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