12: 10-month-old female with a cough

Question 1

Causes of Wheezing in Infants and Toddlers

Answer 1

• viral bronchiolitis
• asthma
• foreign body aspiration
• GE reflux

Question 2

Signs of Respiratory Distress: Paradoxical breathing

Answer 2

• almost always a sign of very severe respiratory distress due to respiratory muscle fatigue.
• occurs when the force of contraction generated by the diaphragm exceeds the ability of the chest wall muscles to expand the rib cage. As a result, the chest is drawn inward with inspiration, and the abdomen rises due to downward displacement of abdominal contents.
• seen m/c in infants and young children than in older individuals d/t the greater compliance of the CW.

Question 3

Signs of Respiratory Distress: Tachypnea

Answer 3

• Hyperpnea (increased depth of respiration) without respiratory distress may suggest a non-pulmonary condition such as fever, acidosis or extreme anxiety (hyperventilation syndrome).
• Hypopnea (reduced TV) increases the proportion of each breath used to ventilate dead space, so may result in hypoventilation even in the setting of a nml or elevated respiratory rate.

Question 4

Signs of Respiratory Distress: Retractions

Answer 4

use of accessory muscles to augment breathing during respiratory distress. Suprasternal and intercostal retractions occur due to excessive negative pleural pressure, and subcostal retractions occur when the diaphragm is flattened during inward pulling on the chest wall.

Question 5

Signs of Respiratory Distress: Nasal flaring

Answer 5

seen in small children with significant respiratory distress and indicates that accessory muscles are being used for respiration

Question 6

Signs of Respiratory Distress: Grunting

Answer 6

seen in infants, consists of forced expiration against a partially closed glottis and is thought to help infants generate the positive pressure necessary to stent airways open.

Question 7

Signs of Respiratory Distress: Head bobbing

Answer 7

due to use of the accessory muscles of respiration (in this instance, the neck strap muscles). In synchrony with each inspiration, the head is noted to bob forward owing to neck flexion caused by use of the neck strap muscles. Head bobbing is best observed during sleep.

Question 8

Bordetella Pertussis: Infectious Resp Dz

Answer 8

• The initial catarrhal stage lasts 1-2 weeks and is characterized by upper respiratory tract infection symptoms.
• The paroxysmal stage that follows lasts 4-6 weeks and is characterized by repetitive, forceful coughing episodes followed by massive inspiratory effort, which results in the characteristic “whoop.” Infants generally do not develop a “whoop” due to relative weakness of their inspiratory effort.
• The paroxysms of cough gradually decrease in frequency and severity as the convalescent stage is entered. Episodic cough may persist for months.

Question 9

Asthma general

Answer 9

characterized by infiltration of inflammatory cells into the airway mucosa, mucus hypersecretion, and mucosal edema, accompanied by bronchoconstriction.

Question 10

Asthma radiographic findings

Answer 10

hyperinflation due to air trapping, increased interstitial markings and patchy atelectasis.

Question 11

Acute exacerbation tx

Answer 11

The mainstays of treatment for an acute episode are anti-inflammatory therapy with corticosteroids and bronchodilation with beta-2 agonists such as albuterol, together with supportive care for hypoxemia or dehydration.

Question 12

Maintenance therapy

Answer 12

• Choice of therapy for chronic asthma is based on the frequency, severity and type of symptoms, as well as by other comorbidities.
• Children with frequent symptoms are prescribed an inhaled corticosteroid as a daily controller medication, with an inhaled beta-agonist such as albuterol as needed for breakthrough symptoms.
• Alternative and additional medications (such as montelukast) are also used under appropriate circumstances.

Question 13

Acute bronchiolitis

Answer 13

• -viral disease of the lower respiratory tract of infants and represents the most common cause of wheezing in infants.
• -RSV is the m/c cause, but other viruses such as influenza and parainfluenza may cause bronchiolitis as well.

Question 14

Pathophysiology of Pneumonia

Answer 14

inflammation of the lung parenchyma. It is generally caused by microorganisms, but non- infectious causes include aspiration of gastric contents or hydrocarbons.

Question 15

PNA Etiology

Answer 15

most common cause of pneumonia in children is a respiratory virus, including:
Adenovirus, RSV, Parainfluenza, Influenza

Question 16

Bacterial infections are less common causes of pneumonia than viruses but tend to be more severe:

Answer 16

• In the neonatal period, bacteria transmitted from the maternal genital tract must be considered, including Group B streptococcus, E.Coli, and Klebsiella.
• PNA d/t Chlamydia pneumoniae usually presents with a staccato cough 4-12 weeks
• Strep pneumo is the m/c bacterial c/o pna in the U.S. among infants beyond the neonatal period and children up to 5/6 yo.
• In school-aged and older children, Mycoplasma pneumoniae is the predominant cause, followed by S. pneumo.

Question 17

“Laryngotracheobronchitis” (aka croup)

Answer 17

• viral disease of the upper respiratory tract and is a common cause of cough and stridor in children, with a peak age of incidence of 2 years.
• Most cases are due to parainfluenza
• chest radiograph may demonstrate narrowing in the subglottic region (“steeple sign”)

Question 18

Stridor

Answer 18

• Due to airway narrowing above the thoracic inlet.

- Usually heard with inspiration, but can be biphasic if obstruction is severe.

Question 19

Wheezing

Answer 19

• Typically due to airway narrowing below the thoracic inlet.
• With mild airway obstruction, wheezing is usually heard only in expiration.
• With increasing obstruction, wheezing may become biphasic and may even disappear altogether when obstruction is severe.
• Although typically diffuse, focal wheeze may be heard in some settings such as mucus plugging.
• Wheezing can also be characterized as polyphonic or monophonic: Polyphonic wheeze is characterized by multiple pitches and is typical of asthma; monophonic wheeze is characterized by only a single pitch and is typical of focal airway obstruction.

Question 20

Rhonchi

Answer 20

• Coarse, low-pitched rattling sounds heard best in expiration.
• Thought to be due to secretions and narrowing of airways.

Question 21

Crackles

Answer 21

• Finer breath sounds heard on inspiration.
• Associated with either fluid in the alveoli or with opening and closing of stiff alveoli (as in interstitial disease).
• Sometimes described as either coarse or fine. (Coarse crackles are usually thought to be associated with purulent secretions in the alveoli as with pneumonia; fine crackles are often associated with pulmonary edema or interstitial lung disease.)

Question 22

Air entry

Answer 22

• The amount of air entry should be noted during every lung exam.
• Decreased air entry can be a sign of consolidation, atelectasis, pneumothorax, pleural effusion or airway obstruction.

Question 23

Bronchial breath sounds

Answer 23

• Lower in pitch and more hollow-sounding than normal breath sounds.
• Caused by air moving through areas of consolidated lung.

Question 24

These are the findings you would expect with an aspiration obstructing the right airway:

Answer 24

• -PA film (with the child in a sitting position): Right hemidiaphragm is flattened, suggesting unilateral hyperexpansion on the right.
• -Right decubitus: With child on her right side, the mediastinal structures remain in the midline, rather than shifting towards the right lung due to gravity, further demonstrating the fixed hyperinflation of the right lung.
• -Left decubitus: With child on her left side, the mediastinal structures shift towards the left lung as expected.

Question 25

Joe, a previously healthy 11-month-old male with 5-day history of a "cold," is brought to the ED by mom for one day of acute worsening cough and intermittent wheezing. Per mom, the cough was initially dry but has become more "phlegmy," making it difficult for Joe to breathe, particularly when he is feeding or more active. His immunizations are up to date, and he has no known allergies. His family history is significant for a 6-year old sister who was diagnosed with asthma four years ago. On exam, Joe is afebrile, mildly tachypneic with normal O2 saturation. He has prominent nasal flaring and mild subcostal retractions. He has clear rhinorrhea but no evidence of oropharyngeal erythema. Lung exam reveals decreased breath sounds and wheezes on the right. What is the most likely diagnosis?

Answer 25

Given Joe's age, foreign body aspiration should always be included in the differential diagnosis for acute onset wheezing. The lung findings of asymmetric breath sounds and wheezing support this diagnosis. Foreign body in the airway can be confirmed by bilateral decubitus or inspiratory/expiratory chest films, characterized by decreased deflation on the affected side. If complete obstruction, x-ray will generally reveal atelectasis (whiting out) and signs of volume loss (mediastinal shift towards affected side to compensate for loss of volume).