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Respiratory Disorders Notes

Medicine Notes > Paediatrics Notes

This is an extract of our Respiratory Disorders document, which we sell as part of our Paediatrics Notes collection written by the top tier of University Of Nottingham students.

The following is a more accessble plain text extract of the PDF sample above, taken from our Paediatrics Notes. Due to the challenges of extracting text from PDFs, it will have odd formatting:

Respiratory Disorders The Child With Wheeze

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Polyphonic, expiratory sound associated with obstruction of airways

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Airway resistance is proportional to radius4

o

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Small change in radius = large change in resistance

The child with wheeze:

o

Intrinsic ChangeAsthmaBronchiolitisPneumoniaViral wheezeCFCiliary disease

o

Extrinsic lower airway compression

o

Intraluminal obstruction inhaled foreign body / aspiration

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Half of children will wheeze at some time in the first three years of life

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In general there are two patterns of wheeze

o

Transient Early WheezingMost preschool children have virus associated wheeze episodic viral wheeze and wheezy bronchitisSmall airways are more likely to narrow and obstruct due to inflammation / immune responseTransient early wheezers have decreased lung function from birth associated with smoking and prematurityo

More common in males and typically resolves by 5 years of age

Persistent and Recurrent Wheezing

maternal

?

IgE to common inhalant allergens is associated with persistent wheezing beyond preschool yearsRecurrent wheezing plus evidence of allergy (skin prick test or IgE bloods) = Atopic asthmaAssociated with other atopic diseases*

Eczema

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Rhinoconjunctivitis

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Food allergy

Small number of children will suffer persistent wheeze for other reasons

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Non atopic asthma

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Recurrent aspiration of feeds

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Inhaled foreign body

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CF

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Recurrent anaphylaxis in child with food allergy

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Idiopathic

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Congenital abnormalities

Asthma

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Affects 1520% of children

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Chronic airway inflammation, bronchial hyperreactivity and reversible airway obstruction

Half of paediatric cases will present before 10 years of age Clinical Features

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Suspected in any child with more than one episode of wheeze

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Other key features associated with a high probability of asthma include:

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Worse at night / early in the morning

o

Triggers

*

*

*

o

Interval symptoms ask about cough (esp. in morning) and SOB on exertion

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Personal or family history of atopy

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Positive response to therapy

History:

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Frequency

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Triggers are sport and general activity affected

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How often is sleep disturbed

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How severe are interval symptoms cough and SOB

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How much school has been missed

Examination

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Hyperinflation

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Barrel shaped chest

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Expiratory wheeze

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Prolonged expiratory phase

o

Harrison sulci depressions at the base of the thorax associated with muscular insertion of the diaphragm

o

Eczema / allergic rhinitis?

o

Growth is only affected in severe cases

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Clubbing, wet cough and sputum think chronic infection (CF, bronchiectasis)

Investigations

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Typically diagnosed from history and examination

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Skin prick testing for common allergens

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CXR may be useful to rule out other causes

o

Peak flowUncontrolled asthma leads to diurnal variability (morning worse) and daytoday variability

?
o

Spirometryo

Typically <80%

FEV1/FVC <80% predicted

Response to treatment is the most helpful investigationPEFR and spirometry is expected to increase by 1015% following bronchodilator

Management

*

*

*

Step 1; Mild intermitted asthma

o

Inhaled short acting B2 agonist (prn)

o

Infants and young children consider inhaled ipratropium bromide (anticholinergic)

Step 2; Regular preventer therapy requires 3 or more B

inhalations per week

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Add inhaled steroid

o

<5 years consider ORAL leukotriene receptor antagonist if inhalers not tolerated

Step 3; Poorly controlled on conventional doses of inhaled steroids 'add on therapy'

o

o

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2 5 years or overAdd inhaled long acting B2 agonist (LABA) NOT without inhaled steroidAssess control:

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Good response continue

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Benefit but inadequate go to step 4

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No response try leukotriene receptor antagonist OR theophylline

<5 yearsConsider adding in leukotriene receptor antagonist<2 years refer

Step 4; Persistent poor control

o

o

Over 5 yearsIncrease inhaled steroid doseNo response go to step 5 or refer

<5 years*

Refer

Step 5; Continuous frequent use of oral steroids

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Daily oral steroids

o

Refer for specialist care

Types of Medication Bronchodilator Therapy

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*

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Short Acting Inhaled B2 agonists salbutamol, terbutaline

o

Effective for 24 hours

o

Acute asthma prn

Long Acting B2 Agonists (LABA) salmeterol, formoterol

o

Effective for 12 hours

o

NOT in acute asthma

o

NOT without inhaled steroid

Ipratropium Bromide anticholinergic bronchodilator

o

Young infants

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When other treatments are ineffective or in severe acute asthma

Inhaled Corticosteroids

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Budesonide, beclometasone, fluticasone

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Preventers

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Decrease airway inflammation

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Used in conjunction with LABA

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No clinically significant side effects unless used in v. high doses

o

Adrenal suppression

o

Impaired growth

o

Altered bone metabolism

o

Oral candidiasis (rinse mouth after use)

Add On Therapy

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Over 5 years LABA

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Under 5 years oral leukotriene receptor antagonist (montelukast)

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Slow release oral theophylline (methylxanthine - think caffeine) is an alternative but has side effects such as:

o

Vomiting

o

Insomnia

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Headaches

o

Poor concentration

Other Therapies

*

*

Oral prednisolone

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Given on alternate days to prevent adverse effect on height

o

In severe persistent asthma where all other treatment has failed

AntiIgE therapy

o

Delivery of Therapy Types of Inhaler

Omalizumab Injectable monoclonal antibody

*

*

*

*

Pressurised metered dose inhaler (pMDI) and spacer

o

Appropriate for all age groups

o

Facemask and spacer in those aged 02

o

Increases drug deposition to the lungs

o

Useful in acute asthma attacks when poor inspiratory effort limits use of other inhalers

Breathactuated metered dose inhalers

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6+ years

o

Useful when 'out and about'

Dry powder inhaler

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4+ years

o

Needs a good insp. Flow NOT in acute attacks

Nebuliser

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Any age

o

Used in acute asthma

o

In combination with oxygen

Acute Asthma

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Clinical features

o

Wheeze and tachypnoeaRR >50 in children 25 years>30 in children over 5

o

SOB which interferes with talking good indicator of severity

o

Tachycardia>130 in children 25

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