RESPIRATORY PAEDIATRICS

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RESPIRATORY PAEDIATRICS

• Dr Pamela Lewis

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OBJECTIVES

• History Key points
• Examination
• Common respiratory problems in children

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The Respiratory History

• History of presenting complaint
• Nature of symptoms
• Chronic symptoms
• Risk Factors
• Associated symptoms
• Growth
• Impact

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Respiratory Risk Factors

• Prematurity
• Chronic lung disease
• Smoking
• Atopy
• Family history
• Immunodeficiency
• Social

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Respiratory Examination

• Observe
• Respiratory rate
• Clubbing
• HR
• Cyanosis
• Chest Shape
• Expansion
• Percussion
• Auscultation

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Bronchiolitis

• Viral infection of the small airways
• Respiratory Syncitial Virus
• Infants
• Symptoms
• Signs
• Management
• Prevention

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Bronchiolitis Presentation

• Cough, respiratory distress, poor feeding
• Tachypnoea, recession, crackles and wheeze
• Supportive management Oxygen,
  fluids no proven role for bronchodilators or
  steroids, limited evidence for ribavarin,
  ventilatory support

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Bronchiolitis Prevention

• Palivizumab
  monoclonal antibody, monthly injections to at
  risk population
• Vaccine? Not currently
  

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CROUP

• Viral infection of the upper airways
• Parainfluenza virus
• Presentation
• Management

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Croup Presentation and Management

• Barking cough, respiratory distress poor feeding
• Stridor, tracheal tug, recession, not toxic
• Limit anxiety and call for assistance if severe
• Steroids oral dexamethasone
• Consider nebulised adrenaline
• Airway support if necessary

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Epiglottitis

• Severe upper airway infection
• Haemophilus influenzae
• Presentation
• Management
• Prevention

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Epiglottitis Presentation and Management

• Toxic, drooling stridor and respiratory distress
• Medical Emergency
• Call for HELP
• Keep child calm
• Rapid Sequence induction of anaesthesia
• IV Ceftriaxone
• Hib Vaccine

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Asthma

• Common 1.1 million children in uk receiving
  treatment for asthma
• Inflamatory condition of the bronchial airways
  resulting in increased mucus production, mucosal
  swelling and muscle contraction. Reversible

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Diagnosis of Asthma in Children

• Presence of key features
• Assessment of trials of treatment
• Repeated reassessment and question diagnosis if
  not responding
• Pulmonary function tests (if age appropriate)

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Key Features in Asthma

• Symptoms cough, wheeze, SOB,chest tightness,
  exertional symptoms
• Risk Factors atopy, FH, smoking, preterm
• Signs None, hyperexpansion, Harrisons sulci

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PFT in Diagnosis of asthma

• Depends on age
• gt20 diurnal variation in PEF on gt3 days/wk for 2
  weeks
• FEV1 gt 15 after salbutamol
• FEV1gt 15 drop after 6mins running
• Bronchial hyperreactivity

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Differential Diagnosis in Asthma

• Viral wheezing
• GOR
• Suppurative lung disease
• Congenital structural leision
• Immunodeficiency
• Cardiac

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Primary Prevention

• Allergen avoidance
• Breast feeding
• Microbial exposure
• Smoking

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Secondary Prevention

• Allergen avoidance
• House Dust Mite eradication
• Smoking
• Pollution
• Dietary
• Homeopathy

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British Thoracic Society Management

• Aims of treatment
  Early control
  maintain control with stepwise approach
• Assessment
  Minimal symptoms day and night No
  exacerbations
  No reduction in exercise capability normal
  lung function

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BTS Asthma Management

• STEP 1
• Mild intermittent symptoms
• Use beta 2 Agonist as required
• Move to step 2 if needed gt3x/week or night
  symptomsgt1x/week or if exacerbation in last 2
  years

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BTS Asthma Management

• Step 2
• Regular preventer therapy
• Inhaled beta 2 agonist prn and regular standard
  dose inhaled corticosteroid

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BTS Asthma Management

• Step 3
• Add on Treatment
• Beta 2 agonist as required and regular standard
  dose inhaled corticosteroid and if gt5yrs regular
  long acting beta 2 agonist, if not controlled
  increase inh steroid dose to top of standard
  range and if still uncontrolled add in
  leukotriene antagonist or oral theophyline

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BTS Asthma Management

• If lt5years add leukotriene antagonist

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BTS Asthma Management

• Step 4
• If under 5yrs child should be refered to a
  respiratory paediatrician
• If gt5yrs inhaled beta 2 agonist as needed and
  high dose inhaled steroids and regular long
  acting beta 2 agonist and leukotriene antagonist
  or theophyline

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BTS Asthma Management

• Step 5
• Refer to respiratory paediatrician
• As for step 4 and consider regular steroid
  tablets or immunosuppressants

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Acute AsthmaSeverity Assessment

• Mild cough and wheeze, no distress , able to
  speak and feed, sats gt92
• Moderate cough, wheeze, use of accessory
  muscles, satsgt92, feeding, able to speak but
  breathless.PFgt50 if over 5yrs and able to
  perform
• Severe sats lt92, toobreathless to talk or feed,
  tachypnoea and use of accessory muscles,
  tachycardia nb the silent chest

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Acute Asthma

• Oxygen
• Beta 2 Agonist (salbutamol) neb repeat as
  required
• Ipratropium nebs
• Steroids prednisolone or iv hydrocortisone
• IV salbutamol/ aminophyline
• IV magnesium

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Drugs in Asthma

• Beta 2 Agonists eg salbutamol, terbutaline, can
  be administered as inhalor or nebulised (BLUE)
• Long acting beta 2 agonists inhalors (GREEN)
• Steroids inhaled eg beclomethasone (BROWN),
  Fluticasone(ORANGE). Oral Prednisolone. IV
  Hydrocortisone
• Leukotriene antagonists eg montelukast tablets or
  sprinkles

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CYSTIC FIBROSIS

• 7500 cases in uk
• 125 carrier rate
• Autosomal recessive, chromosome 7
• Commonest deletion in UK delta 508 affecting the
  CFTR protein which codes for chloride channel
• Average life expectancy 30-40

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CYSTIC FIBROSIS

• Multisystem disease
• Respiratory recurrent resp infections with
  resultant bronchiectasis
• GIT pancreatic insufficiency, meconium ileus
  equivalent
• Hepatic CF liver disease
• Endocrine diabetes, infertility

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CYSTIC FIBROSIS MANAGEMENT

• Multidisciplinary team approach
• Physiotherapy
• Dietetics
• Therapeutic
• psychological

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