Lecture 8: Pulm and Ophthalmology Flashcards
What is the leading cause of infant hospitalization?
Bronchiolitis
Overview of Bronchiolitis
- Clinical syndrome of resp distress < 2 yo
- Lower respiratory tract infection
- Causes URI symptoms, followed by acute onset of wheezing, crackles, hyperinflation, and tachypnea.
MCC of bronchiolitis
RSV (50-95% of cases)
What age do most cases of bronchiolitis occur during?
1st year of life, esp 1-10mo old.
80% of cases are 1st year.
RFs for HIGH RISK bronchiolitis
- PREEMIE
- Age < 12 wks
- Cardiopulm disorders
Guidelines for high risk are different than regular!
If an infant has had multiple instances of wheezing, how do we approach in terms of bronchiolitis tx?
Do not follow bronchiolitis guidelines for a recurrent wheezer.
Bronchiolitis is primarily referring to the initial episode.
Dx of bronchiolitis
- Clinical
- O2 sat
- NP swab
- No imaging necessary
NP swab is really only for pts getting admitted.
Tx of nonsevere bronchiolitis
- Supportive care
- Hydration
- Relieving nasal congestion
- Monitor for worsening
It is viral.
Indications for hospitalizing bronchiolitis
- Increasing respiratory effort
- Hypoxemia < 92% (disclaimer: might drop when sleeping, thats ok)
- Apnea
- Acute resp failre
- Toxic looking
- Poor feeding
- Lethargy
- Dehydration
- Parents can’t care for child at home (social concerns)
Assess them WITHOUT a fever! Fever will change presentation.
Inpatient management of bronchiolitis
- Hydration
- Nasal suctioning
- Supplemental O2 between 90-92%
- CPAP if risk of resp failure
- ETT last resort
If they are febrile, control fever and reassess after its controlled.
When is an antiviral used in bronchiolitis and which one?
Ribavirin can be used for significant immunocompromised pts only
Discharge criteria for bronchiolitis
- RR < 60 for < 6mo old
- Stable on RA
- Caretaker knows how to bulb suction
- Adequate PO intake
- Caretakers can take care at home
- Resources at home are sufficient
What is to be AVOIDED in bronchiolitis?
- Inhaled BDs
- Systemic glucocorticoids
- Inhaled saline
Pt education pearls for bronchiolitis
- Improvement within a few days
- Discharge takes 3-7 days
- Cough/congestion takes 1-2 weeks to resolve.
Prevention of bronchiolitis
- Palivizumab (Beginning of RSV and monthly throughout RSV season)
- Nirsevimab (single shot and cheaper!)
Do not need to memorize recommendations!!
Can you coadminister the MABs for bronchiolitis with other childhood vaccines?
Yes
Overview of CF
- Autosomal recessive inheritance
- MC Lethal genetic disease
- Develops bronchiectasis and thick mucus over time.
- MC in caucasians
Where is the mutation for CF?
Chromosome 7, defect in CF gene that regulates CFTR channels
Essentially an inability to clear mucus properly.
CF transmembrane conductance regular protein
How do we dx CF?
- Newborn screening
- Meconium ileus
- Respiratory symptoms
- Failure to thrive
Delay in passing meconium
What part of the newborn screen checks for CF?
Heelstick
What sign is virtually diagnostic of CF until a confirmatory test is performed?
Meconium Ileus = CF until we do a sweat test or genotyping/
What is the primary underlying cause for failure to thrive in a CF pt?
Pancreatic failure of the acini cells (digestive), overall leading to malabsorption
Pancreatic insufficiency + malabsorption + recurrent pancreatitis
Gold standard test to Dx CF
Sweat chloride test, showing > 60 mmol/L for a positive test, and 40-60 as borderline/retest!
Normal is < 30 mmol/L
When is genotyping done for CF?
- After sweat chloride is positive
- Checking carrier status or borderline sweat chlorides
How do we check for pancreatic insufficiency in CF patients?
Fecal elastase, which is absent in most CF pts.
Tx of CF pts
- Peds
- Peds pulm
- RT
- Diet/Nutriton
- Social Work
What can help with improving mucociliary clearance in CF?
- Pulmozyme (mucolytic)
- Hypertonic saline
- Inhaled BDs
- Chest physiotherapy
- Antipseudomals
- CFTR modulators
- Vaccinations
Tx of GI issues in CF
- High calorie diet: proteins and fat
- Daily vitamins
- Calorie supplements
- Consider G-tube if FTT.
S/S of acute CF exacerbations
- New/increased cough
- New/increased sputum production or chest congestion
- Deceased exercise tolerance or DOE
- Increased fatigue
- Decreased appetite
- Dyspnea at rest/increased RR
- Change in sputum appearance
- Increased nasal congestion
Tx of acute CF exacerbations
Cover pseudomonas with 2 drugs, and another one.
Common: Tobramycin + Ceftazidime + Vanco (MRSA)
5-year survival rate of lung transplant for CF
50-60%
What kind of infant does IRDS (Infant respiratory distress syndrome/hyaline membrane disease) MC occur in?
Preterm infants
Can affect term if mother has DM
Deficiency in ____ is the primary cause of IRDS?
Pulmonary surfactant in an immature lung
Clinical features of IRDS
Dx of IRDS
- Clinical
- CXR: low lung volume + Diffuse ground-glass appearance
- Pulse ox
- ABG
Tx of IRDS
- Supportive care
- Nasal CPAP (ideal initial intervention)
- Surfactant replacement
How do we help prevent IRDS?
Dexamethasone to mother at least 7d prior to delivery
Will help develop lungs quicker
What are thyroglossal duct cysts?
- Remnants of epithelium
- MC congenital neck mass
- Midline mass at level of thyrohyoid bone
Clinical presentation of TDC
- Upper midline neck mass with cystic features
- Preceding URI can make it bigger
- Potentially can be infection
Dx of TDC
- CT of neck w/ con
- FNA to r/o other
- MRI
- US
Tx of TDC
- Sistrunk procedure (resection)
- Can only tx after infection/inflammation is controlled.
- ABX for infection/inflammatio (Augmentin, Clinda, Keflex)
How is vision for a newborn?
- Start at 20/200 - 20/400
- 20/60 by the age of 3
- 20/20 by age of 5 ideally
- Infant should be able to track by 3mo
Amblyopia
Functional reduction in VA either unilateral or bilateral d/t misuse/disuse during visual development
MCC of visual impairment in children
Why does VA loss occur in amblyopia?
Improper/lack of stimulation between brain and eye => brain learns to see poorly.
RFs for amblyopia
- Prematurity
- 1st degree relative
- SGA
- Neurodevelopmental delays
Classifications of amblyopia
- Strabismus: misalignment of visual axes
- Refractive: 1 or more eyes having a refractive error
- Deprivational: Obstruction by cataract or complete ptosis affecting retinal development
Describe strabismic amblyopia
- One eye moves weirdly
- Brain will turn off the bad eye, lowering vision in it.
- Long-term suppression of the affected eye results in strabismic amblyopia
MCC of refractive amblyopia
Asymmetric refractive glasses
Esp in people who are farsighted.
What is the rarest form of amblyopia?
Deprivational amblyopia
What causes deprivational amblyopia?
Obstruction essentially distorting an eye’s fovea/visual axis
When is refractive amblyopia most commonly caught?
4-5, when we start screening VA with letters.
How do you check for amblyopia in a non-verbal child?
- Fixation reflex (checking tracking of each eye separately)
- Amblyopia shows as inability to maintain tracking with amblyopic eye when both are uncovered
- Differential occlusion objection test: child will cry when better eye is covered.
How do you check for amblyopia in a verbal child? (3yo+ usually)
- Allen or snellen chart
Start at 20/40 and move up if they miss 2+
When you should refer for amblyopia?
- VA worse than 20/40 in 3-5 or 20/30 in 6y+
- VA difference of more than two lines (i.e. 20/20 20/40)
- Strabismus
- Abnormal red reflex
- Asymmetry of vision
- Unilateral ptosis
Tx of amblyopia
- Start ideally prior to 7, up to age 10
- Elimination of obstructions
- Correction of refractive errors
- Encourage use of amblyopic eye
What are the 4 descriptions for strabismus?
- Nasal: Eso
- Temporal: Exo
- Upward: Hyper
- Downward: Hypo
What can mimic strabismus in children?
Prior to 3mo, children tend to naturally have unstable ocular alignment.
Intermittent strabismus = NORMAL prior to 3mo of age.
What is pseudostrabismus?
- Apparent esotropia in children (asian) with wide nasal bridges or large epicanthal folds
- Optical illusion, not real.
What is a red flag in addition to strabismus?
Abnormal head postures
What is the primary screening technique for strabismus?
Corneal reflex test (hirschberg)
What is the cover test?
Strabismus testing
- If they have it, the uncovered eye will refixate when you cover their other eye
- AKA, if the good eye is covered, the bad eye will refixate and move to the center.
- If the bad eye is covered, the good eye just remains normal.
Watch the vid if this is unclear
What is the cover/uncover test?
- Affected eye covered will be deviated when it is rapidly uncovered, before it refixates.
- Indicated when the strabismus is not clear, but you suspect it
Without something to fixate on, it will naturally deviate.
Looks for latent strabismus
What is the bruckner red reflex test?
Strabismus
- Simultaneous red reflex test
- Misaligned reflexes via fundoscope on largest diameter light.
Indications to refer for strabismus
- Constant
- Intermittent after 6mo
- Positive test of any of the 3 (corneal, cover, cover/uncover)
- Positive bruckner
- Deviations changing with gaze
- Torticollis not explained by muscle spasm
- Eye fatigue
- Prematurity/genetic disorder
- Parental concern
Tx of strabismus
- Corrective lenses
- Patching
- Surgery: recession to adjust EOMs (decreasing effect on globe)
- Surgery: resection to shorten EOMs (increasing effect on globe)
