Pediatric Resp Flashcards
Common resp illnesses in kids:
Croup
Asthma
Bronchiolitis
Pneumonia
Foreign body aspiration
Upper airway symptoms:
Stridor
Supraclavicular and suprasternal retractions
Lower airway symptoms:
Wheezing
Subcostal and intercostal retractions
Important features of physical exam in resp peds emergencies:
General appearance
Level of activity
speaking/crying
Vital signs
Work of breathing
Lung exam
Hydration/circulation
Mental status
The 5th vital sign =
Pulse ox
Normal SpO2 in kids
Over 95%
Sensitivity of spO2 in predicting outcomes
Not sensitive
Respiratory Emergencies:
Differential Diagnosis
Croup
Rings and slings
GE reflux
Pulmonary disease
Asthma
Bronchiolitis
Foreign body aspiration
Cystic Fibrosis
Anaphylaxis
Pneumonia
Cardiac disease
15 mos healthy male
Acute onset of barky cough/gasping Awoke from sleep
1 day of rhinorrhea
Crying, upset with hoarse voice
Inspiratory stridor
Clear lungs
Diagnosis?
Croup
Croup:
- Aka?
- Ages?
- Etiology / Organisms?
- Most common etiology?
- Laryngotracheobronchitis
- Age 6 mos-3 yrs
- Always VIRAL etiology (RIPAM)
- RSV
- Influenza
- Parainfluenza
- Adenovirus
- Measles
- Parainfluenza
Pathophysiology of Croup:
Invasion of pharyngeal epithelium
Spread to larynx
Mucous production and edema
Subglottic larynx and vocal cord involvement
Croup:
History?
Preceeding URI symptoms
Fever
Abrupt onset of barking cough Distress with crying/agitation
Improvement on way to ED
Croup:
Physical Exam
Mild to moderately ill, nontoxic
Rarely cyanotic or hypoxemic
WOB
Inspiratory stridor
Barky, seal-like cough
Lungs clear
Croup:
Radiology
Rule out other dx
Subglottic narrowing
Steeple sign
Remember, croup is a clinical diagnosis!
Croup:
Labs?
Generally not useful
CBC with leukocytosis
Croup:
Differential Diagnosis?
Foreign body aspiration/obstruction
Viral URI
Tracheitis
Croup:
Therapy?
Cool mist/hot shower
Dexamethasone 0.6mg/kg (8mg) - PO or IM
Racemic Epinephrine – nebulized (if there is an audible stridor at rest)
Croup:
Disposition vs admit?
Majority outpatient management
Admission if there is…
- Questionable diagnosis
- Continued audible stridor
- Toxic appearance
- Dehydration and vomiting
- Very young (<3 mos?)
Seven year old with cough/SOB
History of wheezing in the past
Breathless; one-word answers
Sitting forward
Inspiratory & expiratory wheezes
Subcostal & intercostal retractions
What is the diagnosis?
Asthma
Asthma:
Pathophysiology?
- 1) Airway hyperresponsiveness
- Muscle constriction, edema, mucous production
- “Late phase” reaction at 4-12 hours - inflammatory cells and mediator
- Air trapping –> dead space ventilation –> V/Q mismatching
- 2) Chronic inflammation
Respiratory / Electrolyte side effects of asthma:
- Hypoxemia
- Hypercapnea & respiratory acidosis
- Metabolic acidosis
- Increased oxygen demand
- Increased energy consumption
- Respiratory failure
Parts of patient history with asthma to obtain:
A brief focused history + Comprehensive history
Parts of the brief focused history for asthma:
Duration of symptoms
Severity of symptoms
Current medication use
Hx of severe exacerbations
Signs, symptoms of infection
Parts of the comprehensive history for asthma:
Triggers
Possible foreign body aspiration
Activity level
Oral intake
ROS
Asthma:
Risk Factors for Severe Exacerbations and Mortality
History of sudden, severe attacks
Prior intubation, ICU admission
Two or more hospitalizations in the last year
Three or more ED visits in the last month
Hospitalization in the last month
Current or recent use of systemic steroids
Medical comorbidity
Psychosocial problems
Age less than five years
How RR, retractions, and whezing change in mild, moderate, and severe cases of asthma:
RR: Increased –> further increased –> increased or decreased
Retractions: None/mild –> moderate –> severe
Wheezing: Moderate/End-expiratory –> loud throughout exhalation –> inspiratory and expiratory
Radiological imaging for Athma:
- radiological signs of asthma?
- Indications for radiological imaging?
- Hyperinflation, Peribronchial thickening, Atelectasis
- Focal exam, Minimal improvement, Chest Pain, Severe exacerbations, First time wheezing
Labs needed for asthma
None
Differential dx for asthma?
Anaphylaxis
Foreign body aspiration
Bronchiolitis
Rings and slings
Gastroesophageal reflux
Cardiac disease
Therapy for asthma?
- Albuterol (nebulized if severe, puffs if not)
- Ipratropium (anticholinergic bronchodilator–less potent than albuterol–always used in conjuction with albuterol)
- Corticosteroids
- MgSO4
- Parenteral ß-agonists (epinephrine or terbutaline)
Side effects of albuterol:
Tachycardia
Hypokalemia
When asthma patient needs to be admitted:
O2 requirement
Persistent respiratory distress (Need for treatments < Q4 hours)
Air leak
Underlying high risk factors ED visit last 24 hours
Instructions to parents if the asthma patient is D/Ced home:
Observe 60-90 min after last treatment
“Action Plan”
STEROIDS
- Oral 2 mg/kg per day for 4 days
- Inhaled corticosteroids?
Educate
Follow-up with primary doctor
Seven-week-old infant presents with fever, decreased PO, and fast breathing
Cold symptoms for a few days - now has developed these other symptoms
Former 31-week premie
Diffuse wheezing and retractions on exam.
Most likely diagnosis?
Bronchiolitis
- Typical Pathophysiology of Bronchiolitis?
- Other viral causes?
- Bacteria?
- Season?
- Peak age?
- Oldest age?
- Usually due to RSV (85% of cases)
- Other viruses (RIPAM)
- Mycoplasma
- Winter and early spring
- Peak incidence in 2-8 month olds
- May be seen up to 2y/o
What is the patho process of bronchiolitis?
RSV invades nasopharyngeal epithelium
Cell to cell transfer to lower airways
Cell death and sloughing
Mucous production
Airways edema and mucous plugging
Role of airway hyperresponsiveness in bronchiolotis?
In which patients does apnea occur?
Minor role for hyper-respons
Apnea only seen in infants less than 1m
Presentation of bronchiolitis patients?
Questions you should ask about in HPI?
Begins as URI; +/- fever
Progression over 2-5 days
Ask about:
- Activity level
- Ability to feed
- Hydration status (urine output) Apnea or cyanosis
Risk factors for developing severe bronchiolitis:
Prematurity (<35 weeks GA)
Bronchopulmonary dysplasia
Heart disease
Immunodeficiency
Young age (< 3 months)
Physical findings of bronchiolitis:
Grunting
Nasal flaring Retractions
Lung exam
Wheezing
Crackles
Decreased aeration
Exam changes often
Radiological findings of bronchiolitis:
Hyperinflation
Peribronchial thickening
Atelectasis
Bronchiolitis labs
Rapid antigen
Resp Cx
If febrile + <3m –> Urine cx + Blood Cx + Sepsis w/u
Treatment of bronchiolitis:
- Supportive Care:
- Oxygen as needed
- Hydration - IVF’s as needed Close monitoring
- Nasal suctioning
- Pulmonary toilet
- Ventilatory support
- Bronchodilators:
- Albuterol
- Racemic Epinephrine
- Corticosteroids
- Only if older child and if there is concurrent asthma
D/C instructions for bronchiolitis:
Encourage hydration
Acetaminophen
Bronchodilators if patient improves with bronchodilator use in the ED
Close follow-up
Twenty-six month old boy with complaints of fever, vomiting, RLQ abdominal pain
Symptoms since yesterday afternoon
Immunizations UTD
T 38.9oC HR 138 RR 48
Lungs clear, no retractions
Diffuse abdominal pain, rebound in RLQ
Most likely dx?
Pneumonia
Etiology of pneumonia in neonates:
Group B Strep
GN enterics
Etiology of pneumonia in 2wk to 2 month olds?
Chlamydia trachomatis
Viruses
S. pneumo
A. aureus
H. flu
Etiology of pneumonia in 2mo - 3 yo>
Viruses
S. pneumo
S. aureus
H flu
Pneumonia etiology in 3-19 yo?
Viruses
S. pneumoniae
Mycoplasma pneumoniae
Pathophys of pneumonia
Organisms reach the lung by aspiration or hematogenous route
Inflammatory reaction with exudation of fluid and PMN’s
Fibrin deposition; macrophage invasion
Accumulation of fluid in lobe gives lobar pattern on x-ray
Effusions and/or empyema may occur
Cause of UQ abd pain in pneumonia?
T9 dermatome distribution shared by lung and abdomen
Referred pain seen in pneumonia?
Abd complaints
Neck pain and meningismus if of the upper lobes
Back pain
Radiological features of more severe pneumonia
Bilateral involvement
Pleural effusion
Pneumatocele
Pneumonia labs:
- Pneumococcus associated with this lab finding:
- How common blood culture has organism?
- Lab ot collect if there is severe disease?
- Marked leukocytosis
- Rarely
- ABGs
Antitussives in pneumonia
Not indicated
20-month old boy found coughing
Later that day, fast breathing
Afebrile, no URI symptoms
Active, playful
RR 42
Mild right-sided wheezes and decreased breath sounds
Most likely dx?
Foreign body asp
Foreign body much more common on which side?
only slightly more common on the right
Missed dx of foreign body may lead to:
Pneumonia
Radiological findings of foreign body aspiration:
Hyperinflation
Infiltrates
Foreign body
Tx for foreign body asp?
ENT consult –> bronchoscopy
