines, so we actually quite commonly tend to see sometimes people that aren't as experienced with pediatrics. Um In any bill, sometimes hear a wheeze on baby's chest. Um I think, I mentioned before you tend to get weak and crackles and bronchial eyes, as babies when you're listening to them and they'll listen to baby's chest hair weaves, and they might give them abusable nebulizer or they might give them an a prefer the nebulizer and the evidence behind it isn't really there so From what I know babies under the age of one, almost definitely do not have any receptors um for uh salbutamol or ipratropium, so they don't have their kind of beta receptors under the age of two. It's a bit more contentious, so stay under the age of one. There's no point in trialling those medications with nebulizers between the age of one and two. It's a bit more of like a gray area. It says up you can trial it and see you know, have a listen to baby chest first give them the nebulizer, review them afterwards, see whether it actually has made any difference or not, but in most cases doesn't tend to work and I've got this doctrine review up on the right, and they've done a systematic review, which says that would salbutamol, for example, it has no effect on bronchiolitis and children below huges of two years, and it just ends up kind of making them a little bit tacky kartik and a bit upset, so not super helpful right um kind of work up the, the age bracket with the wheeziness, then, so the next two conditions that we'll talk about together are viral induced, week and then obviously acute exacerbations of asthma, So these are it's almost kind of a spectrum in a way so we'll go through viral do, squeezes, first, so it's pretty much what it says on the 10, so it's a wheezy illness that's caused by a viral infection. Again, in terms of what causes it most commonly rsv rhinovirus, are the virus, is that you're looking at that are positive of it. There's a whole host of other ones again doesn't super matter um typical features of a Ireland used ways compared to asthma. As you expect them to be less than three years or I would even go as far as saying less than five years, and they don't tend to have any history of h. P at all so, atp, just being things like uh asthma, hay fever, eczema, and cosmetic protein allergy, So those those are the things that suggest like if you have one of them, it's quite likely that you may have some of the other ones uh of Ireland, the squeezes again only tend to happen during virus infections, um So the reason why the spectrum is because asthma. We generally actually don't formally diagnosed before the age of five. I think it is um so kids that are coming in with the recurrent wheezes before the age of five without a formal diagnosis of asthma. We just tend to call, of Ireland do squeezes, so you'll just quite commonly see it in that age group. Um asthma is obviously a chronic inflammatory condition of the airways where you tend to have episodic exacerbations from constrictions so tight uh guy um which can then cause a wheeze um Can also be caused by viral or bacterial infections and then you have several other factors that can kind of trigger your asthma, so cold weather, just exercising dust um diagnosed commonly with an f. E. N. O. Test that's inhaled nitric oxide test or um more often, you tend to do spirometry, so kind of your lung function tests and seeing whether bronchodilators are actually able to reverse your condition, so that's kind of the main diagnostic criteria for asthma, whether there is any one could dilate reversibility, and it's quite helpful and just to look for that personal or family history of any atp, to kind of guide you towards the diagnosis fine. So in terms of what they'll present with so, with viral induced leaders on their own and also occasionally with asthma because obviously a little dependent on the trigger, you'll you have like a viral prodrome. Again so kind of fever, cough, coryza, so, snotty symptoms and what you tend to see in both of them is essentially you'll get things like progressively worsening shortness threat. You'll get an increased respiratory rate, you'll get increased respiratory distress, potentially, so you'll again similar things to what we mentioned before you get your sub costal external recessions. Potentially, you make your heel tug, you make nasal flaring. You make the head bobbing. Um you'd expect to find an examination is an expiry torrey week throughout the chest and also if they're quite like if they're very bronchoconstricted, then you may have reduced air entry. When you're listening in the chest as well, I've tried putting in a sound, little wheeze over here. Let's see if it works cool, so I don't know if you guys can hear that or not but actually a good sound of wheeze and if commonly uh we are asthmas on your chest to the next slide that in terms of assessment, obviously with any patient that comes in, you'll take, restore eaters and e, approach when you're giving a look over, um you'll do obviously your your basic going through your history and see what's kind of cause the asthma. You want to also talk about like their asthma control and if we're talking about asthmatics, so you want to talk about what medications they're on whether they've had the previous admission's how how if they've escalated or what treatment they previously need um. And then it's also useful for already diagnosed asthmatics finding out how often for example, they're having to take their um their blue inhalers are they taking their preventative inhalers regularly. You can check their inhaler technique as well and see how they're getting on with that because a lot of the time, especially they're not using spacers. Their technique for actually delivering their medication to themselves isn't super efficient um so that could potentially just something to work on before you get them out of hospital. Um So asthma we want to try and classify into whether it's mild, moderate, whether it's severe or whether it's life threatening all of those signs kind of listed over there, so the main things you're looking out for is how they're separations are how high their respiratory rate is uh It talks about peak xperia, tory flow rates over over. There don't actually tend to use peak expiry expiry flow rates in practicing hospital. It's more of an exam thing than a hospital thing I think they do tend to use it in primary care still, but essentially with this criteria of trying to work out which category it fits your, looking for what the worst sign is and seeing which category it fits in, So for example if they've got all these mild moderate um some slash symptoms, but they've got a saturation of 92 that automatically bump them into severe or whether again they're all all of their, their, in the severe infection, but you're listening to their testing. They've got a silent test that automatically puts them into the life threatening section um fine aside from the respiratory respiratory flow rate. You're looking at the work of breathing very good sign if they're talking to you in full sentences and then you obviously want to look out for kind of red flags in your life threatening section, So as we mentioned some chest whether I've never seen this, but whether they've got older, consciousness whether they end up being a bit confused are they trying to get tired to look very clearly cyanosed, yeah, uh and again some places because we're talking about the side of things and even if we're talking about asthma exacerbated by a viral infection um useful to know about whether there any recent ill, close contacts again in the family or at school or something like that um because it kind of gives you a good indicator of where it's all coming from so management. A take the approach of oxygen as needed to keep your sats above 92%. Uh Mainstay of your treatment is giving them bronchodilators to giving themselves beautiful. You can consider adding on an anti muscarinic, so, ipratropium bromide, you can consider adding on steroids as needed, so either prednisolone or hyper uh cortisone, so we'll start with this, so what makes us choose inhalers versus nebulizers think before I started working. I was just thinking along the lines of well nebulizers are just the more kind of effective form of providing medication, but actually in practice the way the way that we the way that we look at it is. Um we only tend to give nebulizers two kids that are requiring oxygen and anyone that's not requiring oxygen, so maintaining that's about 92 were quite happy for them to just use your inhaler because we're obviously looking at like when we're in hospital, we're looking at what do we need to do to get these guys out of hospital as well, so just getting ready to leave. Um oral prednisolone will be for most kids who will be going home or not too unwell. Iv hydrocortisone will be more in very severe, life threatening asthma's or if they're unable to take it orally for any reason. Um Beyond these, actually, we can chat a little bit more about this as well, we can just chat about with the salbutamol inhaler. What would you actually do or what would you give so. The mainstay of it is if it's a super mild asthma, so there's no work of breathing or no signs of increased work of breathing at all, they shelled out with their breathing. You're shouting to you in full sentences. So examinations perfectly normal except for the fact that you've got a teeny bit of a wheeze on the chest. You can give them 3 to 5 puffs and probably send them done if they've got any signs of increased work, breathing for example, uh or their chest sounds like very tight or very wheezy or you're worried about them. For any other reason, you can consider stepping straight up to 10 puffs of an inhaler so that's kind of the maximum that we've given one go and essentially what you want to do after that is you want to see how long can they go before they need another 10 puffs of the inhaler, so you come back and review them intermittently, so you can give them like an hour with and then review that you go and see them after an hour, see whether or not it's made a difference and then potentially if they're fine, see them again an hour later, so now you're stretching them to two hours without an inhaler and then review them on our to still fine. Let's review them on our three and see and that's essentially the person of stretching someone on an inhaler, so kind of seeing how long they're able to go before you feel that there that they've got bad enough that they're requiring uh treatment again um In terms of being on that, so, if patient's had their cell beautiful inhaler slash neb, the ipratropium bromide inhaler slash neb, they've had their their steroid and they're still worsening um. The next steps include giving them iv magnesium sulfate and at this point, you started thinking I really need to step up their treatment, so do do these guys need to do you admission um and then what you would actually do in hD you is, you can consider giving them things like iv salbutamol, iv aminophylline, and then worst case scenario. Obviously, you're looking at, do we need to interview, intubate, and ventilate them, and step them up to I see you after that so that's obviously in your worst case asthmatic um antibiotics obviously not only used because we're dealing with viral infections most of the time, If you've got any convincing evidence of bacterial infection, so any kind of like football, crepitations or like extremely high fevers, for example, um which aren't resolving with your paracetamol, ibuprofen, then you can consider adding on antibiotics um and again similar to bronchiolitis and that's just generally applies to pediatrics. In general, we don't tend to um like really mainly do loads of investigations for everybody, so even these guys are not routinely going to have the bloods done. Um It's because it's not really gonna add much value or it's not really going to change your management plan. Generally, like with a viral infection, you can have a slightly raised CRP for example as well, so I wouldn't necessarily use that to guide um to guide your management. Um Any questions about any of this. So far I feel like I've just been going on and on for a bit. Also I got a bit of a excessive slide. Um So this is kind of just your assessment again in primary care for um children with, to wheeze. Basically it's kind of going through all stuff that we've already spoken about so working out whether you're in the mild category, whether they're moderate categories, there are life threatening what signs you've got for each of those um and again just for example with the mild one you just give them their usual good dilators, 2 to 5 puffs of their use them, all with the moderate and you can give them 5 to 10 puffs reassess them afterwards and repeat if needed, give them their steroids if needed and obviously your life threatening, so you're looking at just giving them nebulizers, for example to start with I guess if they're needing oxygen or if they're able to, for example take their inhaler effectively and then escalating is appropriate, so in terms of when we're looking at getting getting uh orange juice reason asthmatics out of hospital, so after we've admit them so kind of like center to the discharge to the admission criteria, I guess so they're safe to discharge once they're off oxygen for starters. Um You want them to have stretched to four hourly self a small inhalers before you discharge them, so essentially making sure that they're able to go four hours between inhalers without like being particularly bad with their with their work of breathing. They don't need to be wheeze free, so we don't mind if they have a little bit of weed on their chest because that can still be managed at home, but the main thing is just making sure that they're not struggling for their breathing with us. Um Before they go home, you want to make sure that and we don't always say this. The nurses are pretty good with doing this as well. You want to make sure that you assess their inhaler technique and just making sure that they're doing it properly with a spacer, and they're not just you know squirting it to the back of the throat without properly inhaling it. For example, um the other thing that we can do so again similar to bronculitis. We can arrange for a community nurse review for the next day or the next two days to come and see them and see how they're doing with their with their weeds and the work of breathing and the final thing is we took parents through something called a wheeze. Plan. Obviously safety get them to come back in if the child's clinical condition changes in any way so on my next slide, I've just got a little pay of the week, one, so it's actually a pamphlet that we give to parents that is about how we treat wheezes and how we treat asthmatics essentially to help them carry on from where we've already reached with being stretched for our relief, clean salbutamol inhalers, so the main thing to look at over here is kind of this bit, so essentially on day one after being discharged, you're looking at still giving them to 10 puffs of their inhaler and giving it to them four hourly then day too, so, essentially what we're doing is, we're gradually weaning down there salbutamol until they don't need it at all day. Two, you're looking at doing them 4 to 6 puffs and giving it to them four times a day, then 346 puffs three times a day and day 42 to 4 puffs two times a day and then actually just cutting out completely so just making sure that you know like we're giving them a teeny bit of support still until they don't need it anymore, yeah fine. Uh so pneumonia's so pneumonia's I think most people will be a lot more comfortable with. I guess because it's a lot more of an adult condition than just a really pediatric condition, so it's something that we still on occasion to see with kids, but not very commonly, so it is just an infection of the lung tissue can be bacterial. Well is back here a lot of the time, but can also still be viral um which you wouldn't necessarily always expect, but then I guess if you have got something like convincing chest x ray changes, it's always better to just cover yourself with antibiotics um just to be on the safe side because of iron. One will resolve by itself, but bacterial one won't presentations. So things that would more make you suspect pneumonia over the over, other conditions would be um as we mentioned before, so persistently high fevers or 39 we're looking at whereas with bronchiolitis, and with of Ireland, these reasons, you're looking more between 38 13 months old, obviously again not a fixed rule. Um On examination, having focal crackles, so in just one area, the long you've got crackles that's a good sign of pneumonia um cough, typically wet and productive. I guess with adults, we work quite good at asking like is your disputed, you know yellow or is it green With kids, they're not very good at coughing up what's what's inside, so they generally just tend to cough it up and swallow it again, so parents never actually know what the color of their phlegm is, um but what you can get is a wet sounding puff, but then again very dependent on you know whether they have like which parents are coming in and how descriptive they are so the key to tell. Um They can also have signs of increased work of breathing, so again a common theme and obviously if they've got a bacterial infection and they're very unwell with it, they have signs of sepsis, so systemic imbalance, so your tacky cardios and your hypertension and your tachypnea is and then you obviously manage as appropriate and so assessment, So again to the approach as we do with all of our patient's, I like to develop kind of how I'm doing my investigations into three steps, so bedside, so the test I'll do the bedside tests what the blood test that will do and then imaging so at the bedside things you would consider doing is. You could potentially try getting a sputum culture, although, unless they're older, kid it's generally going to be quite tough to get it off them, an easier thing to do would be to get a throat swap and that for both bacterial culture and for viral pcr. Um you can consider center bloods as well you're doing things like an hBCU and the CRP, considering a capillary blood gas again and then obviously, if they're if they're septic, you always want to do blood cultures as part of your sepsis six um And then if you are suspecting pneumonia um so based on your vocal crackles um, then imaging might be helpful to help you kind of see what is actually going on inside, so I just put that's actually a normal chest x ray image that we have on the right. Um I I just put that up first and then we can have a look at an example of an abnormal pediatric chest x right, So okay everyone finds just message outing out where they think that abnormality is in this chest x ray. If we are feeling today, mhm, all right, no worries, um so the abnormality I'll just pointed out on the next slide, so it's very clearly kind of around the left middle zone so got a little bit of consolidation over there, and if Monex, it comes up a very fine so in terms of management, obviously depending on how unwell there are, we try and discourage as many kids as we can. If they, if they look well, then we can look at getting them home with just oral antibiotics. If they are septic and look horrible, then you can consider while you admit them for doing IV antibiotics um foreign temperature control as we may have mentioned previously, you can advise parents to essentially alternate paracetamol and ibuprofen paracetamol. I think in kids you can give generally 3 to 4 times a day with different dosages, I've preference generally three times a day, so the best way of telling parents to take care of their kids temperatures at home. If we are talking about persistently high temperatures is alternate doses of paracetamol and then ibuprofen and the paracetamol and ibuprofen, and it's eventually limit the amount of time they're going without antipyretics because in all honesty that's the maximum that will do to control the temperature in the hospital, so just about getting parents good with that well plus minus six is six, which I've put on the right, so sector six. If we don't already all know, it's your three and three out, so your three inns or your oxygen in if needed, antibiotics in fluids in and then your three out so your blood cultures out your lactate out your urine output out. Um We don't tend to catheterize kids as we do with older adults. If we want to monitor urine output, we do just try and I mean the nurses are just spent generally very good at keeping on top of uh measuring it and with with younger babies, what they do is they just measure how heavy they're wet naps are, so that we can assess their hydration that way um and then obviously um more of like a rather than acute management plus kind of more longer term thinking if there's any child who's having to come in multiple times um needing antibiotics, then we want to consider doing potentially it further investigations to see why they're having recurrent and like recurrent infected, so is it because they've got an underlying lung pathology, is it because they've got an underlying immunological deficiency. Yeah Right next condition um again common pediatric respiratory condition, not something that I've had to deal with that very often because it's something that any er generally very good at dealing with and keeping out rather than referring on two piece is croup, so croup is essentially an upper respiratory tract infection that causes edema in the larynx, so it is laryngotracheal bronchitis, so inflammation of the larynx, trachea, and the bronchi. Old bronc, I and we've got a very nice image on the right over here that kind of shows what a normal larynx looks like so with your vocal cords and your tricky over here and then what it would look like in a creepy baby, so everything just kind of swells up a little bit um commonly, so again whole host of viruses can cause it, including the ones that we've already mentioned, so rsv adenovirus, influenza, but what most commonly tends to cause. Group is parainfluenza virus and that tends to be either type one or type three, um whereas bronchial ISIS were tending to look at baby's below the age of a year uh With the croup, you're generally looking at baby's being more between the ages of six months and going up to two years the presentation, so what you'll actually generally get on your exam. Questions would be they be presenting with a barking cough or a seal like sounding cough, which unfortunately not got on the sound clip. I've got a clip of strider on there, but again a very good one to youtube because it gives you a very good idea of what it sounds like so barking cough. They can come in with a stridor so that's kind of just a respiratory sound which will try and play over here, just listening to send what it is than me trying yeah, so essentially a sound that on inspiration that's caused by the tight airways. Um You expect low grade fever with croup and you can get signs of increased work of breathing so similar to the things that we've already gone through before. Yeah, so, in terms of assessing croup again 80 approach with all of our kids, um doing a thorough history and and then the mainstay of it is something called the Westly score, so that's to help you kind of classify how severe your croup is and that's looking to similar things is what we've kind of gone through already so kind of looking at work of breathing. So it gives you a certain number of points depending on how bad your and your work of breathing is with your recessions, very subjective, though. With this with mild moderate and severe retractions, oh could you not let me get it up again. Hypericism sorry to interrupt. I think when you played the sound uh when you played the sound of the stride earlier, I don't think anyone was able to hear that um do you think you could play on your phone or something because it might be because the computer settings are not. Uh You know they must have been set like that or something yeah. One sec, let me try and play it more time and then let me know if you still can't hear it, yeah. I don't think uh yeah I still can't hear it, sorry, okay all right, I'll just get it up in a second my phone, we can keep hang on here. We go. Stridor is a type they can produce mhm, yeah, that's cool, so that's kind of strider noise, so yeah something that you tend to hear on inspiration, just sounds like they're struggling when they're bringing in um So, yeah, so you're working out with your Wesley score their work of breathing. The second thing you want to see is a do they have stridor and secondly when does the stridor come on, the, the stridor come on when they tend to get a little bit excited or is it present when they're at rest as well. So strider being present at rest is generally a sign that you're going to end up admitting them to hospital. You want to see whether they've got any signs of cyanosis whether or not it's affected their level of consciousness at all, and then obviously when you're listening to their chest, you want to see how their air entry is and whether all of this inflammation going on up here is making a difference um to their air entry and once you worked out all of these points, it gives you a total score and that helps you categorize it into whether there is croup is mild moderate, severe or whether it's worse case scenario, impending respiratory failure. Yeah yeah um This is again a slide kind of looking at the Wesley score in a bit more detail the main thing to take away from here, I'm sure as a haven a variable get these flights sent out to you, guys are you guys getting them sent out, yeah sure if that's well, I mean if you're happy with that, Yeah I mean another problem for me to see you guys can have the information later then. Um So main thing to take away from the Wesley scores with your mild to moderate croup. They generally don't need admission with severe and obviously with impending respiratory failure. You're looking at bringing them in and treating them fairly aggressively. Um Mainstay of treatment, um and group tends to be very responsive to it is well for a lot of kids. A they're not going to need any treatment for storage is because it's again a viral infection and you just explain to parents that because it's viral and we don't generally tend to treat viral things. Is a matter of giving their kids a little bit of time and they'll recover by themselves um for any kid walking through walking into any with a barking cough, though they tend to just pretty much be given dexamethasone, so steroids right away um, and it's found to be a very effective treatment, so after a little while, it tends to bring the swelling down a little bit a little bit, and the barking cough slash strider tends to resolve um in severe group or kind of along the lines of the 12 plus your life threatening ones, so you what you would do is you start off with dexamethasone, so obviously giving it oral or if they're unable to take it orally. For any reason, if it's very severe, you can consider giving it. I am um you want to give them oxygen as needed and then you can give them so nebulizer, adrenaline or nebulizer, the desonide to kind of help open up the airway a little bit and then again in your worst case situations where you're looking at where all these aren't working and you've got like deteriorating gases. For example, then you're looking at getting I see you involved in seeing whether they need intubation and ventilation yeah, so next condition um is kind of similar in a way, it's not a very common conditions. We're talking about epic oh psoriasis here, so it's similar presenting complaint in a way in terms of it tends to present. It's another respiratory condition that presents with strider, epiglottitis is inflammation or swelling of the epic glosses. Um pretty self explanatory, We've got very good image over here, this is a normal airway and over here you can see kind of how badly swollen that epiglottis is and how narrow that airway opening is, so it is an airway emergency. Generally, it's caused by haemophilus influenza type B. It's very rare nowadays because it's covered in vaccination, so I've never seen it myself um only pretty much answered, example questions about us in your exam questions that will tend to be things like unvaccinated children coming in giveaway sign they tend to come in acutely unwell, so you tend to have extremely high fevers. They'll have your basic things that you would expect with airway inflammations or throat difficulty swallowing. The more kind of giveaway features of epiduo, scientists and exam questions, or there's three points at the bottom of the presentation, so you'll have drooling children, they'll look horrible, apparently, so they'll be very septic looking and they'll be in something called the tripod position when she I'll show you on my next slide, so that's essentially let's just go to the next slide, so kids tending to sit forward, so they tend to put their arms forward. They tend to move their neck like extend their neck a little bit, and that's to kind of try and help make a little bit more room in there a way they look like they're kind of struggling for their breath. Um taken a two E approach again as usual. We avoid examining the airways. If you see any trouble with this kind of like horrible appearance with dried or because if they do get upset while you're jamming a tongue depressor down their throat, then that's a higher risk of them potentially just closing off like them distressing themselves to the extent where they're closing off their own airway, so treatment and exam questions, um where what I'll be asking you what's the most appropriate thing to do you want to contact any cyst or a senior pediatrician and it's probably what I would do if I came across one of these kids anyways, um they'll be primarily leading the child care, so they'll look at how to best secure the airway or whether the airway needs securing at this moment in time and once we're happy with the airway, then we can look at getting like proper proper treatment stories it for the actual cause of the airway problems, so giving them IV antibiotics and giving them steroids. Um I think this is the last condition of today, so lauren go malaysia is a structural problem that we tend to see so it's eventually a floppy voice box so structural problem where you're supraglottic hearings causes partial airway obstruction, so as we can see over here so that's kind of what a normal voice box appearances. If you're kind of pairing at it from above. In lowering go malaysia, their voice box tends to kind of curl in on itself. There's different variations of it as well, but essentially what it is is because this voice box is kind of collapsing in a little bit, it tends to cause a similar stridorous noise. Um You tend to find it, so it doesn't generally tend to present when kids are extremely young, like what I mean is when they're still uh like infants. You expect to see it more around the age of like six months to a year. Um It doesn't tend to be a constant strider. It tends to be an intermittent strider, although it could be constant if it was severe enough, um you can exacerbate they're strider when they're a bit excited when they're feeding um when they're lying on their back or it can obviously also be exacerbated when they're ill, so when they've got any viral infection, it's already causing a bit more inflammation around there that will exacerbate the issue. Uh. Usually no associated respiratory distress. Us, Sometimes, if it is severe enough or if for example they're coming in with a background of this and they're unwell with a viral upper respiratory tract tract infection. You can get signs of respiratory distress with it, so 85 to 90% of children tend to grow out the problem by themselves that strider tends to solve, qualify the age of a year. You can consider although again not seen, temporary tracheostomy is being performed, uh water weight permanent solution for it that would obviously be in very severe cases. Um e. N t commonly intervene with luring go malaysia, so they can form a surgery called a super glass opacity so that's essentially taking away a bit of the supraglottic tissue um to open up the area a little bit and help with the stridor and that is everything so thank you guys for listening, do we have any questions yes and if you guys, please fill out the feedback form that these guys as well, I would really appreciate that never yeah um hi guys. Uh If you have any questions, please you can pop in the chat box uh and I've also put up a link to provide feedback. You, guys can fill in that and have you certificate and thank you so much for us, it was a really useful lecture ready um really appreciate it and yeah any questions at all, let us know, and I'll end the session then in a few minutes uh Next wednesday, we're going to have another lecture 6:30 p.m. sorry about the delay for this time, but hopefully it will be on time. Next time. Thank you all right then. I think I'll end the broadcasting now. Thank you so much for us, Thank you. No worries, thank you guys.