Pediatric Respiratory Illness Flashcards
what condition is the leading cause of infant hospitalization in U.S.
Bronchiolitis
A common, acute LRTI that primarily affects small airways
clinical syndrome of respiratory distress in children under 2 years of age
Frequent cause of hospitalization in infants / young children
Bronchiolitis
Bronchiolitis is characterized by what sx, followed by what PE signs?
upper respiratory symptoms
acute onset of wheezing, crackles, hyperinflation, and tachypnea
Resulting in acute inflammation of airways
cause/pathophys of bronchiolitis
Occurs secondary to a virus that attacks and causes inflammation in the small bronchioles
Causes edema, excessive mucus and sloughed epithelial cells that lead to obstruction of small airways and atelectasis making it difficult for a child to breath
MC pathogen causing bronchiolitis
RSV
Followed by enterovirus, rhinovirus, and parainfluenza
bronchiolitis MC affects at what age?
- Primarily in children within first 2 years of life
- > 80% occur during 1st year of life
- Peak ages 1 - 10 months
RF bronchiolitis
Prematurity
- < 12wks
- anatomic defects of airways
- immunodef - cardiopulm disorders
- neuro diseases
- lack of breastfeeding
enviromental causes - passive smoking, crowded household, daycare, older siblings in school
hx for bronchiolitis
- Time of onset - Spring; Winter
- Age
- Prior history of wheezing
- Recent history of signs compatible with common cold
- Decreased appetite
- Decreased sleep
- Increased fussiness
PE of bronchiolitis
- Increased RR
- Irritable
- Lethargic
- Retractions
- Expiratory grunting
- Prolonged expiration
- Deep, somewhat productive cough (bronchiolitic cough)
- Expiratory wheeze
- Otitis media
w/u bronchiolitis? how to dx?
- Clinical mainly
- O2 sat
- NP swab
- Imaging usually not necessary
tx for nonsevere bronchiolitis
- outpatient setting
- mainstay: Supp care and anticipatory guidance
- Adequate hydration
- Relief of nasal congestion
- Monitoring for disease progression
- Education on clinical course and when to seek medical tx for worsening sx
when to hospitalize for bronchiolitis
- Persistently increased rsp effort - tachypnea, nasal flaring, accessory muscle use
- Hypoxemia - O2 < 92%
- Apnea
- Acute respiratory failure
- Toxic appearance
- Poor feeding
- Lethargy
- Dehydration
- Parents unable to care for child at home
inpatient management for bronchiolitis
mainstay: Supportive care and anticipatory guidance
- Adequate hydration
- Rsp care in a stepwise approach
- Nasal suctioning
- O2 to maintain 90 - 92%
- Infants at risk of Rsp failure often receive a trial of CPAP
- Endotracheal intubation - Monitor for disease progression
what is ribavirin?
- An antiviral with good treatment response for bronchiolitis
- May be warranted for significantly immunocompromised patients
- Not routinely used
DC criteria for bronchiolitis
- RR < 60 for age < 6m
- Stable using ambient air
- Caretaker knows how clear infant’s airway using bulb suctioning
- Pt has adequate PO intake
- Caretakers are confident they can provide care at home
- Resources at home are adequate to support
Bronchiolitis - What to Avoid:
- Inhaled bronchodilators
- Albuterol
- short-term effect, but, no’t affect outcome, may have adverse events
- Can possibly be tried if patient is severe, if helps can continue - Systemic glucocorticoids
- Studies show little effect in bronchiolitis - Inhaled saline
- Not routinely used
- Controversial: some studies show efficacy, some don’t
pt ed for bronchiolitis
- Return to office/ED if sx worsen
-
Explain course of illness
- Most improve w/in several days
- Cough/congestion resolve w/in 1-2wks
- Hospitalized pts are DC w/in 3-7d - Link to recurrent wheezing within 2 years of initial episode
- Rare, but some can have lung function abnormalities beyond 10 years
- 18% remained symptomatic after 3 weeks
- 9% after 4 weeks, especially in young infants
- A humanized monoclonal antibody against the RSV F glycoprotein
- The first dose usually before beginning of RSV season, followed by a dose every 28-30 days throughout RSV season
which bronchiolitis prevention?
palivizumab
who is recommended to receive palivizumab
- Infants born at < or = 28wks, 6d gestational age and < 12mo at start of RSV season
- < 12mo of age w/ chronic lung disease of prematurity or hemodynamically significant CHD
- Infants and kids < 24mo with congenital lung disease of prematurity necessitating medical therapy (O2, BD, diuretic, or chronic steroids) within 6 mo prior to beginning of RSV season
Nirsevimab is recommended for who?
- All infants < 8mo born during/entering their first RSV season, including those recommended by the American Academy of Pediatrics (AAP) to receive palivizumab
- 8-19 mo at increased risk of severe RSV disease and entering their 2nd RSV season, including those recommended by the AAP to receive palivizumab.
If nirsevimab is administered, ____ should not be administered later that season.
palivizumab
If palivizumab was administered initially for the season and < 5 doses were administered, the infant should receive ?
1 dose of nirsevimab
No further palivizumab should be administered.
If palivizumab was administered in season 1 and the child is eligible for RSV prophylaxis in season 2, the child should receive ____
what if not available?
nirsevimab in season 2, if available.
If nirsevimab is not available, palivizumab should be administered
Providers should aim for nirsevimab administration when, shortly before and during the RSV season based on geography?
in the first week of life for infants born
What bronchiolitis prevention may be given to age-eligible infants and children who have not yet received a dose at any time during the season.
Nirsevimab
Children 8-19 months of age are recommended to receive nirsevimab when entering their second RSV season if they have these RF:
- have chronic lung disease of prematurity who required medical support
- severely immunocompromised
- Have CF w/ manifestations of severe lung disease (previous hospitalization for pulmonary exacerbation in first year of life or abnormalities on chest imaging that persist when stable) or have weight-for-length that is < 10th percentile.
- American Indian and Alaska Native children
In accordance with the CDC’s general best practices for immunizations, simultaneous administration of ? with age-appropriate vaccines is recommended.
bronchiolitis
nirsevimab
Autosomal-recessive disease involving multiple organs, esp pancreas and lungs
MC lethal genetic disease in US
Usually develop obstructive disease (bronchiectasis), that leads to progressive rsp failure and death
what dx?
CF
CF affects MC what demographic?
caucasians
pathophys of CF
mucociliary clearance problem
- Defect in CF gene on chromosome 7 that encodes an epithelial Cl channel (CFTR)
- leads to problems in salt and water movement across cell membranes
- resulting in abnormally thick secretions in various organs
CFTR is located in numerous organs:
lungs, upper respiratory tract, sweat glands, pancreas, intestines, liver, reproductive tract
Typically diagnosed with CF after presenting with one or more of following symptoms as infant/child:
- Newborn screening
- Meconium ileus
- Respiratory symptoms
- Failure to thrive
How is CF screened in newborns?
heel prick while still in hospital
Obstruction of bowel by meconium in newborn infant
Obstruction occurs in terminal ileum
Virtually diagnostic of CF
diagnosis?
how to r/o CF?
- Meconium ileus
- should be presumed as having CF until a sweat test or genotyping can be obtained
3 other GI tract issues that can be d/t meconium ileus
Volvulus, intestinal atresia, or meconium peritonitis
Poor hydration of intestinal contents, decreased pancreatic secretions, and fecal stasis can cause?
distal intestinal obstruction syndrome (DIOS)
excessive straining or difficulty passing stool with defecation, or coughing d/t increased intraabdominal pressure can cause what other GI tract issue?
rectal prolapse
Chronic sinusitis, Nasal polyps, Persistent cough are what type of rsp tract condition?
CF
Upper rsp tract
Ineffective mucociliary clearance, infections with S. aureus, HIB, and pseudomonas are what type of respiratory tract conditions?
s/s?
CF
Lower rsp tract
- Persistent and productive cough
- Cycle of infection and inflammation develops in lungs, typically punctuated by acute exacerbations
- Destruction of the airways, leading to bronchiectasis
complications from lower respiratory tract conditions
CF
pneumothorax, and death from cor pulmonale; respiratory failure caused by recurrent pulmonary infections
how can the pancreas cause failure to thrive in CF?
pathophys
- abnml lyte secretion = dehydration of ductual secretions and blockage of ducts
-
Destruction of pancreatic acini (produces digestive enzymes) = decreased pancreatic enzymes
- Leads to pancreatic insufficiency
result of pancreatic dysfunction that contribute to failure to thrive in CF
conditions
- DM, secondary to destruction of pancreatic islet cells
- Recurrent pancreatitis
- Pancreatic insufficiency = malabsorption of fats, proteins, carbs and fat-soluble vitamins (A, D, E, and K)
- have a hard time growing/gaining wt = failure to thrive
liver, MSK, and lyte contribution to failure to thrive in CF?
- Liver: Biliary cirrhosis with portal HTN
- MSK: Osteopenia and osteoporosis
- Lyte imbalance: Inc lytes in sweat = loss of body lytes = metabolic alkalosis
Male & female & general genitourinary results from failure to thrive in CF
- Male infertility
- Reduced testicular size and testosterone lvls
- Bilateral absence of vas deferens
- Delayed pubertal development d/t poor nutritional status and decreased glucose tolerance
- abnml menstrual cycles
- Female infertility d/t thick, sticky vaginal mucosa
gold standard dx of CF
sweat Cl testing
Sweat chloride testing indications
- Two weeks old and wt > 2kg
- Positive screening of newborn
- Meconium ileus
- Older children and adults with suggestive sx
- Siblings of pts with confirmed CF
Will confirm CF if (+) newborn screen
Collection of sweat with pilocarpine iontophoresis
nml, borderline, and positive findings of sweat Cl test?
- Nml - < 30 nmol/L
- Borderline - 40-60
- Positive - >60
- Over 1800 CF mutations have been identified
- Indicated after a positive sweat chloride test
- May be utilized in carrier status patients, or those with borderline sweat chloride testing
what type of CF testing?
genotyping
what is Fecal Elastase
- Screens those w/ CF for pancreatic insufficiency
- Checks for pancreatic elastase-1, absent in over 80% or more of those with CF
maintanence tx for CF
- followed by a CF foundation accredited care center
- evaluated by a pediatrician, pediatric pulmonologist, rsp therapist, nurse, dietitian, and social worker, and sometimes others
- seen quarterly to check adequacy of therapies, as well as growth, nutrition, and pulmonary function can be assessed and adjusted as needed
Rsp tx for CF
Airway clearance and aggressive abx
- Pulmozyme (recombinant human DNAse): mucolytic - decreases viscosity of purulent CF sputum
- Hypertonic saline
- Inhaled BD
- Chest physiotherapy
-
Abx for chronic pseudomonas infections
- Screening sputum cx q3mo
- IV and inhaled tobramycin - CFTR modulators: Kalydeco, Orkambi, Trikafta
- Vaccinations
GI tx for CF
- Pancreatic enzyme supplementation combined with high calorie, high protein, high fat diet
- Daily vitamins
- Caloric supplements
- G-tube placement and supplemental feedings in FTT
s/s of CF acute exacerbations
- New/increased cough
- New/increased sputum production or chest congestion
- Decreased exercise tolerance or DOE
- Increased fatigue
- Decreased appetite
- Dyspnea at rest/increased RR
- Change in sputum appearance
- +/- fever
- Increased nasal congestion
tx for CF acute exacerbation
- Systemic abx tx always
- Identify from sputum cx
- at least 1 abx to cover each pathogenic bacteria from CX and 2 for P. aeruginosa
CF prognosis
- Lung transplant
- 5-year post transplant survival 50 - 60%
- Risky procedure
- Anti-rejection drugs - Median survival 47 year
- Rate of lung disease progression usually determines the survival rate
Infant Respiratory Distress Syndrome can affect term babies, especially infants of ____ mothers
diabetic
Infant Respiratory Distress Syndrome MC affects ____ infants
preterm
pathophys of infant rsp distress syndrome
- Deficiency of pulmonary surfactant in an immature lung is the primary cause
- Noncompliant, stiff lungs that are structurally immature and contain insufficient surfactant
- more pressure needed to open alveoli = atelectasis at end expiration, = V/Q mismatch = hypoxemia, hypercarbia, and persistent HTN
clinical features of IRDS
- prematurity
- min-hrs after birth
- tachypnea - intercostal/subxiphoid/subcostal retractions
- nasal flaring - expiratory grunting
- diminished breath sounds
- cyanosis
how to dx IRDS
- clinical - premature infant with onset of progressively worsening rsp failure shortly after birth
- CXR - low lung volume and a classic diffuse ground-glass appearance
- Pulse ox
- ABG
tx IRDS
- Basic neonatal care: Thermoregulation, Cardio support, Nutritional support, Early infection care
- Nasal CPAP is initial preferred intervention
- Surfactant replacement
IRDS prevention
- Prevention of prematurity, asphyxia, avoidance of maternal fluid overload
- Prenatal administration of a single course of steroids to women in preterm labor or at risk of delivery within next 7 days between 24 - 34 wks gestation
Cysts of epithelial remnants of thyroglossal tract
MC form of congenital neck mass
Thyroglossal duct cyst (TDC)
Present characteristically as a midline neck mass at level of thyrohyoid membrane, closely associated with hyoid bone
Arises as a cystic expansion of a remnant of the thyroglossal duct tract - stimulus for expansion not fully known
what dx?
TDC
possible cause of TDC?
lymphoid tissue associated with the tract hypertrophies at time of regional infection, thereby occluding tract with resultant cyst formation
presentation TDC
- midline upper neck mass that is cystic
- Generally no sx, may be slightly tender
- Often preceding URI
- cyst from base of tongue to level of suprasternal notch
- Moves superiorly with swallowing - Can become infected and have some degree of inflammation at presentation
how to dx TDC
-
CT of neck w/ contrast
- shows cysts, confirms dx by defining the typical close relationship to hyoid bone, but also provides info on size, extent, and location - FNA used to dx or r/o other dx
- MRI
- US
tx for TDC
- Sistrunk procedure: resection of cyst and mid-portion of hyoid bone in continuity and resection of a core of tissue from the hyoid upwards toward the foramen cecum
-
Do not perform surgery during acute inflammation or infection, can return
- Broad spectrum abx: Augmentin, Clinda, or Cephalexin
- Surgical excision after inflammation/infection controlled
