Croup: 1. Aka? 2. Ages? 3. Etiology / Organisms? 4. Most common etiology?

1. Laryngotracheobronchitis 2. Age 6 mos-3 yrs 3. Always VIRAL etiology (RIPAM) RSV Influenza Parainfluenza Adenovirus Measles 4. Parainfluenza

Pediatric Resp Flashcards by Ian Danford

Common resp illnesses in kids:

Croup

Asthma
Bronchiolitis
Pneumonia
Foreign body aspiration

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Upper airway symptoms:

Stridor

Supraclavicular and suprasternal retractions

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Lower airway symptoms:

Wheezing

Subcostal and intercostal retractions

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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

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The 5th vital sign =

Pulse ox

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Normal SpO2 in kids

Over 95%

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Sensitivity of spO2 in predicting outcomes

Not sensitive

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Respiratory Emergencies:

Differential Diagnosis

Croup

Rings and slings
GE reflux
Pulmonary disease

Asthma

Bronchiolitis

Foreign body aspiration

Cystic Fibrosis

Anaphylaxis

Pneumonia
Cardiac disease

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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

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Croup:

Aka?
Ages?
Etiology / Organisms?
Most common etiology?

Laryngotracheobronchitis
Age 6 mos-3 yrs
Always VIRAL etiology (RIPAM)
- RSV
- Influenza
- Parainfluenza
- Adenovirus
- Measles
Parainfluenza

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Pathophysiology of Croup:

Invasion of pharyngeal epithelium

Spread to larynx
Mucous production and edema
Subglottic larynx and vocal cord involvement

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Croup:

History?

Preceeding URI symptoms
Fever
Abrupt onset of barking cough Distress with crying/agitation

Improvement on way to ED

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Croup:

Physical Exam

Mild to moderately ill, nontoxic

Rarely cyanotic or hypoxemic
WOB
Inspiratory stridor

Barky, seal-like cough

Lungs clear

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Croup:

Radiology

Rule out other dx
Subglottic narrowing

Steeple sign

Remember, croup is a clinical diagnosis!

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Croup:

Labs?

Generally not useful
CBC with leukocytosis

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Croup:

Differential Diagnosis?

Foreign body aspiration/obstruction

Viral URI

Tracheitis

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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)

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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?)

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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

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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

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Respiratory / Electrolyte side effects of asthma:

Hypoxemia
Hypercapnea & respiratory acidosis
Metabolic acidosis
- Increased oxygen demand
- Increased energy consumption
Respiratory failure

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Parts of patient history with asthma to obtain:

A brief focused history + Comprehensive history

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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

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Parts of the comprehensive history for asthma:

Triggers

Possible foreign body aspiration

Activity level

Oral intake

ROS

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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: 1. radiological signs of asthma? 2. Indications for radiological imaging?

1. Hyperinflation, Peribronchial thickening, Atelectasis 2. 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

1. Typical Pathophysiology of Bronchiolitis? 2. Other viral causes? 3. Bacteria? 4. Season? 5. Peak age? 6. Oldest age?

1. Usually due to RSV (85% of cases) 2. Other viruses (RIPAM) 3. Mycoplasma 4. Winter and early spring 5. Peak incidence in 2-8 month olds 6. 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: 1. Pneumococcus associated with this lab finding: 2. How common blood culture has organism? 3. Lab ot collect if there is severe disease?

1. Marked leukocytosis 2. Rarely 3. 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