Pediatric Croup and Bronchiolitis Flashcards
Pediatric vs adult airway
Larynx more anterior and more rostral
Larger tongue
Epiglottis larger and less cartilaginous…difficult to ID
Narrowest part is the criocoid cartilage (vs. vocal cords)
these things make it more difficult to see
Adult is a nice straight column down…the pediatric is more like a funnel that narrows to the pediatric cricoid cart
Ramifications of pediatricsvs. adults
MOre prone to obstruction (tongue blocks)
INfants are obligate nasal breathers
Smaller larynx means less space
Epiglottis borader in adults…pediatric epiglottis omega
Infant larynx around C2-3…adult around C4-5
Pedaitric resembles adult around 10 y/o
Edema in airway*****
Halving radius increases resistance times 16…so pediatric is far more susceptible to compromise
Grunting Drooling
Can’t keep open their lower airway
Drooling can be upper problem
Inhalation vs. exhalation vs. diphasic sounds `
In - above level of vocal cords
Ex - below (intrathoracic)
Biphasic - involve coval cord issue
Tx modalities
CSs - anti inflam…reduce mucosal edema…but its delayed
Vasoconstrictive - epinephrine…reduces swelling…temporary so could have rebound swelling
Heliox - He less dense than N…can reduce turbulent flow across narrowed airway…less viscous
Adjuncts - oral, nasipharyngeal, LMA, endotracheal intubation
Croup
Viral laryngotracheobronchitis
Vrial resp infection
Most common parainfluenza
Any virus that causes bronchiolitis
Consider bacterial tracheitis as differential
Viral inflammatioj leads to swelling in supraglottic and laryngotracheal area
Increased mucus production
Turbulent flow across narrowed area (stridor)
Croup sx
Cough (barking seal)
Should be inspiratory Stridor
Bacterial tracheitis - toxic appearing and high fever
Epiglottitis, must maintain certain position and cannot change with ease…won’t be croup
They SHOULD be able to change positions easily
Epiglottitis vs. croup radio
Croup - epiglottis will be normal…can see the airway narrow on an AP
Epiglottitis - inflamed thumbprint sign
Croup tx
Supportive care is most important…supplemental oxygen or hydration
Steroids - can reduce inflammation
ENT eval???
Airway forreign body
Lack of viral prodrome
Sudden onset
Biphasic stridor suggests obstruction at level of cords
One volume may be hyperinflated
Air trapping on one side from FB obstructive effect
Acute bact epiglottitis
Raditional cause is Haemophilus type B
Also with S pnumo, GAS, S auerus
Tx with steroids and Abs
If kid stops breathing
Allow them to assume position of comfort
Control the airway
Surgical backup for tracheotomoy
DDx of actue bacterial epiglottitis
Bacterial trachitis - usually not associated with impending airway compromise
Retropharyngeal abscess
Periotonsilar abscess (can be visualized)
Diptheria - psuedomembrane rare in US
Pierre Robin sequence
Mandibular hypoplasia, micrognathia, cleft palate
Resp and feeding difficulty
Cystic teratoma
Obvious airway obstruction
Choaanl atresis
Nasal obstruction in newborn
Uni or bilateral
Bilateral is emergency
Pass tube into nostril
Death by ashphyxia
The flow
Generated by pressure gradient bt alveolus and mouth
Flow in conducting zone is bulk flow
Resp is diffusion based
Airway resistance from IM sized bronchioels
Causes of hypoxia
V/Q mismatch - children
Shunt
Hypoventilation
High elevation (low Patm and low PO2)
Diffusion abnormaitly
Bronchiolitis
Viral lower airwya infection
RSV most common
Under 2 y/o most severe
Older kids/Adults nasty cold/URI
Smaller children develop mucous plugging of small and medium sized airways…leads to increased airway resistance
Dvelop air trapping and obstructive lung dz wirth exp wheezing
Risk factors
Pretaurity
HEart dz
Infansts under 2 y/o
Any other dz really***
Dx
Seasonal peak (nov through march)
In warmer climates throughout year
Nasal congestion
Wheezing
Resp distress
Apnea (neonates)
Nasopharyngeal wwashings for rapid antigen detection
Bronchiolitis most common pop
Most younger than 1 year…over half under 6 mos
Mean hospital stay 3 days
More in boys
Patho of bronchilitis
Viruses enter and cause damage and inflammation
Patho within 24 hours
Bronchiolar cell necrosis, ciliary disruption, peribronchial lymphcytic infiltration
Edema, excessive mucous, sloughed epithelium, lead to airway obstruction and atelectasis
Course
Begin with URI sx
4-6 day is peak
2-4 weeks, sx abate with residual cough
Most is self limited
Bacterial pneumonia or UTI can occur comorbd
Ddx of bronchiolitis
No astham in infants
Bacterial pneumonia - will see focal finding…not much secretion
FB aspiration
GE reflux or dysphagia
HEart dz
Bronchiolitis tx
Supportive care
B2 agonist (maybe)
Steroids - limited but maybe better if chronic lung dz
Ribivirin - not beneficial and associated with significant toxcity
Association with asthma
RSV bronchiolitis at risk for asthma later in life
Prevention
Avoid cigarette smoke
Good hand washing
Avoiding contact
Influenza vaccine for children over 6
Palivizumab - monoclonal AB against RSV…covered if premature, congenital heart dz, NM disease
Asthma differencews
Recurrent epsidoes of wheezing
Hx, age over 2, PFTs, ID triggers
