Case 12: Cough, 10 Month Old

Front 1

Cause of wheezing in infants?

Back 1

• RSV
  
• other viral respiratory infections
  

Front 2

Pathophysiology of asthma?

Back 2

• Airway inflammation
  
• Mucus hypersecretion, and
• Reversible airflow obstruction due to bronchoconstriction.

Front 3

Symptoms of asthma

Back 3

recurrent cough

wheezing

reponsive to bronchodilators

responsive to anti-inflammatories

triggers: URI, allergies, cold air, exercise, amoke exposure

Front 4

Asthma vs reactive airway disease?

Back 4

Controversersial, some physicians use it when kids are young , e.g. less than three

Front 5

Signs of respiratory distress?

Back 5

• paradoxical breathing
  
• tachypnea
  
• nasal flaring
  
• head bobbing
  
• grunting
  

Front 6

What is paradoxical breathing?

Back 6

chest drawn inward with inspiration

abdomen rises

Front 7

What is hyperapnea?

Back 7

increased depth of respiration

may suggest fever, acidosis, extreme anxiety

Front 8

What is hypopnea?

Back 8

reduced tidal volume

may result in hypoventilation

Front 9

What is nasal flaring?

Back 9

seen in small kids with significan resp distress

accessory muscles used

Front 10

What is head bobbing

Back 10

due to accessory muscle use

observed best during sleep

Front 11

What is grunting

Back 11

forced expiration again partially closed glottis

helps generative positive pressure nescessary to stent airways open

Front 12

T/F: respiratory muscle fatigue will reduce signs of respiratory distress?

Back 12

true

Front 13

List the important respiratory diseases?

Back 13

Bordatella pertussis

Epiglottitis

Diptheria

Front 14

Stages of pertussis?

Back 14

catarrhal stage

paroxysmal stage

convalescent stage

Front 15

catarrhal stage of pertussis?

Back 15

1-2 weeks

URI symptoms

Front 16

What is the paroxysmal stage of pertussis?

Back 16

4-6 weeks, lasts

"whoop" cough

forceful cough followed by massive inspiratory effort

Front 17

What is the convalescent stage of pertussis?

Back 17

decrease in frequency of paroxysms of cough

episodic cough may persist for months

Front 18

Complications of pertussis?

Back 18

feeding difficulty

apnea

Front 19

Pertussis vaccine

Back 19

efficacy only 70-90%

protection waynes with time

Front 20

What is epiglottits?

Back 20

life threatening emergency

Hib virus

between 2-5 age

Front 21

Signs/symptoms of epiglottitis? When to consider?

Back 21

fever, stridor, drooling, dysphonia, dysphagia, resp distress

appear toxic

sniff position

Front 22

Intervention for epiglottitis?

Back 22

operating room

anesthesiologist present with gen surgeon or otolaryngologist

Front 23

Radiology findings of epiglottitis?

Back 23

"thumb sign"

thickening of epiglottis

Front 24

What is diptheria?

Back 24

consider in child with pharyngitis and low grade fever, and stridor/hoarseness

raise suspicion if child not immunized

Front 25

List some causes of wheezing?

Back 25

intrinsic or extrinsic compression of airway:

vascular ring/sling

adenopathy

mass or other lesion

Front 26

Stridor

Back 26

airway narrowing

heard with inspiration

Front 27

Wheezing

Back 27

mild: expiration only

increasing: may disappear or become biphasic

Front 28

Rhonchi

Back 28

low pitched rattles

secretions and narrowing of airway

Front 29

Crackles

Back 29

finer breath sounds on inspiration

coarse: pneumonia

fine: pulmonary edema or insterstitial lung disease

Front 30

air entry

Back 30

decreased:

consolidation

atelectasis

pneumothorax

pleural effusion/airway obstruction

Front 31

bronchial breath sounds

Back 31

low in pitch

caused by air moving through consolidated lung

Front 32

asthma presentation

Back 32

acute:cough, wheeze, tachypnea, wheeze, diminished air exchange

more severe: absence of wheeze, presence of cyanosis and pulsus paradoxus

chronic: dyspnea or cough

Front 33

CXR for asthma?

Back 33

hyperinflation

insterstitial markings

patchy atelactasis

Front 34

treatment of acute exacerbation of asthma?

Back 34

corticosteroids

beta 2 agonists

supportive care for hypoxemia or dehydration

Front 35

maintenance therapy of asthma?

Back 35

daily ICS

albuterol, breakthrough

Front 36

asthma prognosis?

Back 36

generally good

depends on ongoing management and pt adherence

Front 37

Cause of bronchiolitis?

Back 37

edema, mucus, cellular debris -> bronchiolar obstruction

RSV common cause

Front 38

Signs/symptoms of bronchiolitis?

Back 38

URI, fever 38.5-39

cough, wheeze, dyspnea, irritability

Front 39

CXR bronchiolitis?

Back 39

hyperinflation

increased interstitial markings

peribronchial cuffing

scattered atelactasis

Front 40

Tx of bronchiolitis?

Back 40

supportive

Front 41

Pneumonia patho?

Back 41

inflammation of lung parenchyma

microorganisms

non-infectious: gastric contents or hydrocarbons

Front 42

Causes of pneumonia?

Back 42

Viral:

Adenovirus, RSV, Parainfluenza, Influenza

Bacterial: neonatal: GBS, E. Coli, Klebsiella

4-12 weeks: chlamydia, staccato cough

up to 5-6: strep pneumo

School age kids: M pneumo, strep pneumo

Front 43

Signs/symptoms of pneumonia?

Back 43

URI prodrome (cough, rhinorrhea)

progression to: fever, tachypnea, crackles

bacterial: fever, cough, resp distress, crackles

Front 44

Viral pneumo CXR?

Back 44

variable: diffuse, patchy interstitial infiltrates

hyperinflammation

pleural effusion

Front 45

Bacterial pneumo CXR?

Back 45

airspace disease

lobar/segmental consolidation

air bronchograms

Front 46

Lab findings viral pneumo?

Back 46

N WBC

viral antigen testing may be helpful

Front 47

Bacterial pneumo lab findings?

Back 47

WBC elevation

Neutrophil predominance

Front 48

Treatment of viral pneumo?

Back 48

supportive, self recovering

Front 49

Treatment of bacterial pneumo?

Back 49

ABx

supportive care

Front 50

Sequelae of foreign body aspiration?

Back 50

composition of foreign body determines local tissue reaction

fatty oils: severe pneumonitis

disc batttery: erosion through bronchial wall

if lodge upper airway, immediately life threatening, 500+ deaths per year in US

Front 51

Stranger anxiety

Back 51

At 9-10 months, infants frequently develop stranger anxiety and often cry when approachedby strangers.Having the parent hold the patient in their lap and asking the parents to help with removing orputting on gowns or clothing may reduce the child's anxiet

Front 52

How to perform an ear and throat exam?

Back 52

do it

be aware uncomfortable for children

Front 53

Antiicipatory guidance for discharge? After foreign body aspiration?

Back 53

recurrent ingestions: contact social services

counselling: non accusatory manner

communication with PCP regarding the pt

Front 54

Important info for cough history?

Back 54

"Is she still drinking?"

"Has she had a fever?"

"Did the cough begin suddenly?Did you see her choke on anything?"

"Has her voice or her cry been hoarse?"

"Has her coughbeen barky? Does she make any noises when she breathes?"

Front 55

cough history cont

Back 55

"Does she have other medical problems? Ear infections? Pneumonia? Spitting up? Chronic diarrhea? Trouble gaining weight?"

"Has she received all of her immunizations?"

Front 56

"Is she drinking?

Back 56

• hydration status
  
• degree of breathing difficulty
  
• dysphagia
  
• during feeds, aspiration
  

Front 57

Fever?

Back 57

Likelihood of infection

Recurrence: superimposed bacterial pneumo

Front 58

"Did the cough begin suddenly?Did you see her choke on anything?"

Back 58

foreign body

if no hx of cough, think foreign body

Front 59

"Has her voice or her cry been hoarse?

Back 59

horase/muffled cry: prob of larynx and pharynx

lower airway: don't affect quality of voice or cry

Front 60

"Has her coughbeen barky? Does she make any noises when she breathes?" "

Back 60

barky/seal: croup, winter months, viral infn (Parainfluenza virus type 1)

mild crup: inspiratory stridor

Front 61

" "Does she have other medicalproblems? Ear infections? Pneumonia? Spitting up? Chronic diarrhea? Trouble gaining weight?"

Back 61

• birth history: prematurity?
  
• recurrent infection, stool pattern, difficulty gaining weight (immunodef or malabsorption, e.g. CF)
  
• reflux, chronic vs acute cough
  

Front 62

"Is she immunized?"

Back 62

unimmunized or partially immunized: higher risk of acquiring of pertussis

Front 63

Allergic rhinitis

Back 63

cough, rhinorrhea, acute

Front 64

asthma:

Back 64

cough, wheeze, can be acute

Front 65

bronchiolitis

Back 65

cough, wheeze, fever, acute

Front 66

croup

Back 66

cough, stridor, acute, fever

Front 67

foreign body aspiration

Back 67

cough, wheeze, acute

Front 68

community acquired pneumonia

Back 68

cough, acute, fever

Front 69

pertussis

Back 69

cough, acute, fever, rhinorrhea in catarrhal stage

Front 70

sinusitis

Back 70

cough, acute, fever, rhinorrhea

Front 71

viral URI

Back 71

cough, acute, fever, rhinorrhea

Front 72

CF

Back 72

cough, chronic

Front 73

anatomic abnormality

Back 73

cough, chronic

Front 74

GER

Back 74

cough, chronic

Front 75

Evaluating for foreign body aspiration

Back 75

PA and lateral XR for initial workup

bilateral decubitius or insp/exp chest film: if obstruction of larger airways present

Front 76

decubitus chest films:

Back 76

If each lung deflates slightly when dependent asexpected, there is less likelihood of an obstruction in a large airway. If one side does notdeflate as expected, this suggests an obstruction in a large airway.

Front 77

insp/exp films:

Back 77

The airwaycontaining an obstruction does not allow the distal lung to deflate fully and results inasymmetric deflation with expiration.

Front 78

Radiographic diagnosis of foreign body aspiration

Back 78

asymmetric wheezing on clin exam

needed to further evaluate etiology of wheeze

Front 79

CXR findings in foreign body aspiration: PA FILM

Back 79

Right hemidiaphragm is flattened, suggestingunilateral hyperexpansion on the right.

Front 80

CXR findings in foreign body aspiration: right decubitus

Back 80

With child on her right side, the mediastinal structures remain in themidline, rather than shifting towards the right lung due to gravity, further demonstrating thefixed hyperinflation of the right lung

Front 81

CXR findings in foreign body aspiration: left decubitus

Back 81

With child on her left side, the mediastinal structures shift towards the leftlung as expected