respiratory distress, airway emergencies, and cough Flashcards
upper airway obstruction signs
snoring drooling stridor facial edema neck mass hoarseness barky cough
upper airway obstruction causes
foreign body
edema (croup, anaphylaxis)
mucous/debris (croup)
anatomic abnormality (vascular rings)
lower airway obstruction causes
pneumonia
bronchiolitis
asthma
lower airway obstruction signs
prolonged expiratory phase, wheeze, hx of atopy
ddx for stridor
laryngomalacia (infants) tracheomalacia (expiratory) vascular rings croup epiglottitis bacterial trachiectasis retropharyngeal abscess peritonsilar abscess foreign body angioedema GERD
croup presentation
peaks 7-36mo
viral prodome, sudden onset barky cough
stridor
resp distress
dx = clinical but xray would show steeple sign
treatment of croup
dexamethasone
if mod-severe then add epinephrine nebulizer
if severe, supplemental O2, fluids, etc
foreign body aspiration presentation, investigations, treatment
sudden onset, often biphasic stridor, decreased air entry, oral secretions
consult ENT immediately for scope
CXR: air trapping, lung remains “inflated” in expiratory xray (do insp + exp)
bacterial trachiectasis presentation + diagnosis
superimposed on viral infection
- fever, stridor, cough, resp distress
- poor response to epi neb + steroids
- xray - steeple sign
- definitive dx: bronchoscopic (exudates, membranes, membranes)
bacterial trachiectasis managment
fluids, antibiotics, +/- antivirals +/- bronchoscopy to clear secretions +/- intubation
Epiglottitis organisms
H influezna, S aureaus, GAS
rarer since HiB vaccine
epiglottitis presentation
URTI –> sore throat, high fever –> drooling, dysphagia, dysphonia, distress, “doom”
toxic tripoding stridor tender at hyoid tachycardia
epiglottitis management
- don’t examine oropharynx
- call ENT immediately
- intubate
- cultures: blood +/- epiglottic
- IV cefuroxime or ceftriaxone
Xray *don’t do, wastes time: thumbprint, ballooning hypopharynx
DDx for wheeze
common
- bronchiolitis - 1st episode
- asthma - recurrent
- pneumonia - fever, cough, malaise
- GERD + aspiration
uncommon
- CF
- foreign body - sudden, wheeze, cough, DAE
- bronchopulmonary dysplasia - hx of mech vent / O2, premie
rare:
- mediastinal mass
- CHF - /w FTT
- bronchiolitis obliterans
- tracheobronchial abnormalities
bronchiolitis description
usually RSV, <2y
URTI –> resp distress
worsens over first 72h, lasts 2-3 wks
low-pitch wheeze +/- crackles
resp distress between coughing (vs in pertussis they’re ok)
+/- post-tussive vomiting
diagnosing bronchiolitis
clinical dx
pulse O2, NP swab if hospitalized
CXR + bloodwork not needed unless unsure if another dx
CXR: airway disease, hyperinflation, +/- atelectasis (vs bacterial pneumonia = consolidation without airway disease)
treatment for bronchiolitis
O2 (sats >90%)
IVF PRN
can try: epi neb, nasal suctioning, combined epi + dex
don’t: antibiotics, antivirals, hypertonic saline/mist, chest physio, corticosteroids, salbutamol (unless older and hx atopy, stop if no response)
asthma exacerbation treatment
O2 to keep >90%
mild: salbutamol 4-8puffs, q20min x3 in first hour, repeat if poor response,
- discharge if ok 2-4h after last dose
mod: salbutamol and PO steroids
severe: salbutamol, ipratroprium /w first 3 doses, steroids PO/IV
critically ill / no response: add MgSO4, IV salbutamol, ICU
discharge instructions: ventolin 4-8 puffs q4h for 1-2 days, complete steroid course (5d), fluticasone for 3 weeks daily or throughout season if freq exacerbations
return if using ventolin >q4h
preschool asthma diagnosis
can diagnose after 2 episodes treated /w clear improvement
if 1 episode and has clear improvement, or 2+ reported episodes of asthma-like symptoms
- freq exacerbations or a mod-severe: ICS x3 mo + SABA PRN
- if not monitor +/- 3 mo SABA PRN trial
if improves, dx asthma, if unclear, stop stop and see if deteriorates
Diagnosing asthma in older kids
if 6+ can do PFT
reduced FEV1/FVC and increased FEV1 after bronchodilator
<0.9 predicted and post is >12% increase
for adults
<0.8% pred, >12% AND 200ml increase post
asthma treatment in 6 - 11 year olds
Intermittent (symptoms <2x/wk and night <2/mo):
SABA on demand only:
- Low dose ICS
- Medium dose ICS
- LTRA or LABA (most pick LTRA first)
specialist consult
- Add the other one of the above
- High dose ICS with LABA and LTRA
- Anti-IgE therapy
- chronic oral prednisone
once controlled, step down to min needed
asthma treatment for 12+ year olds
intermittent sx: SABA on demand only
- Low dose ICS
- : Add LABA to low dose ICS
- Add LTRA or increase to medium ICS with LABA
- Add the other one of above
- High dose ICS with LABA and LTRA
- Anti-IgE therapy
- chronic oral prednisone
asthma “good control”
- day sx <4d/wk
- night sx <1d/wk
- no activity limitation
- rescue inhaler <4x / week
- mild, infreq exacerbations
- FEV1 or PEF > 90% personal best
- PEF diurnal variation <10-15%
Pertussis presentation
URTI sx 1-2 wks first
forceful paroxysms of cough 4-6wks, /w whoop after (not in infants)
convalescent stage: less severe cough, can last months
complications: feeding difficulty (babies), apnea
diagnosing pertussis
NP swab (PCR or culture)
blood serology
treatment for whooping cough
azithromycin if <3wks of kids <6mo
cystic fibrosis symptoms
resp: chronic prod cough, infections, low O2, broncheictasis, pneumothorax, hemoptysis, PHTN / CHF, chronic sinusitis, nasal polyposis
GI: protein + fat malabsorption (pancreas), FTT, mec ileus, obstruction, jaundice, focal biliary cirrhosis, rectal prolapse, recurrent pancreatitis
other: DM, clubbing, low Na, low Cl / acidosis, ADEK deficiencies, dermatitis, Zn deficiency, male infertility, mucous obstruction of cervix
testing for CF
immunoreactive trypsinogen = newborn screen
if positive, DNA test
if mutations, sweat chloride test to confirm
obstructive sleep apnea age + sx
peaks 2-8
enlarged tonsils or adnenoids, obesity in older kids
snoring, gasping, apnea, mouth breathing, nasal obstruction, increased WOB, diaphoresis, neck hyperflexion at night, fatigue, FTT, poor school performance
diagnosing OSA
polysomnogram
treatment OSA
tonsillectomy or adenoidectomy
if obese & surgery ineffective: weightloss, CPAP
