Lower Airway Flashcards
Wheezing
Occurs when air enters narrowed or constricted areas of the lungs
Intermittent Asthma
Asthma is considered intermittent if without treatment ANY of the following are true:
- Symptoms (difficulty breathing, wheezing, chest tightness, and coughing):
- —Occur on fewer than 2 days/ week
- —Do not interfere with normal activities
- —Nighttime symptoms occur on fewer than 2 days/month
Mild Persistent Asthma
Asthma is considered Mild Persistent if w/o treatment ANY of the following are true:
- -Symptoms occur on more than 2 days/week, but do not occur everyday
- -Attacks interfere with daily activities
- -Nighttime symptoms occur 3-4 times/month
- -Lung function tests are normal when the person is not having an asthma attack. The results of these tests are 80% or more of the expected value and may vary a small amount (PEF varies 20%-30%) from morning to afternoon
Moderate persistent asthma
Asthma is considered Moderate Persistent if w/o treatment ANY of the following are true:
- -Symptoms occur daily. Inhaled short-acting asthma medication is used everyday.
- -Symptoms interfere with daily activities
- -Nighttime symptoms occur more than 1 x/week, but do not happen everyday.
- -Lung function tests are abnormal (more than 60% to less than 80% of the expected value), and PEF varies more than 30% from morning to afternoon
Severe persistent asthma
Asthma is considered severe persistent if without treatment ANY of the following are true:
- -Symptoms occur throughout each day.
- -Symptoms severely limit daily physical activities.
- -Night time symptoms occur often, sometimes every night
- -Lung function tests are abnormal (60% or less of expected value), and PEF varies more than 30% from morning to afternoon
Acute Asthma Mild Symptoms
- Increased RR
- Accessory muscles of respiration are NOT used
- HR 95%
Acute Asthma Moderate Symptoms
- Increased RR
- Accessory muscles are typically used
- Suprasternal retractions are present
- Loud expiratory wheezing heard
- Pulsus paradoxus may be present (10-20mmHg)
- O2 sat on room air is 91-95%
Acute Asthma Severe Symptoms
- RR >30
- Accessory muscles are usually used
- Suprasternal retractions are commonly present
- HR > 120
- Loud biphasic (expiratory and inspiratory) wheezing can be heard
- Pulsus paradoxus is often present (20-40 mmHg)
- O2 sat on room air is less than 91%
Pulsus Paradoxus
On inspiration, a drop in systemic arterial pressure greater than 10mmHg.
Asthma Action Plan
- Required by Joint commission for hospital discharge and continuing care
- Environmental controls
- Algorithm for use of long term and rescue meds
- Medication regimens and rescue meds
- Steps to take when treatment is not effective/emergent care
Stepwise approach in treating status asthmaticus
- Supplemental O2- FIRST PRIORITY
- Stacked inhaled bronchodilators (albuterol, levalbuterol)
- Continuous inhaled bronchodilators
- Prednisone or methylprednisolone
- Anticholinergics (ipratropium bromide) - promotes bronchodilation, used in ED to prevent admission
- MgSO4 as bolus
- Terbutaline (controversial) (IV Beta agonist)
- Methylxantines (aminophylline, theophylline)
- Helium-oxygen gas (Heliox) (Controversial)
- Noninvasive ventilation as BiPAP or CPAP for hypoxia
- Intubation and ventilation as a last resort
- Inhaled anesthesia or extracorporeal membrane oxygenation (ECMO) for severe refractory cases
Pneumonia- Definition/Etiology
Infection and inflammation of the lower respiratory tract in association with detectable radiographic changes of the lung parenchyma, interstitial disease. Bacterial or viral.
Pneumonia- Symptoms/characteristics
Prolonged URI, cough, lethargy, decreased appetite, fever, could be low grade or high depending on organism
Pneumonia- Diagnosis
Presence and longevity of symptoms, chest exam, CXR, CBC, CRP, cold agglutins
Pneumonia- Management
Oxygen, antibiotics, fluids, pulmonary toilet, bronchodilators on occasion
Pneumonia- indications for hospitalization
- Hypoxemia- saturation 70 for infants 50 for older children, retractions, nasal flaring, difficulty breathing, apnea, grunting
- Toxic appearance
- Underlying conditions that may predispose to a more serious course of pneumonia
- Complications (effusion/empyema)
- Suspicion or conformation that CAP is due to a pathogen with increased virulence, such as Staph aureus or Group A Strep
Parapneumonic Effusion - Definition/Etiology
Fluid leak into pleural space. Can be compilation of pneumonia.
2 Stages:
- ) Exudative: pleural fluid is free-flowing
- ) Fibrinopurulent: bacterial invasion, white cells and fibrin results in loculation
A parapneumonic effusion is a type of pleural effusion that arises as a result of a pneumonia, lung abscess, or bronchiectasis.
Parapneumonic Effusion - Symptoms/Characteristics
Persistent cough, hypoxia, lethargy, wheezing, persistent fever
Parapneumonic Effusion - Diagnosis
Lateral xray or ultrasound
CT may be obtained
Parapneumonic Effusion - Management
- VATS should be performed when there is persistence of moderate-large effusions and ongoing respiratory compromise despite 2-3 days of management with a chest tube and completion of fibrinolytic therapy
- Open chest debridement with decortication represents another option for management of these children but is associated with higher morbidity rates
VATS
Video-assisted thoracoscopic surgery (VATS) is a minimally invasive surgical technique used to diagnose and treat problems in your chest
During a video-assisted thoracoscopic surgery procedure, a tiny camera (thoracoscope) and surgical instruments are inserted into your chest through several small incisions.
Decortication
Decortication is a surgical procedure that removes a restrictive layer of fibrous tissue overlying the lung, chest wall, and diaphragm. The aim of decortication is to remove this layer and allow the lung to reexpand. When the peel is removed, compliance in the chest wall returns, the lung is able to expand and deflate, and patient symptoms improve rapidly
Bronchiolitis - Definition/Etiology
Inflammation, edema, bronchospasm. Virus induces airways obstruction (increased airway secretions and mucosal edema and/or bronchospasm), can cause increased WOB resulting in tachypnea and subcostal retractions, gas trapping as manifested by hyperinflation and noisy breathing.
Acute inflammatory disease of the lower respiratory tract
Many different viral agents: RSV, influenza, rhinovirus, adenovirus, parainfluenza, human metapneumovirus, mycoplasma pneumoniae (in school age children)
Peaks in winter months, common fall-spring
Bronchiolitis - Symptoms/Characteristics
Most common: Premature infants age
Pertussis - Definition/Etiology
Acute infectious disease caused by bacterium bordetella pertussis (gram negative organism)
AKA Whooping cough
Pertussis - Symptoms/Characteristics
Staccato, paroxysmal cough associated with apnea, hypoxia and fever
Staccato cough
Pertussis
-A staccato cough is essentially a cough that comes as a series of outbursts with time for at least one breath in between each one.
Pertussis - Diagnosis
- Lymphocytosis- fluorescent stain and culture (GOLD STANDARD)
- ——>Lymphocytosis is an increase in the number or proportion of lymphocytes in the blood.
- PCR or Serologic Assay
Pertussis - Management
Azithromycin, Clarithromycin or Erythromycin. ***Treatment of choice for infants
Tuberculosis - Definition/Etiology
Bacterial illness of lungs with other system involvement
Tuberculosis - Symptoms/Characteristics
Chronic cough, fever, anorexia, weight loss. Risk factors: foreign born or travel, living in an urban area, exposed to lose family member who is incarcerated
Tuberculosis - Diagnosis
Most common in children between 1-4 years of age. Nodular changes on CXR. Positive TB skin test.
Tuberculosis - Management
Treatment based on WHO guidelines or CDC
Pneumothroax
- Air in the pleural space
- Sharp chest pain, dyspnea, tachycardia, cyanosis
- Treatment: Chest tube placement, or 100% O2 or observation (small pneumo may go away on its own)
Always consider ____ in a newborn with pneumonia
Chlamydia Pneumoniae
Pertussis requires _____
Treatment of patient and non-immunized contacts
Persistent cough in infant consider _____
Both RSV and Pertussis as causative factors
Antibiotic failure in pneumonia can mean ____
Pleural or parapneumonic effusion
Bronchiolitis Risk factors for Severe Disease
Prematurity, cardiopulmonary disease, infants
Bronchiolitis - Diagnosis
- History and physical
- CXR - shows hyper expansion, patchy atelectasis and peribronchial thickening
- Rapid viral panel is helpful
- Typical organisms: RSV, adenovirus, metapneumovirus
- Pulse ox
Bronchiolitis - Management
Supportive Care
Oxygen
Bronchiolitis - Prevention
Hand washing
Palivizumab as indicated
Asthma Diagnosis
- H&P
- CXR: Hyperinflation, flattened diaphragms, peribronchial thickening, narrowed cardiac silhouette
- ABG, lactate, and electrolytes may be helpful in moderate/severe cases
Status Asthmaticus. When following ABG’s or other CO2 measurements, anticipate…
HYPOcarbia when compensating well for exacerbation
A normal or rising CO2 is worrisome
***PEARL - Intubating Asthmatics
Ketamine typically used for induction in asthmatics requiring intubation due to its bronchodilator effects ***
Young infants & Pertussis
Young infants do not present with “whooping”, they present with APNEA
Highest mortality rate is infants less than 6 months
Postexposure Antimicrobial Prophylaxis after Pertussis
Provided to all household contacts of a pertussis case
Provided to persons within 21 days of exposure to a patient infected with pertussis who are at high risk of severe illness or have close contact with a person at high risk for severe disease (i.e. infants, women in 3rd trimester of pregnancy, immunocompromised persons)
Mag Sulfate Common adverse reaction
Hypotension
Antibiotics for Pertussis
Erythromycin, clarithromycin and azithromycin
Avoid erythromycin in infants
