Pediatric Lung diseases Flashcards
Causes of hypoxia
- Ventilation-Perfusion Mismatch (VQ)
- Hypoventilation
- Shunt
- Diffusion
- Extreme altitude
- Hemoglobinopathies
Compliance =
Minute ventilation =
change in volume/change in pressure
RR x VT
Signs of respiratory distress
1) tachypnea
2) retractions
3) accessory muscle use
4) shortness of breath (trouble talking/crying)
pediatric signs of respiratory distress
in addition to other signs…
1) lethargy
2) poor feeding
3) grunting (closing glottis before end of exhalation)
4) poor weight gain (incr energy and incr work)= chronic
Examples of
1) V/Q mismatch
2) hypoventilation
3) shunt
4) diffusion
5) extreme altitude
6) hemoglobinopathies
1) diffuse pneumonia = viral pneumonia/bronchiolitis
2) sedation/morphine = not breathing enough/deeply enough to clear CO2
3) VSD
4) IPF = thickened interstitium
5) extreme altitude (Denver doesn’t count)
6) methemaglobinemia (interrupt O2 uptake)
Differences in anatomy between children and adults
Difference between children and adult in airway size
Children =
1) higher and more anterior larynx
2) floppy epiglottis
3) weaker intercostals
4) flat diaphragm
1 mm change –> 16 fold incr in resistance (1/r^4)and change surface area
1) lethargy
2) poor feeding
3) grunting (closing glottis before end of exhalation)
4) poor weight gain (incr energy and incr work)= chronic
what do these signs indicate
pediatric respiratory distress
Case #1
Previously healthy 18 month old
2 days of LOW GRADE FEVER + runny nose + STRIDOR + progressively hoarse cough and increased work of breathing + RETRACTIONS
PMH: born full term, never intubated
PE: RR 30 oxygen saturation 97%
growth at the 50th %
croup
Signs and symptoms of upper airway obstruction
EXTRATHORACIC, OBSTRUCTION
1) stridor
2) severe obstruction = drooling, dysphagia, dyspnea
signs and symptoms OF upper airway obstruction
1) stridor
2) severe obstruction = drooling, dysphagia, dyspnea
problems in first 6 weeks of embryology
1) Pulmonary agenesis
2) Tracheoesophageal fistula= if trachea and esophagus
3) Vascular malformationà airway compression
4) Laryngomalacia
what is most common cause of chronic stridor
laryngomalacia
laryngomalacia
1) most common cause of …
1) presents by …
2) worse with
3) better
4) outgrown?
1) chronic stridor
1) 6 weeks
2) eating, crying, activity
= epiglottis floppy and cause OSA or obstruction of feeding –> surgery
3) prone = because epiglottis slips forward
4) outgrown by 1-2 years
Potential problems in 6-16 weeks (pseudoglandular)
1) Airway/Cartilage abnormalities:
Tracheobronchomalacia
congenital lobar overinflation
Assoc with recurrent wheeze (FROM ONE PART OF AIRWAY = MONOPHONIC SOUND), hoarse cough, recurrent illnesses (mucus caught behind closed airway)
below thoracic inlet –> thorax pulled apart so don’t collapse airway breathe in; only out (EXPIRATORY WHEEZE)
Upper airway differences between adult and newborn
In kids, tongue large
epiglottis = large, floppy, high in pharynx, touching soft palate
why is there upper airway difference between adult and newborn?
1) infants breathe through nose for sucking/swallowing
2) changes over 2 years as tongue drops/speech occurs
so upper airway = rpoblem
DDx of acute stridor
1) croup (laryngotracheobronchitis)
2) bacterial tracheitis
3) epiglottis
4) laryngeal foreign body
5) scalding
Croup
1) most common form of. …
2) etiology
3) course
1) acute airway obstruction
2) viral (parainfluenza)
3) mild
1) what are signs of foreign body
2) patient group?
3) treatment
1) acute onset cough + stridor + NO FEVER
2) toddler with small objects
3) BLS choking
3 year old who is not immunized with HIGH fevers and acute onset STRIDOR and increased work of breathing (sitting up and forward) + drooling
• PMH: born full term, never intubated (so no damage to airway)
• PE: RR 40 oxygen saturation 88%
growth at the 50th %
Laryngoscopy = epiglottitis
hypoxemic due to hypoventilation
–> takes lots of swelling in upper airway to cause hypoventilation to desaturate
Acute stridor and HIGH FEVERS
ddx (5)
- Bacterial Tracheitis
* Epiglottitis
Define epiglottitis
1) current etiologies?
unimm children
2) incidence peak when…
3) course…
4) how to treat
ALWAYS EMERGENCY 1) unimm = H flu B (usu vaccinated against) Group A strep supraglottis N. meningitidis supraglottis Noninfectious = hot liquid aspiration
2) 2-7 yrs
3) acute fever + stridor with worsening severe for 2-3 days
4) be nice to child
don’t startle or upset —> because narrow airway and can cause laryngospasm
Anatomy and size of ___ in kids and adult is different
upper airway
• 8 month born at 30 weeks presents to the pediatrician with a copious, clear runny nose, cough, fever to 100 and increased respiratory rate (>60 RR). She has taken only about 4 ounces today and has had no wet diapers.
+ EXPIRATORY WHEEZING
- ROS: She is growing well, normal development
- BH: needed oxygen at birth and went home on room air after 6 weeks in the NICU
• PE: Respiratory Rate: 60 (normal 90%)
Weight at the 50th%
CXR shows air trapping problem = lower airway
viral pneumonia or bronchiolitis given age under 1
Signs and symptoms of lower airway problems
1) hypoxemia
2) wheeze (airway) = large = monophonic wheeze, small= differential swelling in lung = polyphonic wheeze
3) crackles (alveoli)
Potential problems in weeks 16-26 (cannanicular)
kid just beginning to create alveoli (lungs still growing)
1) disruption of growth of diaphragmatic hernia or oligohydramnios (potter’s syndrome = renal agenesis) –> pulm hyperplasia
decr lung tissue, decr SA for gas exchange
histology of bronchopulm dysplasia
thickened interstitium and simplified lung structure
- -> now looks like bigger air sacs with fewer septa (surface area still small) with surfactant
- -> if saccular not developing, fewer alveoli and fewer capillaries
what makes infant chest walls made for vaginal delivery?
1) compliant thorax
2) weak intercostal muscles
3) horizontal ribs so hard to incr A-P diameter and tend to breathe faster
4) flat diaphragm so hard to incr tidal volume and breathe faster
Compliant chest walls and therefore less ___
negative pressure/outward recoil
less tidal volume change due to ___
diaphragm and rib mechanics
with less outward pull, small airways start to ____ at end exhaland –>
close
atelectaiss (airway collapse) at baseline
BPD causes…
Long term effects
1) abnormal oxygenation/ventilation at baseline
problem with viral illness or exercise
2) need for oxygen/ventilation, decr activity
3) decr surface area for gas exchange, incr O2 need
4) permanently thickened interstitium –> decr compliance, incr distress
ACUTE POLYPHONIC WHEEZE DDX
lower airways
1) viral pneumonia/bronchiolitis
2) cystic fibrosis
3) heart disease
4) aspiration pneumonia
5) asthma
describe viral pneumonia/bronchiolitis
1) most common cause of ….
2) syndrome includes…
3) caused by …
4) course
1) hospitalization in children
2) tachypnea, retractions, wheeze = mucus and swollen and collapse = hard to V/Q match
3) inflammation by bronchioles; viral (RSV)
4) variable
compensatory mechanism for bronchiolitis
1) nasal obstruction + decr compliance (stiff lungs = inflamm)
2) to maintain VE and minimize atelectasis,
a) early retraction –> incr TV
b) tacypnea –> incr RR
c) grunting (close vocal cords at end expiration to keep airways open)
- 2 year old girl born full term
- Growing normally
- She reports a history of recurrent cough and cough with activity
- She was given an inhaled beta agonist (albuterol) and improved
asthma
signs and symptoms of lower airway/parenchymal problems
1) hypoxemia
2) wheeze (airway)
3) crackles (alveoli)
DDX of wheezes in upper/central airways
1) foreign body
2) vascular ring or sling
3) laryngo/tracheo/bronchomalacia
DDX of wheezes in lower iarways
– Bronchiolitis – Cystic fibrosis – Bronchopulmonary dysplasia – Heart disease – Aspiration/GERD – Asthma
Most common acquired chronic pediatric airway disease …
asthma
Asthma
1) symptoms
2) improvmeent with …
3) caused by …
4) 90% of pediatric asthma is …
5) must be …
1) recurrent cough, wheeze, dyspnea worse at night or exercise
2) bronchodilator
3) narrowed bronchiole
4) allergic
5) recurrent and respond to bronchodilator
the ___ can help rule out asthma
asthma patients should not have …
physical
1) crackles
2) clubbing
3) failure to thrive
4) O2 requirement
airway changes with asthma
1) incr inflamm
2) bronchoconstriction
3) incr airway secretions
PFT’s in kids with asthma
1) FVC = 95%
FEV1 = 80% FEV1/FVC = 70
after bronchodilator
FEV1 = 95%
Risk factors for continued wheeze and asthma
1) wheeze with illness/exercise
2) allergic
3) parents with asthma
Risk factors for less likely to continue wheeze and asthma
1) wheeze with illness ONLY
2) no allergies
3) parents no allergies
• Isabelle is a 5 year old who is previously healthy and presents with cough and fever. She has had cold symptoms for 4-5 days and now has fevers to 102 and cough. She is complaining of abdominal pain.
Physical Exam
• VS: RR 45, HR 120, Oxygen saturation 85% • PE:
– Increased work of breathing with mild retractions
– Crying and therefore difficult exam but decreased aeration right vs. left
– Could not examine belly
V/Q mismatch
= RLL infiltrate pneumonia
Normal HR, RR at age
less than 1
1-2
2-5
less than 1 = 30-60 RR, 100-160 HR
1-2 = 24-40; 90-150
2-5 = 22-34, 80-140
Treatment for pneumonia
for 0-3 months
over 3 months
0-3 months= admission for IV
ampicillin IV and aminoglycoside IV for widespread
> 3 months = determined admission based on hypoxemia and work of breathing
amoxicillin
Case #7
• 11 year old Latina girl moves to Colorado from Mexico. She was born full term and has a history of recurrent pneumonia and poor growth. She has severe limitation of her activities.
• Physical exam: RR 40 Saturation 80% weight and height less than 5th%
– Crackles heard throughout her chest – Significant clubbing noted on exam
cystic fibrosis
DDx of recurrent pneumonia
Lower Airways disease – Immunodeficiency – Aspiration pneumonia – Cystic Fibrosis – Airway anomalies – Airway compression – Foreign Body – Chronic infection (TB) – Poor mucous clearance (neuromuscular)
DDx of poor growth
1) poor absorption
2) poor intake
3) metabolic use (incr work of breathing)
CF
1) most common in which race
2) caused by…
3) inheritance
1) caucasian
2) mutation in CFTR (defective ion transport in epith cells) = movement of salt and water into and out of cells –> thick mucous
3) AR
organ dysfunction
1) sinusitis
2) pancreatic exocrine insufficiency
3) diabetes
4) meconium ileus
5) constipation
6) infertility
recurrent infections from bacteria in mucus
neutrophils release elastase, –> bronchiectasis
end stage lung disease in CF
1) bronchiectasis
2) fibrosis
3) infection/inflamm
4) mucus plugging
current treatments for CF
1) airway clearance = flutter
2) antibiotics
3) inhaled mucolytics = hypertonic saline and DNAse to remove sticky DNA and clear mucus; salt hydrating airway
4) bronchodilators
5) enzyme replacement
6) A, D, E, K vitamins
7) antacids, acid blockers
what does this kid have?
croup > 4 or 5 y/o with bigger airway and high fevers —>
why is it so high mortality
bacterial tracheitis
extra pus accumulating rather than just isolated to epiglottis –> throughout airway
–> till have pus below ET tube and lower airways
can cause complete obstruction
==> pus can go into alveoli –> ARDS
in children with Potter’s syndrome,
severe pulmonary hypoplasia.
due to renal agenesis or leaking fluid. In renal agenesis, as you know, fetal urine is a large component of amniotic fluid and if the fetus does not have kidneys and therefore has oligohydramnios or too little fluid, then the child cannot swallow and inhale the fluid. Inhaled amniotic fluid drives pulmonary development and too little fluid leads to pulmonary hypoplasia.
smaller outward negative pressure —> FRC below closing volume so part of lung is
collapse (worse with more mucus —> start closing off glottis with inflammation
(ending breath sooner to hold
everything open)
a
Pathophysiology with premature bronchopulmonary dysplasia
1) decr surface area for gas exchange –> incr O2 need
2) permanently thick interstitium –> decr compliance and incr resp distress
–> hospitalized
