Childhood Respiratory Conditions

Learning Outcomes

By the end of the session you should be able to;

• Recognise how common conditions present

• Initiate management

• Identify high risk groups

• Answer questions on respiratory topics

Case 1

• A 3 month old presents with;– Increased WOB– Reduced feeding– Less wet nappies

• He has had a runny nose for 4 days

• Obs: HR 155, RR 48, T 37.4oC

Case 1

• On examination;– Appears upset, crying– Signs of respiratory distress– Widespread inspiratory crackles bilaterally– Mild scattered wheeze

• What are the differentials?

• What investigations might be useful?

Case 1

• Investigations;– Oxygen saturations

89% on room air

– Chest x-ray

• What’s the diagnosis?

Case 1: Bronchiolitis

• Acute LRTI

• Most common between 2-6 months of age

• Presents with breathing difficulties, cough, coryza and decreased feeding

• Often follows a viral URTI

• Usually due to RSV (50-90% of cases)

Case 1: Bronchiolitis

• Most infants managed at home

• Hospital if;Feeding <50% of normal GruntingLethargy CyanosisSignificant tachypnoea Sats <94%

• Supportive hospital management;– Oxygen– Nasogastric feeds

Case 1: Bronchiolitis

Case 1: Bronchiolitis

• Usually lasts 7-10 days

• Most infants make a full recovery

• Mortality is higher with underlying heart and lung disease

• Immunoprophylaxis is available for certain groups

Case 2

• A 2 year old girl presents with;– 3 day history of sore throat and coryza– Fever– Inspiratory noises at rest– Loud, barking cough for the last 20 hours

• On examination there are signs of respiratory distress, tachypnoea and tachycardia

Case 2: Croup

• Upper respiratory tract inflammation

• Usually secondary to viral URTI

• Symptoms of URTI, barking cough and stridor

• Parainfluenza viruses cause ~80%

• Most common between 6 months – 3 years

Case 2: Croup

• Most managed at home after dexamethasone

• Last around 3-7 days

• Consider hospital admission if;Aged <6 months Severe obstructionPoor oral intake Immunocompromise

• Keep upright, minimise distress, give O2 to keep sats >93%, steroids, nebulised adrenaline

Case 3

• A 4 year old is referred to clinic with FTT

• 6 admissions with LRTI in the last year

• On examination;– Small for his age – Widespread bilateral crackles– Upper zone wheeze

What diagnoses needs to be considered?

Case 3: Cystic Fibrosis

• Autosomal recessive disease

• Mutation of the CFTR gene on Chr 7

• Affects 1 in 2500 newborns

• Usually identified on the newborn Guthrie test

• Other investigations include sweat testing, genetic testing, CT head and thorax

Case 3: Cystic Fibrosis

Perinatal presentation;Screening Prolonged jaundiceMeconium ileus Haemorrhagic disease

Infancy and childhood presentation;Recurrent LRTI FTTDiarrhoea Rectal prolapseNasal polyps Acute pancreatitis

Case 3: Cystic Fibrosis

Signs include;- Clubbing- Cough- Purulent sputum- Crackles- Wheeze - Obstructive FEV1

Case 3: Cystic Fibrosis

• Best managed in a tertiary CF centre

• Respiratory problems;Chest physio Regular sputum samplesSaline nebs Prophylactic abx

• Pancreatic insufficiency and nutrition;Creon Vitamin supplements

• Estimated survival is 40-50 years

Case 4

• A 5 year old girl presents to resus with;– Acute SOB– RR 42– HR 138

• How should she be assessed?

Case 4

• Airway: speaking, but not in full sentences

• Breathing: RR 42, sats 91% on RA, intercostal and subcostal recession, poor AE/wheeze bilaterally

• Circulation: HR 138, systolic BP 100

• Disability: GCS 15/15, CBG 6.2

• Expose: no other sign of injury or illness

Case 4: Asthma

• Most common respiratory illness in children

• Characterised by;– Chronic airway inflammation– Bronchial hyper-reactivity– Reversibility with bronchodilators

• Often a family history or history of atopy

Case 4: Asthma

• Symptoms;Dry cough WheezeChest tightness Breathing difficulties

• Acute exacerbation;Tachypnoea TachycardiaLow saturations Decreasing

consciousness

• Peak flows are useful >5 years of age

Case 4: Asthma

Case 4: Asthma

Case 4: Asthma

• Acute management;– High flow oxygen if SpO2 <92%

– Inhaled/nebulised β2 agonists– Early steroids – Consider inhaled/nebulised ipratropium bromide– Consider nebulised MgSO4

• If not improving IV salbutamol and aminophylline

• Consider critical care review

Practice Questions

Questions: MCQs

1. A chloride concentration of _____ is diagnostic of CF.a. >40mmol/L b. >60mmol/Lc. >80mmol/L d. >120mmol/L

2. Which of the following is a side effect of inhaled steroids?a. Genital candidiasis b. Growth stuntingc. Immunosupression d. Gastric ulcers

Questions: MCQs

3. What is the next step for a 4 year old child with uncontrolled asthma already using PRN salbutamol and 200mcg of inhaled steroid?a. Regular salbutamol b. 400mcg steroidsc. Montelukast d. Paeds referral

4. CF may present with...a. Early jaundice b. Recurrent URTIc. Female sterility d. Nasal polyps

Questions: MCQs

5. Risk factors for bronchiolitis include...a. Obesity b. Infants <6 monthsc. Passive smoking d. Only child

6. Most common cause of pneumonia <5 yearsa. Staph aureus b. E. colic. Mycoplasma pneum. d. Strep pneumonia

Questions: EMQ 1

a. Bordetella pertussis b. Parainfluenzac. Haemophilus influenza d. RSVe. Adenovirus f. Rhinovirus

1. A 7 week old child presents with bouts of coughing, followed by a loud noise & vomiting. He has been unwell for the last 2 weeks.

2. An 6 month old ex-26 weeker presents with signs of respiratory distress & poor feeding. Temp 37.2, RR 47, HR 145.

Questions: EMQ 1

a. Bordetella pertussis b. Parainfluenzac. Haemophilus influenza d. RSVe. Adenovirus f. Rhinovirus

3. A 2 year old presents with a barking cough and coryza for 48 hours. Temp 36.4.

4. A 2 year old presents with 2 hours of fever and pyrexia. He is drooling and very still. Temp 38.7. There was no prodrome.

Questions: EMQ 2

a. Inhaled salbutamol b. IV salbutamolc. IV MgSO4 d. Prednisolone

e. Nebulised salbutamol e. Aminophylline

1. A 4 year old child presents with acute SOB, RR 34, sats 95%, HR 125.

2. A 7 year old with acute asthma is not responding to nebulisers and steroids.

Questions: EMQ 2

a. Inhaled salbutamol b. IV salbutamolc. IV MgSO4 d. Prednisolone

e. Nebulised salbutamol e. Aminophylline

3. A 9 year old acute asthma is not responding to IV salbutamol or IV steroids.

4. A 4 year old is referred from her GP as she is not responding to 10 puffs of salbutamol.

Questions: Image 1

a. What drug is in this inhaler?

b. When should it be used?

Questions: Image 2

a. What type of device is shown?

b. What % of oxygen can it deliver?

Questions: Image 3

Child presents with 5 days of SOB, cough and fevers. Started on abx by GP 2 days ago, but no response.

a. What is the diagnosis?

b. Where are they most likely to occur?

Questions: Image 4

This 11 year old boy presents with acute SOB and RR 32.

a. What is the diagnosis?

b. What treatment is needed?

Answers

Answers: MCQs

1. A chloride concentration of _____ is diagnostic of CF.a. >40mmol/L b. >60mmol/Lc. >80mmol/L d. >120mmol/L

2. Which of the following is a side effect of inhaled steroids?a. Genital candidiasis b. Growth stuntingc. Immunosupression d. Gastric ulcers

Answers: MCQs

3. What is the next step for a 4 year old child with uncontrolled asthma already using PRN salbutamol and 200mcg of inhaled steroid?a. Regular salbutamol b. 400mcg steroidsc. Montelukast d. Paeds referral

4. CF may present with...a. Early jaundice b. Recurrent URTIc. Female sterility d. Nasal polyps

Answers : MCQs

5. Risk factors for bronchiolitis include...a. Obesity b. Infants <6 monthsc. Passive smoking d. Only child

6. Most common cause of pneumonia <5 yearsa. Staph aureus b. E. colic. Mycoplasma pneum. d. Strep pneumonia

Answers : EMQ 1

a. Bordetella pertussis b. Parainfluenzac. Haemophilus influenza d. RSVe. Adenovirus f. Rhinovirus

1. A 7 week old child presents with bouts of coughing, followed by a loud noise & vomiting. He has been unwell for the last 2 weeks.

2. An 6 month old ex-26 weeker presents with signs of respiratory distress & poor feeding. Temp 37.2, RR 47, HR 145.

Answers : EMQ 1

a. Bordetella pertussis b. Parainfluenzac. Haemophilus influenza d. RSVe. Adenovirus f. Rhinovirus

1. A 7 week old child presents with bouts of coughing, followed by a loud noise & vomiting. He has been unwell for the last 2 weeks.

2. An 6 month old ex-26 weeker presents with signs of respiratory distress & poor feeding. Temp 37.2, RR 47, HR 145.

Answers : EMQ 1

a. Bordetella pertussis b. Parainfluenzac. Haemophilus influenza d. RSVe. Adenovirus f. Rhinovirus

3. A 2 year old presents with a barking cough and coryza for 48 hours. Temp 36.4.

4. A 2 year old presents with 2 hours of fever and pyrexia. He is drooling and very still. Temp 38.7. There was no prodrome.

Answers : EMQ 1

a. Bordetella pertussis b. Parainfluenzac. Haemophilus influenza d. RSVe. Adenovirus f. Rhinovirus

3. A 2 year old presents with a barking cough and coryza for 48 hours. Temp 36.4.

4. A 2 year old presents with 2 hours of fever and pyrexia. He is drooling and very still. Temp 38.7. There was no prodrome.

Answers : EMQ 2

a. Inhaled salbutamol b. IV salbutamolc. IV MgSO4 d. Prednisolone

e. Nebulised salbutamol e. Aminophylline

1. A 4 year old child presents with acute SOB, RR 34, sats 95%, HR 125.

2. A 7 year old with acute asthma is not responding to salbutamol nebs and steroids.

Answers : EMQ 2

a. Inhaled salbutamol b. IV salbutamolc. IV MgSO4 d. Prednisolone

e. Nebulised salbutamol e. Aminophylline

1. A 4 year old child presents with acute SOB, RR 34, HR 125.

2. A 7 year old with acute asthma is not responding to nebulisers and steroids.

Answers : EMQ 2

a. Inhaled salbutamol b. IV salbutamolc. IV MgSO4 d. Prednisolone

e. Nebulised salbutamol e. Aminophylline

3. A 9 year old acute asthma is not responding to IV salbutamol or IV steroids.

4. A 4 year old is referred from her GP as she is not responding to 10 puffs of salbutamol.

Answers : EMQ 2

a. Inhaled salbutamol b. IV salbutamolc. IV MgSO4 d. Prednisolone

e. Nebulised salbutamol e. Aminophylline

3. A 9 year old acute asthma is not responding to IV salbutamol or IV steroids.

4. A 4 year old is referred from her GP as she is not responding to 10 puffs of salbutamol.

Answers: Image 1

a. What drug is in this inhaler?Salbutamol

b. When should it be used?When required to RELIEVE symptoms

Answers: Image 2

a. What type of device is shown?Non-rebreathe or trauma mask

b. What % of oxygen can it deliver?~80%

Answers: Image 3Child presents with 5 days of SOB, cough and fevers. Started on abx by GP 2 days ago, but no response.

a. What is the diagnosis?Inhaled foreign body (right)

b. Where are they most likely to occur?Right main bronchus

Answers: Image 4

This 11 year old boy presents with acute SOB and RR 32.

a. What is the diagnosis?Tension pneumothorax (right)

b. What treatment is needed?

Thoracocentesis

Summary

• Respiratory conditions are common in infants

• Early recognition and management decreases mortality

• Good communication with parents helps to relieve distress and anxiety

• Knowledge of causative organisms is important clinically, and also for exams!

Any questions?