RESPIRATORY RESPIRATORY PAEDIATRICSPAEDIATRICSRESPIRATORY RESPIRATORY PAEDIATRICSPAEDIATRICS

Dr Pamela LewisDr Pamela Lewis

OBJECTIVES• History – Key points• Examination• Common respiratory problems in

children

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

Respiratory Risk Factors

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

Respiratory Examination

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

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

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

Bronchiolitis Prevention• Palivizumab

monoclonal antibody, monthly injections to at risk population

• Vaccine? Not currently

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

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

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

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

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

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)

Key Features in Asthma• Symptoms: cough, wheeze,

SOB,chest tightness, exertional symptoms

• Risk Factors: atopy, FH, smoking, preterm

• Signs: None, hyperexpansion, Harrisons sulci

PFT in Diagnosis of asthma

• Depends on age• >20% diurnal variation in PEF on

>3 days/wk for 2 weeks• FEV1 > 15% after salbutamol• FEV1> 15% drop after 6mins

running• Bronchial hyperreactivity

Differential Diagnosis in Asthma

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

Primary Prevention• Allergen avoidance• Breast feeding• Microbial exposure• Smoking

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

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

BTS Asthma Management

• STEP 1• Mild intermittent symptoms• Use beta 2 Agonist as required• Move to step 2 if needed >3x/week

or night symptoms>1x/week or if exacerbation in last 2 years

BTS Asthma Management

• Step 2• Regular preventer therapy• Inhaled beta 2 agonist prn and

regular standard dose inhaled corticosteroid

BTS Asthma Management

• Step 3• Add on Treatment• Beta 2 agonist as required and regular

standard dose inhaled corticosteroid and if >5yrs 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

BTS Asthma Management

• If <5years add leukotriene antagonist

BTS Asthma Management

• Step 4• If under 5yrs child should be refered to

a respiratory paediatrician• If >5yrs inhaled beta 2 agonist as

needed and high dose inhaled steroids and regular long acting beta 2 agonist and leukotriene antagonist or theophyline

BTS Asthma Management

• Step 5• Refer to respiratory paediatrician• As for step 4 and consider regular

steroid tablets or immunosuppressants

Acute AsthmaSeverity Assessment

• Mild: cough and wheeze, no distress , able to speak and feed, sats >92%

• Moderate: cough, wheeze, use of accessory muscles, sats>92%, feeding, able to speak but breathless.PF>50% if over 5yrs and able to perform

• Severe: sats <92%, toobreathless to talk or feed, tachypnoea and use of accessory muscles, tachycardia nb the silent chest

Acute Asthma• Oxygen• Beta 2 Agonist (salbutamol) neb repeat

as required• Ipratropium nebs• Steroids prednisolone or iv

hydrocortisone• IV salbutamol/ aminophyline• IV magnesium

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

CYSTIC FIBROSIS• 7500 cases in uk• 1:25 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

CYSTIC FIBROSIS• Multisystem disease• Respiratory; recurrent resp infections

with resultant bronchiectasis• GIT; pancreatic insufficiency, meconium

ileus equivalent• Hepatic; CF liver disease• Endocrine; diabetes, infertility

CYSTIC FIBROSIS MANAGEMENT

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