Download Paediatric Resp

The Respiratory System
Paediatrics OSCE Revision
Elizabeth Evans
Plan
 What could come up in the OSCE
 Respiratory examination
 Respiratory conditions
Key Points
 Likely to be one examination from: CV/Resp/GI
 May have a station with images or recordings
 May have a history
 Mostly normal children
 Know a little about everything: Vivas are v. short
 Easiest way to get marks: Be nice to the child!
What could come up?
Most respiratory disease in children presents acutely, thus
unlikely to appear in the OSCE.
OSCE:
History:
-Normal
-Asthma
-CF
-CF
-Hyperexpanded chest
from asthma
-Infection
Respiratory Examination
 Inspection- increased work of breathing
 Hands- cyanosis, clubbing (CF or CHD)
 RR and HR – remember changes with age
 Face- central cyanosis
 Avoid trachea in children – indicate to examiner
 Chest shape
 Palpation- apex beat and chest expansion
 Percussion- do not go straight for this on the chest!
 Auscultate
Dyspnoea in a child
 Nasal flaring
 Subcostal and intercostal recession
 Expiratory grunting
 Difficulty feeding
 Added sounds eg expiratory wheeze
CONDITIONS
Respiratory infections
 URTI: common cold
 LRTI: pneumonia
sore throat
bronchiolitis
otitis media
whooping cough
croup
diptheria
acute epiglottitis
Croup
 Viral laryngotracheobronchitis (parainfluenza virus)
 6 months – 6 years (peak in 2nd year)
 URTI symptoms (coryza/fever) for 2 days before onset of a characteristic
barking cough and stridor (subglottic oedema) lasting around 3 days
 Most improve spontaneously within 24h
 1 in 10 require hospitalisation: under 12months, severe illness or signs of
respiratory failure
 Single dose of dexamethasone or nebulised budesonide is beneficial
 Nebulised adrenaline provides transient improvement (reduces oedema)
and is used in more severe cases to enable time for transfer to ITU
Acute epiglottitis
 Life-threatening emergency
 Haemophilus influenza type B (Hib immunisation has caused reduction)
 1- 6 years
 Rapid onset, intensely painful throat, febrile child, unable to swallow and
reluctant to speak. Sat upright with open mouth drooling saliva.
 Resus room, call ENT and anaesthetist
 Do not examine the throat!
 Secure airway, then take bloods for culture and commence IV cefuroxime
 Rifampicin for household contacts
Diptheria
 Cornyebacteria diptheriae
 Sore throat, fever, lymphadenopathy and stridor
 Hallmark sign= thick grey material on back of throat
 Potentially fatal, highly infectious
 Eliminated by immunisation programme
Bronchiolitis
 Commonest serious respiratory infection of infancy
 1-9 months
 Viral infection (mainly RSV)
 Coryzal symptoms followed by dry cough with increasing SOB
 Tachypnoea, hyperinflation, bilateral fine crackles and wheeze
 CXR: chest hyperinflation
 Supportive management to address hypoxia and maintain
hydration (1% require assisted ventilation)
Whooping cough
 Bordetella pertussis (highly contagious)
 Spread by droplet infection
 Characteristic inspiratory whoop (may be absent in infants)
 During paroxysms of coughing the child may go blue and vomit
 May persist for 3 months
 Culture organism from nasal swab
 Erythromycin reduces infectivity but does not shorten duration of
symptoms
Asthma
 Most common chronic respiratory disorder of childhood- 10%
 Clinical diagnosis usually based on history and examination
 If >5 able to demonstrate diurnal variation in PEFR
 Wheeze= whistling noise made by the chest
 History:
 Examination
Nocturnal cough
Usually normal between attacks
Intermittent symptoms
In chronic severe asthma:
Triggers
-hyperexpansion
Exercise tolerance
Atopy
FH of asthma
Parental smoking
-pectus carinatum
-Harrison sulcus
Asthma Treatment
 Aim- asymptomatic with no exacerbations
 Educate child and parents on avoidance of triggers, importance of
regular therapy and correct inhaler technique
 Stepwise approach: British Guidelines for Asthma Management:
Step 1: Inhaled SABA
Step 2: Low dose inhaled steroids (if requiring 3xday SABA)
Step 3: Add LABA or leukotriene antagonist
Step 4: Increase inhaled steroid. Oral Theophylline. Leukotriene
antagonist.
Step 5: Alternate day oral steroids.
Metered dose inhaler plus spacer:
useful in all children, highly effective as
do not rely on technique.
Metered dose inhaler: competent older children
Dry powder inhaler: 5 years +
Cystic Fibrosis
 Autosomal recessive disease affecting 1 in 2500
 Mutation in CFTR protein resulting in defective chloride channel,
increased viscosity of secretions in respiratory tract and pancreas
 Consider in any child with recurrent chest infection or failure to thrive
 Repeated infections lead to bronchial wall damage and abscesses
 Deficiency of pancreatic enzymes results in malabsorption and
steatorrhoea
 Diagnosis: screening performed as part of Guthrie test.
Gold standard diagnostic test is the sweat test. Genetic testing also
useful to confirm diagnosis.
CF Examination
General: small for age, Creon supplements or insulin around bed
Peripheral: finger clubbing
Airway: nasal polyps, hyperinflated chest, crackles
GI: scar from meconium ileus operation
CF Management
 MDT approach
 Respiratory: physio, aggressive treatment of lung infections
 Nutritional: high calorie diet, vitamin ADEK, Creon (pancreatic
enzyme supplements)
 Severe lung disease may be considered for lung
transplantation
Thank you