RESPIRATORY PAEDIATRICS

1. RESPIRATORY PAEDIATRICS Dr Pamela Lewis

2. OBJECTIVES • History – Key points • Examination • Common respiratory problems in children

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

4. Respiratory Risk Factors • Prematurity • Chronic lung disease • Smoking • Atopy • Family history • Immunodeficiency • Social

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

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

8. 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

9. Bronchiolitis Prevention • Palivizumab monoclonal antibody, monthly injections to at risk population • Vaccine? Not currently

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

12. 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

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

14. 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

15. 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

16. 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)

17. Key Features in Asthma • Symptoms: cough, wheeze, SOB,chest tightness, exertional symptoms • Risk Factors: atopy, FH, smoking, preterm • Signs: None, hyperexpansion, Harrisons sulci

18. 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

19. Differential Diagnosis in Asthma • Viral wheezing • GOR • Suppurative lung disease • Congenital structural leision • Immunodeficiency • Cardiac

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

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

22. 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

24. 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

25. BTS Asthma Management • Step 2 • Regular preventer therapy • Inhaled beta 2 agonist prn and regular standard dose inhaled corticosteroid

26. 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

27. BTS Asthma Management • If <5years add leukotriene antagonist

28. 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

29. BTS Asthma Management • Step 5 • Refer to respiratory paediatrician • As for step 4 and consider regular steroid tablets or immunosuppressants

30. 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

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

32. 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

33. 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

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

35. CYSTIC FIBROSIS MANAGEMENT • Multidisciplinary team approach • Physiotherapy • Dietetics • Therapeutic • psychological