NZ Respiratory Flashcards
Respiratory abnormalities associated with T21
- Pulmonary hypertension
- Bronchial stenosis
- Subpleural cysts
- Alveolar simplification
Diaphragmatic Hernia
- 1: 2-3000
- Contralateral lung is usually affected
- Long term nutritional problems are common
- Malrotation occurs in 30-60%
- R sided in 12% of cases
Poor prognostic factors for CF
- Malnutrition
- Pseudomonas
- Burkholderia cepacia
- Diabetes
- Frequent exacerbations
- Female gender
Indications for lung transplant in CF
- FEV1 <30% predicted
- Poor nutritional status
- Poor exercise tolerance
- Rapid decline in lung function
- Major life threatening complications
- QOL issues
Stages of sleep in childhood
N1: transition to light sleep, easily roused
N2: light sleep, k complexes and spindles
N3: deep sleep or “slow wave sleep”, still, very hard to rouse, very regular breathing
REM: “dream sleep”, decreased tone, rapid eye movements, partial paralysis, vivid dreams, irregular breathing, increased upper airway resistance, decr. tidal volume
–> Occurs during the latter half of sleep
Stages of sleep in newborns
Different due to decreased myelination
- Active sleep: equivalent to REM sleep
- Quiet sleep: equivalent to N3
- Indeterminate sleep
Respiratory events: apnoeas
Apnoea >90% decrease in baseline flow for 2 or more respiratory cycles
- Obstructive: continued effort
- Central: absence of effort + desat >3% or arousal
- Mixed: starts central ends obstructive
Hypopnoea >30% decreased baseline flow for 2 or more resp cycles with desat or arousal
- More commonly seen in children with OSA, usually don’t have apnoeas, but partial obstruction or hypopnoea
Normal number of obstructive events per hour of sleep
<1/hr (<5/hr in adults)
Respiratory events on polysomnograph
- Drop in nasal flow
- Look at effort bands (thorax and abdo) to see if there is increased effort of breathing - obstructive vs central
- Confirm arousal or desaturation
Parasomnias
- Occur in N3 stage of sleep –> disturbance occurs, brain half awake
- -> To fully wake someone up and stop the event, need to go back go sleep. Waking someone up will prolong the event
- Includes confusional arousals, night terrors, sleep- walking
- Usually occurs 60-90min into sleep, usually 1 or 2 per night, positive FHx
DDx for parasomnias
Nightmares
Frontal lobe seizures - very stereotyped events, features of pointing, pelvic thrusting, more likely to stand, sudden offset
Night terror vs nightmare
- Night terror: N3 phase, occurs 60-90min into sleep (predictable), not awake!, unable to be settled/comforted, unable to recall the event (like a seizure!)
- If extreme, can trial clonazepam or zopiclone - Nightmare: REM phase, no specific timeframe, able to be comforted as they can wake up from event, takes ~20min to settle, can recall events
Anticipatory waking
Since parasomnias are predictable in their timing, wake up the child 30min before event to reset the sleep cycle
- Events may still occur
Periodic limb movement disorder
- Non-sleep stage specific disorder
- Part of restless legs syndrome
- Increased frequency of periodic limb movement during sleep –> disturbs pt from sleep
- Due to partial iron deficiency in basal ganglia
- Tx with Fe supp and aim for ferritin >50
Narcolepsy
- Hypersomnia disorder
- Genetics: HLA-DR2, DRB11501, DQA0102, DQB1*0602
- Hypocretin-1 level in CSF (low hypocretin/orexin)
- Features:
- -> Short latency (<8min) with REM sleep during the day
- -> Cataplexy: sudden loss of muscle tone
- -> Sleep paralysis and hypnagogic hallucinations
- Mx: good routine, scheduled naps, stimulants
- -> Stim: ritalin, modafinil
- -> Cataplexy: sodium oxybate, tricyclics, SSRIs, venlafaxine
Associations between sleep and obesity
Sleep deprivation associated w/ inc obesity
- Sleep dep –> for next 48hrs, increased hunger and caloric intake
- Other factors: altered thermoregulation and increased fatigue –> reduced energy expenditure
Behavioural insomnia
Mostly mixed phenotype
- Sleep association type i.e. children need to learn to fall asleep, need to have positive associations with bed time
- Limit setting disorder type i.e. naughty children with parents who can’t set limits
- Mx:
- -> Exclude physiologic causes for night waking e.g. OSA, GORD, asthma, eczema etc
- -> Sleep hygiene and better associations
- -> Sudden or graduated extinction: let them cry, parents don’t interact with children
- -> Fading with positive bedtime routines: 20min of positive, quiet activity before bed, move bed time backwards by 15min each night
ADHD and insomnia
Decreased sleeping, increased movement in sleep
Increased sleep latency, more restless sleep
More night-time wakings
Difficulty waking/irritability with daytime sleepiness
- Is stimulant the problem? Trial children on atomoxetine instead of ritalin, consider clonidine or melatonin
- Behavioural therapy
Autism and insomnia
- 44-83% have sleeping problems (significant)
- Issues: difficulty settling, waking during the night for hours, early morning waking
- Mx:
- -> Behavioural therapy: 50% find it helpful
- -> Melatonin: helps with sleep onset, but does not help decrease night time or early morning waking due to short half life
- -> Melatonin SE: binds receptors in gonads, in animals - affected puberty and fertility
Delayed sleep phase treatment for a petulant adolescent
- Sleep hygiene
- Dim light before bed, no texting, no computer/TV in room - Bright light when awake
- Advance bed time by 15min every 3 nights
- Melatonin can be used as adjuvant
N.B. Sunlight can move body clock by 2hrs, melatonin can move body clock by 20min!
Adverse effects of OSA
- Causes defects of executive function (MC): impulsiveness, inattention/poor concentration, memory decrements
- Disrupts sleep - tiredness/irritability
- Hard to wake or daytime sleepiness
- HTN, elevated lipids, insulin resistance
- Severe: FTT, pulmonary HTN, cor pulmonale
Major features of OSA in Hx
- Most sensitive: Snoring - 50%
- Increased odds ratio: (strength of association)
- Frequent mouth breathing asleep + awake
- Witnessed pauses or apnoea
- Struggling to breath
- Parents feel they have to poke child - Ex-prem, FHx
- Minor features: restless sleep, sweating, cough or vomit in sleep, morning headache
Examination findings on OSA
Tonsil size and mouth breathing (increased OR)
Nasal patency: hyponasal speech
High arched or narrow palate
Investigations for OSA
Diagnosis = polysomnography
Risk stratification for adenotonsillectomy = oximetry
- Motion-resistant oximeter with 2 second averaging time
- 5 or more clusters of desats to <80%, associated elevated early AM CO2 on blood gas
Treatment options for OSA
- Adenotonsillectomy
- Nasal corticosteroids
- Halve PSG score and cure mild OSA (shrinks adenoids) - CPAP
- For moderate post-surgical disease, severe but on waitlist, surgical contraindication
Outcomes from T&As in OSA pts
- 80-85% of near or total cure
- 50% cure in obese or severe OSAs
- Benefits: improves behaviour and QoL, but not necessarily IQ and executive function
Risk factors for respiratory compromise (e.g. apnoeas, atelectasis) post-T&As
- Syndromes: T21, DMD
- Morbid obesity
- Severe OSA
- <3yo
- Complications of OSA present prior to T and As –> FTT or cor pulmonale
Which pt groups are at risk of developing OSA?
- Large tonsils/adenoids
- Obese children
- Floppy children: T21, NMD
- Narrowing/crowding of upper airway: craniosynostosis, Pierre Robin sequence, Crouzon syndrome
I.e. more at risk of obstructing upper airway
Obesity and pathophysiology of OSA
- Decreased lung volumes due to increased pressure on chest and diaphragm squashes from below
- Fatty deposit around pharynx narrowing airway further
- Combined effect –> small airway volume –> increased pharyngeal collapsibility and airway resistance –> obstruction
OSA in obese pts increases risk of…
- Metabolic syndrome and insulin resistance
- HTN (sympathetic surge)
- Stroke > MI (vibration of snoring of carotid arteries)
- Poor sleep –> increases appetite
- Pro-inflammatory state
ABG Rules: AG - HCO3
(Change in AG) - (Change in HCO3) in high anion gap metabolic acidosis to identify co-existing NAGMA and met alkalosis
= (Calc. AG - (N) AG) - (Measured HCO3 - (N) HCO3) = >6 is abnormal
- Remember: the ratio ofchange in acidic anion and HCO3 should be 1:1 i.e. addition of 1 acid –> decrease in 1 base (neutralisation)
- If change in AG > change in HCO3 = concurrent met alkalosis, there must have been more base to start with to have a smaller decr in HCO3 c.f. bigger increase in AG
- If change in HCO3 > AG = concurrent NAGMA, there must be another acidotic process going on, as change in AG alone can’t explain sig decrease in HCO3
ABG Rules: Compensation
- When PCO2 and HCO3 move in the same direction, compensation is present
- -> Metabolic compensation implies chronicity as renal comp takes hours/days to complete - Resp acid/alkalosis: every 10mmHg change in CO2 (40) –> HCO3 (24) to change by 1 (acute) or 4 (chronic)
- Metabolic acidosis:
- pCO2 = (1.5xHCO3) + 8 (+/-2) OR
- Last 2 digits of pH = CO2 (e.g. pH 7.19 = CO2 19) - Metabolic alkalosis: pCO2 ~50 is the max that can be expected for compensation, otherwise expect a second process
- (0.7 x HCO3) + 20
Exhaled ntric oxide (FeNO)
- NO usually exhaled in breath. In asthma, high levels of NO + high levels of inducible NO synthase on epithelial cells of airways
- High FeNO suggests up-regulation of airway inflammation and presence of eosinophilic inflammation
- FeNO can decrease with corticosteroid therapy –> non-invasive method to MONITOR response to anti-inflammatory Tx
- NOT conclusive for asthma diagnosis
- Asthma = >35ppb in school aged children
Ix for primary ciliary dyskinesia
- Nasal nitric oxide
- Abnormal = <250ppb or <75nL/min (incorporates flow)
- True PCD <100ppb - Ciliary biopsy/brushings - look at ultrastructure of cilia
- Genetic testing
DDx for nodular miliary pattern
= innumerable, small 1-4 mm pulmonary nodules scattered throughout the lungs
- TB
- PJP
- CMV
- Lymphocytic interstitial pneumonia
- Metastatic lesions (e.g. osteosarcoma)
- Sarcoidosis
When does the risk of pulmonary hypoplasia increase?
Oligohydramnios prior to 26 weeks gestation
Lung development: pseudoglandular stage
Weeks 6-16: development of lower conducting airways
- By this stage all major elements of the lung have formed, EXCEPT for those involved in gas exchange
- Aberrant development: bronchogenic cysts, congenital lobar emphysema, CDH
Lung development: canalicular stage
Weeks 16-26: formation of acini
- Bronchial lumen and terminal bronchials become larger
- Lung tissue becomes highly vascular, pulm capillaries occur
- Terminal bronchioles form respiratory bronchioles –> divide into primordial alveolar ducts
- -> The alveolar sacs allow beginning of gas transport
Lung development: terminal sac stage
Weeks 26-36: refinement of blood-air barrier & surfactant
- Many more alveoli develop and epithelium become very thin (type I pneumocytes)
- Capillaries begin to bulge into sacs - increases alveolar-blood barrier surface area
- Development and maturation of surfactant system
Lung development: alveolar phase
Weeks 36 to 3yrs: alveolar proliferation + development
- Saccules become alveoli and alveoli attain polyhedral shape
- Thinning of acinar walls, dissipation of interstitium and invagination of alveoli by pulmonary capillary
Role of betamethasone
Increases surfactant production
Lung development: embryonic phase
Weeks 3-6: development of proximal airways
- Laryngotracheal groove develops caudal to fourth pair of pharyngeal pouch
- Lung bud (laryngotracheal diverticulum) arises from foregut day 21 to 26
- Aberrant development:
- -> Laryngeal web or atresia: failure to recanalise the larynx after 10th week
- -> Tracheal agenesis, tracheal stenosis: usually assoc. w/ variants of tracheo-oesophageal fistula
- -> TOF: incomplete division of cranial foregut into resp and oesophageal parts during 4th wk
- -> Pulmonary sequestration (accessory lung bud)
Gurgling upper airway noises
DDx:
- Lingual cyst
- Pharyngeal airway abnormality
Pulmonary hypoplasia
- Usually associated with congenital abnormality or pregnancy Cx that prevents adequate development of lung, airways and alveoli
- Causes:
- Physial constraint: CDH (can cause hypoplasia on contralateral side if squashed), CCAM, pleural effusions due to hydrops, thoracic dystrophy
- Oligohydramnios: foetal renal insuff, PROM
- Isolated - Presentation:
- Resp insufficiency
- PPHN
- Tachypnoea/distress with viral infections in infancy - mild presentations
Management of pulmonary sequestration
Risk of complications from unresected sequestration outweighs risks of surgery
- With extralobar seq, if infected, may require lobar resection
- Very small risk of cancer in remaining abnormal lung tissue
- Thorascopic resection
Where are pulmonary sequestrations located?
Most commonly, LLL - 90% extralobar, >60% intralobar
Complications associated with pulmonary sequestrations
Receives blood supply from systemic circulation (thoracic or abdo aorta)
- Recurrent infections and pneumonia
- Respiratory distress
CPAM
- Benign hamartomas or dysplastic tumours (mixed w/ N lung tissue) –> overgrowth of terminal bronchioles in glandular pattern
- Communicates with lung, normal pulmonary arterial and venous supply
- Lower lobes > upper lobes, R=L, rarely multilobar
- Antenatal USS: polyhydramnios, mediastinal shift, pleural effusion, hydrops (IVC comp)
- Macrocystic dz assoc w/ better prognosis (type I)
- Presentation: severity depends on degree of mediastinal compression and secondary pulmonary hypoplasia
- Main risks: PTX, infection and bronchiectasis, small risk of malignant transformation –> all determined by size + degree of compression
- Tx: plan with HRCT, surgical resection <12mth, TRUE spont resolution rare (can get smaller/disappear on XR)
Congenital lobar emphysema
- Secondary to bronchial obstruction (other pathology) –> distension –> irreversible destruction of alveolar septae
- Expiratory air trapping within affected lobe –> overdistension of affected lobe + compression of adjacent structures
- -> Atelectasis of ipsilateral normal lung, mediastinal shift
- Normal lung parenchyma, assoc. bronchial collapse
- Main clue: lungs are NOT inflated on antenatal scans as air trapping occurs postnatally
- Presentation: MC incidental finding on CXR for neonates with RDS
- LUL (40-50%), RML (30-40%), RUL (20%)
- Screen with echo as 15% associated with CHDs
- Mx depends on Sx and lung function: observe vs surgical excision
Bronchgenic cysts
- Abnormal budding from tracheobronchoeal diverticulum before 16 wks –> can be found anywhere along conducting airways
- Single, unilocular, R is MC
- Presentation: incidental finding vs tachypnoea, wheezing +/- FTT if compression of adjacent structures + lobar collapse
- -> Older children: infections
- Cx: infection, if ruptures –> PTX or haemoptysis, malignant transformation
- Mx: Surgical resection
Airway abnormalities and syndromes
Choanal atresia
CHARGE syndrome
Airway abnormalities and syndromes
Down Syndrome
Subglottic stenosis
Tracheal stenosis
Airway abnormalities and syndromes
Velocardiofacial syndrome
Submucosal clefts
Laryngeal webs
Airway abnormalities and associations
Tracheal stenosis
Tracheo-oesophageal fistula - pre and post-operatively
CFSPID
CF sweat test positive, inconclusive diagnosis
- 2 genes positive, normal sweat test
- 1 gene positive (hetero) or no genes, indeterminate/borderline sweat test
At risk of “delayed” CF