PEDS RR Flashcards
Harsh sound caused by partially obstructed extrathoracic airway
More commonly heard during inspiration
Stridor
Partial obstruction of the lower airways
More commonly heard during expiration
Wheezing
Irregular coarse rattling due to secretions in intrathoracic airways
Rhonchi
Fluid/secretions in small airways produce sounds like crumpling cellophane
Rales (crackles)
What is the narrowest part of the airway in children
Children <3 years: cricoid ring → narrowest portion of airway
Older children & adults: glottis → narrowest portion of airway
What is the most common cause of stridor in peds
Upper airway obstruction:
Most common cause in infants: laryngomalacia (floppy larynx)
Aggravated by swallowing problems & gastroesophageal reflux
Most common causes of CROUP
PAIR!
Parainfluenza (75%)
Adenovirus
Influenza
RSV
Age range for croup
Children 6 mo-3 years, peak at 2-3yo
What is the MGMT approach to Croup
Airway management and treatment of hypoxia
Racemic epi
(watch for rebound effects
+dexamethasone
(Shortens hospital stays)
If severe: Intubation
What is the criteria for admission for Croup
Multi dose of racemic Epi
Age <6 months
Multiple ED visits in 24 hrs
Suspicion of secondary bacterial infection
Stridor at rest
Common agents of epiglottitis
Group A streptococcus, S. aureus; H. influenza type B
or diphtheria
(unimmunized patients)
How do you dx epiglottis
Dx: direct observation of inflamed, swollen supraglottic structures & swollen, cherry-red epiglottitis
Perform in OR w/ anesthesiologist & surgeon → can place an endotracheal tube, or emergency tracheostomy , ET not possible
What is the tx for epiglottis
antibiotic therapy IV
+/- steroids
endotracheal intubation remains as long as needed to maintain airway
Rapid recovery; most children can be extubated w/in 48-72 hrs
What vaccination prevents Epiglottis
HiB vaccination
What is the most common cause of airway obstruction in peds
Infants most common cause: liquids
Older children common causes:
Grapes, nuts, hot dogs, candy
ANY child in the proper setting with the sudden onset of choking, stridor, or wheezing has….
foreign body aspiration until proven otherwise.
First time wheezer, especially if unilateral, needs x-ray!!
What are the 2 phases of Asthma
Early → bronchospasm
Late → airway inflammation
What is the pulsus paradoxus in asthma
Pulsus Paradoxus
-Decrease in BP >15mmHg with inspiration
When are PFTs used in asthma Dx in peds
An adjunct to clinical suspicion in peds
Establishes diagnosis, directs treatment, monitors treatment response, & assesses disease progression
Diagnostic: Obstructive pattern after a stimulus (i.e., exercise or methylcholine challenge) & reversibility w/ β agonist
When to get CXR in peds pts
Baseline at time of initial presentation to r/o other diseases/anatomic abnormalities
Intermittent Asthma Classification
Daytime S/s less than 2 days a week
With less than 2 (age >5) or 0 (age 0-4) night time awakenings
Using a SABA less than 2 days a week
With NO INTERFERENCE IN NML ACTIVITY
MILD Asthma Classification
Day time s/s > 2 days a week but NOT DAILY
Night time awakenings
(Age 0-4) 1-2 x a MONTH
(Age >5) 3-4 x a MONTH
SABA use more than 2 days a week
But NOT DAILY and not more than one time a day
Minor Limiations of Activity
Moderate Asthma
DAILY S/s
Night awakenings
(0-4) 3-4 x a month
(>5yrs) more that 1 x a week but NOT NIGHTLY
SABA use daily
Interference with SOME limitation
Severe Asthma classification
Daytime S/s repeatedly throughout the day
NIght time awakening
(0-4) more than 1 x a WEEK
(>5yrs) often every night
SABA use several times per day
And extreme activity limitation
What are the two steps of Asthma treatment
- What is the level of severity
2. What is the level of control
Define well controlled Asthma
S/s less than 2 days a week but not more than once a day
Less than 1 x a month of awakenings
With no interference into dialy activities
FEV1 >80%
Rule of 2s for Asthma Tx
Rule of Twos → determine need for daily anti-inflammatory medication:
-Daytime symptoms → ≥2 times/week
OR
-Nighttime awakening → ≥2 times/month
Increase (stepped up) & decrease (stepped down) therapy as needed
What is the role of Ipatropium in asthma (peds)
Adjunct if minimal improvement after albuterol treatment
Often co-administered with albuterol (Duoneb)
Oral Steroids and Inhaled Steroids to use in Asthma Peds Pts
Oral : Prednisone/ Dexamethasome
Inhaled: Fluticasone (1st line)
-reduced short time growth velocity in kids
What is the Rx that is used in exercise induced asthma AND concurrent allergic rhinitis
Leukotriene receptor antagonists (i.e., montelukast)
IF a pt is in need of a LABA in asthma
What is the role of the PA
Do NOT use as single therapy → increased exacerbations & death
Should only be used in combination w/ inhaled steroids for chronic asthma management
Typically, if considering need for this, send to Pulmonology!!
What is the role of Epinephrine in ASthma Pts
Administer IM
Status asthmaticus
Indicated for: Severe asthma associated w/ anaphylaxis or unresponsive to short-acting bronchodilators
What is the role of Omalizumab in asthma pts
Anti-IgE monoclonal antibody → prevents IgE binding to basophils & mast cells
Moderate to severe allergic asthma in 12 yrs or older
Subcutaneous injection every 2-4 weeks
Which are better MDI or Nebulizers
MDIs w/ spacers are as effective as nebulizers
What is the approach for intermittent vs persistent asthma
Intermittent asthma: intermittent use of albuterol
Persistent asthma (mild, moderate, or severe)
→ initiate inhaled corticosteroid
(preferred; alternatively, leukotriene receptor antagonist)
What is the ED tx for status asthmaticus
continuous albuterol, IM steroids, PICU
Avoid intubation if possible!
What are the three stages of pertussis
Catarrhal stage (1-2 weeks)
Paroxysmal Stage (2-4 weeks)
Convalescent stage (1-2 weeks)
Catarrhal Pertussis stage
Non-specific signs (nasal secretions & low-grade fever)
Paroxysmal Stage of Pertussis
Cough starts as dry, intermittent, irritative hack
Distinctive stage: paroxysmal coughing (expiration)
→ lose their breath (clustered violent coughing fits)
Posttussive emesis—esp in older children
Exhaustion
Convalescent stage of Pertussis
Decreasing symptoms (cough, paroxysms, whoops)
How do infants less than 3 months present with whooping cough/ pertusssis
No classic stages
Catarrhal phase is a few days, or unnoticed
After a startle, they can choke, gasp, gag, flail with red face
Cough may not be prominent, not classic whoop
Apnea and cyanosis can follow a coughing paroxysm, or apnea alone—CNS damage!
Any infant that presents with apnea and cyanosis
Should get what lab?
R/o pertussis
Prominent cough with NO fever, malaise or myalgia, exanthem, sore throat, hoarseness, tachypnea, wheezes or rales
Think
Pertussis
Older children with a cough that is ESCALATING at 7-10 days
AND coughing in spurts
Think
Pertussis
Lymphocyte-dominant leukocytosis
Think
Pertussis
Test of choice for pertussis
PCR (polymerase chain reaction) of nasopharyngeal wash is lab test of choice in early phases
What is the Drug of Choice for pertussis mgmt
Azithromycinis the drug of choice in all age-groups
treatment or postexposure prophylaxis
If less than 3 months= ADMIT
What is the prevention for pertussis
DTaP vaccine: 2, 4, 6, & 15-18 mos w/ booster at 4-6 yo
Tdap single booster: 11-12 yo, adults, pregnant patients w/ each pregnancy
All close contacts exposed to pertussis should get what ABX
prophylactic macrolide
(azithromycin x 5 days
or clarithromycin
or erythromycin x 7-14 days)
What is the #1 cause of Bronchilolitis
Respiratory syncytial virus (RSV) 50%
Peak age of bronchiolitis
2-6 months
6 month old presents with low grade fever and increased work of breathing, nasal flares and intercostal retraction
Think
Bronchiolitis
Treatment for Bronchiolitis
Supportive, prevent dehydration
Do not give meds or ABX
What is the role of Palivizumab for Bronchiolitis prevention
Palivizumab: IM injection of RSV-specific monoclonal antibody
Indications: (Change periodically)
- Under 24 months of age
- Prematurity (<29 wks gestation)
- Chronic lung disease of prematurity (<32 wks at birth)
Significant congenital heart disease in 1st yr of life (rarely in 2nd yr of life)—Gestational age doesn’t affect
Given before onset of RSV season! Then every month during the season,.
Most common etiology of PNA in neonates
Group B streptococcus (GBS)
Escherichia coli
Streptococcus pneumoniae
most common PNA in age 1mo-5 years
Viruses (RSV #1, parainfluenza, influenza)!!
Streptococcus pneumoniae
Haemophilus influenza (type B & nontypable)
MC PNA in peds over 5 yrs
Mycoplasma pneumoniae
Streptococcus pneumoniae
Chlamydophyla pneumoniae
What is the 1st sign of PNA in neonates and young peds
fever, apnea, hypoxia often ONLY signs
apnea often 1st sign of pneumonia!
How does bacterial vs viral NA present on CXR
Bacterial findings: lobar consolidation, pleural effusion
Viral findings: diffuse infiltrates, hyperinflation
What is the ABX for bacterial suspected PNA
amoxicillin 80-90 mg/kg/day 1st line for most
Admission Criteria for PNA
Age <6 months (some exceptions)
Immunocompromised state
Toxic appearance(DUH)
Moderate to severe respiratory distress
Hypoxemia (oxygen saturation <90% breathing room air at sea level—altitude lower threshold)
Complicated pneumonia
Sickle cell anemia with acute chest syndrome
Vomiting or inability to tolerate oral fluids or medications
Severe dehydration
No response to appropriate oral antibiotic therapy
Social factors (e.g., inability of caregivers to administer medications at home or follow-up appropriately)
ABX for atypical PNA
If you suspect atypical bacteria:
->Azithromycin, clarithromycin, doxycycline (for children >7)
Can do combination therapy with amoxicillin
ABX for INpt PNA in neonates
Ampicillin/gentamycin
Or penicillin G
(local epidemiologic data documents lack of substantial S. pneumoniae resistance)
Staphylococcus aureus concern → vancomycin
HSV → acyclovir
INpt tx for PNA in older pts
Atypical causes more common—Azithromycin
Hib coverage needed as well—Ampicillin
PICU: 3rd gen cephalosporin (Cefuroxime, Ceftriaxone)
Viral causes still present and need supportive care
THESE ARE IV meds!
