Peds pulmonary diseases Flashcards
What is Croup? (laryngotracheobronchitis)
- usual cause?
- most common age?
- infection causing inflammation of the larynx, trachea, and bronchi
- usually caused by parainfluenza virus
- also by RSV, influenza virus, and adenovirus
- 6 months to 3 years
Wha are the key features of Croup?
- URI sxs with BARKING dry cough and stridor (upper airway, heard upon inspiration), low grade fever or may be absent
DDx of Croup?
- think about epoglottitis
How do you differentiate between Croup and Epiglottitis?
- Croup: child might be in distress but won’t be toxic, will have barking cough
- epiglottitis: will be toxic, ill appearing, can’t swallow, child will be stoic, focused on breathing (caused by H flu), will have high fever
When do you tx child with croup w/ steroids?
in clinic setting, during the day when the cough isn’t so prominent (you know it will get worse at night)
- dexamethasone 0.6 mg/kg one dose
When should you hospitalize pt with croup?
- when they are not responding to tx
Tx options for croup
- generally steroids
- if barking cough and no stridor at rest: supportive therapy, hydration, minimal handling, mist therapy, cold air
- if stridor at rest: O2, neb racemic epi
- if sxs resolve within 3 hours of steroid and epi use, can be safely d/c
- hospitalize if recurrent epi txs are required or if respiratory distress persists
Epiglottitis?
- true medical emergency!!!
- most commonly due to H flu Type B
Presentation of Epiglottitis?
- SUDDEN onset: fever dysphagia DROOLING muffled hot potato voice inspiratory retractions soft stridor
What should you do when pt comes in with epiglottitis?
- don’t examine pt
- get a STAT soft tissue lateral portable x ray of neck and prepare to intubate immediately
- Call in ped anesthesia team ASAP
Hallmark sign of Epiglottitis on XR? Looking in throat?
- thumb sign - enlarged epiglottitis
- looking in oropharynx: cherry red spot
6 mo old girl presents with fever, worsening cough, and rapid breathing, rhinorrhea, increased rate of breathing (during winter)
- becoming more irritable, refusing bottle
- attends daycare
- grunting, chest intercostal retractions, wheezing audible in all fields, 88% on RA
- CXR show bilateral interstitial infiltrates and hyperaeration with mild consolidation at bases
What is the dx?
Tx?
- RSV (bronchiolitis) -respiratory synctial virus
- supportive care: O2, fluids
Pathology of bronchiolitis?
- inflammatory process of smaller lower airways, usually caused by RSV
- can progress to respiratory failure and is potentially fatal
- infants with congenital heart disease, chronic lung disease, immunodeficiences at risk for severe disease and poorer outcomes
- mucus is stuck in bronchioles, can’t cough it out
Presentation of bronchiolitis (RSV)
- usually fever, URI sxs, accompanied with tachypnea and wheezing
Other causes of Bronchiolitis?
- adenovirus
- parainfluenza virus
Who should recieve palivizumab (synagis)?
- premature babies
- it is a IM monocolonal Ab that provides passive prophylaxis against RSV
What is Ribavirin? Who gets this?
- synthetic nucleoside analog with activity against RSV, usually reserved for severely ill or immunocompromised pt, given by inhalation
Presentation of Bronchitis? lab work up?
- URI sxs with cough and malaise
- coarse bronchial sounds
- WBC will be normal, CXR clea, most the time it is viral
- ** the presence of mucopurulent sputum doesn’t imply a bacterial infection so abx aren’t helpful
Most pneumonia cases in children viral or bacterial?
- viral
Presentation of viral pneumonia?
- prodrome of rhinorrhea, cough, low grade fever, and pharyngitis
- not a sudden presentation like bacterial
- won’t see a lot of consolidation on CXR
Presentation of bacterial pneumonia?
- more abrupt sxs, will have high fever, cough, chest pain and shaking chills
- vitals will be bad
- babies usually quit feeding, inspiratory retraction
- but it has a wide spectrum of presentation because of broad spectrum of disease
- some cases: tachypnea only sign of underlying pneumonia
may have elevated WBC - CXR: much more variable than with adults, don’t see classic lobar consolidation
Tx considerations for pneumonia?
- abx: if you think it is bacterial
- bronchodilators: if wheezing
- fluids, O2: if less than 95%?
- hospitalize if you think condition is severe
What is Pertussis or whooping cough caused by? Why is it making a comeback? Who do we worry about getting perttussis?
- caused by bordetella pertussis
- highly communicable disease, making a comeback because less people are vaccinating and vaccination not always effective, and many people lose immunity over time
- Worry about babies getting pertussis - infection isn’t what kills but the respiratory distress from coughing does
How long does pertussis last?
- 4-12 weeks
Presentation of Pertussis?
- onset is insidious, starts as URI sxs and slight fever may be present, cough is initially irritating but not paroxysmal
- after about 2 weeks: cough becomes paroxysmal with classic whoop (stage lasts 2-4 weeks)
- cough can be so harsh that it can cause vomiting
What are the guidelines for dx pertussis?
- ask about immunization status
- classic presentation than you should suspect pertussis
- cough for more than 2 weeks, suspect pertussis
- nasal swab for culture (Bordet-Gengou culture medium)
or - nasal swab for PCR more sensitive: sent to state lab, results in 3-7 days
Tx for pertussis?
- erythromycin for 14 days
- azithro for 5-7 days
- usually tx awaiting lab results if hx of known exposure
- will not shorten course of cough unless given in early phase but it will prevent transmission (must tell this to pt)
Pearls for Bronchiolitis
- usually caused by RSV
- peaks at 6 mos of age, generally fever with marked tachypnea and wheezing, highly contagious and seasonal
Difference b/t bronchitis and pneumonia in peds?
- tx pneumonia?
- viral bronchitis: URI sxs and coarse bronchial sounds and usually no fever
- with bacterial pneumonia: acute onset of fever, productive cough, SOB w/o URI sxs and with fine crackles, not coarse breath sounds
- pneumonia is usually viral but difficult to distinguish from bacterial pneumonia so usually tx with abx
2 yo boy presents with persistent “hacking” cough (6 mo), dx with asthma 4 months ago, cough gets worse with each cold, and he vomits occassionaly. Smaller than most children his age (in 3rd percentile)
- Repeated URI infections after being dx with RSV bronchiolitis
- ** born at home, UTD on immunizations
- had formula intolerance - stools frothy and bulky - not digesting fat
PE: slight increased AP diameter of chest, diffuse wheezes, and crackles
most likely Dx?
- Cystic fibrosis
- do sweat chloride test - 90 mEq/L (anything above 60 is abnormal)
- failure to thrive because lungs are full of mucus, huge metabolic disruption and all intake is going towards breathing, also losing fats because of pancreas
How should you tx CF pneumonia?
- combo of abx: amino glycoside tobramycin (cover pseudomonas) and antipseudomonal PCN - piper or ticarcillin
- also neb bronchodilators, O2 prn, chest physiotherapy, mucolytics, and maybe steroids
What should you be worried about when Rx tobramycin?
- ototoxicity
- nephrotoxicity
Can you use cipro on this 2 yo child?
No, worried about arthopathy (joints) and osteochondrosis
Common findings in CF population?
recurring sinusitis
mucus secretions
nasal polyps
Cystic fibrosis pathology?
- autosomal recessive inheritance
- 1/6000 CAUCASIAN births
- carrier rate: 1 in 32 adults
- disease of exocrine gland system (reach an epithelia surface and assoc with external secrteion, whereas endocrine - secretes directly into bloodstream): defective chloride channel results in highly viscous secretions
- theory: decrease in chloride secretion leads to relative dehydration and abnormal mucociliary clearance
Clinical features of CF?
respiratory insufficiency: excessive mucus - pulmonary fibrosis - obstruction - frequent infections - chronic sinusitis pancreatic insufficiency: - malabsorption of fats anf proteins: steatorrhea, meconium illeus - failure to thrive - rectal prolapse - intussuseption (currant jelly stool)
Dx tests for CF?
- IRT assay
- DNA assay
- sweat chloride test (newborns)
- typical pulmonary features
- typical GI features
- family hx
Tx options for CF?
- pulmonary: bronchodilators mucolytics (acetylcysteine) steroids abx (always has to cover pseudomonas) - pancreatic: pancreatic enzyme supplements vitamin supplements high caloric high protein diet
Survival rate for CF? Often dx when?
- primary morbidity is from progressive obstructive lung disease
- pancreatic enzyme replacement meds have increased survival - now 37 yo
- often dx in hospital at birth because of meconium ileus, signs also include abdominal dissension, and thick sticky meconium
- also dx with presenting during infancy with failure to thrive, respiratory compromise
What is cause of respiratory distress syndrome of the newborn?
- common in preterm infants
- from deficiency in pulmonarry surfactant
- cause of major morbidity/mortality in preterm infants
- lungs aren’t allowed to fully develop if preterm because of lack of surfactant (surfactant isn’t produced until 3rd trimester)
- greatest risk: 28 weeks and lower
Pathophys of Respiratory distress syndrome of newborn?
- surfactant deficiency
- inflammation
- pulmonary edema
- decrease in pulmonary fxn
- hypoxemia
Clinical manifestations of respiratory distress syndrome?
- tachypnea
- nasal flaring
- expiratory grunting
- accessory muscle breathing
- cyanosis
Clinical course of respiratory distress?
progresses over 48-72 hours
- marked diuresis
- tx greatly improves pulmonary fxn
Dx respiratory distress?
- clinical picture of premie
CXR: air bronchograms, ground glass opacities
ABGs
hyponatremia (because of water retention - inflammation)
Tx of respiratory distress?
- give O2, maybe CPAP
- surfactant replacement therapy given through ET tube
