Pediatric pulmonolgy Flashcards
Epiglottitis
acute inflammation in the supraglottic region
Who gets epiglottitis
typically kids <6 months
rare in the US
Why type of kids are at risk for epiglottitis
they are not fully immunized
What causes epiglottitis?
- strep pyogenes
- strep pneuo
- staph
- H flu (less likely in pedi)
Clinical presentation of epiglottitis
Rapid onset
- muffled voice
- drooling!
- pain
- labored breathing
- tripodding
What is the tripod position
- neck hyperextended
- mouth opened
- chin up sniffing
- leaning forward
- outstretched arms
Late findings of epiglottitis
- air hunger
- stridor
- restlessness
Pre apnea–> coma–> death
Diagnosis of epiglottitis is what
Clinical suspicion!!!!
can do xray–> look for thumbprint sign
If you have clinical suspicion of epiglottitis–>
ANESTHESIA
if in office, call ED and EMS
What do you do before anesthesia arrives in a child with epiglottitis
- keep patient calm and quiet
- O2 if tolerated
- establish 2 lines if tolerated
Treatment of epiglottitis
- intubation
- IV abx (ceftriaxone, cefotaxime)
- supportive care
Is epiglottitis contagious
NO!
but if unimmunized or immunosuppressed family contacts consider ppx (rifampin)
What is croup
subglottic inflammation of the larynx and trachea
Etiology of croup
typically viral
Who gets croup
- children 3 months to 5 years (2 is peak)
- males slightly more often than females
When is croup typically seen
- in fall and spring
- between 10pm and 4am
Virus that causes croup
- parainfluenza 1,2,3
- influenza A or B
- adenovirus, RSV
Symptoms of croup. When do they occur?
day 0-2
- rhinorrhea
- low grade temp
- +/- cough
- +/- pharyngitis
Day 0-5
- barking cough
- +/- stridor
How long does it take croup to resolve
5-7 days
When does the course of croup worsen
day 2 and 3 of the barking cough
Diagnosis of croup?
clinical diagnosis!!
When do you do outpatient treatment for child with croup? What is it?
mild or moderate croup- no stridor
Decadron (IV solution given orally)
Treatment for moderate to severe croup
- decadron
- racemic EPI by neb
- watch for 2 to 3 hours and watch for recurrence
- if you need to give another dose consider admission
At home mild croup treatment
- cold night air
- humidified air
- breathe air from air conditioning or freezer
Resolution of croup
within 5 to 7 days
What is bacterial tracheitis
bacterial infection of the trachea that can cause complete respiratory failure by blockage of the trachea with swelling and purulent drainage
Bronchiolitis
inflammation of the lower respiratory tract
Who gets bronchiolitis
kids less than 2 years old
Which kids with bronchiolitis are at the greatest risk for morbidity/mortality
- kids with underlying cardiopulmonary disease
- kids <2 months are at risk for respiratory compromise
What causes bronchiolitis
- > 50% caused by RSV
- viral–> parainfluenza and adenovirus
- Bacterial–> mycoplasma
What causes the symptoms seen in bronchiolitis
inflammation fo the bronchioles, secretions into the inflamed bronchial tree
What is the typical presentation of bronchiolitis
- begins with URI (copious clear rhinorrhea, congestion, low grade fever)
- wheezing +/- crackles
When is bronchiolitis most commonly seen
late fall throughout winter
How is bronchiolitis spread
respiratory droplets
Vitals in child with bronchiolitis
- fever (up to 102)
- tachycardia
- tachypnea
- respiratory distress
Lung sounds in bronchiolitis
- wheezing
- rhonci or fine rales
If decreased breath sounds in bronchiolitis patients–>
BAD
When do you preform a nasal washing to do a PCR for RSV
- pt <2 to 3 months or has underlying risk factors
- if you will hospitalize pt
- if youre in the ED and the pcp or hospitalist asks you!
When should you do a CXR in pt with suspected bronchiolitis
if it is first episode of wheezing ever–> look for foreign body
Treatment for bronchiolitis
- albuterol
- cool mist
- PO steriods (decadron, prednisolone)
- supportive treatment (fluids, tylenol)
When should a patient with bronchiolitis be hospitilized
-if hypoxic
awake <91-93%
asleep <91%
- apneic episodes
- premie <12 weeks
- NB to 12 weeks and any suggestion of resp distress
- underlying cariopulm disease
- parents unable to care for child
ANY CHILD THAT IS WORRISOME
Inpatient bronchiolitis treatment
- oxygen support
- consider CPAP or high flow O2
- intubation if impending respiratory failure
What is the course of bronchiolitis
- gets worse days 2 to 5
- last for 10 to 12
RVS vaccine prophylaxis
Synergis
Pediatric asthma–>
spacers! spacers! spacers!
Does wheezing always equal asthma
NOPE
Making the diagnosis of asthma
- demonstration of variable episodic expiratroy airflow limitation that is reversible
- exclusion of other reasons for the finding
If a child presents with first time wheezing can you say they have asthma
NO, reactive airway disease
Symptoms of asthma
- dry cough
- wheezing
- possible breathlessness, chest tightness, chest pain
Symptoms pattern with asthma
- intermittant w/ asxs at baseline
- chronic with periods of worsening
- worse in the morning (“morning dipping”)
Asthma triggers
- seasonal allergies
- houshold allergies
- URIs
- exercise
- weather
- stress
- perfumes, hair spray, cleaning products, paint
Atopic illness?
- asthma
- atopic dermatitis
- food allergies
- allergic rhinitis
What causes pertussis
- bortadella pertussis–> epidemic pertussis
- para pertussis–> sporadic pertussis
What is bortadella pertussis
gram negative coccobaccilus that colonizes the ciliated epithelium
How is pertussis spread
through the air by infection droplets from respiratory mucous membrane
*highly contagious
How long is the incubation period for pertussis
3-12 days
Stages of pertussis
- catarrhal stage
- paroxysmal stage
- conval
What stage of pertussis is most contagious
catarrhal stage
What classifies each stage of pertussis? How long does it last?
Catarrhal stage: 1 to 2 weeks: runny nose, sneezing, low grade fever and mild cough
Paroxysmal stage: 1 to 6 weeks: burst of numerous, rapid coughs followed by a long inhaling effort characterized by a high pitched whoop
Convalescent stage: can last for months: paroxysms may recur whenever the patient suffers any subsequent respiratory infection
Children or infants with paroxysms may have what types of thing
- respiratory distress
- tongue protruding
- face turning purple
- eye bugling
- watery eyes
- post tussive emesis and exhaustion
Pertussis in adolescents and adults
- typically milder
- persistent cough similar to that found in other URIs
- have the cough in paroxysms without or without he “whoop”
Diagnosis of pertussis
Clinical!–> if suspiscious, treat and watch for results
can do nasopharygneal swab
Treatment of pertussis
Zithromax 10mg/kg on day 1 then 5mg/kg days 2-5
supportive care
Mild complications of pertussis
- ear infection
- loss of appetitis
- dehydration
- pneumonia
- rib fracture
More severe complications of pertussis
if hypoxic from paroxysm–> encephalopathy and seizures
Are there usually complications of pertussis
nope!
Partial airway obstruction=
stridor
Airway obstruction=
silence
No airway=___=___=___
no airway =no oxygenation= no ventilation= tissue death
Most FBA in infants and toddlers
food–> peanuts
What causes fatal aspiration
- balloons
- balls
- marbles
- toys
anything strong, round and unbreakable
Where does the FB lodge in kids
proximal mainstem bronchus
When should you suspect a FB aspiration in a kid
- witnessed choking event
- wheezing
- formerly speaking and wont speak
- coughing without URI symptoms
Acute and life threatening foreign body aspiration has what symptoms
- respiratory distress
- cyanosis
- altered mental status
Symptoms of less acute and not emergent life threatening FBA
Classic triad!
- wheezing
- decreased air entry especially regionally
- cough
Diagnosis of FBA
History!
Bronchoscopy is diagnostic tool and treatment
+/- xray
When do you do a flexible bronchoscopy for diagnosis of FBA
- chronic or recurrent pneumonia
- chronic cough
- can remove object
When do you use a rigid bronchoscopy for diagnosis of FBA
-if you suspect a non emergent FBA
- anesthesia required
- less risk of dislodgement
Complications of FBA removal
- dislodgement or breakage w/ advancement into bronchioles or lings
- infection if fb is in too long
- inflammation
What is cystic fibrosis in its simplest form
genetically driven disruption of the chloride channel
Which protein affected in CF? What does that protein typically do
CFTR protein–> complex chloride channel and regulatory protein found in exocrine tissue
CF causes viscous secretions where
- lungs
- intestine
- pancreas
- liver
- reproductive tract
What happens to sw3eat gland secretions in CF
increased salt content
Respiratory features of CF
- persistant productive cough
- hyperinflation of lungs on cxr
- PFTs consistent with obstructive airway disease
Progressive respiratory symptoms of CS
- chronic bronchitis
- bronchiectasis
- increase cough/sputum-tachypnea
- malaise
- anorexia and weight loss
- clubbing
What colonizes in the lungs of CF patients
- staph aureus
- h flu
- pseudomonas
Extrapulmonary clinical features of CF
- panopacification of sinuses
- nasal polyposis
Pancreatic features of CF
- exocrine function typically insufficient
- insufficient digestive enzymes–>malabsorption–> FTT, electrolye abnl, anemia
+/-glucose intolerance or CF related DM
What is an important early clinical feature of CF
meconium ileus and distal ileal obstruction in newborns
Distal intestinal obstructive syndrome–> seen in sicker CF patients
Billiary issues for CF
- focal billiary cirrhosis caused by impissated bile
- hepatomegaly
- aymptomatic liver disease
- cholelithiasis
Muscluoskeletal manifestations of CF
- reduced bone mineral content
- hypertrophic osteoarthropaathy
- clubbing of fingers and toes
What is needed to make diagnosis of CF
- clinical sxs in at least one organ system
- evidence of CFTR dysfunction on any one of the following tests (sweat chloride, presense of 2 disease causing mutation, abnormal nasal potential difference)
Classic CF
- disease in or or more organ systems
- pt has elevated sweat chloride
Non-classic CF
- meet disease criteria in one or more organ systems with normal or borderline sweat test
- requires DNA analysis for dx
- more common in adults and older adolescents–> milder
Clinical features that make you suspicious of CF
- chronic reproductive cough
- recurrent upper and lower resp infections
- hyperinflation on CXR
- PFTs that show obstructive disease
Newborn screening for CF
measure levels of immunoreactive trypsin on dried blood sample
confimred by DNA or sweat tsting
Primary test for dx of CF?
sweat test
How is a sweat test done
by applying pilocarpine iontophoresis and determining the chloride concentration in the resulting sweat chemically
When is a sweat test done
if positive new born screen
meconium ileus after DOL 2
When is molecular dx done for CF
on all pts w/ intermediate sweat test results
prognostic and epidemiologic interest
How many mutations are screened when testing for CF
23
pt has to have at least 2 to be considered positive for CF
Infants at risk for RDS
born before 30 weeks
When does formation of alveoli begin
24 weeks
The majority of RDS infants are born before when
28 weeks
Etiology of RDS
surfactant deficiency–> atelectasis–> V/Q mismatch–> pulmonary inflammatory response–> potential lung injury and pulmonary edema
Clinical manifestation of RDS
- tachypnea
- nasal flaring
- expiatory grunting
- retractions
- cyanosis/pallor
- decreased breath sounds
- diminished peripheral pulses
- peripheral edema
- poor urine output
ARD on chest xray
- airbronchograms
- low lung volume
- ground glass appearance
- pneumothorax
Ways to prevent RDS
- antenatal corticosteriods
- exogenous surfactant
- assisted ventilation
Who gets antenatal corticosteriods
pregnant women at risk of delivery before 34 weeks
When is eogenous surfactant given to infants
preterm infants with resp distress/apnea/ fail cpap
given through ET tube
Positives of mechanical ventilation in ADS babies
- PEEP corrects atelectasis and give route for exogenous surfactant
- improves arterial oxygenation
Negative to mechanical ventilation in ADS babies
- traums by volume adn pressure
- oxygen toxicity
- intervention can lead to BPD
- intubation injury
New ventilation for RDS?
- nasal CPAP
- NIPPV
Other things to think about for RDS babies
- thermoregulation
- fluid management
- cardiovascular management
- nutritional support
