RESPIRATORY PAEDIATRICS Dr 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 Asthma Severity 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