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Pediatrics Module 2 > Lecture 1: Pulmonology > Flashcards

Lecture 1: Pulmonology Flashcards

1
Q

derangements of breathing in pediatrics

A
  • respiratory disease is the most common reason for pediatric hospitalization
  • hallmark distinction of airway noise
    • upper airway obstruction - stridor
    • lower airway obstruction - wheeze
    • air trapping and prolonged expiratory phase can occur in either upper or lower obstruction
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2
Q

nasal obstruction

A
  • Newborns and young infants are obligate nasal breathers
  • Significant respiratory distress can occur
  • Can also lead to difficulty feeding
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3
Q

oxygenation vs. ventilation

A
  • ventilation and oxygenation occur independent from one another
    • processes compromise each function differently
    • both may be affected by severe obstruction
  • Oxygenation affected first
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4
Q

respiratory rate varies with age

A
  • age
    • infant
    • 1-3 years
    • 4-6 years
    • 7-14
    • 14-18
  • respiratory rate
    • 24-38
    • 22-30
    • 20-24
    • 16-24
    • 14-20
  • always count respiratory rate over 60 seconds
  • *Periodic breathing*
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5
Q

respiratory exam

A
  • observe over time since external stimuli may influence the exam
  • do not be afraid to palpate and undress patient
  • tachypnea is the most sensitive sign of pneumonia in children
  • stridor is most commonly inspiratory, monophasic, noise
    • Can be inspiratory, expiratory or fixed depending on the cause
  • wheezing is continuous sound caused by turbulent flow in narrow airways
    • Pitch can identify the part of airway involved
  • rales (crackles) are fine, interrupted sounds that suggest pulmonary parenchymal disease
  • Rhonchi are coarse, interrupted sounds that suggest large airway disease
  • Egophany CAN be used in children who can follow instruction
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6
Q

respiratory distress in children

A
  • children mount a progressive effort with worsening compromise
  • first, tachypnea
  • then, further labored breathing
    • retractions
      • abdominal (“subcostal”)
      • intercostal
      • supraclavicular
    • nasal flaring
    • grunting
      • attempt to maintain area for gas exchange by providing extra end expiratory pressure
  • positioning
    • upright (gravity aids diaphragmatic contraction)
    • tripodding (allows more efficient scalene and intercostal work)
    • sniffing position (opens upper airway)
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7
Q

cyanosis

A
  • Blue discoloration of skin due to hypoxemia
  • Central cyanosis occurs first
    • Perioral/lips/tongue
    • Trunk
    • Extremities
  • Poor prognostic factor for severity of disease
    • Usually prompts admission to the hospital
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8
Q

plain chest film

A
  • good screening test for parenchymal or pleural disease
  • poor test of pulmonary function
  • upright film at limit of inspiration is best
    • often difficult in small children, may require repeat of film
    • radiography tech often forgets to compensate for child size when determining exposure
  • lateral films very useful for evaluation of retrocardiac space
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9
Q

arterial blood gas

A
  • useful measure of pulmonary function
  • even more useful if serial measurements allow description of trends
  • worrying findings include
    • rising pCO2 over 45 mmHg (respiratory acidosis)
    • decreasing pO2 less than 85mmHg (hypoxemia)
    • acidemia (uncompensated acidosis)
  • Capillary and venous blood gases are easier to obtain, but pO2 is less helpful
  • no utility of pO2 in venous blood gases
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10
Q

pneumonia

A
  • = Infection of alveolar spaces
  • Viruses
  • Bacterial pneumonia
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11
Q

viral etiologies of PNA

A
  • Respiratory Syncytial Virus (bronchiolitis)
  • Rhinovirus (bronchiolitis)
  • Human Metapneumovirus (bronchiolitis)
  • Influenza Virus
  • Parainfluenza Virus
  • Adenovirus
  • Herpes Simplex Virus
  • Varicella Virus
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12
Q

bacterial etiologies of PNA

A
  • Neonate 0-2 months
    • Group B Strep
    • E. Coli
    • Chlamydia trachomatis
  • Infant 2 months to 24 months
    • Streptococcus Pneumonae
    • Group A Streptococci, other streptococci
    • Haemophilus Influenza
    • Staphyloccocus
  • Toddler/School Age
    • Streptococcus Pneumonae
    • Staphylococcus
    • Mycoplasma
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13
Q

When to suspect PNA

A
  • History- fever, cough difficulty feeding, fussiness, chest pain
  • Physical Exam- TACHYPNEA, fever, rales, wheezes, decreased breath sounds
  • Labs
    • CBC, blood culture- Leukocytosis, Pathogen capure only 10-12 percent (hospitalized patient)
    • CXR- “gold standard”
    • Rapid Antigen Testing- available for RSV, Influenza, sometimes adenovirus, parainfluenza
    • Titers- Mycoplasma, HSV
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14
Q

tachypnea in PNA: definition

A
  • Younger than 2 months: > 60 breaths/min
  • Two to 12 months: > 50 breaths/min
  • One to 5 years: > 40 breaths/min
  • > 5 years: > 20 breaths/min
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15
Q

viral PNA tx

A
  • Supportive Care
    • Hydration
    • Oxygen
    • Positioning/Nutrition
  • Anti-Viral Agents
    • Influenza- Tamiflu
    • HSV- Acyclovir for systemic disease
    • Varicella- VZIG prophylaxis for immunocompromised exposure
  • Antibiotics
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16
Q

Bacterial PNA tx

A
  • Treatment- empiric tx
    • Neonate- GNR=> Cephalosporin
      • Staph=>Vancomycin
    • Infant- Strep Pneumo=>Ampicillin
    • Children- Strep Pneumo=>Ampicillin
      • Mycoplasma=>Azithromycin
      • Staph=> Clindamycin
      • Staph (bad infection) => Vancomycin
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17
Q

complications of PNA

A
  • Pleural effusion
  • Empyema
  • Treatment
    • Sometimes still just antibiotics
    • Can require surgical drainage and chest tubes
  • Most often Strep pneumo and Staph aureus
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18
Q

phase of stridor

A
  • Inspiratory
    • Above the thoracic inlet
  • Expiratory
    • Below the thoracic inlet
  • Biphasic
    • Fixed lesions
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19
Q

stridor ddx

A
  • laryngeal papillomatosis
  • laryngeal trauma
  • larygomalacia
  • viral croup
  • epiglottitis
  • bacterial tracheitis
  • anaphylaxis
  • vocal cord paralysis
  • vocal cord dysfunction
  • foreign body
  • subglottic stenosis
  • retropharyngeal abscess
  • congenital anomalies
    • Pierre-Robin sequence
    • neuromuscular disease
    • Hemangioma
    • Vascular rings/slings
    • Tracheal stenosis
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20
Q

croup

A
  • respiratory illness (inflammation of larynx and surrounding airways) that manifests in young children with
    • hoarse voice
    • dry, barking cough
    • inspiratory stridor
  • most commonly viral
    • fever and cough
  • steeple sign
21
Q

viral croup

A
  • typically 6 years of age and younger
  • occurs any time of year
    • most commonly late fall and winter
  • symptoms typically worse at night
  • 2nd and 3rd nights usually the worst
  • most commonly parainfluenza viruses
  • also
    • influenza A and B
    • adenovirus
    • respiratory syncytial virus (RSV)
  • diagnosis based on clinical findings
  • screen all patients with stridor for immunization history, recent choking or foreign body aspiration, food allergies
  • plain films only useful if atypical presentation
  • pulse oximetry usually normal in viral croup unless a severe case
    • if main airway is compromised to the point of hypoxemia, inpatient monitoring is warranted
  • visualization of epiglottis not usually indicated unless concern for epiglottitis (drooling, toxic-appearing)
22
Q

treatment of viral croup

A
  • cool mist
    • home shower “steam”
    • car ride with windows down
    • cool water humidifiers
  • systemic corticosteroids
    • onset of action is several hours after dose
    • no demonstrable benefit for more than two daily doses of dexamethasone
  • nebulized racemic epinephrine
    • benefit is transient
  • for severe cases
    • endotracheal intubation (avoided if possible)
    • helium-oxygen mixture
23
Q

cystic fibrosis

A
  • defect in the cystic fibrosis transmembrane conductance regulator resulting in a deficiency in chloride ion transport, causing abnormal fluid secretion
  • secretions, including mucus, are thick and tenacious
  • multi-organ involvement including chronic pulmonary disease and exocrine pancreatic insufficiency
  • autosomal recessive
  • most prevalent in northern Europeans
    • Caucasians 1 in 2,500
    • African-Americans 1 in 17,000
    • Asians 1 in 90,000
24
Q

diagnosis of cystic fibrosis

A
  • newborn genetic screening
  • family history
  • sweat chloride
    • functional test
    • most sensitive
  • DNA testing
    • less sensitive
    • can only screen for known mutations
25
Q

clinical presentation of cystic fibrosis

A
  • meconium ileus & chronic constipation
  • prolonged jaundice (biliary obstruction)
  • failure to thrive
  • signs of malabsorption
    • Pancreatic insufficiency
    • bulky, foul smelling stools
    • greasy or oily stools
  • recurrent lung disease
  • Tastes “salty”
  • Smell of pseudomonas aeruginosa (common pathogen)
26
Q

management of cystic fibrosis

A
  • chronic recurrent and indolent pneumonias
  • recurrent infections contribute to airway and lung parenchymal changes
    • bronchiectasis
    • asthma
27
Q

diagnosis of cystic fibrosis

A
  • Newborn Screen
  • Sweat Chloride testing
  • DNA mutation testing
    • Tests for most common mutations in CFTR gene
28
Q

treatment of cystic fibrosis

A
  • systemic and inhaled antibiotic therapy
  • airway clearance measures, assist patient with decreasing chronic inflammation clearance and prevent chronic infection
    • Albuterol
    • Chest physiotherapy
    • Cough Assist
  • Nutrition
    • pancreatic enzyme replacement
29
Q

obstructive sleep apnea

A
  • spectrum of disorders where obstruction of airflow results in increased respiratory effort and frequent sleep arousal, increased respiratory effort, hypoventilation, and (sometimes) hypoxemia
  • may progress on to
    • pulmonary hypertension
    • cor pulmonale (right heart changes and ultimately failure)
  • sleeping difficulties
    • frequent sleep arousals
    • increased sleeptime respiratory effort
    • daytime hypersonmonlence impairing school performance
      • less common in children than in adults
    • snoring
      • common in pediatric population
      • ~15% of children have habitual snoring on history
  • peak incidence age 4-8 years
  • History
    • Screen for OSA by asking
    • “Does your child snore”
  • exam
    • “allergic shiners”
    • allergic rhinitis
    • tonsillar and adenoidal hypertrophy
    • hyponasal speech
30
Q

diagnosis of obstructive sleep apnea

A
  • Polysomnography (gold standard)
    • monitors oxygenation and ventilation during sleep
    • gas challenges to determine source of apnea
      • central vs. obstructive
  • also
    • lateral neck film to evaluate airway
    • EKG to screen for right ventricular hypertrophy
31
Q

medical managment for temporary relief if sleep study is unremarkable

A
  • medical management for temporary relief if sleep study is unremarkable
    • treat allergic rhinitis
    • treat tonsillitis
  • surgical management
    • tonsillectomy and adenoidectomy
    • palatouvuloplasty (less common)
32
Q

differential diagnosis for wheezing

A
  • bronchiolitis
  • pneumonia
  • aspiration
  • laryngotracheomalacia
  • vascular rings
  • airway stenosis or Web
  • paratracheal adenopathy
  • mediastinal mass
  • airway foreign body
  • BPD/BOOP
  • cystic fibrosis
  • vocal cord paralysis
  • vocal cord dysfunction
  • cardiovascular disease (CHF)
  • asthma
33
Q

bronchiolitis cause

A
  • most common cause of acute hospital admissions for infants less than 2 years of age during the winter months
  • most common cause
    • RSV (respiratory syncytial virus)
    • infects about ~1/3 of all children every year
    • immunity is not long-lasting
  • other causes
    • influenza, parainfluenza, adenovirus, metapneumovirus
  • pathogenesis
    • infection and inflammation of the lower airways
    • obstruction results from edema, mucus plugging
34
Q

presentation of bronchiolitis

A
  • begins much like a typical upper respiratory infection
    • fever
    • rhinorrhea
    • cough
  • Often progressing to lower airway disease
    • lower airway secretions => wheezing, rales, coarse breath sounds, worsening cough
    • tachypnea
35
Q

diagnosis of bronchiolitis

A
  • RSV and influenza enzyme immunoassay
    • may be useful for cohorting if performed rapidly
  • CXR - hyperinflation, atelectasis, multifocal (and often shifting) infiltrates
  • CBC - commonly normal, may show mild lymphocytosis consistent with viral illness
36
Q

prevention of bronchiolitis

A
  • Prevention (RSV infects at high rate)
    • hand-washing
    • RSV intravenous immune globulin
      • palivizumab
      • given to high-risk groups during RSV season each year
37
Q

treating bronchiolitis

A
  • no curative therapy
  • supportive care
    • oxygen
    • hydration IV fluids/frequent feedings
    • pulmonary toilet (nasal suction, airway clearance, positioning)
  • Monitoring
    • Assess risk factors (prematurity, chronic lung disease, other underlying pulmonary disease)
    • Apnea risk
38
Q

foreign body presentation

A
  • Obstruction => emergency airway management
  • Upper Airway => stridor, drooling
  • Lower Airway => wheezing
  • Late Presentation => infection, chronic changes, abscess
39
Q

foreign body diagnosis

A
  • History, Physical Exam, CXR to screen
  • Gold Standard to rule in or rule out
    • Bronchoscopy
40
Q

atopic disease

A
  • Asthma
  • Atopic dermatitis (eczema)
  • Allergic rhinitis (hay fever)
41
Q

asthma

A
  • asthma is the most common chronic disease of childhood
  • despite technologic advances, morbidity has increased
  • asthma management has significantly changed over the past decade
  • health disparities issues abound in asthma
    • African-Americans have a disproportionate amount of disease burden for asthma
    • Certain zip codes are disproportionately affected
  • airway hyperresponsiveness to triggers
  • disease of excess inflammation, all processes narrow lumen of airway
    • inflammatory cell infiltration
    • mucus plugging
    • shedding of airway epithelium
    • mast cell activation
    • bronchoconstriction
  • widespread small airway constriction and obstruction impairs air movement, particularly during exhalation
  • air trapping evident on exam and chest plain films
  • tidal volume reduced as patient must inspire again before exhaling sufficient volume
42
Q

asthma symptoms and signs

A
  • baseline symptoms may be very subtle and clinically hard to diagnose
  • mild asthma exacerbation
    • cough
    • wheeze
    • exercise intolerance
    • chest congestion
  • moderate asthma exacerbation
    • dyspnea
    • chest tightness
    • labored breathing
  • severe asthma exacerbation
    • mental status changes
    • may become paradoxically unlabored when entering respiratory failure
    • cyanosis
    • pulsus paradoxus
43
Q

treatment of asthma

A
  • treatment of acute exacerbation
    • systemic corticosteroids
      • mainstay of therapy
      • impairs new inflammation
      • inflammation present in airways needs time to “burn out”
    • β2-agonist (albuterol) – briefly impairs small airway smooth muscle bronchoconstriction
    • ipratropium – inhaled atropine analog (anticholinergic) for large airway dilation
  • supportive care (oxygen, hydration)
44
Q

asthma diagnosis

A
  • no specific laboratory findings
  • hypoxia with significant airway compromise
    • or with significant atelectasis
  • chest plain films
    • lung hyperinflation
    • atelectasis related to airway plugging
    • peribronchial thickening/cuffing
  • pulmonary function testing
    • reveal small airway disease
    • methacholine challenge
    • FEV1 reduced, FEV25-75 reduced
    • improvement with administration of β-agonist
45
Q

treatment of severe cases of asthma

A
  • parenteral β2-agonist (terbutaline)
  • parenteral epinephrine
  • parenteral magnesium
  • parenteral theophylline
  • mechanical ventilation generally avoided, but if necessary:
    • ketamine plus halothane anesthesia with helium-oxygen mixture
46
Q

chronic asthma treatment

A
  • education
  • medications
    • inhaled corticosteroids
    • long-acting β2-agonist – associated with increased risk of death
    • leukotriene modifiers
    • mast cell stabilizers (cromolyn)
  • environment modification
    • Hepa filters
    • smoking
    • dust mite control
    • pets
  • reduction of exacerbating factors
    • identify triggers and find ways to avoid them
    • treatment of reflux, sinusitis, allergic rhinitis
    • stress reduction
    • influenza vaccine
47
Q

larger treatment goals of asthma

A
  • anti-inflammatory agents
  • individualized management plans
  • reduction of risks must be ongoing
  • early diagnosis and vigilant monitoring with utilization of latest treatment modalities
48
Q

albuterol administration

A
  • Nebulization
  • Mask/spacer

Pediatrics Module 2 (7 decks)

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