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On to our first lecture in the Med Ed specialty series. Can I just confirm if everyone can hear me? Ok, if someone could just pop something into the chat that super helpful? Um ok, that's fine as well. So, um so yeah, we're starting off with Peds in the month of Feb and then we'll have some more lectures on Ong and on psychiatry in the following month. So do keep an eye out for messages and on the Instagram. So we have Doctor Redone with us today to give us a lecture on pediatric respiratory emergencies. So I'll hand over. Hello, everyone. Uh Can I just double check that you guys can hear me as well and then we shall take it from there then. Ok. So what we're gonna do um is we're gonna go a bit through pediatric emergency medicine, um respiratory emergencies and, and we will take it from there. Ok, a bit about myself. Um Do let me know if you can see that the slides going forward or not? So, I am II work as a registrar at um Chelsea and Westminster Hospitals. I've got a very interesting job. 70% of my work at Chelsea and 30% of my job is as a Global Emergency Medicine fellow. Uh Sorry, I did not include a picture. I've completely forgot that. Um um my global Emergency medicine fellow bit is working a bit around the world really. Um um currently involved in projects in Ethiopia and India and one in Bangladesh where I'm originally from. Um So it's an interesting job that includes a bit of work abroad. Little bit of work. My focus has been mostly on education and training because that's been my interest and that's what I've been doing mostly and this is something I want to continue into my career. So this was uh towards the end of my emergency medicine training. I I'm I finish in November if everything goes good. Um I might use it by doing an extra year in pediatric emergency medicine. Um I graduated from Bristol in 2017 and then therefore left to up in the Midlands. My main training is actually in the east of England. Uh Cambridge, Watford, Luton, West Suffolk have mostly been involved in teaching with uh the University of Cambridge where we used to get to do an undergraduate clinical supervisor role. And then when I was at Watford and Lu got a bit of hands on with UCL. And then finally, whereas Chelsea now a bit of work with you guys, um I don't know if anyone was a care conference this weekend that was there on Sunday doing a bit of chest teaching. We're gonna do a bit of etiology, a bit of history, a bit of presentation investigations and management. Um We're gonna mostly not, we're not, not gonna cover everything of pediatric respiratory. We're not even going to cover all of pediatric respiratory emergencies, but we're going to cover some really hardcore uh topics. Uh you know, the core stuff that come on and most important with practice questions. I've got 10 questions of practice today. So the focus will be on those and a lot of discussion around the questions. So the cases not as much do interact on the chat. Uh The one good thing about metal as compared to Zoom or uh teams. I can actually look at the chat. So please do answer on the chat and I we can interact that way. You don't have to talk to me but you can OK, we start off with what you see. The commonest thing that comes in respiratory medicine, adult or Children, you know, medicine or A&E or pediatrics or actually even respiratory is the cough in patient. But you've got a case of an unusual cough. So you have 5 a.m. a 23 month old girl, not 23 years old, 23 month old comes up with an unusual cough. The parents are a bit worried because they've never heard them cough like this before. It's unusual patient was very upset when they woke up breathing was making a bit of a whistling noise. However, currently the child looks well, has got a bit of a snotty nose, has had a snotty nose for the last two days and this is all, you know, so far, how do you assess the patient or do your differential diagnosis or what do you want to do? How do you want to treat them any takers? So, one quick thing about, yeah, I was just about to say, you know, you want to do a two assessment. Yes, good. That's good. Uh As you go to do that, airway is currently patent, there is no whistling noise that the mother mentioned that is present at the moment. Uh in terms of breathing, there's a bit of cough. There's uh when you listen to the chest, the chest is clear, uh you know, observational or within range temperature 37 8. So a bit of a low grade fever circulation wise, there was good, good volume pulses. Uh cap was less than two seconds. Nothing really worrying. We didn't do a BP because it's a child. Uh dis the patient's alert. Um G CS would be treating from falling into one, but we didn't do any um no glucose was done because she's alert and es there is no actual rashes or anything that you see when you've completely stripped the child off. There's no signs of distress on just viewing even and there wasn't any when you examined them for B, so that's a two E assessment. That's your assessment of the patient. She is otherwise. Well, the only history is the unusual cough and when she coughs she's still got that weird cough. You know, perhaps you've never heard this before. It's the first time you've heard it as well. Uh, but you've got a weird coffee patient and it's just woken up with it. What do you guys think? What are your differential diagnosis? What are your differential diagnoses of weird coughs? You know, uh, that's waking patients up. Had a bit of whistling noise with it. Let's, I'll add a bit more to it. Yeah. Good. Bronchiolitis. Good. Very good. You're going around down the right route. 23 month old is likely viral. Wheeze is possible as well as the, we'll, we'll talk about when bronchiolitis becomes viral. Wheeze and viral. Wheeze and bronchiolitis overlap with each other later in whooping cough. Very good. Right. You've talked about whooping cough. Um, what makes it slightly unlikely for this to be whooping cough, by the way, there's something in the story that doesn't really go with the story of whooping cough. It's possible but it's not for a reason. Um, I haven't actually told you about the vaccination. The vaccination history was positive, but even if it was negative, this history doesn't really go with a whooping cough. The reason being mainly is that this is a cough that's been going on n only tonight, you'd expect with a whooping cough for it to have been going on for a while and to be there to be some few other systemic symptoms or constitutional symptoms, you know, they've been losing weight, not really getting better, weeks and weeks and weeks and otherwise, you know, you wouldn't really expect to str or, I mean, you can, it's not impossible but it's unlikely. So that's why it's not whooping off, but you can think about it. So if I changed the history and I said this is a 23 month old child who has been um fleeing war has lived in multiple refugee camps and has come to come to the UK uh as a asylum seeker and they've been living in squalor conditions for the last, since the age of birth and have, you know, missed all vaccinations and there's nothing and has had this cough for the last six months. I think whooping cough is a very possib big possibility there versus here where it's just overnight and it's not really there, but very good to think about it. So you kind of got all the right differentials, improve bronchiolitis, viral, wheeze whooping cough. Anything else you can think of? I'll have one for myself. You guys have added yours. Um, bacterial tracheitis is another one. So it's when the tonsils look fine, but there's a lot of uh um um you know, sore throat and difficulty in uh so in terms of uh re feeding and things like that. And they've also got a cough. They're often though very sick. Uh, so their, uh, temperature would be high. They'd be tachycardic and I wouldn't get normally to a, ok. So this kid was a kid of Croup. Croup is an upper airway DS barking cough and struggle. I did not give, give away the barking cough in the vignette because intentionally, I mean, why would I, you would know immediately what the answer is, but that's not what patients tell you, patients tell you, they've got unusual cough and a cough that I've not seen before or not heard before. And the whistling noise as they're breathing, that's a bit of stridor. It's worse when they're crying worse when they're usually a bit unwell and then often gets better on its own. The PK to six months for three years and is often preceded by viral respiratory symptoms. As in this patient had about, uh, you know, two days of coral symptoms, other differentials you guys have all mentioned it. I've mentioned bacterial tracheitis myself, but you've mentioned bronchiolitis and viral wheeze and whooping cough, foreign body aspiration is another one, especially if it's still further up. Uh, you would still expect though, you'd expect when you examine the chest, that one side is having less, uh, air entry, for example, or there should be a part of the chest. You wouldn't hear good air entry and, you know, I also wouldn't come really in the middle of the night would be well, more, you know, child was playing and things, but you want to ask these questions and these are good questions. Epiglottitis. Again, possible, you'd hear the whistling sound but the child wouldn't just spontaneously get better. The child would remain unwell and, you know, that's what we are. Ok. So, uh, if you got any questions, obviously just fire away in the chat and I'll get along with them. Uh But you can ask questions towards the end as well. Uh But before we go ahead, uh just a bit of different stuff, signs of respiratory distress, um very poss, you know, usual questions that come up and if you've got like a nosy, they'll probably give you a completely normal child uh to do a respiratory exam on. But they will ask you, what are you looking for when you're looking for the respiratory distress? And these are the things you want to see. It's not just raise the respiratory rate and it's not just difficulty in breathing. It's also ac Children can't tell you I'm struggling to breathe. They can't talk and the really little ones can't talk. So you can't really defer based on, you know, how can they finish a full sentence or? So you want to look at, are they using the accessory muscles? Is their tummy going in and out? Are there intercostal muscles going in and out? Subcostal muscles going in and out is a nasal flaring head bobbing, uh, you know, tracheal tug, uh that you might see is there cyanosis are their lips blue, are their hands blue and is there abnormal airway noises, you know, stride or uh that you might hear? Um, you know, and is either doing inspiration or expiration, you can get here in both. So, you know, that's slightly what you want to look into and what we, what do you want to see? Ok. And these are the things that will be coming in on the questions towards the end as well. We'll look into it. Ok. Er, there's loads of different schools. I do not need to follow this one. My advice would be, you look up what is on nice. Er, this was the hospital I was working in at that time, I was working in Cambridge at the time and they used this score and really the easy way of remembering this is a mild group is where the Children are actually well enough. They haven't got much recessions or anything and there's no Stridor. Stridor has to be off any Stridor and we're heading towards moderate or severe. Ok. Stridor when agitated or active is moderate. Stridor when at rest is severe. Ok. Same with intercostal recessions, you can tolerate a little bit of anything more than you want to air entry on auscultation should be normal. Croup is an upper airway disease. So if there's lower airway issues, you're thinking there is probably a sick patient and their airways blocking up. And that's why they've got uh reduced air entry cyanosis. Again, it's an upper airway disease. If there's cyanosis, it's an airway problem, not a breathing problem. So it's an a issue and a issues always make us worried. Ok. And then again, level of consciousness should be normal because if they, if they've got decreased level of consciousness, either the sleep middle of the night or it's concerning. And in terms of the treatment, treatments again, vary, the doses vary as well. I mean dexamethasone, I think nice advise is 0.15. But uh hospitals do even go up to 0.6 and that is still acceptable. Uh 0.150 0.30 0.6. I've seen all of them given uh you start off with one, you can give it twice as well. If required, they come back. Um You can observe them after a while if they've got mild croup for a moderate group. Uh you want, you know, say you want senior to come in, get some more dexamethasone and consider desonide. And for the severe group, you want to give nebulized adrenaline. Ok. So really most kids are either in the mild or severe it, you do sometimes see a few in the moderate and I have sometimes given two different ones. Ok? And obviously respiratory failure is horrific, you know, give adrenaline get like a an anne is down and you know, that's how you get through. Ok. Um So really three layers, mild um nebulize, so, oral steroids, oral dexamethasone, nebulized steroids, uh nebulized budesonide, a second level and third level is nebulizer, adrenaline. Really just three different types of medication. There's much else to go through. Um But so it's not as bad. Ok, so we've talked about cough. Ok. We remain on cough. Second patient has also got a bit unusual cough. Three is slightly different. I'll come to it actually. Uh the story here, this is a 21 month old child. He's got a 10 day history of a barking cough. This time. The patient's father tells you it's a barking cough. He's had a couple of doses of dexamethasone from GP, but he's just not improving. He's coming and he's in respiratory. He's, he's struggling, he's struggling to breathe and he's, you know, this is your finding in a, you hear an inspiratory stridor in B you hear rapid breathing. There's all signs of respiratory distress. You know, you can think of there is intercostal recession, there's nasal flaring, there is subcostal recession. The child is flushed and cap for four seconds, oxygen levels is down. It was a decision. Now you put some oxygen on, nurses, put some oxygen on and this is what they find. There's good air injury to the left side, reduced air injury to the right side. No other findings are note, but it's a very lethargic child, it's not really responding much and this is what you've got. Ok, guys, what do you want to do? What are your differentials, what the further investigations want to do and what do you think is going on far away? And if there's any other questions you want to ask the father, you can ask and I will try to be father and tell you good someone's asking for foreign body, inhalation, chest x-ray, Very good point. Foreign body again, chest X ray, VBG. Fantastic. Um, ok, there's something in the history that goes against foreign body. Can anyone tell me that? How long is this going on for pneumonia? Yeah. Good, good trout because it's going on for about 10 days. You know, so you don't really know. Is this is having said that it could still be pneumonia in the foreign body, right? Er, 10 days, if they said nine days, he just had a bit of a cry suddenly one second he suddenly become severe distress. Uh, it was, and it was a progressive decline. So if they said something like that, he can do something about the foreign body. However foreign body or pneumonia. What is the, you know, you guys have already mentioned the medication you want to do a chest X ray, you know, a chest X ray will tell you either way what is going on. Uh, and that's a very good drug. So me, I, when I I'll tell you what I did. Uh obviously, this kicked me in and he had the most creepy sounding cough I've ever heard. And I'm like, come on, this really has to, I know this is 10 days. So what I did shoved him on some nebulizer bide and then sent him for an X ray after he settled slightly. Ok. Uh This is the X ray. What do you guys see? I don't know how clearly this project is obviously, you know, lighted. It doesn't, but what do you see? Just tell me what do you see? Don't have to give a diagnosis. Just tell me what do you see and what your concerns on this you guys have, let's say foreign body and and pneumonia are our differentials of the moment. Now, this is where we are. What does the x-ray take you towards or talk a briefly? I don't actually have a foreign body x-ray and I'll tell you what we would see. Good Sica, you've said um right out and learn pacification. Fantastic. I agree with you. Next question. Is this pneumonia like opacification or is this a foreign body uh classification? Very good question, Andre uh is a bila bihilar lymphadenopathy? There is there is, I think there is uh it's not very clear, but I think this is bihilar lymphadenopathy. Uh just to pissed me off, they never repeated this chest X ray in six weeks time. I mean adults or Children, you probably should uh presuming the child has been, well, it's been years, this, this case was from 2022 I think. Um So. Yup. Good. Um So this is, so I'll tell you what you would see. So if this was, if this is a foreign body inhalation, you can see lung collapse. But if you uh look at the right lower lobe, you see there are some lung markings there in the midst of the collapse. So there is, it's more pacification rather than a true lung collapse. There, there is a bit of lung collapse as well, but it's like a low. So whereas with a foreign body, sometimes you actually see air beyond the body as well, it's just air that's just stuck. So you just see a bit of lung which doesn't have any movement in it. So sometimes you will see actually a complete lung collapse and there's nothing there. Whereas in this, you see a bit more of a patchiness to it. It's focal, it's focal right lower lobe, but it's not really ok. And yeah, so this was a bacterial pneumonia. It is still the major killer of Children worldwide. You will still see it in your careers. If you work in pediatrics, you will see pediatric pneumonia no matter how well off the child is. And they are not necessarily immunocompromised Children. Well, Children get it as well. Majority cases are still viral. The idea is viral. Pneumonia is generally bilateral pat pacification mostly at the bases. Whereas focal consolidation, focal finding is more bacterial pneumonia. The suggestion is that you find, uh even in viral pneumonia. When you listen, you hear crackles everywhere and crackles that move, that are there and then there's cough and it moves away. Whereas the bacterial pneumonia, you hear crackles, focal and just remain in one place. Um, uh, chest examination might actually be normal sometimes. So it's not necessarily very good but you do still and you treat base a treatment based on how sick a patient is. You can give oral antibiotics. IV, antibiotics. I have antibiotics to come back, outpatient and antibiotics and things like that. Um Risk factors are also important to consider in, in the management of patients. Can anyone tell me of risk factors that make you more worried about a patient? Actually, before that, first of all, where, where are you guys going? Are you guys going towards? Um, it's actually create a pole. What that biopsy? Ok, guys. So tell me how you'd want to pull this. I've given you guys a poll. How do you want to give the antibiotics? Do you want to give us an IV, an oral, an IV as an outpatient? And you know, just let me know and I also bit mine as well. I will answer later. So let's see. So everyone seems to be well, one response, 10 responses, everyone seems to be going for IV. Good and uh that's very uh good that you're doing that fantastic. I'm laughing because of completely different reasons. Nothing to do with you guys. Uh, it's all starting to distract me. Um, ok, one of you gone for oral. That's fantastic. Uh, I'd really want to know why, but please tell me, let me know why you want, want to go for oral antibiotics if you want to. Uh, I'd like to know. Uh, I don't think that's the wrong response, by the way. Um, because he can keep someone in hospital and decide to give them oral antibiotics. That's not. Um, the current evidence does go towards, um, that actually there isn't much of a difference between oral versus IV. Actually in a child you would want to. So I would go for IV for another reason, I will go back, go back, go back to something else. So pneumonia itself does not mean you need to go IV. What is important in this child for me is c look at it. Cap refill is four seconds. So this is not just pneumonia, this is a child that's going into bed more bit more multi, multi organ. Ok. They're dehydrated, they're going towards sepsis in this. So that's what will make go towards IV. But if the cap refill were normal and this child just had an oxygen demand, he could still go away with oral antibiotics. Lots of places will. Um, but especially I work in a global setting and you start thinking of in multiple different, um, countries you have to think of whether they have to buy the antibiotics. IV is way too expensive. Sometimes you can sometimes just give them oxygen and give them oral antibiotics and survive. It's possible. So, oral is not a bad, but in this question, if in a UK setting we'd give IV. But more because it's heading towards the, because it's just pneumonia. If it was just pneumonia, we wouldn't. Ok. Well done. How are you guys? What, what do you want? Uh, what are risk factors you want to think of before we go to the third case, what risk factors you want to think of before deciding how heavily to treat a patient going, once, going twice. Um, that's all right. Uh, so, I mean, the risk factors are very similar to what you think of in adults. Uh, anyone who is, um, you know, yeah, that's good. Premature preexisting lung conditions. Fantastic, premature baby is the only thing that is an extra in the anus, uh, in, in Children. But everything else preexisting lung conditions, you know, there are Children who've got lung fibrosis, there are Children who've got cystic fibrosis. Uh, there are Children who've got infantile asthma and all sorts of the lung conditions that might, you know, there might be congenital conditions that might Children with cancer, Children with hematological malignancy, any other immunocompromise, you know, they might have juvenile arthritis and they're on some sort of immunosuppressant, they're on um, anything else that makes immune, compromised ITP, for example, they don't have any platelets at the moment. You know, anything else? Anything hematological, for example, in terms of premature babies, it's important to get a bit more deeper into the history because some kids are premature and they're fine. Some kids are premature and spent a long time in NICU and they're still fine by the time they're 21 months old, they have turned around and then are healthy babies. Some of them have spent time in NICU and I have got longstanding lung fibrosis and lung issues that I keep going. So there are things like that that are going on. So you need to be careful of uh what's going on in terms of that. So um very good, very good guys. We go to the case of the wheezy child. So this is uh II will never forget this child, December 20 22nd wave of COVID 21 month old presents with a five day history of being generally unwell. If any of you been to any of my session, either you, you're not allowed to answer because uh but anyway, runny nose, poor, all anti cough fever, mothers attending as a childhood breathing fast and more lethargic focused examination revealed there's some wheeze some inspir rotations, bilaterally, childhood desaturating grade started on oxygen, 15 L with non rebreed masks, saturation. Now 8 98% there's intercostal vision, subcostal recession, tracheal tug and all of this. Uh but there is what's different in the child is there is wheeze, there is cough, wheeze cough. The cough is not barking. The cough is normal. It's not productive. I'll give you that extra. What do you do guys? You got to start with? Two? Eo I'm presuming. But what else? What else? And what are your differential diagnoses guys? And if anyone's got, so let's do another poll or should we? Now? That's fine. Let's do messages first for now. We'll do a poll later. Respiratory assessor. No. Fantastic. Viral indu wheeze you bang hit it right. 21 month old. So can be viral induced. Wheeze can be bronchiolitis both. So I'll let's induce both. So as Abby was saying bronchiolitis, so be sure you've said viral induced. Wheeze uh both. IV, but you, you've added in bronchiolitis as well. Respiratory distress syndrome. Fantastic that you've got onto that. It's important to remember that can happen. And you know, Children too, you know, a DS, not just an another disease. Um that second wave of COVID. So you probably might be thinking of COVID is going on as well. Um But yeah, so let's hit it as bronchiolitis. And uh OK, I did have another slide. Oh, there it is. That's fine. Anyway, let's talk about this. Bronchiolitis is common cold gone bad. OK. It's a viral illness. It's usually R SV starts off with a very and up to the age of two low grade fever, chronic symptoms, cycnia, dyspnea, possibly respiratory distress, a see wide spectrum of disease and a bit of cough to intubated, ventilated, struggling about to die. Anything in between his bronchiolitis. Ok. Uh Mostly self-limiting. Very few patients need hospitalized it, but a lot of them do 7 to 10 days of illness. But two killers in bronchiolitis, actually hypoxia and reduced feeding. We often forget about the feeding. So it's very important to ask what the feeding bit is during. Um, for you guys, you ask 50% of normal feed or some people say 75%. But depending, I think nice says 50%. So you go by 50% if it's coming questions, but you need to be, put it in context. Ok? We work in Chelsea. 50% of feeding is still overfeeding because kids are being fed at 200% of what you should be feeding. These are like chubby, you know, well, looked after kids who are being fed all the time, you know, and they'll come in feeding and a mum is telling you the child does feed. It's very funny. But so reduced feeding, you need to try and quantify reduced feeding. Another way of quantifying be feeding is to figure out how many, er, nappies, er, they're going through in a day. Um, if they're going through more than be nappies, it's less but it's still pretty good. Uh, if they're going through half of their normal nappies. That's when you start to think. Actually they, they're, they're starting to get sicker. OK. So this is a diagram about bronchiolitis, you know, stuffy nose, coughing, fever, wheezing, difficulty in breathing. So you've got a bit of all of them. It's at the top is where you start with the mildest and obviously at the bottom is the most difficult. OK. Management of bronchiolitis is entirely supportive. There's no drug that shows efficacy. We try lots of different things. My favorite is giving a bit of saline because it just reduces some drops straight into the nose or selis makes the child look a bit better. Has no mortality benefit. But I kind of like it because why not um keep the oxygenation good nasal cannula. So start off with just normal nasal cannula, then you go to mask and then you go to high flow nasal cannula and then CPAP, that's the ascending order of oxygenation. Important that you remember that we'll have questions about this later. So we'll discuss this more when we do the questions. They're often dehydrated because they just can't have a good feed because they're struggling to breathe the supplement fluids, oral fluids. Are, are you going to give IV unless they need, but I always remember that ABCD antibiotics only for patients who are less than three years old or if they're admitted to ICU or if you've got a really, really good indication that this is a bacterial coinfection along with it. Most patients will receive salbutamol in 25%. Do have some improvement, doesn't mean it. They've got asthma though. Uh There is no harm in doing one dose of salbutamol to see if they improve. If they do improve. We can treat them as broner viral induced. Wheeze um do double check, nice guidance on this one. But the hospital I was working in at that time, the guidelines were that any child with three or more of us should not be discharged, you know, duration of symptoms, less than five days, respiratory rate, greater than 50 heart rate, 100 and 55 oxys less than 97 and age less than so, obviously, oxygen less, that's less than 97 as a as itself. No, but along with two more of these things at their age less than 18 weeks, um the duration less than five days is because uh you know, they're getting unwell very quickly. We're just worried because day 5 to 7 at the peak of the disease and we want to see them get better before that. Ok. However, we've got this wheezy child, they're not getting any better. Um You know, the story they're desaturating again, despite the oxygen you're giving this audible wheeze on examination. So we've thought about bronchiolitis and managed to bronchiolitis is not improving. What else could it be guys? You've already mentioned it. So, what else do you think it is? And how can we try and treat them. Ok. Good. Yeah. R DS again. Good. Respiratory distress room. We've got lots of wheeze, you know, we can try and focus on the wheeze for a bit before we jump into just treating the R DS. So the R DS is intubation ventilation. I mean, you can do that as well, but we can try and focus on the wheeze a bit. Maybe. Uh there is a viral program to it and the patient is wheezy and 21 months old. It's just that borderline age between uh viral indu disease and bronchiolitis. So we could, uh so if we look at this, so there is that thing where bronchiolitis and viral wheeze co exist and then there's a bit where the asthma and viral wheeze coexist as well. So, um we will think of ideas but in terms of viral these or asthma, you classified very similarly into mild, moderate, severe and life threatening. You guys will have known this, uh look at up before your exams. These are very favorite questions. Er, in older Children or in adults, you go mainly by peak flow but it can go by how, how much they can speak moderate, they can, they're just mild, they're able to finish sentences, moderate, they're just able to finish one severe, they're just saying words, life threating are probably not speaking, they've got a silent chest uh and things like that. So there's tables to look into, I've not kept it here because it's a bit long and you know, the asthma dedicated talks will talk to you about this in here we go. Um But we going into a R DS, this kid did have a R DS. So you guys are right 100%. But just, just talk about these while we can. Uh the nic I use is oh shit, me, even though one of them, the, you know, the um all the specialists in respiratory medicine have destroyed tea for me. So o oxygen, we've given that to begin with what we thought it was bronchitis. S isol eight is hydrocortisone doesn't have to be IV or im hydrocortisone. It can give prednisoLONE or DEXAmet as an oral dose as well. I is ira T is theophylline or aminophylline. Unfortunately, it is going out of the guidelines. Now, Doxylin is remaining as the tablets are remaining as preventers sometimes in some patients. But the emergency management uh with IOP or theophylline is out. Magnesium remains. You can dive. Mostly some hospitals do allow them to be given nebulizers when e is escalated. So I'm out of the edit. So I just need to change the key and find something else uh to fit the Pneumonic and to because I should meet the best Pneumonic. I mean, you never forget and when you have a really sick wheezy child, you do say oh shit to me and that is something I'd want. So that's about it really. Um ok. Anyway, so we can move on. Uh So, but check it was given loads of bronchodil some salbutamol me presc him some steroids IV does not improve anything. The pediatrician calls for ICU support. At that time, I was the ICU doctor. He get some I access, we give some empirical antibiotics, he gives some magnesium. He's now gone on from normal oxygen to high flow, nasal oxygen and on nasal oxygen. His F I OT is 80% on 40 L as uh F I 2 80% 40 L and it still has saturation is 88% decision is made to intubate. I'm not really gonna ask what's the likely condition you guys got it before me. It's A R DS. Well, what do we not do in all of this? Uh We've done loads of things for this kid. We've given them some oxygen to think we've given him a nebulizer thinking uh you know, is viral wheeze or asthma or something we give you antibiotics now and magnesium as well. But what have you not given? What do we, what have we not done in terms of uh what's going on with this child? You know, is there something we could have done something we should have done uh imaging wise or um any other blood or VG or anything investigation wise that we could have done with that? We haven't that you can think of. Ok. So we shall. Ok? I will give it to you guys. Ok. Well, obviously he could have done an E BGA lot earlier, which we did a bit late. And when we did it, it did show that his P CO2 was up. P CO2 was up, which is obviously very concerning in a wheezy child of any kind or any child P CO2 is normal in Children. That is a sign that they're pretty unwell. Uh And then we, we actually did a chest X ray after intubation and this is what we saw. What do you guys think? What do you see? You guys have said A R DS, there's some signs of a RD in there, but do you still see anything else in this chest X ray? I added another information. I didn't say about this kid. The kid has a twin who was absolutely fine whereas this kid was really well. So what do you see in the X ray guys? Do you see anything? OK. Movement chest X ray. Yeah. Good. Yeah, congenital diaphragmatic hernia, possible patchy infiltrates. Um Thankfully, we did confirm later on that it wasn't a diarrhetic hernia, but you do see uh some signs I might suggest it, but there is a big blob in the abdomen and I'll come back to that later. Er But yeah, patchy infiltrates er a as you've said, it's absolutely new, right? Um And my chest X rays earlier as well, which is what we uh what I decided to show you guys uh there is patchy infiltrates and this is suggested this is what a viral pneumonia picture looks like. Except this one has got a bit more if you look to, especially in the right middle lobe, you do see some uh cannon ball like lesions as well. This is very unusual in a child, but this was present. And then when we put two in together and post intubation, a full examination, the problem was the child was so sick. We never moved past B we were in A BS and we never got to see or e in terms of managing this child. Um But once we felt the tummy, there was a mass, we felt the left iliac course and that's what's possibly causing that air bubble in the stomach is because it's probably pressing on the, on the bowel or the stomach or somewhere. Um This kid basically had metastatic lung cancer, a metastatic lung cancer. The primary later was found out to be a metastatic rhabdomyosarcoma which was in the tummy, which was that mass in the left fossa. So this is a pretty sad case. Uh The child was still alive as as of 2023 despite lots of has responded very well to chemo and was doing pretty well, cancer standards. Um uh has had issues with like DVTs and stuff on because of lots of lines and things. But uh thromboembolism, but otherwise it's been all right, So if you look at the uh the X ray, this passion for bilaterally that is suggest a viral pneumonia. A this is what it looks like. But if you look very, very closely, you might see some cannonball lesions and they this kid did have, have, have, have cancer. And when we did a ct that it was all over l needed loads of um needed loads of uh chemo before we could extubate the child as well. Sorry to finish. That's our last case before we go, move on to questions. Sorry to finish on such a very difficult case. Um You guys can always come back to this later, but I'll leave a slide on. This is a good revision exercise before your exams as to which one has what? And I won't let you guys do. I don't know it too long because I've got questions coming up before you go to questions. Please fill, fill this feedback form where you can and the we shall move on to question soon and I'll give you a couple of minutes and in the meantime, I'll try and prepare a poll. OK? I'll start off with the first question and we'll get there. Ok, guys, first question. Two year old child presents with barking cough, stridor and mild respiratory distress. What is the most appropriate initial treatment? Everyone's going for the right one. Good, good, good, fantastic guys. 10 of you have answered and you've all God forbid that's good. B is the right answer. Um There is Miles Stridor but and mild respiratory distress, but that still means you can give it. Is there, there's, there's, there's tricks in the question guys. OK. The trick in the question here, you could argue in how good is an eye. But the trick in the question is the most appropriate initial treatment. OK. That word, initial, is it? So obviously, barking cough has dried tty its re but the initial bit is what tells you that, uh, oral dexamethasone is what you go for. Ok. And, um, and that's what you're treated with. Ok. And then, ok, those messages as well. Ok, let's go to question two. Let me create a poll for that as well. Actually, it's much more fun doing calls I think. Ok, question two is three month old. Infant presents with wheezing, increased work of breathing and poor feeding. There is no history of at which is the most likely diagnosis. First of all, I mean, you wouldn't expect a to be in the, in a, um, I don't know in a three month old. But anyway, it says, but sometimes some kids have been just far a allergic from like birth. What do you think is going on? Three if you have answered? Come on, I'll give you a bit more time not giving you too many. It's too much time because, because intentionally I don't want to keep you guys beyond eight o'clock. 15 of you, everyone's getting it right. It's fantastic. I mean, it's right. If you wanna tell me, why do you think it's not bacterial pneumonia? What would the question probably say if it was one of you has gone for one of you have gone for it? Fantastic. I, so you could be back to your pneumonia. Um, the key is actually three months if I said a two month old infant. Yeah, fever is a good point. It's a very point. Um No. So obviously in real life, you might not always get uh examination, find your focal um focal correlation or focal signs. But in exam questions, they'll always say right, low, low uh auscultation or some crackles, Danny have got a very good question, productive cough. Uh Unfortunately, they're that young. They don't always, they're not always productive. Um The older Children, if they're two or three years on and above and they will be, they'll be chesty, they'll be sicker. OK? They'll have a fever, they'll be tachycardic and none of that is mentioned, it's three months. If it was a two month old child, if I said two months, you still probably call it bronchiolitis, but you probably want to give uh and I've said fever as well, you probably want to treat them with some antibiotics because they're slightly too young. But that's again, uh goes back to the fever chart, but it's very good. Uh It is, the answer is actually bronchiolitis. OK. It's the, you know, the, the giveaway is less than one years old. It's typically caused by R SV, by the way. And um, it presents with wheezing respiratory distress, poor feeding, poor feeding as well. Actually, I didn't highlight that, but it's really important pneumonia patients might not actually poor feed. Um, but that's about it. Ok, let's create another pole then. So. Ok. Question all that is out before the question with the question of a three year old with a history of asthma, sorry, five year old with a history of asthma presents with acute shortness of breath and wheezing oxygen saturation is 92% on room air. Which of the following is the most appro again guys focus on the question, most appropriate first line treatment. OK. All of them are valid treatment by the way, I mean, Budesonide is unusual but you can still give it, it's still a steroid and it's still nebuli a trip to this. So with any questions, any multiple choice best of fives is often 2 to 3 which are definitely in low. So you can kick them out and there's two or three sometimes which might be correct. So you wanna narrow down to those ones and I think you guys have got it right. The narrowing down here is B and C and which one goes first and this goes very much on. Uh And I've initially made intentionally made this slightly hard and both B and C are very, very important you in real life, you do both probably. Mm but there is something here. Look at the patient, look at the, look at the uh the, the you know the story what's given there. And also the question comes, what is normal oxygen saturation? OK. 20 view. So I'll move on. The answer is actually B is not C so acute asthma is obviously men mm managed with nebulized bronchodilate and then systemic steroids. Uh hydrocortisone is an option. But you do that just after you give them some nebulizer. Uh The reason you don't give oxygen is in this one is because the oxygen saturation is 92% on room air. 92 is our current cough for asthma unless have changed it back. Do always look before your God. Uh you know, before your exams don't what it is. But currently most local call in the hospitals are working. If it's 92 and above, you don't really need to get oxygen A B. When you give them Nebulizer album you're giving, you're driving it through oxygen as well. OK. So there is, but if, if I frame this question and I said the oxygen sat is 80% on air C would be the correct answer. So it's very important you look at what is there. OK. So make sure you have a very good look at the question. OK, guys, we're gonna move on to question four. You guys are doing fantastic. I'm sorry for the trick. We have got the pull up for you. I mean. Oh, fantastic. Uh I've got two left. Ok. Can I give you, give you guys the, uh, uh, thing to do Paul? So I'll stop my one. Yeah, we'll do the pa for you for each question. That be such a, such a lifesaver. Really? Ok. We're moving on to question four. So just do the first poll, guys. I'll stop pulling the, uh, 2nd 17 year old child presents with fever, cough and pleuritic chest pain, chest X ray shows consolidation in the right lower lobe. What is the most likely causative organism? You look at it and you're like, yes, I've got the diagnosis and then I've changed the question. Sorry guys, intentionally. That's what they do to you. That's what exams do. See, I am taking the Mick because I've just recently finished all the exams I have to do. If I do any more exams in my life, it's out of choice. I don't have to do any exams out of uh compulsion anymore. I've finished both my membership and fellowship exams and a couple of them are actually quite, you know, hard even for our levels. So keep going. So six of you have answered, you're going down the one route. Well, the problem with polling is, you know, people choose one answer and then everyone goes for that one. You, you, you, it creates an unconscious bias. Think of something else to think of it. Good answer. So you guys are all going for this. So the problem is the strep pneumonia is common mycoplasma pneumonia is also common. Hemophilus is also common staph A is not as much, but again, also not impossible. And R SV is the most likely causative of a viral pneumonia. So you just need to figure out what it is and you guys seem to have figured out that this is a bacterial pneumonia and you're right now, what is 60 of you answered? I'll probably move on if all answered. B as your main answer. Uh So we're gonna move on and the answer is strep pneumonia in the UK. Ok, guys, problems you need to uh the questions will be both K based hemohim less and less common er, various types of hemophilic risks, but it's become lesson strep pneumonia is still the most common. Uh All of them are present in and all of them you'll see probably through your career, but strep pneumonia is the most common one and that is what we do. So we're gonna move on to the next one. Uh And fantastic. IP is on. Thank you. Next pa is ready. So a 10 month old infant now I've given you the dino and this one has got bronchiolitis, but it has got worsening, respiratory distress, oxygen saturation is 87% on room air. What is the most appropriate next step. I've made the question slightly easy. Actually, I should have made it a bit harder and there's something else I could have added. But anyway, I'll let you go outside. 1413 responses. Come on, guys. Far away. Ok, guys. So the 19 of you have gone so good uh immediate intubation could be. Um So the right answer, uh especially if I told you that patients got had loads and loads of treatment and then come there, but it's not really the first line. It is an appropriate step. Um Now, salbutamol, you can never say yes to it. During an exam on that, we've said it's called bronchiolitis IV antibiotics, which is not your first dresser, high flow nasal cannula is the answer actually is a preferred ex escalation in severe bronchitis before considering ventilatory support. Ok. That's why it's not intubation immediately. However, I was thinking whether I should add another er, question to say, um give 15 L non rebreathe. And that would have put a real Spanner in the works because then what do you do first? Because you start off with lower levels of oxygen before you wake up, right? Nasal cannula, 2 L 15 L, non re breaths and then you work up to high flow nasal cannula and then that's how it goes, right? Um And the que my answer, I think I'll give you the answer because shorter time it would be, I think if it's that in a question and it's about 87%. You could start off with 15 L. No re because you could put it up immediately, setting up high flow takes at a time. OK? And we're gonna go it that way. OK, guys, question six. Which of the following clinical features as most suggests of bacterial pneumonia in a child, the pulse already on. So I do request. Uh This is an easy question actually. Uh Yeah, relatively easy question. Ok. Almost every one of you has gone for C for one. Uh, he might be true, but it is not actually most again, the question most suggestive you can, you can, you might even get all of them in a bacterial pneumonia basically because bacterial pneumonia differs. But it's most suggestive as the answer. Ok. So I'm gonna move on to the answer, which is c this to tell you which ones which, by the way, uh, especially strep pneumonia bacteria in a like this. But just to tell you which ones, which reason prolonged expert phase would be viral, wheeze or asthma, dry or barking cough would be pro high fever. That's pneumonia, gradual onset of dry cough. And malaise is more like a viral upper respiratory tract infection. If they're adding a bit more distressing stuff, it'd be, um, like bronchiolitis, inspiratory whooping cough is whooping cough. Ok. We're gonna move on to question seven. Um, cold here. Four year old child presents with Stridor, high fever and drooling the child appears toxic and is sitting in a tripod position. This is a condition we have not discussed, I believe what is the most appropriate next step? I did not make it easy and just say give some um with the diagnosis. But what do you want to do? Ok, guys. So there's one saying to lateral leg, x-ray, lateral leg, x-ray might actually give you a diagnosis. However, this patient is a bit too far down the line. Um So um it will be CC is the right answer. So one of you has gone for start IV cataract. And again, I think we would as well, but there, there's drooling and high fever and steral. So this child is clearly safe. This is epiglottitis. OK. This happens due to hip mostly in patients who are not vaccinated, but you can get it in vaccinated people as well because it can be very at different times of things. It's not just hip um medical emergency, secure the airway immediately. That's what you want to do because what you don't want, you want to give them IVC its own parade. But you know, getting the cannula might cause a child to get distressed and completely block the airway. Lateral neck, x-ray, some kind of a problem if they're early on just a bit of bruiting. No stridor yet. Sure get the lateral neck. X-ray, give some oral dexamethasone, you still able to sort of, you know, that's, that's all fine. Give some nebulized adrenaline. That's all. Ok. But when it's in this position, sitting in a tripod position appears toxic. It's sick. This child is sick. The next step is get, get the intubation. Don't try adrenaline, don't, don't, you know, make this child um for lack of a better pissed off. Ok. Next question guys. So five-year-old previous history of wheezing and listen very carefully. Presents with cough and breathless and swallowing a viral infection. What is the most likely diagnosis? OK. Viral wheeze bronchiolitis. Good. You guys are all good for it has a bit of split as one. Um Just uh bronchiolitis will be wrong because of the age. Um uh The story goes pretty well, but if it was five month old, it would go for bronchiolitis would be the correct answer in this one. Uh in terms of asthma and viral induced. Wheeze the child is just five. So five is when you start diagnosing asthma, they've had previous history of wheezing. It doesn't necessarily mean it will be asthma. If it said there's no viral infection and this has just happened, then asthma would be the more likely diagnosis. So both you consider both in real life but most likely would be viral. Wheeze. OK. It's what in in young Children with that of asthma. So this says previous history of wheezing does not say past medical history as asthma. So do not assume they've got stabbed asthma yet, but and it's triggered by a V action. OK. But well done guys, foreign body would be wheezing with no history of viral infection and pertussis is um you know, again, long standing cough and will usually follow with a saying that no vaccination has been done. OK. Question nine. Which of the following oxygen therapy methods is most appropriate for an infant? Uh This is a bit wrong because you've done anyway, severe bronchitis and hypoxia and saturation less than 90% most approve, it doesn't say next. So most appropriate. OK. It can be. So the answer if, if the answer was most appropriate first present uh treat uh therapy method versus uh most appropriate in general. So think about that. Uh and I'll tell you the answer if it was slightly, you know, the first appropriate treatment would be slightly different. In this case, a bit of a split for you guys. I see you've done well. There's a split between C and D non rebreather and high flow. And that's very good. And, and the split is because non rebreather would be your first line, whereas the most appropriate would be high flow. Um It's a bit of a, so it provides better oxygenation than CPAP. Uh CPAP would be what you go to next. So basically this one, we don't, just to add uh for those who have answered b we don't use venturia in cer ventura is a very adult thing. Um So we'd go for a low flow nasal cannula. And that's more like if it was above, it was, if it was floating between 9091 below 90 you go straight to a non rebreed. That's the first thing you do. But the best thing is usually high flow, nasal cannula and then you go down to CPAP, uh if high flow fails as well. Ok. Last question before we're finishing, we're about three minutes over uh a two year old child previously. Well, with no prodrome presents the sudden onset of coughing and stridor while playing. What is the most likely cause guys? Uh Wait, what's happened there? Uh I've messed, messed up the uh Let me actually just tell you what the, I'll tell you what the things are and then I will um I have messed up putting a question there. So I'll tell you. So A is croup B is asthma, C is foreign body aspiration. D is tracheomalacia and E is pneumonia. OK. A is croup B as asthma, C is foreign body aspiration. D is tracking malacia and E is pneumonia. OK. Good. So people are doing between accumulation and foreign body aspiration. Good. There's a, there's one difference here that will determine why it's one or the other. It is not uh pneumonia by the way, guys, and we're gonna go through. Sure. So the it's foreign body and the foreign body is, it's foreign body because it's sudden onset. Ok? There's no problem tracking Malaysia will have a bit of illness before it as well. Ok, sudden onset strid or coughing, respiratory distress in a well child. And that is usually, and, and the child was playing. So that's often when they, they inhale foreign bodies or put foreign bodies in their mouth and things like that. OK? And that's where that's coming from. OK. Interest of time I shall head off. Uh And let you guys do this, there's another link to the feedback form again. Uh It would be very useful for me if you guys give us some feedback would be very helpful. And uh thank you so much for tuning in. Thank you very much for coming. Um Guys, can you please please fill in the feedback form? We haven't received feedback form from everyone yet. So it will be really appreciated if you can do that for us. Um And we have read your feedback form and many of you wants more sessions um with these. So we do have sessions coming up every single week. Um So please look out on our me Instagram. We will be letting you know when the next lectures are. Mm Thank you very much for coming today. We'll see you again next week. Thank you guys. Thank you.