Pediatric Lung Disease Flashcards
- Croup (laryngotracheobronchitis)
Infection causing inflammation of three things. What are they? - Most often caused by _______ virus
- Can be caused by other organisms such as ________, ________ _____, and _______?
- Most common age?
- Key features? 3
- Fever ?
- During what months is it most common?
- What gets really bad at night?
- ER Treatment?
- Whats the worst night with this disease?
- Clinic treatment?
- Where is the disease?
- larynx, trachea and bronchi
- parainfluenza****
- RSV, influenza virus, and adenovirus
- 6 months to 3 years
- -URI symptoms with
- -barking cough** and
- -stridor*** (wait a minute, where else do we see stridor?)
- usually absent or low grade
- WInter months
- Paroxysm coughing
- Racismic epi and steriods
- 3rd night
- Steriods (decadrone)
- Imflammation in subglottic space
- What’s the difference between stridor and wheezing?
- How do you differentiate croup from epiglottitis?
- When do you worry about hospitalizing patients?
- Wheezing is Inspiration and expiration
Stridor is only inspiration - Toxic, blue, very distressed! Croup isnt that sick
- If they arent responding to treatment with steriods or racemic epi
- Treatment?
- Treatment for barking cough, no stridor at rest? 5
- Treatment for stridor at rest? 2
- When can we discharge the pt with croup?
- When should we hospitalize? 2
- Generally steroids are used
Dexamethasone 0.6mg/kg IM one dose - Supportive therapy,
- hydration,
- minimal handling,
- mist therapy,
- cold air
- Oxygen,
- nebulized racemic epinephrine
- If symptoms resolve within 3 hours of steroid and epinephrine use, can be safely discharged
- Hospitalize if
- recurrent epinephrine treatments are required or
- if respiratory distress persists
- What is epiglottis due to? 2
- Generally present with SUDDEN onset: Symtpoms? 7
- HOw should we proceeed to treat this pt?
4
1
- Most commonly due to H. flu Type B
- Also with strep pneumo now in adults
- Fever
- Dysphagia
- Drooling
- Muffled “hot potato” voice (rasping, like something is stuck in their throat)
- Inspiratory retractions
- Soft stridor
- CHERRY RED SPOT
- DO NOT EXAMINE THIS PATIENT!!!!
- GET a STAT soft-tissue lateral PORTABLE X-ray of the neck AND 3. PREPARE TO INTUBTE IMMEDIATELY!
- CALL IN YOUR PEDIATRIC ANESTHESIA FOLKS NOW!
How to differentiate croup and epiglottitis?
3 questions to ask yourself
- Was the child immunized for HIB?
- Is the child drooling?
- What do the neck radiographs show?
RSV causes what?
bronchiolitis
CC: Sally is a 6mo old girl who presents with fever, cough, and rapid breathing
HPI: Sally presents to your evening winter clinic with a 4 day history of fever, rhinorrhea, and cough that has worsened. Since last night, she has had a progressively increasing rate of breathing and worsening symptoms. Mom reports that Sally has also become more irritable. She is also now refusing her bottle. No vomiting or diarrhea. She does attend day care, where there are numerous ill contacts.
- What are the three most worrisome things about this situation?
- What do you want to assess for first?
- Is her age concerning? 5
- Does the fact that she is presenting in the winter alter your differential?
- PMHx: Birth VD at term without complications
Meds: Tylenol prn fever
Allergies: NKDA
FamilyHx: Dad has asthma
SocialHx: Smokers in the home
Immunizations: UTD
DietHx: Just started solids last week
DevHx: Appears grossly normal for 6mo
Vitals: Temp 101F, BP 95/55, HR 165, RR 58 Weight (50%)
Physical exam:
General alert, interactive, crying infant, grunting** mildly with each breath;
HEENT AT/NC, PERRLA, copious nasal secretions, nasal flaring, oropharynx erythematous, TMs with erythema without bulging and appropriate landmarks (cone of light, pearly gray) visualized
Chest intercostal retractions, shallow rapid breathing, wheezing audible in all fields, decreased aeration at bases, some crackles heard at bases (alveolar collapse- air not moving well)*
CV mildly tachy, regular rhythm, no murmurs
Ext cap refill at 2 seconds, pulses normal
Abdomen mildly distended but soft, NT, BS positive, no organomegaly
Skin no lesions
Pulse oximetry on room air was 88%*****
We start Sally on oxygen and this improves to 95%
She’s admitted to the hospital to receive IV fluids and oxygen support
Chest x-ray shows bilateral interstitial infiltrates and hyperaeration, with mild consolidation at the bases
- WHat does our PE show? 2
- Biggest reason to admit?
- A rapid viral antigen test is positive for what?
- -Increases respiration/airway compromise
-dehydration
-fever
(get really sick, really fast) - Get vitals first.
- 6 month old
- are they active
- no wet diapers
- is she feeding
- growth curve
- what does she eat? - Yes
- Lost of inflammation deep in the lungs
O2 88%
Start on 1 L and can increase from there. - Not feeding so we admit for dehydration
- Respiratory Syncytial Virus (RSV), confirming that Sally has bronchiolitis
What will premis get?
3
Why is RSV worse for babies?
Steriods
Surfactant
RSV vaccine
Very deep consolidation and they cant cough it out.
- What is Bronchiolitis?
- What can it progress to?
- Which kids are at higher risk for severe disease and poorer outcomes? 3
- Presentation? 4
- Management?
- Prognosis?
- Inflammatory process of the smaller lower airways, usually caused by RSV
- Can progress to respiratory failure and is potentially fatal
- Infants with
- congenital heart disease,
- chronic lung disease (usually former premature infants), or
- immunodeficiencies - Presentation is usually
- fever,
- URI symptoms, and accompanied by
- tachypnea and
- wheezing - Management is supportive care
- Generally the prognosis is excellent
- What other viruses can cause RSV?
- What medications will not work on RSV pts?
- What provides prophylaxis for RSV and who recieves this?
- What are the treatments for RSV and who recieves them?
- Bronchiolitis is not always caused by RSV. Other viruses that can cause this include
- -Adenovirus and
- -parainfluenza virus. - Using
- -bronchodilators and
- -systemic corticosteroids is controversial
- -Antibiotics are not routinely recommended - –Palivizumab (Synagis) is an IM monoclonal Ab that provides passive prophylaxis against RSV (Who do you think gets this? Premature babies)
- Ribavirin, which is a synthetic nucleoside analog with activity against RSV is usually reserved for severely ill or immunocompromised patient and given by inhalation
- Presentation of Bronchitis? 3
- PE? 1
- CBC? CXR?
- What is the cause most of the time?
- The presence of mucopurulent sputum does not imply a bacterial infection. What is it? 2
- ***URI symptoms with cough and malaise
- Coarse bronchial sounds (diffuse rhonchi not like pneumonia)
- WBC normal, CXR clear (if you feel you need to do this probably just prescribe antibiotics)
- Most of the time it is viral!
- due to the presence of
- -desquamated bronchial epithelial cells and
- -live/dead white blood cells!
- Most cases in children what is the cause?
- Unable to predict which cases are viral so we treat with what? 3
- Viral pneumonia often with prodrome of what four things?
- Bacterial pneumonia presentation more what than viral?
- Often presentation is what 4 things?
- When would we want to admit them? 3
- viral
- antibiotics, plus hydration/rest
- rhinorrhea,
- cough,
- low-grade fever, and
- pharyngitis (this is what confuses things)
- abrupt!
5.
- high fever,
- cough,
- chest pain, and
- shaking chills
- dehydrated,
- O2 sats,
- will their parents take care of them right,
Things to ask on followup call for pneumonia?
4
high fever
cant breath well
cough is worse
vitals
Symtpoms in new borns for pneumonia
4
- poor feedings
- irritable early, stoic late
- tachypnea,
- vitals
Most common infections in new borns? 3
3 months later, what is the most common infection? 1
Adolescent most common infection?
Group B strep
Listeria
Gram Neg (e. coli, klebsiella)
After three months, strep pneumo
walking pneumonia (mycoplasam)
Pneumonia is a wide spectrum disease
1. In some cases________ may be the only sign of underlying pneumonia
2. Elevated ___
CXR- Much more variable than with adults, don’t often see a classic ____ __________.
- tachypnea
- WBC
- lobar consolidation
What is different about viral Pneumonia on a chest X-ray?
no consolidation
- Treatment considerations for pneumonia? 3
- What if the patient is wheezing?
- Prognosis?
- What will determine if they need to be admitted?
- Antibiotics
- Fluids,
- oxygen therapy if they are less than 95
- Bronchodilators
- in immunocompetent is excellent
- Severity of presentation will determine whether hospitalization is in order
Pertussis (Whooping Cough)
Making a comeback
1. Caused by?
2. How contagious is pertussis?
- Can we exclude the disease if the pt is vaccinated for pertussis?
Why or why not? - The danger with pertussis is in the small infant. Why?
- **Duration?
- What should we look for ion the History?
- What kind of antibiotics should we treat with?
- Bordetella pertussis
- Highly communicable disease
- Not all individuals will seroconvert with vaccination.
- Many will lose immunity over time
- The infection is not what kills but the respiratory distress from the coughing
- 4 – 12 weeks
- cough for a looooong time that makes you vomit you cough so hard
- Macrolides: Azithro (doesnt really make the coughing shorter but will make you noncontagious)
Pertussis (Whooping Cough)
Describe the onset and progression of pertussis?
(early 3 to late 2)
Onset is insidious.
Early: starts as
- URI symptoms and
- slight fever may be present,
- cough is initially irritating but not paroxysmal
After about 2 weeks,
- coughs become paroxysmal with classic “whoop” (this stage lasts 2-4 weeks)
- The coughing can be harsh enough to cause vomiting
Pertussis (Whooping Cough)
Guidelines for Diagnosis
- Whats the first thing we should do?
- Classic Presentation for Pertussis?
- What lab tests should we do to diagnose pertussis? 2
- What do we have to do with the results of this test?
- Ask about immunization status!
- whooping sounding cough for more than 2 weeks
- -Nasal swab for culture (Bordet-Gengou culture medium)
- -Nasal swab for PCR more sensitive
- Sent to State Lab
Results in 3 to 7 days
Pertussis (Whooping Cough)
1. Treatment? 2
1.
Erythromycin for 14 days
Azithromycin for 5 to 7 days
If there is a little kid what do we immediately need to think of?
is there an organic failure to thrive because we are missing something- think bigger than just infection
Cystic fibrosis:
1. What causes the failure to thrive? 3
- What is a common side effect for Tobramycin? 2
- Does Tobramycin cover Strep Pneumoniae?
- Is there a problem with using Ciprofloxacin?
- How prevalent is sinusitis in the Cystic Fibrosis population?
- lungs are full of muscous/
huge metabolic cost to overcome this.
Also is fighting the URIs - Ototoxicity and Nephrotoxicity
- Covers pseudomonas but not strep pneumo. Probably also whnt to use a beta lactam/augmentin
- Cant use cipro in kids
- Very common/Lots of nasal polyps too
- How is CF acquired?
- What is it a disease of?
- Describe this.
- Autosomal recessive inheritance
- Disease of the exocrine gland system
- Defective chloride channel results in highly viscous secretions
Theory is that the decrease in chloride secretion leads to what?
2
- relative dehydration and
2. abnormal mucociliary clearance
- What is the difference between endocrine and exocrine glands?
- What does autosomal recessive mean and what is the rate?
- Exocrine glands reach an epithelial surface and are associated with external secretion (external secretion means ducts) of a gland whereas
an endocrine gland is one that secretes directly into the bloodstream
- -Both parents must at least be a carrier and the rate is about 1 in 32 adults
What are the clinical features of CF? 2
Respiratory insufficiency
Pancreatic insufficiency
What processes in CF will contribute to Respiratory insufficiency?
4
- Pulmonary fibrosis
- Obstruction
- Frequent infections
- Chronic sinusitis
What processes in CF will contribute to Pancreatic insufficiency?
4
- Malabsorption of fats and proteins
- Failure to thrive
- Rectal prolapse
- Intussusception
Malabsorption of fats and proteins causes what in CF?
2
- -Steatorrhea
- -Meconium Ileus—CF
What will the stool look like with intussusception?
current jelly stool
Diagnosis of CF
6
- IRT Assay
- DNA Assay
- Sweat Chloride Test
- Typical pulmonary features
- Typical gastrointestinal features
- ⊕ Family history
CF: Treatment Options
Pulmonary? 4
Pancreatic? 3
- Bronchodilators
- Mucolytics (acetylcysteine)
- Steroids
- Antibiotics (ALWAYS have to cover pseudomonas)
- Pancreatic enzyme supplements
- Vitamin supplements
- High-caloric high protein diet
What is the primary morbidity in CF?
progressive obstructive lung disease
How is CF diagnosed at birth?
What other abnormal GI signs would point to CF? 2
What are two other common ways infant CF pts are diagnosed? 2
Often diagnosed in hospital at birth (17%) because of meconium ileus (***must be suspected if meconium not passed in 24 hours).
Signs include
- abdominal distention and
- thick, sticky meconium with enema examination
- with failure to thrive,
- respiratory compromise, or both
- Respiratory Distress Syndrome of the Newborn. Common problem in preterm infants. What makes a baby preterm?
- When do lungs develop in the fetus?
- RDS is a deficiency in what?
- Anything less than 36 weeks
- Lung development in 28-30 weeks
- Deficiency in pulmonary surfactant (relieves surface tension)
Cause of major morbidity/mortality in preterm infants
Respiratory Distress Syndrome of the Newborn:
What three things are affected?
3
- Immature Lung Development
- Pulmonary Surfactant
- Prematurity
Describe the pathopysiology of RDS?
5
- Surfactant deficiency
- Inflammation
- Pulmonary edema
- Pulmonary function
- Hypoxemia
RDS clinical manifestations?
5
- Tachypnea
- Nasal flaring
- Expiratory grunting
- Accessory muscle breathing
- Cyanosis
RDS clinical course?
3
What do we treat with? 2
- Progress over 48-72 hours
- Marked diuresis
- Treatment has greatly improved pulmonary function
- Antinatal glucocortiod
- Exogenous surfactant
- Oxygen/CPAP
How do we diagnose RDS?
3
Clinical picture of a premature infant
- CXR (ground glass appearance, air bronchogram, atelectasis)
- ABGs (hypoxic, give oxygen, CPAP)
- Hyponatremia
Preterm babies born earlier than what weeks of maturity are at the highest risk?
28 weeks and lower at greatest risk
In prep for breathing what would a normal fetus start to produce?
surfactant.
What disease process does lack of surfactant and alveolar collapse cause?
Atelectasis
Lung collapse and fluid lead to infection and pneumonia.
Really sick baby.
Whats the other name for RDS?
hylaine cartilage disease
What does this baby need if they are born in FEB?
Synergist
