Module 12 The Respiratory System Flashcards
What do you need to have an understanding of in this Respiratory system module?
The Childs respiratory System?
- Assessment
- Bronchitis
Bronchitis is an infection of the main airways of the lungs (bronchi), causing them to become irritated and inflamed. The main symptom is a cough, which may bring up yellow-grey mucus (phlegm). Bronchitis may also cause a sore throat and wheezing. - Bronchiolitis
It happens when tiny airways called bronchioles (BRONG-kee-olz) get infected with a virus. They swell and fill with mucus, which can make breathing hard.
Bronchiolitis is more common during the fall and winter months. Most cases can be managed at home.
- Asthma
- Reactive Airways Disease
- Foreign Bodies
- Cystic fibrosis
- Pneumonia
What are causes of Stridor?
https://www.youtube.com/watch?v=JSdEK79J4dw
- Stridor is a sign of upper airway obstruction. It is a harsh, high-pitched sound, usually inspiratory (but can be expiratory also).
- It is produced by turbulent air flow through the upper airways.
- There are a number of causes of stridor:
- Inflammation involving the vocal cords and structures inferior to the cords – laryngitis, laryngotracheitis, and laryngotracheobronchitis
- Inflammation of structures superior to the cords – supraglottitis
What are things we are looking for on Inspection for th respiratory system?
- General appearance
- respiratory rate (RR)
- depth & rhythm of respiration
- dyspnoea Dyspnea, which some refer to as shortness of breath, is a feeling that you cannot breathe enough air into your lungs.
- chest & abdominal movements
- chest shape
- lesions
- spine & scapulae
- clubbing
- cyanosis
- cough
- sputum
General appearance – look for
1. Toxic appearance
2. Tripod position for breathing
3. Alertness (decreased)
4. Distress, irritability
5. Head position to assist breathing
Respiration rate
a. Normal at rest (per minute) –
a. 1 year – 30
b. 2- 5 year - 20-25
c. 10 year – 20
b. Increased respiratory rate is associated with upper and lower airway obstruction
1. Oxygen needed above 50 breaths/minute
2. 40-50 breaths/minute raises suspicion of respiratory
distress
Depth and rhythm of breathing
1. Tachypnea–rapid,shallowbreathing
2 types of abnormal chest shape
Pectus excavatum
Pigeon breast or pacts carinatum
Respiration rate for a full term new born?
1 year?
2-5 years?
10 year
Full term new born
Average 45 awake 35 asleep
Best to measure when asleep as may rise to 70-80 with little excitation
1 year = 30
2-5 years = 20-25
10 years = 20
- Periodic breathing with brief respiratory pauses of up to 10 seconds without cyanosis is common during sleep in normal infants especially premature infants and in the early weeks of life
- Apnoea monitors are generally set to respond if 20 seconds elapses between breaths
- Breathing during infancy is typically abdominal, a thoracic component in young infants suggests pulmonary disease
- The thoracic type of respiration becomes predominant at 7-8 years
What is Apnoea?
What are the 3 types?
Cesstation of breathing for 20 seconds or more, or for a brief periods if accompanied by bradycardia, cyanosis, pr pallor
3 types
1. Obstructive apnoea eg pharyngeal collapse, or incoordination of tongue
- Centra-l airflow and chest wall motion absent
- Mixed- Has characteristics of both central and obstructive apnoea
- mixed
What is Dysponea?
(Shortness of breath)
What are the 5 signs of Dysponea? Exam question
Respiratory effort has to increase as they have shortness of breath:
- Use of accessory muscles - neck
- Suprasternal retractions
- Intercostal retractions
- Infrasternal retractions
- nasal flaring.
(slight retractions may be normal)
Where is cyanosis best observed?
What is the normal 02 saturation?
Cyanosis is best observed over the 1. nail beds
2. lips
3. tongue
4. mucous membranes
Normal O2 saturation is 96-97%,
90% saturation will be detectable by the trained eye,
85% will be obvious to anyone - the tongue must be examined for central cyanosis
What is this and what does it indicate?
Clubbing of fingers - Associated with chronic cyanosis
Cough
What are some causes of a recurrent cough?
What are causes of a Persistent cough?
Recurrent Cough:
-Bronchial reactivity, including allergic asthma
-drainage from upper airways
-aspiration syndromes
-Frequently recurring RTI in immunosuppressed or immunodeficient patients
-Idiopathic pulmonary hemosiderosis
Idiopathic pulmonary hemosiderosis (IPH) is a rare disease, found primarily in children, that is characterized by recurrent episodes of diffuse alveolar hemorrhage (DAH).
PERISTENT COUGH:
reactive airways disease (asthma)
Chronic sinusitis
Pertussis syndrome (whooping cough)
Habit cough
GERD
Hypersensitivity of cough receptors after an infection
How do Chiros treat a cough
The most common cause of persistent and recurrent cough in children is chronic viral infection
Look for signs of chronic/ recurrent URTI, enlarged liver and possible enlarged spleen as well as enlarged tonsils and adenoids (snoring)
Treat for Th1 deficiency and or Th2 excess
Wheezing
Whats it indicative off?
Most recurrent or persistent wheezing n children is the result of reactive airway disease.
The most common cause of wheezing in infants is caused by inflammation, usually due to a viral infection.
Other causes may be nonspecific environmental factors such as cigarette smoke may be important contributors.
Frequently recurring or persistent wheezing starting at or soon after birth suggests a variety of other diagnoses, including congenital structural abnormalities involving the LRT
Wheezing that attends cystic fibrosis is most common in the 1st year of life.
Sudden onset of sever wheezing in a previously healthy child should suggest foreign body aspiration.
List the Risk factors of the ‘wheezing’ child
- Fetal nutrition
- Maternal smoking
- Prenatal and birth complications
- Prenatal environmental allergens
- High infant adiposity
- Fetal and infant immune system priming
- Respiratory viruses in early infancy
- Exposure to airborne molds
- Food allergy
- Dustmite, pet allergens
Wheeze
How would I as a Chiro manage it?
- The most common cause of persistent and recurrent wheeze in children is chronic viral infection.
- Look for signs of chronic/recurrent URTI, enlarged liver and possible enlarged spleen as well as enlarged tonsils and adenoids (snoring).
- Treat for Th1 deficiency and or Th2 excess.
- Examination
1.Assess if localised or generalised by auscultating all 5 lobes
Viral infections are associated with generalised wheeze
2. Assess if inspiratory or expiratory (most common) or both
Palpation for the respiratory system
- tracheal position
- apex beat
- chest wall movement
- masses & lymph nodes
- areas of tenderness
- subcutaneous emphysema
Subcutaneous emphysema occurs when air gets into tissues under the skin. This most often occurs in the skin covering the chest or neck, but can also occur in other parts of the body. - tactile & vocal fremitis
- friction rubs & thuds
What is going on here?
What are some reasons this may occur?
We always need to check tracheal position - it should be midline
If it is not then the cause must be found - a cervical chest X-ray may be needed.
Tracheal deviation may occur with:
1. Foreign body aspiration
2. Lunge collapse, pneumothorax
3. Cardiomegaly and congenital heart disease
4. Mediastinal mass
5. Neck mass
Elevated left hemidiaphragm with volume loss in the left lung and tracheal deviation to the right (this image)
When we auscultation lung sounds what are we looking for
- Rate
- Rhythm
- Sounds
Rhythm:
Normal: Usually inspiration longer than expiration
Abnormal: Expiration prolonged eg asthma, bronchial sounds
2. Short gap between inspiration & expiration eg bronchial
Crackles:
-coarse eg bronchitis
-finer pneumonia
-may decrease with coughing eg bronchitis
Wheezes: asthma, local (obstruction) usually in expiration.
Stridor: M.c inspiratory
Decreased breath sounds= collapsed lunch, or consolidation ie pneumonia.
What are the different sounds and what do they mean?
https://www.youtube.com/watch?v=DJ0cyDgaRQc
https://www.youtube.com/watch?v=tQSjoybsO4M
- Tracheal breath sounds are normally heard over the trachea and larynx
They are louder with a higher pitch
Expiratory phase is louder and longer - Rhonchi are musical, continuous, wheezes and vibrations
- Rales are crackling or bubbling, discontinuous sounds
- Pleural friction rub causes a grating jerky leathery creaking rubbing sound that seems close to your ear
Crackles:
local or general
coarse eg. bronchitis
finer eg. pneumonia
may decrease with coughing eg. bronchitis During inspiration (usually) or expiration
WHEEZES:
widespread eg. asthma, bronchiolitis local eg. obstruction
usually in expiration
STRIDOR
Most commonly inspiratory, or biphasic
Indicate upper respiratory tract obstruction
Often widespread, but heard closer to the sternum and clavicles
Can listen on anterior neck and cheeks – upper respiratory sounds will be louder than lower respiratory sounds
DECREASED BREATH SOUNDS
Collapse, consolidation – lobar pneumonia
* Decreased vesicular breathing may occur early in
1. Pneumonia (consolidation)
2. Hydrothorax
3. Pneumothorax
Chest pain that may spread to the shoulder and back Shortness of breath
Fast, shallow, breathing
4. Lobar emphysema
5. Bronchitis
6. Muscle paralysis
What are some causes of wheeze?
Bronchoconstriction may be induced by three
principal pathways:
1. A direct effect on airway smooth muscle
2. A neural reflex bronchospasm via vagal pathways
3. Release of chemical mediators by degranulation of mast cells.
- Reactive airway disease
- Aspiration
- Cystic Fibrosis
- Cardiac failure
- Bronchiolitis Obliterans
- Extrinsic Compression of airways
- Gastroesophageal reflux
- Pulmonary hemosiderosis
- Hysterical airway closure
- Environmental insults
Bronchiolitis
https://www.youtube.com/watch?v=FWCItp5jceg
- The most common lower respiratory tract infection in children
- Viral illness of the lower airways with up to 80% of cases involving Respiratory Syncytial Virus (RSV) infection.
- May be a mild infection or may need hospital admission
- Infants are at greater risk of respiratory distress due to marrow airways
RSV= Respiratory syncytial virus, or RSV, is a virus that causes respiratory infections. Infections usually peak in late autumn or winter in NSW. RSV can occur in children and adults. It can cause a cold with runny nose, sneezing, sore throat, fever and headache and also cough, wheezing and difficulty breathing.
What is the diagnosis?
The clinical presentation is usually an infant with sudden onset of:
- fever,
- cough,
- sneeze,
- nasal discharge,
- dyspnea,
- irritability and wheeze,
- with a prodrome of URTI.
Incubation period of 3-5days
Tachypneagreaterthan60pmisasignofhypoxia/hypercapnia.
Medically - A family history of asthma, repeated episodes, no prodrome of infection, and eosinophilia all suggest a diagnosis of asthma
- Starts with upper respiratory symptoms – o Rhinorrhea(clear)
o Unproductivecough o Fever (in some cases) o Drooling
o Decreasedappetite - Once it spreads to the lower respiratory tract, bronchiolitis develops – o Toxicappearance
o Dyspnea
o Irritability
o Use of accessory muscles for breathing – subcostal, supraclavicular, and intercostal retractions o Tachypnea – which can interfere with feeding, leading to dehydration
o Wheezes
o Apnea (in infants younger than 2-6 months of age)
o Usually there is no diarrhea or vomiting - Approximately 25% of all infants with RSV infection develop lower respiratory tract symptoms, but it is only the most severe 10% of these who are hospitalized
Bronchiolitis
physical exam of bronchiolitis
- Most dominant feature – wheezing
- Pulse oximetry and determination of carbon
dioxide level is essential
o Hypoxaemia is oxygen saturation below 92% - Nasal flaring and retractions may be present with
breathing - Auscultation – fine crackles, or overt wheezes
o Prolongation of expiratory phase - Respiratory rate above 60-70 breaths/minute
- Barely audible breath sounds suggests near- complete obstruction
- Liver and spleen may be palpable with lung hyperinflation
Immune response to RSV from Bronchialitis
Bronchiolitis usually begins in the upper respiratory tract by virus attacking nasal epithelial cells.
- The ratio of Th-1 versus Th-2 cell types may be related to the severity of the disease.
- Clinically, infants with mild bronchiolitis tend to have increased Th-1-produced cytokines and reduced Th-2- produced cytokines, whereas infants with severe bronchiolitis are characterized by a higher percentage of Th-2 cells, or even a Th-2-predominant response.
- Besides severity of the RSV infection, the T cell response may play a role in the development of chronic wheezing.
- Viral levels fall before symptoms peak, suggesting that inflammation control is the best treatment for this condition
What is the management of Bronchiolitis
Antibiotics have no therapeutic value unless there is secondary bacterial pneumonia.
The low incidence of bacterial complications is not reduced further by antibiotic therapy.
Corticosteroids are not beneficial and may be harmful under certain conditions.
- Use Acute Illness Observation Scale to monitor need for referral to hospital
Hospital management is to maintain O2 saturation and assist breathing until child can return home.
Antibiotics are not needed
Infants with respiratory distress should be hospitalized, but only supportive
treatment is indicated. - Treat for TH1 deficiency
- Look for issues with TH2 excess – eczema, hayfever etc
If present manage Th2 excess
CHIRO TX:
* Adjust and monitor
Adjustments may be required hourly during acute period. Adjustment
1. Improves immune response
2. Decreases cortisol levels
3. Increases IgA levels
Hyper reactive airways disorder
What is it?
What are the causes?
Characterised by?
https://www.youtube.com/watch?v=bm6iQpSzhO4
A reversible underlying state of hyper-reactivity.
an airway that responds both too much and too easily to various stimuli
Often those diagnosed with asthma are simply suffering
HRA.
Causes include
1. neural mechanisms,
2. immune deficiency,
3. infection and
4. inflammation.
Characterised by?
* This disease is characterized by the following symptoms:
* Bronchial irritability – to many non-specific stimuli
* Nocturnal dyspnea
* Morning tightness for longer than one hour
- Due to current exposures
o eg.Seasonalallergens,dustmites,exercise,viralinfections
o Removal of environmental stimulus improves the inflammation and
hyperresponsiveness
What changes will you see with persistent Hyper reactive airways disorder
Infection and HRA disorder?
Bronchoconstriction mediated by parasympathetic nerves (vagus).
Bronchodilation is a result of sympathetic stimulation of airway smooth muscle.
- Structural and physiological airway changes (airway remodeling)
- Has been thought to be related to the chronicity of the airway
disease and inflammation - Due to the effects of chronic airway inflammation
- Can be unresponsive to treatment with inhaled corticosteroids
- May be present in asymptomatic or mildly symptomatic (asthma) individuals who show little response to exposure to allergens, exercise or cold air
Viral infections can cause an increase in HRA
Most infants who wheeze have transient conditions associated with diminished airway function and have no increased risk of asthma or allergies later in life.
In a minority early wheezing episodes are related to a predisposition to asthma.
These children already have elevated serum IgE levels during the first six months of life and have substantial deficits in lung function by the age of six years
ASTHMA
What is it?
What are risk factors that predispose you to it?
What are protective factors?
- Asthma is defined as a chronic inflammatory disorder of the airways, involving mast cells, eosinophils, T lymphocytes (mainly Th2), macrophages, neutrophils and epithelial cells.
It involves a variable degree of
1. reversible airflow obstruction,
2. bronchial hyperresonsiveness, and
3. airway inflammation with mucous hypersecretion and
4. airway remodelling
Risk Factors:
* Atopy
* Either parent ever had asthma
* Serious respiratory infection in the first 2 years of life
o This includes bronchiolitis, pneumonia, whooping cough, bronchitis or croup
* High intake of polyunsaturated fats
* Being the first born child
* Low birth weight and premature birth * Use of antibiotics in the first year of life
Protective factors include (these protective factors tend to promote a Th1 response)
* Breast feeding
* Having three or more older siblings
* Early exposure to animals, either livestock or pets
* Exposure to bacterial endotoxins
* Living on a farm
Risk factors include * Atopy
* Either parent ever had asthma
* Serious respiratory infection in the first 2 years of life
o This includes bronchiolitis, pneumonia, whooping cough, bronchitis or croup
* High intake of polyunsaturated fats
* Being the first born child
* Low birth weight and premature birth * Use of antibiotics in the first year of life
What is the clinical presentation of Asthma?
Signs you would see on an exam?
- Clinicalpresentationinvolvesthe symptoms of
Recurrent wheezing,
coughing,
chest tightness/difficulty breathing.
Worse at night or in early morning
Examsignsinclude;
rapid breathing,
wheezing,
cough
prolonged expiratory time,
Hyperinflation of the lungs
retractions and nasal flaring
Positive response to bronchodilators
Application of provocative agents such as methacholine and exercise increasing airway resistance and bronchial hyperresponsiveness
Absence of crackles on chest auscultation
Discuss the pathophysiology of Asthma
What are the long term changes that occur?
Discuss immune system imbalance responsible for Asthma?
Asthma creates the following changes
* within the lung tissue:
* Smooth muscle hypertrophy and hyperplasia
* Inflammatory cell infiltration
* Oedema
Mucous hypersecretion
* Protein deposition, including collagen
* Epithelial desquamation
- Long term changes in the airways also include:
- Increased smooth muscle
- Increase in bronchial blood vessels
- Thickening of collagen layers
- Loss of normal distensibility of the airway
Asthma is associated with active T- cell immune responses to inhaled allergens that are skewed toward the Th2 phenotype
as compared to the Th1-skewed immunity in healthy individuals
Th2 phenotype is the pro-allergy state, and has thought to be brought about by
increased hygiene, immunization, decreased sibship size antibiotic use
(The Th1/Th2 cytokine balance has been shown to be important.
* Asthma is related to a downgraded Th1 response, and an upgraded Th2 response.
Inhibition of Th2 cells, mast cells and eosinophils, OR promotion of differentiation of Th0 cells into Th1 cells may be considered protective)
Structural changes in asthma
1. Epithelial shedding
2. Collagen deposition
3. Fibrosis
4. Basement membrane thickening
5. Goblet cell hyperplasia
6. Smooth muscle size increase - smooth muscle contraction is determined by inflammation and neurotransmitters.
Use of broad spectrum anti-biotics in the first six months of life was associated in an 8.9 times increased risk of developing asthma.
Still, there is clear evidence that antibiotic exposure during prenatal period, infancy, or early childhood is associated with high risk of allergic diseases and asthma during infancy, childhood or early adolescence.
- The physiological and pathological processes of these respiratory conditions are likely to begin early in life (even prenatally).
- The early role of subluxation, atopy/allergy, breast feeding and mother’s immune status, antibiotic use, vaccination and Th1/Th2 balance establishment are all important.
- There is considerable crossover and similarity between the physiological and pathological processes in each of these conditions, and the sequela that results.
- Therapies should be directed at early intervention, addressing the underlying mechanisms of hyper- reactive airways. These therapies are more likely to be successful if conducted before structural remodelling of airways takes place.
Just Good Info to know
Bronchitis
Inflammation of the lining of the Bronchial Tubes - m.c after viral respiratory infection
clinical presentation
AB vs no AB?
PHYSICAL EXAM
- Usually is preceded by a viral URTI and is usually viral
- Secondary bacterial infection may occur
- Clinical Presentation
Typically dry, hacking, unproductive cough with gradual onset 3-4 days
Low substernal discomfort or burning anterior chest pain is often present and may be aggravated by coughing
May develop whistling sounds (rhonchi) and shortness of breath
After several days the cough becomes productive
Within 5-10 days mucous thins and cough clears
May stay quite unwell for a further week (entire episode usually lasts about two weeks) - In healthy children complications are few
- There is no specific medical treatment
- Antibiotics do not shorten the course of the illness or reduce incidence of bacterial complications
Physical Examination:
* Early findings are absent or are
low-grade fever and
upper respiratory signs such as
nasopharyngitis,
conjunctivitis, and rhinitis.
- Auscultation of the chest may be unremarkable at this early phase.
- As the syndrome progresses and cough worsens, breath sounds become coarse, with coarse and fine crackles and scattered high- pitched wheezing.
- Chest radiographs are normal or can have increased bronchial markings.
- The principal objective of the clinician is to exclude pneumonia, which is more likely caused by bacterial agents requiring antibiotic therapy.
Pneumonia- What is it?
What are the causes of Pneumonia
Discuss Viral pathogens
Infection that inflames air sacs in one or both lungs which may fill with fluid or puss.
Can be life threatening to anyone- but particularly infants.
Causes:
-Mostly micro-organisms/ bacteria
-Others can be gastric acid or food inhaled
-hypersensitivity reactions
A bacterial or viral cause can be identified in 40-80% of children due to new testing procedures
VIRAL PNEUMONIA
-prominent cause of LRTI in infants and children <5 pro
-Viruses = 45% OF HOSPITILISED PNEOMonia in children.
-usually occurs between 2-3 yrs
-M.c Common is Influenza virus and respiratory Syncytial virus. (major in children)
PNEUMONIA
Clinical presentation
What would you see in the Physical Examination?
-Often occur after several days of symptoms of URTI, typically rhinitis and cough.
-In viral pneumonia, fever is usually present, temperatures are generally lower than in bacterial
-Tachypnea is the most consistent clinical finding
(increased work of breathing ie intercostal, subcostal and suprasternal retractions, nasal flaring and use of accessory muscles is common)
-Sever infections- may get cyanosis
-Auscultation = crackles and wheezing, but often difficult to localise.
-Its often not possible to differentiate between viral and bacterial
Physical examination:
-depends on stage of pneumonia
Early on: diminished breath sounds, scattered crackles, and rhonchi are commonly heard over the affected lung field
Later on with more consolidation: dullness on percussion notes and diminished breath sounds.
A lag in respiratory excursion often occurs on the affected side.
Abdominal distention may be prominent because of gastric dilation from swallowed air or ileus.
Abdominal pain is common in lower lobe pneumonia
-liver seems to be enlarged because of downward displacement of the diaphragm
Pneumonia in Infants
there may be an abrupt onset of:
respiratory distress shows as (EXAM Q)
How do we diagnose Pneumonia?
Infants may get abrupt onset of:
-fever
-restlessness
-apprehension
-respiratory distress
Some infants with bacterial pneumonia may have associated GI disturbances, vomiting, anorexia, diarrhoea, abdominal distention.
Rapid progression of symptoms in most sever cases of bacteria pneumonia.
These infants appear ill, with respiratory distress manifested as:
-Grunting
-Nasal flaring-Retractions of the supra-clavicular, intercostal and subcostal areas
-Tachypnea (fast breathing rate) >60
-Tachycardia (fast heart rate)
-Air hunger
-Often cyanosis
Diagnosis of Pneumonia:
-Chest Xray may show - infiltrate/ pleural effusion
-Lobar consolidation
-The Xray alone is not diagnostic, other clinical features must be considered
Predicting Pneumonia
What are the key clinical findings that have excellent sensitivity
-Fever
-Decreased Breath sounds
-Crackles
-Tachypnea
Describe what you see?
6 month old infant
* A, Radiographic findings characteristic of respiratory syncytial virus pneumonia in a 6 mo old infant with rapid respirations and fever.
* Anteroposterior radiograph of the chest shows hyperexpansion of the lungs with bilateral fine air space disease and streaks of density, indicating the presence of both pneumonia and atelectasis. An endotracheal tube is in place.
* B, One day later, the AP radiograph of the chest shows increased bilateral pneumonia.
What do you see?
- Radiographic findings characteristic of pneumococcal pneumonia in a 14 yr old boy with cough and fever. Posteroanterior (A) and lateral (B) chest radiographs reveal consolidation in the right lower lobe, strongly suggesting bacterial pneumonia.
How do you diagnose Viral Pneumonia?
- The definitive diagnosis of a viral infection rests on the isolation of a virus or detection of the viral genome or antigen in respiratory tract secretions.
- Growth of respiratory viruses in conventional viral culture usually requires 5-10 days, although shell vial cultures can reduce this “turnaround time” to 2-3 days.
- Reliable DNA or RNA tests for the rapid detection of RSV, parainfluenza, influenza, and adenoviruses are available and accurate.
How do you diagnose bacterial Pneumonia?
- The definitive diagnosis of a bacterial infection requires isolation of an organism from the blood, pleural fluid, or lung.
- Culture of sputum is of little value in the diagnosis of pneumonia in young children.
- Blood culture results are positive in only 10% of children with pneumococcal pneumonia.
- Acute infection caused by M. pneumoniae can be diagnosed on the basis of a positive polymerase chain reaction (PCR) test result or seroconversion in an IgG assay.
- Serologic evidence, such as the antistreptolysin O (ASO) titer, may be useful in the diagnosis of group A streptococcal pneumonia.
What is the treatment of Pneumonia?
Viral and bacterial?
An prognosis?
- If viral pneumonia is suspected, it is reasonable to withhold antibiotic therapy, especially for those patients who are mildly ill, have clinical evidence suggesting viral infection, and are in no respiratory distress.
- Up to 30% of patients with known viral infection may have coexisting bacterial pathogens.
- Therefore, if the decision is made to withhold antibiotic therapy on the basis of presumptive diagnosis of a viral infection, deterioration in clinical status should signal the possibility of superimposed bacterial infection, and antibiotic therapy should be initiated.
PROGNOSIS:
-Bacterial: symptoms (fever, cough, tachypnea, chest pain) improve within 48-96 hours after antibiotics. But Chest Xray evidence takes substantially longer/
What is this?
Pneumonia
Bilateral central pulmonary infiltrates, but most marked in the right middle and left lower lobes. The left lower lobe infiltrate is best seen on the lateral view inferiorly over the spine. The lungs are hyperaerated.
Impression: Right Middle and left lower lob infiltrates
A 10 year old male who came to the E.D. with a history of coughing and fever. Poor breath sounds were noted on the left.
- The left lung is consolidated. This atelectasis results in a mediastinal shift to the left. There are air bronchograms evident over the left lung. On the original film, there is a suggestion of a 1.5cm cylindrical foreign body in the left mainstem bronchus. Further history revealed that he had “swallowed” a plastic bullet several days ago.
- Impression: Consolidation of the entire left lung with the suggestion of a foreign body in the left mainstem bronchus
An 11-month old female with a history of a previous pneumonia who now presents with fever and coughing. Mild wheezing and rales are noted on auscultation.
- There are small interstitial central pulmonary infiltrates.
- Impression: Small interstitial central pulmonary infiltrates most consistent with a viral pneumonia.
A 6-week old male infant. His parents brought him to the E.D. because of coughing and congestion. He had a 20 minute episode of frequent coughing, but now seems to be better. He is feeding well. There is no history of fever or cyanosis. His vital signs are normal. Oxygen saturation is 100% in room air. Auscultation is clear.
- The upper mediastinum shows the usual prominent thymus for this age. The thymic shadow is larger on the infant’s right than on his left. There is a density in the right upper lobe, but it is obscured by the thymus. Part of this density appears to be from the scapula, but on close inspection, there are densities suggesting infiltrates aside from the thymus and the scapula in the right upper lobe.
- Impression: Right upper lobe infiltrate or partial atelectasis.
Atelectasis (at-uh-LEK-tuh-sis) is a complete or partial collapse of the entire lung or area (lobe) of the lung. It occurs when the tiny air sacs (alveoli) within the lung become deflated or possibly filled with alveolar fluid. Atelectasis is one of the most common breathing (respiratory) complications after surgery.
An 18-month old female with a history of prematurity and mild bronchopulmonary dysplasia. She arrives in the emergency department with a history of fever, coughing, and difficulty breathing. Coarse breath sounds and mild wheezing are noted on auscultation.
- There is a small area of atelectasis in the right middle lobe. This is best seen on the lateral view as an oblique flattened wedge shaped density over the heart. Instead of the normal triangular shape of the right middle lobe, it appears to be flat and compressed indicating atelectasis.
- Impression: Right middle lobe atelectasis.
Atelectasis (at-uh-LEK-tuh-sis) is a complete or partial collapse of the entire lung or area (lobe) of the lung. It occurs when the tiny air sacs (alveoli) within the lung become deflated or possibly filled with alveolar fluid. Atelectasis is one of the most common breathing (respiratory) complications after surgery.
A 12-year old female complaining of a headache and productive cough. Onset of fever last night to 39 degrees. Rales are noted in the left base.
A 12-year old female complaining of a headache and productive cough. Onset of fever last night to 39 degrees. Rales are noted in the left base.
- There are infiltrates in the right middle and left lower lobes. The right middle lobe infiltrate is blurring the right heart border. It can also be seen on the lateral view as streakiness over the heart. The left lower lobe infiltrate is best seen on the lateral view posteriorly on the diaphragm. It can also be seen on the PA view as haziness in the lower lung on the left. The infiltrate in the right middle lobe was noted two years ago on a previous radiograph, and the possibility of a chronic infiltrate was raised.
- Impression: Right middle and left lower lobe infiltrates.
The term pulmonary infiltrate is considered a context-dependent, non-specific and imprecise descriptive term when used in radiology reports (plain film or CT).
From a pathophysiological perspective, the term “infiltrate” refers to “an abnormal substance that accumulates gradually within cells or body tissues” or “any substance or type of cell that occurs within or spreads as through the interstices (interstitium and/or alveoli) of the lung, that is foreign to the lung, or that accumulates in greater than normal quantity within it”
This is a 9-year old male with a history of fever, headache, nausea, and coughing.
This is a 9-year old male with a history of fever, headache, nausea, and coughing.
- There is a circular density in the right lung. This is the superior segment of the right lower lobe. Although this has the appearance of a mass, it is most likely an infectious process.
- Impression: Spherical consolidation in the right lower lobe (round pneumonia).
- This is a 6-month old male who presents to the pediatric clinic with difficulty breathing. He has had similar episodes in the past. He has been diagnosed with asthma and has been treated with albuterol with only modest improvement.
- He has some nasal congestion, but no fever, vomiting or diarrhea.
- He feeds well and he has been gaining weight well.
- His past history is remarkable for multiple upper respiratory infections and wheezing during the past several months.
- He was born at term. His family history is significant for asthma in several relatives and his older siblings. He has three siblings who currently have colds.
- Exam: VS T 37, P 114, R 39, BP 100/75, oxygen saturation 99% in room air. He is alert, active, and in no distress. He is not toxic. HEENT significant for clear nasal mucus, normal TM’s and a clear pharynx with normal oral mucosa. Heart regular without murmurs, but his breath sounds are noisy so it is difficult to be sure. He has mild inspiratory and expiratory “wheezing”. His lung fields demonstrate good aeration. He has no retractions. His abdomen is soft, non-tender and without organomegaly. His neurologic exam is unremarkable.
- An albuterol aerosol is administered and following this, his lung exam is unchanged. A chest radiograph is ordered. An airway anomaly is also suspected so a lateral neck is also ordered.
PERTUSSIS (whooping cough)
How is it diagnoses?
Whooping cough is a bacterial infection caused by Bordetella pertussis. It spreads when an infected person coughs or sneezes and you breathe it in. The bacteria affect the lungs and airways, causing a person to cough violently and uncontrollably. This can make it hard for the infected person to breathe.
Whooping cough is a serious disease because it can lead to pneumonia, brain damage and sometimes death.
How is it treated?
Diagnosis:
-should be suspected in kids who has a pure predominant complaint of cough, especially if the following features are absent: fever, malaise or myalgia, sore throat, tachypnea, wheezes and rales.
A cough >14 days duration with at least 1 associated symptom of
-paroxsms,
-whoops
-post- tussle vomiting has sensitivity of 81%
-Pertussis should be suspected in older children whose cough illness is escalating at 7-10 days and whose coughing episodes are not continuous
-Pertussis should be suspected in infants <3mo of age with gagging, gasping, apnea, cyanosis, or an apparent life threatening event.
-Sudden infant death is occasionally caused by B pertussis.
TREATMENT:
-maximise nutrition, rest and recovery without sequelae
-Infants <3 months suspected. always admitted to hospital
-No medications provide symptomatic relief from pertussis - associated cough
-Antibiotics eliminate B pertussis from the nasopharynx and reduce the risk of transmission
-AB have not been shown to reduce duration or severity of cough.
FINITO
