Case 12: 10month old - Foreign body aspiration Flashcards
wheezing in infants
- diffdx
- etiology
- complications
- tx
- asthma
- croup (stridor)
- foreign body aspiration
- Bronchiolitis: Viral respiratory (RSV) ==> airway inflammation and wheezing
complications = later development of asthma
tx = NO bronchodilators, steroids
EXCEPT in those with strong FHx asthma; clear response to bronchodilators.
Asthma
- pathophys
- sxs
- triggers
- dx
- pathophys (acute)
1) airway inflammaiton
2) mucus hypersecretion
3) reversible airflow obstruction d/t bronchoconstriction - sxs = recurrent coughing and/or wheezing responsive to bronchodilators (beta-agonists) & anti-inflammatory meds (steroids)
- triggers = URI, allergies, cold air, exercise, smoke exposure
- dx = responsive to bronchodilators (beta-agonists) & anti-inflammatory meds (steroids); no other identifiable cause for wheezing (regardless of age)
what is the difference between asthma and reactive airway disease (RAD)
BOTH = airway hyperresponsiveness
reactive airway disease (RAD) = children with early wheezes that stop at 2-3yo.
what is a characteristic of chronic asthma? (less likely in acute asthma)
smooth muscle hyperplasia and hypertrophy
signs of respiratory distress
- paradoxical breathing [respiratory muscle fatigue] == subcostal retractions + rising abdomen,
where force of diaphragmatic contraction»_space;
ability of chest wall to expand rib cage (infants, young children – greater compliance of chest wall) - tachypnea, with increased depth & degree of effort (hyperpnea / hypopnea)
- nasal flaring = accessory muscles of respiration
- head bobbing (esp. during sleeping) = accessory muscles of respiration [neck strap]: neck flexion –> head bob forward
- grunting = forced expiration against partially closed glottis –> to help generate positive pressure to stent airways open
- sudden decrease in “signs of respiratory distress” with increase of PCO2 (or decreased HCO3) ==> hypoventilation d/t respiratory muscle fatigue
define & interpret hyperpnea
hyperpnea= increased depth of respiration
hyperpnea (-) respiratory distress == non-pulmonary condition
- fever
- acidosis
- extreme anxiety (hyperventilation syndrome)
define & interpret hypopnea
hypopnea = reduced tidal volume
==> increased proportion of each breath used to ventilate space –> can lead to hypoventilation even in the setting of a normal / eleavated RR.
diffdx infectious respiratory diseases
- Bordetella pertussis
- epiglottitis
- diphtheria
- retropharyngeal / parapharyngeal abscess == pharyngitis + dysphagia + stridor
describe Bordetella pertussis
- course:
- complications:
- prevention:
- course:
1) catarrhal stage (1-2w) = URI sxs
2) paroxysmal stage (4-6w) = “whoop” (repetitive, forceful coughing THEN massive inspiratory effort); less so in infants
3) convalescent stage (months) = episodic cough - complications: (esp in infants) difficulty feeding, CNS complications (apnea)
- prevention: acellular pertussis vaccine (efficacy = 70-90%); wanes over 10y
Epiglottitis
- epidemiology
- course:
- complications:
- prevention:
- epidemiology: uncommon d/t immunization [Staph, Strep, Hib]. Ages 2-5yo
- course:
1) fever, stridor, drooling, dysphonia, dysphagia
2) respiratory distress == toxic; position “sniffing;” prefer sitting, leaning forward with neck hyperextended & chin protruding - complications: acute airway obstruction
- prevention: Hib vaccine
- dx: lateral neck xray = thickening of the epiglottis (“thumb sign”), thickened aryepiglottic folds
- tx
diphtheria
- signs
- dx
signs = pharyngitis, low-grade fever (esp. with stridor, hoarseness) dx = pharygeal gray pseudomembrane
esp. if not immunized
extrinsic causes of wheezing
- vascular ring / sling
- adenopathy
- mass / other lesion
sounds heard on lung exam and what they mean
AIR ENTRY
- if decreased (or differential b/w inspiration and expiraiton) ==> consolidation, atelectasis, pneumothorax, pleural
effusion or airway obstruction.
STRIDOR
- airway narrowing above thoracic inlet [external = lymphadenopathy, neoplasm; croup, inhaled foreign bodywith partial obstruction; laryngomalacia]
- esp. with inspiration; biphasic if severe
WHEEZE (continuous)
- airway narrowing below thoracic inlet [internal = edema, mucus, foreign object]
- esp. with expiration; biphasic or NONE if severe –> esp of multiple small / moderate-sized airways ==> continuous sounds
==> focal: mucus plugging
==> generalized (mostly)
- polyphonic / monophonic
RHONCHI (continuous)
- coarse, low-pitched rattling sounds
- esp. with expiration
==> secretions, narrowing of airways d/t mucus / secretions
CRACKLES (DIScontinuous)
- finer == pulmonary edema & bronchiolitis, interstitial lung dz
- coarse == purulent secretions in alveoli [pneumonia]
- ESP WITH INSPIRATION
==> fluid in alveoli or with opening / closing of stiff alveoli (interstitial dz)
compare wheezing and stridor
stridor
- airway narrowing above thoracic inlet [external]
wheezing
- airway narrowing below thoracic inlet [internal]
define polyphonic / monophonic wheeze
polyphonic= multiple pitches [asthma]
monophonic = single pitch [focal airway obstruction below thoracic inlet]
what does this indicate?
decreased air flow / differential between inspiration and expiration
consolidation, atelectasis, pneumothorax, pleural
effusion or airway obstruction.
dz)
what does stridor indicate?
- airway narrowing above thoracic inlet [external]
- esp. with inspiration; biphasic if severe
what does wheezing indicate?
- airway narrowing below thoracic inlet [internal]
- esp. with expiration; biphasic or NONE if severe
==> focal: mucus plugging
==> generalized (mostly) - polyphonic / monophonic
what does rhonchi indicate?
- coarse, low-pitched rattling sounds
- esp. with expiration
==> secretions, narrowing of airways
what do crackles indicate?
- finer == pulmonary edema, interstitial lung dz
- coarse == purulent secretions in alveoli [pneumonia]
==> fluid in alveoli or with opening / closing of stiff alveoli (interstitial
define: asthma
inflammation of the airways that leads to airway obstruction
1) infiltration of inflammatory cells into large airway mucosa –> mucosal edema
2) mucus hypersecretion
3) bronchoconstriction
asthma presentation
CHRONIC==> recurrent episodes of dyspnea and/or cough
ACUTE exacerbation
- cough, wheezing, tachypnea, dyspnea
- EXAM: wheezing, diminished air exchange
IF SEVERE
- minimal air exchange; NO WHEEZE d/t poor airflow, cyanosis, and pulsus paradoxus
what is the cause of wheezing in asthma
1) diffuse
2) focal wheeze ==> d/t mucus plugging
you think the child you are seeing in the ED has an asthma exacerbation, but you hear nothing on exam. what should you consider?
IF SEVERE ASTHMA
- minimal air exchange; NO WHEEZE d/t poor airflow, cyanosis, and pulsus paradoxus
radiographic findings in asthma
- hyperinflation d/t air trapping
- increased interstiital markings
- patchy atelectasis
goals of asthma therapy
ACUTE
1) reduce airway inflammation (STEROIDS)
2) dilate airways - bronchodilation (ALBUTEROL)
3) supportive care for hypoxemia / dehydration
MAINTENANCE
- based on severity
- controller: daily ICS,
- rescue: inhaled b-agonist
prognosis of asthma
generally good –> depends on adherence and appropriate step up management
define: bronchiolitis
acute bronchiolitis = viral disease lower respiratory tract of infants [starts out as upper respiratory]
==> bronchiolar obstruction (of small airways) ==> d/t edema, mucus, cellular debris
= RSV, influenza, parainfluenza
most common cause of wheezing in infants
bronchiolitis
sxs of bronchiolitis
VARIABLE
- mild URI sxs, fever of 38.5-39C
==> cough, wheezing, dyspnea, irritability
cxr findings of bronchiolitis
- hyperinflation
- increased interstitial markings
- peribronchial cuffing
- scattered atelectasis (d/t bronchial obstruction)
treatment of bronchiolitis
SUPPORTIVE
- adequate oxygenation
- adequate hydration
+/- Abx if secondary bacterial pneumonia
OTHERS [tenuous]
- if strong FHx of asthma and it works == bronchodilators
+/- corticosteroids
+/- hypertonic saline to clear mucus
define: pneumonia
== inflammation of lung parenchyma (NOT AIRWAYS)
- bugs
- aspiration of gastric contents, hydrocarbons
diffdx of coughing in an infant
- asthma
- bronchiolitis
- pneumonia
- foreign body aspiration
most common cause of pneumonia in children
viral pneumonia
- adenovirus
- RSV
- parainfluenza
- influenza
most severe cause of pneumonia in children
bacterial pneumonia [based on age]
- NEONATAL = GBS, E. coli, Klebsiella (transferred from maternal genital tract)
- 4-12 WEEKS = Chlamydia pneumonia ==> staccato cough
- <5-6yo = Strep pneumoniae
- > 6y = () mycoplasma pneumoniae; (2) Strep pneumoniae
sxs of viral pneumonia
1) prodrome = URI - cough, rhinorrhea
2) progressive cough, fever, tachypnea, crackles
sxs of bacterial pneumonia
abruptly
or secondary to viral pneumonia
==> fever, cough, signs of respiratory distress (dyspnea, tachypnea, retractions)
- crackles, decreased breath sounds
CXR of viral pneumonia
- diffuse/patchy interstitial infiltrates
- hyperinflation
- small pleural effusions
Lab findings of viral pneumonia
- nml, slightly elevated WBC
- respiratory secretions = viral antigen testing
CXR of bacterial pneumonia
- lobar / segmental consolidation
- air bronchograms
Lab findings of bacterial pneumonia
- high WBC
- high neutrophils
treatment of viral pneumonia
- supportive (hydration)
treatment of bacterial pneumonia
- antibiotics
- supportive
foreign body aspiration
- causes
- local tissue reaction
- sequelae
most common = foods, candy, nuts, grapes
local tissue reaction
- aspirated food = fatty oils ==> more severe pneumonitis (surrounding airway mucosa = erythematous, friable) compared to nonfoods.
- disc battery ==> erosion through bronchial wall
- lodged in upper airway (trachea, bronchi) ==> LETHAL
==> can lead to blockage, infection, pneumonia
key questions to ask when presented with a child with coughing
“is she still drinking”
- hydration status; severity of breathing difficulty, problems coordinating feeding and breathing
- dysphagia==> concerns of pharyngeal / esophageal foreign body aspiration/laryngeal cleft / TE fistula (esp. choking, coughing, gagging), OR infection
- more important: drinking > eating
“has she had a fever”
- fever / vasculitis
- RECURRENCE of fever several days into respiratory illness ==> superimposed bacterial pneumonia
“did the cough begin suddenly? did you see her choke on anything?”
- esp. in infants and toddlers
“has her voice or her cry been hoarse”
- UPPER AIRWAY (different voice/cry): infection in larynx/pharynx ==> phargyngitis, tonsillitis, epiglottitis
- LOWER AIRWAY (voice / cry is the SAME)
“has her cough been barky? does she make any noises when she breathes?”
- CROUP (laryngotracheobronchitis) - esp. in 2-5yo d/t parainfluenza virus ==> (1) non-specific URi sxs, (2) variable airway obstruction = barky cough, inspiratory stridor
“does she have any other medical problems?”
- birth hx –> PREMATURE = underlying respiratory conditions (e.g. bronchopulmonary dysplasia –> cough and wheezing)
“ear infections? pneumonia? chronic diarrhea? trouble gaining weight?”
- ? immunodeficiency / malabsorptive conditions (e.g. CF)
“spitting up? reflux?”
- likely chronic cough
“has she received all her immunizations?”
- esp. pertussis
history
- heritable conditions = asthma, environmental allergies, CF
- social/environmental = exposure to sick contacts [+/- sick contacts]; childcare, tobacco smoke
what does this indicate: coughing with liquids
aspiration
what does this indicate: coughing with solids
narrowing of posteiror oropharynx/esophagus
what does this indicate: hoarse / different voice or cry
UPPER AIRWAY problem (different voice/cry): infection in larynx/pharynx ==> phargyngitis, tonsillitis, epiglottitis
how does the inspiratory stridor change with the severity of the croup
MILD = during agitation MODERATE = at rest, agitation SEVERE = expiratory stridor
CXR findings in a foreign body aspiration (in the R side)
- PA film = R hemidiaphragm is flattened == UL hyperexpansion
- R decubitus ==> mediastinal structures remain in midline, rather than shifting to the R b/c of fixed hyperinflation of the R lung
- L decubitus ==> mediastinal structures shift to the LEFT (dependent position)
Evaluation for foreign body aspiration (e.g. on R)
1) Exam = asymmetric breath sounds (decreased on R); cough sounds obstructed (with end-expiratory wheezes) on R. Cough, tachypnea, focal wheeze, retractions, afebrile.
??? fever
??? cyanosis
??? stridor
2) PA and lateral chest films
- BL decubitus = when dependent lung does NOT deflate as expected ==> obstruction in the large airway
OR
-inspiratory / expiratory chest films ==> where obstruction does not allow the distal lung to deflate fully ==> UL asymmetric deflation with expiration d/t air trapping (more subtle v. decubitus films)
3) Chest fluroscopy = dyanamic evaluation that allows visualization of the airways over several breaths v. single breath
4) Albuterol = wheezing would not improve
diffdx of UL large airway obstruction
INFANTS
- foreign body aspiration
- TB (where it is endemic)
ADULTS
- airway tumors
- extrinsic compression
- lymphadenopathy
distinguish partial v. complete airway obstruction due to foreign body
PARTIAL - hyperinflation ==> "ball valve" effect 1) inspiration = partial obstruction 2) expiration = full obstruction ==> air trapping with each breath
COMPLETE = total lack of airflow to the bronchus
==> atelectasis
==> signs of volume loss on xray = mediastinal shift TOWARD affected side / elevation of hemidiaphragm on affected side
In what conditions can you have “normal” O2 sat, but actually have low percentage saturation of oxyhemoglobin
- methemoglobinemia (certain toxins, too much anaesthesia)
- carboxyhemoglobinemia (CO poisoning)
- compensated asthma: where hyperventilation –> decreased PCO2 –> as child tires, and can no longer maintain adequate ventilation == PCO2 normalized, elevated + normal oxygenation ==> impending respiratory failure [GET BLOOD GASES]
Which of the following signs indicates the most severe respiratory distress? Select the ONE best answer.
A Tachypnea B Retractions C Nasal flaring D Grunting E Paradoxical breathing
E
d/t respiratory muscle fatigue
baby had been having trouble breathing before, but not looks more comfortable on a respiratory level. what do you have to watch out for? What do you do?
respiratory muscle fatigue ==> can reduce signs of respiratory distress BUT pt is actually deteriorating
–> get blood gases == for elevation of PCO2 ==> HYPOVENTILATION
interventions for respiratory distress
1) observation == to see if EMERGENT
2) O2 for hypoxemic = blow-by, NC, facemask, endotracheal tube
This patient is known to have respiratory disease, such that she is a chronic “CO2 retainer”, and her O2 sats at baseline are always a little low. Should you give her O2?
== chronic hypercarbia
NEVER withhold O2 in cases of severe hypoxemia (<88%)
1) monitor closely
2) give only as much O2 as needed to maintain minimum saturation
3) endotracheal intubation ==> for pts where respiratory failure is imminent or loss of airway is anticipated.
diffdx: Healthy 10-month-old One-week history of respiratory illness Acutely worsening cough Rhinorrhea Wheeze No history of fever Family history of allergies and asthma
how can you start to rule it out?
A Allergic rhinitis B Anatomic abnormality C Asthma exacerbation D Bronchiolitis E Congestive heart failure F Cystic fibrosis G Croup H Foreign body aspiration I Gastroesophageal reflux J 56.8% Community-acquired pneumonia K 4.5% Chlamydia trachomatis L Pertussis M Epiglottitis N Sinusitis O Viral upper respiratory infection (URI)
- allergic rhinitis
- asthma exacerbation
- bronchiolitis
- croup
- foreign body aspiration
- CAP
- pertussis
- sinusitis
- viral URI
- NO FEVER –> less CAP
- NO STRIDOR –> less Croup (unless it’s actually stridor and not a wheeze)
- ACUTE sxs –> less sinusitis = usually longer duration, even though she does have rhinorrhea
- NO CHRONIC ==> less anatomic abnormality, CF, GERD
- VITALS OTHERWISE NORMAL - no CHF
- OLDER - no chlamydia
- NO RESPIRATORY DISTRESS, STRIDOR ==> less epiglottitis
what extrisic compression of the airway can cause wheezing?
- a vascular ring or sling
- adenopathy
- a mass or other lesion
differentiate rigid v. flexible bronchoscopy
- visualize:
- function:
RIGID = only into the mouth;
==> visualize: upper & large airways
==> function: transbronchial biopsies; remove foreign bodies
FLEXIBLE = nose or mouth
==> visualize: more distal airways
==> function: suction; collect lavage specimens.
Question
A 12-year-old male presents to the ED with complaints of anorexia, weight loss, and persistent cough, with nocturnal coughing fits that have been waking him from sleep for the past three weeks. He denies fever, chills, myalgia, sore throat, or rhinorrhea. The patient presented to his primary care physician one week prior with the same complaint, and was treated with amoxicillin and bronchodilator therapy. His chest x-ray was negative for infiltrates at that visit. The patient’s symptoms did not improve with this regimen. The cough became more frequent, sometimes causing emesis. Which of the following is the most likely diagnosis?
A Reactive airway disease
B Infection with Bordetella pertussis in the catarrhal stage
C Infection with Bordetella pertussis in the paroxysmal stage
D Atypical pneumonia due to Mycoplasma pneumoniae
E Laryngotracheobronchitis
C
paroxysmal stage of pertussis lasts four to six weeks and is characterized by repetitive, forceful coughing episodes, followed by massive inspiratory effort. This massive inspiratory effort is what results in the characteristic “whoop”-sounding cough. This is consistent with the patient’s presentation and duration of illness. The forceful coughing fits in pertussis can even lead to conjunctival hemorrhages and pneumothoraces from the increased intrathoracic and intracranial pressures from Valsalva. The antimicrobial agents of choice for treatment of pertussis are azithromycin, clarithromycin, and erythromycin. Antibiotics given in the paroxysmal phase will reduce communicability but will not alter the clinical course.
NOT catarrhal – 1-2w, “URI” sxs.
A 12-month-old previously healthy girl presents with cough and mild subcostal retractions. She is afebrile, and physical exam reveals asymmetric wheezing. Chest x-ray demonstrates unilateral air trapping. What is the most likely diagnosis?
A Croup B Pneumonia C Acute bronchiolitis D Foreign body aspiration E Asthma
D
unexplained wheezing and asymmetric breath sounds, as well as air trapping in one lung indicating unilateral airway obstruction. The right main bronchus is the more commonly obstructed due to anatomy (it is wider and more vertical than the left). The most commonly aspirated foods are hot dogs, nuts, hard candy, grapes, and popcorn.
A 10-month-old infant is brought to the Peds ED by her parents, who say she has been coughing persistently for the last three hours. The parents were watching a movie at home when they first noticed their daughter coughing. Patient is a vaccinated, well-nourished infant in moderate distress with retractions, nasal flaring, and grunting. On auscultation, you immediately notice diminished breath sounds in the right lung with normal breath sounds on the left. What other associated physical exam finding do you expect to hear?
A Stridor B Asymmetric breath sounds and wheezing C Rhonchi D Crackles E Bronchial breath sounds
B
watching movie== popcorn
This infant is in respiratory distress from foreign body aspiration, cBnsistent with the history of acute onset of distress and asymmetric breath sounds. Common foreign bodies include peanuts, popcorn, grapes, hard candy and hot dogs. Respiratory distress from foreign body aspiration is usually accompanied by asymmetric breath sounds and wheezes on auscultation.
Susie is a 3-year-old girl brought into the clinic by her mother because she has a gradually worsening cough and she has been having trouble breathing. Her mother says Susie sounds like she is barking when she coughs. Susie is up to date with her vaccinations. Susie’s mom always watches her when she’s playing. On physical exam, you note that Susie has inspiratory stridor. She does not have wheezing, there are no retractions, and she has symmetrical breath sounds. No pseudomembranes are appreciated on physical exam. What is Susie’s most likely diagnosis?
A Epiglottis B Croup (laryngotracheobronchitis) C Pertussis D Pneumonia E Foreign body aspiration
B
due to a viral infection (Parainfluenza type 1). It is most common in the winter, and often occurs in children age 2 to 5 years. Croup can lead to non-specific URI symptoms with some degree of airway obstruction. A barky or seal-like cough and inspiratory stridor (which should be differentiated from expiratory wheezes) is common in croup.
Her barking cough is more suggestive of croup than the “whooping” cough of pertussis.
Epiglottitis is a life-threatening emergency caused by an infection with H. influenzae type B. It is less common now with the advent of Hib vaccine, but in rare cases can occur due to staphylococcal or streptococcal infections. It most often occurs in children ages 2 to 5 years. Children with epiglottitis present with fever, stridor, drooling, dysphonia, dysphagia, and respiratory distress. They frequently appear toxic and sit in the “sniffing position” (sitting, leaning forward, neck hyperextended, chin protruding). A “thumb sign” (thickened epiglottis and aryepiglottic folds) appears on films. Susie is not exhibiting any of these characteristic symptoms and she is up to date with vaccines, making epiglottitis a less likely diagnosis for her cough.
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?
A RSV bronchiolitis B Epiglottitis C Viral URI D Asthma E Foreign body aspiration
E. 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).
NOT bronchiolitis –> everything looks right, EXCEPT for asymmetrical wheezing and decreased breath sounds
