PaediatricsRespiratory system

T. CymesStage 3 student doctorUniversity of Cambridge

Plan

Examination tips differences from adults red flags

Asthma Bronchiolitis Pneumonia Cystic fibrosis

Other diseases

Examination – how to survive

Get to their level! Let young children play with your stethoscope

Great toy! Lets them get used to it

Let parents undress the child only when needed Start with least invasive examination Show on parents, toy etc Auscultate early Save percussion until the end

▪ Start on arm or knee – they get used to it!

Examination – difference from adults

Position Infants – lying on couch Toddler – on parent's lap Pre-school – while at play

Initial impression important ?unwell child

Look for dysmorphic features Percussion can be omitted

Little information in infants

Accessory muscles

Wheeze

Stridor

Grunting

Silent chest

Examination – respiratory distress Tachypnoea / tachycardia

Intercostal recessions

Harrison’s sulcus

Cyanosis

Nasal flaring

Source: BMJSource: Wikipedia Source: englishclass.jp

Source: gponline.com

Source: lumen.luc.eduSource:

quickbase.intuit.com

Asthma

Epidemiology 15% prevalence Associated with atopy

History Wheeze & cough Worse a night Ask about▪ Triggers▪ Frequency▪ Interval symtpoms

Examination out of attack ± wheeze Reduced PEFR

Examination during attack Signs of respiratory distress Hyperexpansion Ascultate Reduced PEFR SpO2

Asthma management

Acute attack – O SHIT! Oxygen Salbutamol Hydrocortisone Ipratropium Theophylline ! – get help!

Monitor SpO2 and PEFR

Chronic management ladderMild • SABA

≥3 week• Inhaled steroids at

conventional dosage

Poor control• LABA• Reasses

No response• Leukotriene antagonists• Theophylline

Poor control •Maximise inhaled steroids•Refer

Poor control •Oral steroids•Immunosuppression / immunomodulation

Bronchiolitis

By RSV Epidemiology

Winter 1-9 months old

Symtpoms Initially coryza SOB Sharp dry cough

Signs Tachypnoea Wheeze & crackles Hyperinflated

Investigations CXR Nasopharyngeal aspirate

Management Humidified O2 ± fluids ± parenteral feeding

Source: Wikipedia

Pneumonia

History Often URTI Cough Poor feeding “Unwell child”

Examination Tachypnoea Nasal flare Chest indrawing

Investigations CXR Nasopharyngeal aspirate

Management Usually at home Oxygen & anaelgesia as

neededAge Pathogens Empirical antibiotics

Neonate GBSE. coli

Ampicillin + gentamicin

> 5 years old

ViralStrep. pneumoniaeH. influenzaeB. pertussis

AmpicillinCeftriaxone

> 5 years old

Strep. pneumoniaeH. influenzaeGASMycoplasma

AmoxicillinErythromycin

Cystic fibrosis

Part of Guthrie test

Autosomal recessive 1:2500 live births 1:25 are carriers

History Meconium ileus (10-20%) Persistent cough Recurrent/chronic chest infection Bronciectasis in children Malabsorption failure to thrive Male infertility

Signs Hyperinflated Wheeze Coarse crackles

Management Monitor lung function Prophylactic + rescue antibiotics Physiotherapy Bilateral lung transplant when end-

stage

Nutrtional▪ Pancreatic enzyme supplements▪ 150% healthy calorie intake

Other diseases

Croup Parainfluenza virus URTI barking cough +

stridor Improve over 24h Symptomatic management ?Steroids

Acute epiglottitis H. influenzae type b Very painful throat Sits up with open mouth Drooling DON’T examine throat Intubate, then:▪ Blood culture▪ Cefuroxime IV

Other diseases

Whooping cough B. pertussis Coryza Coughing paroxysms▪ Inspiratory whoop

Erythromycin

Acute otitis media RSV, pneumococci, Hib, GBS Earache in older children Fever Exclude via otoscopy in any

ill oddler Management▪ Symptomatic▪ amoxicillin

Thank you!