Peds Pulmonary 2 Flashcards
breath sound for partial airway obstruction?
stridor
breath sound for complete airway obstruction?
no sound/silence -> NO AIRWAY
80% of FBA episodes occur at what age?
< 3 y/o
what do kids most commonly aspirate?
peanuts, nuts, popcorn, hot dogs
food is M/C in infants and toddlers
non-food is M/C in older kids
what causes FATAL aspiration?
Balloons, anything unbreakable
in kids, what is the most common location for foreign body to get stuck?
proximal mainstay bronchus (before the branch), R = L
can be in larynx if large enough
why is larynx foreign body associated with higher morbidity/mortality?
b/c if it’s in the larynx you’re not moving an air at all vs if in right or left bronchi still have air moving from side that isn’t blocked
when should you suspect FB aspiration in kids?
- chocking (witnessed event)
- wheezing
- formerly speaking and won’t speak
- coughing w/out URI sx’s
when do kids usually present with FBA?
within 24hrs of FBA (can have chronic FBA as well)
sx’s of acute and life threatening FBA
- respiratory distress
- cyanosis
- AMS
sx’s of less acute (chronic) and not emergently life threatening FBA
CLASSIC TRIAD
- wheezing
- decreased air entry especially regionally
- cough
dx of FBA
HISTORY IS KEY
May also need X-rays (if radiopaque object)
what will you see on x-ray for FBA?
swelling on lateral neck film
air trapping distal to PARTIAL obstruction on expiratory CXR
what is dx tool and tx if hx, PE, x-rays lead to suggestion of FBA?
Bronchoscopy
what are complications of FBA removal?
- dislodgement or breakage with advancement into bronchioles or lungs
- infection by FB that’s in too long -> requires abx
- inflammation -> may require steroid burst
how do you prevent FBA in kids?
EDUCATE THE PARENTS!!!
what is Cystic Fibrosis (CF)?
Genetic disruption (mutation) of the CHLORIDE CHANNEL
viscous secretions in what organs in CF?
Lungs, Pancreas, Liver, Intestine, Reproductive tract
Respiratory sx’s of CF
- Persistant productive cough
- Hyperinflation of lungs on CXR
Respiratory tract colonized with what bacteria in CF?
Staph aureus and H. flu in childhood
can get pseudomonas pneumonia and then get colonized with pseudomonas (pseudomonas found in CF adult pts)
Sinus sx’s of CF
Panopacification of sinuses by the age of 8 months
Nasal polyps
Pancreas sx’s of CF
Pancreas becomes thickened, so it doesn’t produce enough digestive enzymes -> malabsorption -> failure to thrive, electrolyte abnl, anemia
what is a pathognomonic clinical feature of CF?
meconium ileus
what other clinical features do you see in CF?
Infertility
biliary issues, clubbing of fingers and toes, recurrent DVT, nephrolithiasis and neprhocalcinosis
depression, drug abuse both (d/t having chronic disease)
why are males and females with CF infertile?
95% of males w/CF d/t absent vas deferens or poorly develop Wolffian structures
up to 20% of females are infertile due to amenorrhea secondary to malabsorption and tenacious cervical mucous
how do you dx CF? what about newborns?
Clinical sxs of CF in at least 1 organ system
Evidence of CFTR dysfunction by any of these tests:
-sweat chloride elevated (>60mmol/L) on 2 occasions
In newborns, don’t need any organ system involvement
why do patients need to meet both criteria for dx of CF?
b/c there are other CFTR related d/o’s that will NOT be CF
ex: chronic rhinosinusitis, idiopathic bronchiectasis, etc.
what is classic CF?
- disease in 1 or >1 organ system
- Pt has elevated sweat chloride (>60mmol/L)
what is non-classic CF?
- meet disease criteria in 1 or more organ systems with normal or borderline sweat test results
- requires DNA analysis for dx
what is the most common form of CF diagnosed in adults or older adolescents?
non-classic CF
diagnosed in them d/t milder physical findings
what is the most likely chief complaint leading to dx of CF in infants and children? examples?
respiratory sx’s
Ex: persistant or chronic URI, wheezing of unclear etiology or recalcitrant
with what respiratory sx’s should suspicion in setting of no CF dx be raised?
- chronic productive cough
- recurrent URIs or LRIs
- hyperinflation on CXR
- PFTs c/w obstructive disease
how are 50% of CF cases diagnosed?
by newborn screening with heel stick dry blood sample
how is newborn screened for CF? when must it be done? confirmation?
heel stick dry blood sample
measure levels of immunoreactive trypsin (IRT)
must be done before 8 weeks of life
a lot of false positives and negatives, so positive must be confirmed by DNA or sweat test
what is the primary test for dx of CF?
sweat test
how is the CF sweat test done?
by applying pilocarpine iontophoresis and determining the chloride concentration in the resulting sweat chemically
when is the CF sweat test done?
if asymptomatic positive newborn screen, after 2 weeks of life and >2 kg
if meconium ileus after DOL 2
when is DNA testing for CF done? how is it done?
on all pts w/intermediate (possible) sweat test result
also done for prognostic and epidemiological interest on all CF pts
23 common mutations screened
pts should have 2 mutations to be considered positive for CF
main tx for CF?
Tezacaftor/Ivacaftor for >6 y/o (improves lung fxn by 4%)
Ivacaftor for >6 y/o
Azithromycin PO for ppx use and anti-inflammatory effects (>6 y/o)
Bronchodilators (albuterol daily use)
what meds enhance airway secretion clearance for CF?
DNASE
Inhaled Hypertonic Saline (>6 y/o)
so what do CF pts inhale for rx?
Albuterol -> Hypertonic Saline -> Chest PT -> DNASE -> abx
DON’T MIX!!!
what are other CF pulmonary tx’s?
STEROIDS
-chronic PO, short-term, or inhaled
OXYGEN, BiPAP, IMMUNIZATIONS
what immunizations are recommended for CF?
influenza, pneumococcal, palivizumab for RSV ppx if age appropriate
what tx must you consider if CF is a multi system disease?
lung transplant
use of chronic PO steroids in CF not recommended in…
kids 6-18 y/o d/t adrs
use of short-term PO steroids no more than…
5 days
use of inhaled steroids if…
chronic asthma like sx’s or aspergillosis ONLY
what is RDS in preterm infants?
Respiratory distress syndrome
aka Hyaline Membrane Disease
increased risk of RDS in infants born below…
30 weeks
when does formation of alveoli begin in babies?
at 24 weeks
93% of RDS infants at what age?
<28 weeks
what is the etiology of RDS in preterm infants?
born too early, so have Surfactant Deficiency (quantity and quality deficient) -> atelectasis -> V/Q mismatch -> Pulmonary Inflammatory Response -> Potential Lung Injury and Pulmonary Edema
what else complicates the issue of poor surfactant in preterm infants?
increased risk of PDA and foramen ovale b/c premature -> extra pulmonary shunting -> increased hypoxemia
sx’s of RDS?
- tachypnea, nasal flaring
- grunting-expiratory
- retractions
- cyanosis, pallor
- decreased breath sounds (may be developing pulmonary edema)
- peripheral pulses diminished
- peripheral edema
- poor urine output (b/c of renal failure)
dx of RDS
history and PE
what imaging for RDS? what can you see on it?
CXR
- airbronchograms (air trapped w/in bronchi)
- low lung volume
- ground glass appearance
- pneumothorax
what are interventions to prevent RDS in preterm infants?
Antenatal corticosteroids (given to mom before 34 weeks of delivery to promote development of surfactant for babies)
Exogenous surfactant (natural preferred by endotracheal tube w/in 30-60 min of life)
Assisted Ventilation
good things about mechanical ventilation in RDS?
- PEEP corrects atelectasis and gives route for exogenous surfactant administration
- this improves arterial oxygenation
bad things about mechanical ventilation in RDS?
- trauma by volume and pressure
- O2 toxicity
- intervention can lead to bronchopulmonary dysplasia (BPD)
- intubation injury
possible new ventilation tx’s for RDS?
nasal CPAP, nasal intermittent positive pressure ventilation
what is NOT advocated for as tx for RDS?
nitrous oxide, ECMO
other considerations in RDs therapy?
- thermoregulation
- fluid management
- CV management
- nutritional support
