Pediatric Pulmonology Flashcards
What happens in acute epiglottitis?
Inflammation of supraglottic region (epiglottis, vallecula, arythenoids, aryepiglottic folds)
Acute epiglottitis typically occurs in kids age ____. Why?
<6mo. Not fully immunized
Acute epiglottitis is typically caused by what organisms (3)
- S. pyogenes (strep throat)
- Stre. pneumonia
- Staph
Presentation of epiglottitis
- Mild sore throat and fever → rapidly turns into respiratory distress
- Drooling, tripoding (impending doom)
- Stridoer (late finding)
Dx epiglottitis
Clinical suspicion - pts tend to deteriorate before imaging can be done
If you were doubtful of epiglottitis and just needed to rule it out, what diagnostics/imaging could you get? What would you see if it was positive?
- Lateral neck film → thumb print sign
- Direct visualization via intubation/endoscopy
Management of epiglottitis
- Anesthesia STAT for intubation → if office setting, call EMS then ED to have anesthesia on standby
- Keep child calm/quiet
- O2, IV access if tolerated
- IV ceftriaxone or cefotaxime
- INTUBATION for 2-3 days while abx take effect
Is epiglottitis contagious?
No BUT the causative organism is
Your pedi pt has epiglottitis, should mom be worried about it spreading to the rest of the fam?
Epiglottitis isn’t contagious but causative organism is → consider rifampin ppx if non-immunized/immunocompromised or <6mo without complete HIB vaccine
What happens in croup?
Inflammation of subglottis region (trachea, larynx)
Etiology of croup
Parainfluenza 1-3 virus
Common age of croup pts
3mo-5yo
When do you usually see croup?
Spring/fall
10pm-4am
What is pathognomonic for croup?
Barking cough
Presentation of croup
- Days 0-2 → URI sx’s (rhinorrhea, low-grade fever, +/- cough/pharyngitis)
- Days 0-5 → barking cough +/- stridor
How long does croup usually last?
5-7 days
Croup tends to worsen on days ________
2-3
Diagnosis of croup
Clinical dx
Tx mild-moderate croup (i.e. no stridor)
- IV dexamethasone (Decadron) given PO
- Cold night air
- Humidified air
- NO abx
Dosing for dexamethasone (Decadron) for croup pt
IV solution given PO
0.6mg/kg x1 → max 10-12mg
Tx mod-severe croup (i.e. stridor)
- Emergency Department
- IV dexamethasone (Decadron) given PO
- Racemic Epi via neubilizer prn
If racemic epi doesn’t work for croup, what should you consider?
- Continuous racemic epi after 2nd dose
- IM epi
- Consider transfer to ICU
What happens in bronchiolitis?
Inflammation of lower respiratory tract with secretions into inflamed bronchial tree
Pts at greatest risk for morbidity/mortality with bronchiolitis
- <2mo
- Cardiopulmonary disease → preemies, asthmatic, immunocompromised
Etiology of bronchiolitis
RSV (>50%)
Presentation of bronchiolitis
- Begins with URI (rhinorrhea, congestion, low-grade fever)
- Wheezing
When is bronchiolitis commonly seen?
Late fall and throughout winter
Bronchiolitis worsens on day______
2-5
Bronchiolitis usually lasts _____
10-12 days
Prognosis of bronchiolitis
40% will have wheezing again
Diagnostics involved with bronchiolitis
- NO CBC
- CXR if 1st episode of wheezing ever or considering PNA
- Nasal washings for RSV PCR if <2mo, risk factors, hospitalization, or requested
Tx bronchiolitis
- +/- bronchodilators, cool mist
- PO steroids (dexamethasone, prednisolone)
- NO abx
Should you hospitalize pts with bronchiolitis?
Yes if:
- O2 required
- Apneic episodes
- Preemie <12wo
- <12wo and signs of resp. distress or days 1-3 of illness
- Underlying cardiopulmonary dz/risk factors
- Parent unable to care for child at home
Tx for inpatient bronchiolitis
- O2 → SpO2 >94%, high flow O2 if <92% on O2
- Consider CPAP, no chest PT
- PICU if intubation needed or expected
Tx for outpatient bronchiolitis
- Fluids
- Tylenol/motrin
- ED if worsens, tachypnea w/o fever, or resp. distress
What is Synergis?
IM vaccine ppx for certain pts during RSV season
Who might need Synergis?
- 0-12mo → preemi <12wo, chronic lung dz, neuro dz, CHD, CF, heart transplant, immunocompromised
- 12-24mo → chronic lung dz needing O2, heart transplant during RSV season, immunocompromised, some CF pts
All pedi asthma pts should use ______
spacer
When can you officially diagnose asthma in kids?
Age 4-6 when methacholine challenge can be administered
Presentation of asthma in kids
- Cough (could be only sx)
- Wheezing
- Breathlessness, chest tightness, chest pain
Kids with asthma usually have ______
Other atopic illnesses (e.g. atopic dermatitis, food allergies, allergic rhinitis)
Dx asthma
Improvement of >8% of FEV1 with bronchodilator
Tx asthma in kids
- Mild (intermittent) → SABA
- Persistent → ICS (low-high dose) +/- adjuncts, consult pedi pulmonologist
Etiology of pertussis
Bortadella pertussis (95% US cases) → G- coccobacillus that colonizes ciliated epithelium
Transmission of pertussis
Spread via respiratory droplets → nearly 100% contagious to non-immunized close contacts
Is there a vaccine for pertussis?
Yes, it’s extremely effective but immunity wanes after 5 yrs and disappears by 12 yrs (booster)
Incubation period of pertussis
3-12 days
3 stages of pertussis. During which one is pt most contagious?
- Catarrhal stage → most contagious
- Paroxysmal stage
- Convalescent stage
How long does catarrhal stage of pertussis last?
1-2 weeks
What happens in catarrhal stage of pertussis?
URI sx’s - rhinorrhea, sneezing, low-grade fever, mild cough
How long does paroxysmal stage of pertussis last
1-6 weeks, up to 10 weeks
What happens in paroxysmal stage of pertussis?
Paroxysm of numerous rapid coughs, followed by whooping cough → pt may be in resp. distress, protruding tongue, purple face, bulging/watery eyes, post-tussive emesis/exhausion
What is pathognomonic for pertussis?
Whooping cough
What happens in convalescent stage of pertussis?
Paroxysms may recur when pt suffers subsequent respiratory infections → may last for months
Dx pertussis
Nasopharyngeal swab BUT if highly suspicious, treat b/c takes days to weeks
Tx pertussis
Azithromycin
Partial vs. complete airway obstruction
Partial = stridor Complete = silence
80% FB aspirations involve pts age _____
<3 yo
Most common FBs aspirated by infants/toddlers
*Peanuts (50%)
*Nuts
*Popcorn
*Hot dogs
Coins, toys, batteries, seeds
Most common FBs aspirated by older kids
Nonfood items - coins, paper clips, pen caps, coins
FBs that lead to fatal aspiration
- Balloons
- Balls
- Marbles
- Toys
- Strong/round/unbreakable
Location of FB aspiration in kids
Proximal mainstem bronchus - no preference over R vs. L b/c similar size/angle
Highest morbidity/mortality d/t FB aspiration occurs with ______ . Why?
Laryngeal FB - blocks R and L airways
Classic triad of FB aspiration
- Wheezing
- Cough
- Decreased air entry regionally
What’s one of the most important ways of diagnosing FB aspiration?
History
Sure, history is important in diagnosing FB aspiration. But what’s the official way of diagnosing it?
Bronchoscopy → diagnosis + treatment
What may you see on radiograph of FB aspiration?
- FB if radiopaque
- Subglottic density/swelling
- Air trapping distal to partial obstruction
- Atelectasis if complete obstruction
- Late = consolidation d/t infection, abscess, bronchiectasis
What happens in cystic fibrosis?
Mutation in CFTR protein → dysfunctional Cl- channel in exocrine tissues
Epidemiology of cystic fibrosis
Caucasians
What is pathognomonic for cystic fibrosis?
Meconium ileus
Respiratory signs of cystic fibrosis
- Persistent productive cough
- Recurrent URI/LRI
- Obstructive airway dz findings → hyperinflation on CXR, PFTs
- Colonization with S. aureus and H. flu in childhood; Pseudomonas in adulthood
Reproductive effect of cystic fibrosis
95% males are infertile (and up to 20% females)
What organ systems are involved in cystic fibrosis?
- Pulmonary
- Sinuses
- Pancreas
- Liver
- Intestines
- Reproductive tract
- Kidneys
- Bone
Dx cystic fibrosis
- Newborn screening via heel stick → high rate of false positives (see below)
- Chloride sweat test
- Molecular DNA testing if sweat test inconclusive → 2 mutations = dx
- Nasal potential difference if above inconclusive
When is newborn screening for CF via heel stick performed?
Well before 8wo b/c trypsin levels fall
When is chloride sweat test performed?
- Asymptomatic positive heel stick
- After 2wo and >2kg
- Meconium ileus after day 2
When is molecular DNA testing done for CF?
- Inconclusive sweat test
- All CF pts for prognosis and epidemiologic interest
Infants and children with CF usually present with ________
Respiratory sx’s - chronic URI, wheezing of unclear etiology
Tx for CF
- Expansive list b/c multisystem
- Ivacaftor → CFTR modulator
- Specific sequence of inhaled Rx: albuterol → hypertonic saline → chest PT → Dnase → azithromycin
- Steroids (PO or inhaled)
- Supportive → O2, BiPAP, immunizations
- Lung transplant (but remember, multisystem dz)
Respiratory distress syndrome usually occur in what pts?
<28wo GA
Pathophysiology of respiratory distress syndrome
Prematurity = surfactant deficiency, incr. risk of PDA and foramen ovale
Dx respiratory distress syndrome
Clinical diagnosis
What might you see on CXR of respiratory distress syndrome
- Airbronchograms
- Low lung volume
- Ground glass appearance
- Pneumothorax
Prevention of Respiratory Distress Syndrome
- Antenatal corticosteroids for pregnant pts at risk for delivery at <34wks GA
- Exogenous surfactant within first 30-60 min. of life for <30wks GA with resp. distress
- Assisted ventilation w/ PEEP
- Thermoregulation, fluids, CV management, nutrition support
