Pediatric pulmonary Flashcards
Infant Respiratory Distress Syndrome is primarily seen in?
- premature infants under 36 weeks
- infants of diabetic mothers
- multifetal pregnancies
- c-section
- family history
primary cause of RDS?
Surfactant deficiency
RDS signs within minutes of birth:
- tachypnea
- grunting
- intercostal and subcostal retractions
- nasal flaring
- duskiness
RDS Physical exam:
- diminished breath sounds
- falling BP
- Pallor
- Progresses to: Apnea and mixed responses/metab acidosis
RDS Diagnosis:
- clinical
- CXR- ground glassappearance
- ABG
RDS DDx:
Early onset sepsis
- pneumonia
- cyanotic heart disease
- persistent pulmonary HTN (normal X-rays with this)
- Transient tachypnea of newborn (very common)
Infant RDS prevention:
*Beta methasone 48 hours prior to delivery between 23 – 34 weeks (speeds up production of surfactant)
Should be administered to all pregnant women at 23 – 34 weeks gestation who are at increased risk of preterm delivery within the next 7 days to prevent or decrease the severity of neonatal RDS
Infant RDS:
- Careful and frequent monitoring
* Warm humidified O2 to keep arterial levels between 55 – 70 (sats >90%)
infant RDS Tx:
*If intubation needed at birth – infant should be given surfactant after initial stabilization
*nCPAP with selective use of intubation and surfactant therapy vs. routine intubation with prophylactic or early surfactant administration
Rescue surfactant for infants with hypoxic respiratory failure attributable to secondary surfactant deficiency
Bronchiolitis:
- inflammation of bronchioles- usually from viral infection
- ***most common lower respiratory tract infection in infants and children <2 yo
- Most common causative agents: RSV Respiratory Syncytial Virus and adenovirus, human metapneumovirus, influenza, and para influenza
Bronchiolitis Dx:
- Hx and PE
- Labs and radiological studies not recommended
Bronchiolitis presentation:
- recent URI Sx’s: *rhinorrhea
- Lower respiratory findings: *cough, *Tachypnea, *Increased Respiratory Effort
- *Elevated RR- *earliest and most sensitive sign
- nasal flaring, grunting
- tachycardia due to dehydration and hypoxemia
- apnea in very young infants
Bronchiolitis Course:
- Illness severity- determined by RR, work of breathing, hypoxia
- Characteristic pattern- worsening clinical symptoms- peaking at 3-4 days of illness
Bronchiolitis Dx studies:
- not routinely recommended
- CXR- hyperinflation, atelectasis, infiltrates, findings do not correlate with disease severity and don’t not guide management
- Childeren > 60 days with fever - low risk of serious bacterial infection
- Children <60 days with fever- evaluate for sepsis
Bronchiolitis management:
- hydration
- pxygenation
- nasal suction
- influenza antivirals
- Ribavirin- in severe cases
Bronchiolitis prognosis:
-most recover without sequelae
-40% recurrent wheezing through age 5
-10% wheeze after age 5
-
Leading cause of infant death from viral infections?
Respiratory Syncytial Virus (RSV)
by what age do most children have rsv by?
2
RSV can happen isn any age and it appears as what?
common cold/ minor URI
-dangerous in elderly
RSV in boys verse girls.
1.5:1 in boys
incubation of rsv
4 days
how is rsv spread?
- large droplets
- remains on surfaces for days
- high risk of nosocomial infection
RSV clinical manifestations?
similar to bronchiolitis
who’s is most at risk for RSV?
Congenital heart disease with increase pulmonary bloodflow
Chronic lung disease, i.e. cystic fibrosis
Premature infants less than 6 months old (especially those with chronic lung disease)
RSV labs:
- rapid antigen tests
- diagnosis doesn’t alter tx course, more useful at beginning of season to see what RSV has started
RSV complications:
- otitis media
- bacterial pneumonia
RSV prevention:
- washing hands
- respiratory/ contact isolation
- cohort care
- avoid exposure to tobacco smoke
- Synagis
Synagis-
-costly
-Infants born at less than 29 weeks in their first year of life
Infants born at less than 32 weeks with O2 requirement for at least 28 days after birth (Chronic Lung Disease
Infants less than 24 months of age with CLD still requiring medical intervention
Other categories based on risk factors
Pediatric Asthma:
- Chronic inflammatory condition of the lung airways resulting in episodic airflow obstruction
- environmental, biological,andgenetic vulnerabilities
Asthma Epi.
- Male>Females
- African-American>non African-American
- More common in lower SES
- One of the most common causes of ED visits
- 80% of all asthmatic patients report disease onset prior to 6yo
Asthma with recurrent wheezing:
- Early Childhood
- Triggered by viral infections or upper airway
Chronic asthma:
- associated with allergy
- presists into late childhood and adulthood
Asthma Clinical manifestations:
Intermittent dry coughing and expiratory wheezing
SOB and chest tightness in older children
*Symptoms worse at night
Asthma triggers:
Physical exertion Hyperventilation (laughing) Cold or dry air Airways irritants Inhaled allergens
Asthma physical findings:
Expiratory wheezing, prolonged expiratory phase
Decreased Breath Sounds (regional hypoinflation due to airways obstruction)
Retractions, accessory muscle use
Asthma DDx:
*GER (gastroesophageal reflux)
Rhinosinusitis
Recurrent aspiration, tracheobronchomalacia, congenital anatomic abnormality of the airways
Asthma Tx:
-NIH guidelines
-*Regular Assessment and Monitoring
Patient Education (triggers, bad times of your, what to do in asthma attack)
Control of Factors Contributing to Asthma Severity
Principles of Asthma Pharmacotherapy
Asthma assessment and monitoring:
Assessing severity (intrinsic intensity of disease) *Intermittent *Persistent – mild, moderate, severe Degree to which symptoms, ongoing functional impairments and risk of adverse events are minimized and goals of therapy are met 3 levels of control Well-controlled Not well-controlled Very poorly controlled
asthma pt education:
Basic education about the pathogenesis of asthma Expectations of good asthma control Written asthma management plan Daily routine plan Action plan to manage worsening asthma
controlling asthma severity:
*Eliminating and reducing problematic environmental exposures
Minimize allergen exposures
Remove airway irritants – tobacco smoke, dusts, strong odors
Treat co-morbid conditions – GER, sinusitis
2 acute inflammatory upper airways obstruction:
Croup (laryngotracheobronchitis)
Epiglottitis
Croup clinical manifestations:
*URI symptoms for 1 – 3 days before the symptoms of upper airway obstruction
barky cough, hoarseness, inspiratory stridor
*Worse at night
Crying and agitation aggravate symptoms and signs
Occurs in 3 month – 5 years of age, peak in second year of life
Croup Epi:
Usually due to parainfluenza viruses (75%)
Also: influenza, RSV, adenovirus
Seen in 3mo – 5 year olds with peak in 2nd year of life
Boys > girls
Usually late fall and winter
Croup Dx:
- clinical
- steeple sign on X-ray if done (slide 55)
Croup airway management:
Usually managed at home
Cool mist
Steamy bathroom for exacerbations
Croup hospital/ED management:
Nebulized racemic epinephrine
Corticosteroids
When to hospitalize for croup:
Progressive stridor Severe stridor at rest Respiratory distress Hypoxia Cyanosis Depressed mental status
Croup - acute
*Always associated with viral illness of upper respiratory tract
Croup - spasmodic (recurrent)
- Allergic component
* Resolves rapidly with treatment
Acute Epiglottitis:
Acute, fulminating course of high fever, sore throat, dyspnea, rapidly progressing respiratory obstruction
Much less prevalent nowadays since introduction of HiB vaccine
-seen in unimmunized
Acute epiglottis clinical manifestations:
-Tripod position
-Otherwise healthy child suddenly develops a sore throat and fever (they look sick)
Within few hours – toxic appearing, difficulty swallowing and breathing
Drooling
*Stridor is a late finding and suggests near-complete airway obstruction
Epiglottis Dx:
Visualization of a large, “cherry-red” swollen epiglottitis
Should occur in controlled environment – i.e. operating room
Should only be performed by someone capable of maintaining airway – i.e. ENT or anesthesiologist
-*do not agitate child, leave in parents lap to examine
Epiglottitis management:
*Establish an airway – intubation
*As many as 6% of children without an artificial airway die
Oxygen
Culture blood, epiglottis
Antibiotics
Ceftriaxone, cefixime or combo of ampicillin and sulbactam
DDX of acute inflammatory upper airway obstruction:
*Diphtheric croup
*Aspiration of foreign body (no feer, not sick)
Retropharyngeal or pertonsillar abscess
Extrinsic compression of the airway (laryngeal web, vascular ring) (usually not acute onset)
Pertussis:
Whooping cough
Bordetella pertussis
Prevented by pertussis vaccine
Pertussis clinical manifestations:
6 week course Catarrhal Incubation period 3 – 12 Nondistinctive symptoms of congestion and rhinorrhea -6 week course continued *Paroxysmal Cough at first is dry, intermittent, irritative hack Evolves into inexorable paroxysms – hallmark of the disease Number and intensity of paroxysms progresses over days to a week and then plateaus for days to weeks Convalescent Slow resolution of paroxysmal episodes Infant with pertussis Infant in ICU with Pertussis Child with pertussis Toddler with whooping cough -***kids under 3 months, do not whoop***
Pertussis Dx:
Suspect in patient who has predominant complaint of cough *especially in the absence of fever, malaise, myalgia, exanthema or sore throat
- Leukocytosis with absolute lymphocytosis
- Culture is gold standard, but do not wait on results to treat*
- Reportable disease
Pertussis Tx goals:
- Limit number of paroxysms, observe the severity of cough, provide assistance when necessary, maximize rest and recovery
- Antimicrobial agents – Erythromycin or azythromycin*
Pertussis and antibiotics:
may ameliorate disease in catarrhal stage, will not alter course in paroxysmal stage but will limit spread*
When to hospitalize with pertussis:
- Infants under 3 months of age
- 3- 6 months with severe paroxysms
- Premature infants or children with underlying cardiac, pulmonary, muscular or neurologic disorders
Pertussis Complications:
- Mortality – 1 % in < 2 month olds
- Hospitalization
- Pneumonia
- Seizures
- Apnea
- Secondary infections
Pertussis prevention:
Vaccine
