Zero to Finals: PAEDS
whooping cough: management
* <6months should be admitted * notifiable disease * oral macrolide (e.g. clarithromycin, azithromycin, erythromycin) indicated if the onset of cough is within previous 21 days (to eradicate organism) * household contacts offered AB prophylaxis
surfactant deficient lung disease: management
* prevention during pregnancy: maternal corticosteroids to induce fetal lung maturation * oxygen * assisted ventilation * exogenous surfactant given via endotracheal tube
acute asthma: mild to moderate management
- B-2 agonist via a spacer (child <3 years use close-fitting mask) - 1 puff every 30-60s up to a max of 10 puffs - symptoms not controlled, repeat beta-2 agonist and refer to hospital - steroid therapy - all children with asthma exacerbation (3-5 days) - 2-5 years: 20mg od - >4 years: 30-40mg od
cystic fibrosis: symptoms
- Chronic cough - Thick sputum production - Recurrent respiratory tract infections - Loose, greasy stools (steatorrhoea) - Abdominal pain and bloating - Parents may report the child tastes particularly salty when they kiss them - Poor weight and height gain (failure to thrive)
cystic fibrosis: signs
- Low weight or height on growth charts - Nasal polyps - Finger clubbing - Crackles and wheezes on auscultation - Abdominal distention
cystic fibrosis: presentation
- screened for at birth with the newborn bloodspot test - meconium ileus (not passing meconium within 24 hrs, abdominal distention, vomiting) - CF is not diagnosed shortly after birth, later in childhood with recurrent lower respiratory tract infections, failure to thrive of pancreatitis
episodic viral wheeze: management 1st line 2nd line
- symptomatic - b-2 agonist (e.g. salbutamol) or anticholinergic - intermittent leukotriene receptor antagonist (montelukast), intermittent ICS or both (little role for oral prednisolone in children who do not require hospital treatment)
cystic fibrosis: consequence of CF mutation (3)
- thick pancreatic + biliary secretions (blockage of the ducts resulting in lack of digestive enzymes e.g. lipase) - low volume, thick airway secretions (bacterial colonisation + susceptibility to infections) - congenital bilateral absence of the vas deferens (infertility)
viral induced wheeze: presentation
1-2 history of viral symptoms (fever, cough, coryzal symptoms) SOB respiratory distress expiratory wheeze throughout chest
viral induced wheeze: most common in children of what age?
1-3
chronic asthma: management <5
1. SABA 2. SABA + 8-week trial of paeds mod-dose ICS (newly diagnosed asthma with >/=3/weeks or night time waking) - stop after 8 weeks and monitor symptoms - if symptoms resolved then reoccurred within 4 weeks of stopping ICS, restart at low dose - symptoms resolved then reoccurred beyond 4 weeks of stopping ICS, repeat 8-week trial 3. SABA + paeds low-dose ICS + LTRA (montelukast) 4. stop LTRA + referral
chronic asthma: management 5-16
1. SABA 2. SABA + ICS (paediatric low-dose) (newly diagnosed asthma with >/=3/weeks or night time waking) 3. SABA + ICS + LTRA 4. SABA + ICS + LABA 5. SABA + paediatric low dose ICS/ LABA (MART) 6. SABA + paeds mod dose ICS/ LABA (MART) 7. SABA + any of the following - increase ICS to paeds high-dose - additional drug e.g. theophylline - referral
bronchiolitis: can rarely be diagnosed in children up to what age?
2 (particularly in ex-premature babies with chronic lung disease)
whooping cough: features
2-3 days coryza precede onset of: - coughing bouts (worse at night + after feeding; may be ended by vomiting & associated with central cyanosis) - inspiratory whoop (not always present; forced inspiration against closed glottis) - apnoea in infants - persistent coughing may cause subconjunctival haemorrhages or even anoxia leading to syncope & seizures - symptoms may last 10-14 weeks (more severe in infants) - marked lymphocytosis
RSV: chest symptoms are generally at their worst on day ___
3/4
bronchiolitis: generally considered to occur in children of what age? 90% of cases are within which age group? peak incidence? higher incidence during what time of year?
<1 1-9 months (90%) 3-6 months (peak incidence) (maternal IgG gives protection to newborns) winter
asthma: most common in children of what age?
>4
cystic fibrosis: define
AR disorder causing increased viscosity of secretions (e.g. lung an pancreas) caused by a defect in the CF transmembrane conductance regulator gene (CFTR) which codes a cAMP- regulated chloride channel 80% of cases due to delta F508 mutation
whooping cough: causative organism, gram -ve or +ve?
Bordetella pertussis gram-ve
surfactant deficient lung disease: define
also known as respiratory distress syndrome. condition seen in premature infants caused by insufficient surfactant production and structural immaturity of the lung.
pneumonia: tests which can be done to investigate recurrent LRTI?
FBC (check levels of WBC) CXR (structural abnormality/ scarring) serum immunoglobulins (selective antibody deficiency) immunoglobulin G levels (immunoglobulin class-switch recombination deficiency) sweat test (CF) HIV test (especially if mothers status is unknown/ positive)
pneumonia: management when there is sepsis or a problem with intestinal absorption
IV antibiotic
epiglottitis: features
rapid onset high temperature, generally unwell stridor drooling of saliva (no cough)
bronchiolitis: NICE recommend clinicians 'consider' referring to hosptial if any of the following apply
RR >60/min difficulty with breastfeeding or inadequate fluid intake (50-75% of usual volume) clinical dehydration
pneumonia: causative agents (viral) (45%)
RSV parainfluenza virus influenza virus
viral induced wheeze: common organism
RSV rhinovirus
acute asthma: severe attack
SpO2 < 92% PEF 33-50% best or predicted Too breathless to talk or feed Heart rate - >125 (>5 years) - >140 (1-5 years) Respiratory rate - >30 breaths/min (>5 years) - >40 (1-5 years) Use of accessory neck muscles
acute asthma: life-threatening
SpO2 <92% PEF <33% best or predicted Silent chest Poor respiratory effort Agitation Altered consciousness Cyanosis
acute asthma: moderate attack
SpO2 > 92% PEF >50% best predicted No clinical features of severe asthma
cystic fibrosis: organisms which may colonise CF patients
Staphylococcus aureus Pseudomonas aeruginosa Burkholderia cepacia* Aspergillus
croup: CKS criteria to grade severity: moderate
frequent barking cough easily audible stridor at rest suprasternal + sternal retraction at rest no/ little distress or agitation child can be placated and interested in surroundings
croup: define
URTI seen in infants and toddlers. characterised by stridor cause by a combination of laryngeal oedema and secretions. parainfluenza viruses account for the majority of cases.
URTI caused by Bordetella pertussis (a gram negative bacteria).
Whooping cough (pertussis)
pneumonia: management (1st line) what can be added if there is no response to therapy? what will cover mycoplasma if suspected? if associated with influenza what is recommended?
amoxicillin macrolide macrolide co-amoxiclav
bronchiolitis: NICE recommend immediate referral (by 999 ambulance) if they have any of the following
apnoea (observed or reported) child looks unwell to a healthcare professional severe respiratory distress (e.g. grunting, marked chest recession, RR> 70) central cyanosis persistent low sats of <92% on air
pneumonia: characteristic chest signs of pneumonia
bronchial breath sounds (harsh breath sounds, equally loud on inspiration and expiration) focal coarse crackles dullness to percussion
7 month old boy bought into ED 12hr Hx of difficulty breathing he has had "a cold" since yesterday generally miserable all day and has refused 1/2 of his usual feeds. OEx: bilateral expiratory wheeze + crackles + moderate subcostal recession RR: 62 Sats: 90% HR: 152 CRT: <2s What is the diagnosis + most appropriate management?
bronchiolitis admit for O2 therapy, consider NG tube feeds
what is useful in severe respiratory distress and in monitoring children who are having ventilatory support?
capillary blood gases
epiglottitis: management ABx (once airway is secure)
ceftriaxone cefotaxime (broad spec to cover Haemophilus influenza + staph aureus)
epiglottitis: what investigations should be performed
clinical diagnosis (if pt is acutely unwell, Ix should not be performed)
croup: investigations
clinical diagnosis (vast majority) CXR (posterior- anterior view sill show subglottic narrowing- Steeple sign; lateral view will show epiglottis swelling- Thumb sign)
bronchiolitis: presentation
coryzal symptoms (including mild fever) precede: - dry cough - increasing breathlessness - wheezing, fine inspiratory crackles (not always present) - feeding difficulties associated with increasing dyspnoea are often the reason for hospital admission
pneumonia: presentation
cough (wet + productive) high fever (>38.5ºC) tachypnoea tachycardia increased work of breathing lethargy delirium (acute confusion associated with infection)
whooping cough: diagnostic criteria
cough lasting for >/=14 (without another apparent cause) * paroxysmal cough * inspiratory whoop * post-tussive vomiting * undiagnosed apnoeic attacks in young infants
what is shown here?
croup thumb-print sign
what is shown here?
croup Steeple sign
croup: CKS criteria to grade severity: severe
frequent barking cough prominent inspiratory stridor at rest marked sternal wall retractions significant distress + agitation or lethargy or restlessness (sign of hypoxaemia) tachycardia (more severe obstructive symptoms + hypoxaemia)
croup: management (all cases) emergency treatment
dexamethasone (0.15mg/Kg) to all children regardless of severity (prednisolone is an alternative) high-flow oxygen + nebulised adrenaline
epiglottitis: management
do not distress patient alert senior paediatrician + anaesthetist ensure secure airway (most pts do not require intubation, however there is a risk of sudden airway closure so preparation need to be made to perform intubation at any time) intubation tracheostomy (if airway completely closes) ICU IV Abx (ceftriaxone) steroids (dexamethasone) O2 + IV fluid
A 4-year-old boy presents to the emergency department with complaints of dysphagia, fever, drooling, and muffled voice. Symptoms have progressively worsened over the course of the day. He is toxic-appearing, and leans forwards while sitting on his mother's lap. He is drooling, and speaks with a muffled 'hot potato' voice. The parents deny trauma or evidence of foreign-body ingestion. They have no recollection of the child receiving a Haemophilus influenzae type B (Hib) vaccine. what is the diagnosis?
epiglottitis
inflammation and swelling of the epiglottis caused by infection. Life threatening emergency.
epiglottitis
unvaccinated child, fever, sore throat, difficulty swallowing, sitting forward, drooling
epiglottitis
epiglottitis: difference between epiglottitis and croup
epiglottits has more rapid onset
pre school wheeze: classification into two groups
episodic viral wheeze (only wheezes when has a viral URTI and is symptom-free in-between episodes) multiple trigger wheeze (as well as viral URTI, other factors appear to trigger the wheeze e.g. exercise, allergens and cigarette smoke. more likely to develop asthma)
grunting: define
exhaling with the glottis partially closed to increase positive end-expiratory pressure
surfactant deficient lung disease: CXR
ground-glass appearance on CXR indistinct heart border
sound caused by exhaling with the glottis partially closed to increase positive end-expiratory pressure (prevent collapse of alveoli)
grunting
epiglottitis: typical causative agent
haemophilus influenza type B
signs of respiratory distress:
increased RR use of accessory muscles of breathing (sternocleidomastoid, abdominal, intercostal muscles) intercostal + subcostal recessions nasal flaring head bobbing tracheal tugging cyanosis abnormal airway noises (wheezing, grunting, stridor)
whooping cough: who are vaccinated against pertussis?
infants (2, 3, 4 months and 3-5 years) pregnant women (newborns are particularly vulnerable, 20-32 weeks)
focal wheeze: what could it be?
inhaled foreign body tumour
acute asthma: bronchodilator step up
inhaled/ nebulised salbutamol inhaled/ nebulised ipratropium bromide IV magnesium sulphate IV aminophylline
another name for croup
laryngotracheobronchitis
croup: CKS criteria - who should be admitted? features which should prompt admission?
moderate + severe croup * < 6 months of age * known upper airway abnormalities (e.g. Laryngomalacia, Down's syndrome) * uncertainty about diagnosis (important differentials include acute epiglottitis, bacterial tracheitis, peritonsillar abscess and foreign body inhalation)
epiglottitis: prognosis
most recover without intubation pt who are intubated can be extubated after few days death in cases without prompt management
bronchiolitis: other pathogens
mycoplasma adenovirus
pneumonia: atypical bacterial cause with extra-pulmonary manifestations e.g.___
mycoplasma pneumoniae erythema multiforme
wheezing: define
narrowed lower ariways during expiration (can happen inspiration or both)
stridor: define
narrowed upper airway high pitched inspiratory noise (can happen expiration or both)
croup: CKS criteria to grade severity: mild
occasional barking cough no audible stridor at rest no/ mild suprasternal recession and/ intercostal recession happy child (eating, drinking, playing)
a monoclonal antibody that targets RSV. It's a monthly injection given to high risk babies as prevention against bronchiolitis.
palivizumab
croup: classic cause for croup
parainfluenza virus
croup: epidemiology (2)
peak incidence at 6 months - 3 years more common in autumn
whooping cough: diagnosis
per nasal swab culture for Bordetella pertussis (several days or weeks to come back) PCR and serology
infection of the lung tissue which can be seen as consolidation on CXR.
pneumonia
when should palivizumab be given to children?
premature chronic lung disease congenital heart disease immunodeficient
surfactant deficient lung disease: risk factors
prematurity male sex diabetic mothers Caesarean section second born of premature twins
pneumonia: what could lead to a child having recurrent admissions requiring antibiotics for LRTI?
reflux aspiration neurological disease heart disease asthma CF primary ciliary dyskinesia immune deficiency
epiglottitis: clinical triad
respiratory distress dysphagia drooling
bronchiolitis: most common causative agent (75-80%)
respiratory syncytial virus (RSV)
coryzal symptoms
rhinorrhoea sneezing mucus in throat watery eyes
the most helpful signs of poor ventilation: (2)
rising pCO2 falling pH (type 2 respiratory failure)
moderate to severe acute asthma: management (stepwise approach)
salbutamol inhaler via spacer (10 puffs every 2 hrs) nebulised salbutamol/ ipratropium bromide IV hydrocortisone IV magnesium sulphate IV salbutamol IV aminophylline put out a paeds peri-arrest call
acute asthma: ominous sign
silent chest (airways too tight to produce a wheeze, reduced respiratory effort, fatigue, life threatening)
pneumonia: investigations
sputum cultures + throat swabs for bacterial culture and viral PCR (establish causative organism and guide treatment) blood cultures (if septic)
pneumonia: most common causative agent of a bacterial pneumonia in children other causes of bacterial pneumonia (5)
streptococcus pneumoniae group A strep (Strep. pyogenes) group B strep (occurs in pre-vaccinated infants, contracted during birth) staph aureus haemophilus influenza mycoplasma pneumonia
is a high pitched inspiratory noise caused by obstruction of the upper airway, for example in croup
stridor
croup: features (4)
stridor barking cough (worse at night) fever coryzal symptoms
whooping cough: complications (4)
subconjunctival haemorrhage bronchiectasis pneumonia seizures
bronchiolitis: typical management
supportive management - humidified O2 via a headbox is recommended (if <92%) - nasogastric feeding (if inadequate fluid intake) - suction (for upper airway secretions) - ventilatory support (if required)
pneumonia: signs which may indicate sepsis secondary to pneumonia
tachypnoea tachycardia hypoxia hypotension fever confusion
surfactant deficient lung disease: features
tachypnoea intercostal recession expiratory grunting cyanosis
what does this lateral neck Xray show? what does this sign suggest? what can be excluded in a neck Xray?
thumbprint sign epiglottitis foreign body
multiple trigger wheeze: management
trial of ICS or leukotriene receptor antagonist (montelukast) fo 4-8 weeks
epiglottitis: why is it now rare
vaccination against haemophilus influenza
Children who have had bronchiolitis as infants are more likely to have ___ during childhood.
viral induced wheeze
an acute wheezy illness caused by a viral infection. Typically affects children <3 years.
viral induced wheeze
define bronchiolitis:
viral inflammation and infection of the small airways (occurs in children <1 year)
whistling sound caused by narrowed airways, typically heard during expiration
wheezing
acute asthma: when can discharge be considered?
when a child is well on 6 puffs 4 hrly of salbutamol (finish course of steroids if started, 3 days normally, safety net, asthma action plan)