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87 Cards in this Set
- Front
- Back
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Laryngomalacia
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Under-developed/collapsed supraglottic structures.
Cartilage folds over glottis and causes obstruction. Usu. from birth - 2 months M/C cause of persistent stridor in infants - usu seen in first 6 weeks Inspiratory stridor - worse in supine position/URI/feeding Associated w/GERD Usually resolves by age 2 Omega Shaped Epiglottis --> found w/direct laryngoscopy Tx: not usually needed; if severe, refer Complications: GERD |
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Croup
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aka: Laryngotracheobronchitis
Primarily subglottic, but affects other structures Epidemiology: 75% Parainfluenza viruses; common in fall/winter Common in 6 mos - 3 yrs S/S: URI prodrome progressing to: +/- barking cough, inspiratory stridor, hoarseness W/progression: may see retractions/cyanosis/stridor w/every breath CXR: steeple sign (Usu. not indicated Tx: based on Sxs, |
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Croup Tx
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Mild = barking cough and no stridor at rest --> supportive therapy w/oral hydration and minimal handling
Mist Therapy x 1-2 hrs Oral prelone x3d Moderate = Stridor at rest --> active intervention Nebulized racemic epi --> rapid onset (10-30min) Glucocorticoids: Dexamethasone, PO, IM, IV (0.6mg/kg IM as one dose) - improves Sxs/decreased intubation frequency Inhaled Budesonide ~ 2 hr Oxygen, prn --> if O2 desaturation Observe 3- hrs If respiratory failure impending --> smaller diameter tube |
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Bacterial Tracheitis
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A severe bacterial form of croup
Severe Croup sxs; toxicity; no response to regular therapy High Fever Left Shift Mgmt = Emergent! 60% require intubation IV ABX + Culture |
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Epiglottitis
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Main cause --> H. influenzae type B
Swelling of supraglottic structures (epiglottis and arytenoids) Acute Peak age 1-7 yrs Incidence reduced w/vaccine CXR: thumbrint sign Sx: SUDDEN ONSET High fever, sore throat, toxicity, inspiratory stridor, tripod position 4 D's Dysphagia, Dysphonia, Drooling, Distress Progression to total obstruction possible: retractions/cyanosis/resp. distress Airway visualization (specialist): cherry red/swollen epiglottis and arytenoids |
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Epiglottitis Tx
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Tx: Keep pt calm; NO tongue blades!
Dx; then intubate immediately! W/anesthesia preferred; Hospitalize ASAP -->intubate/tracheotomy, cultures and IV ABX (H. flu Type B) Extubate in 24-48 hrs when direct visualization shows reduction in epiglottis IV ABX cont. for 2-3 days w/oral ABX to complete 10 day course |
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Foreign Body Aspiration:
Upper Respiratory Tract |
Abrupt onset of cough, coughing or wheezing
M/C in ages 6 mos-4 yrs Anticipatory guidance w/parents! Locations: Supraglottic (M/C), Trachea, Main Stem Bronchus (Right M/C) Small distal airways (younger - could be either, w/age R is M/C), Exophagus Sxs Partial: sudden onset of choking/coughing --> helps expel drooling, stridor, coughing Complete --> cyanosis Coughing, vocalizations are absent 5 Back thrusts/chest compressions or heimlich NEVER blidn finger sweeps! Persistent apnea -> tracheotomy/needle cricothyrotomy |
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Foreign Body Aspiration:
Lower Respiratory Tract |
3 possible stages:
1) initial event - sudden coughing/wheezing/resp. distress --> may diminish over time 2) asymptomatic 3) complications - abscess, etc Asymmetrical physical findings of decreases of breath sounds Persistent, localized wheeze Assymetrical CXR findings --> forced expiratory view Look for hyperinflation, mediastinum shift, atelectasis (may be NORMAL) Ball-valve effect of FB: localized hyperinflation distally to FB |
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Foreign Body Aspiration Tx
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• Management
• Hospitalize acute cases • Bonchoscopy • Tx o Acute→ Hospitalization o Chronic→ X-ray→ refer If not shown on image --> then if 2/3 criteria met, indicates bronchoscopy Complications: Infection, wheezing, bronchiectasis |
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Bronchiolitis
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RSV (M/C), Rhinovirus, Adenovirus
Winter, Nov-April, peak in Jan/Feb Older kids --> shows as just a cold Leading cause of children <1 y/o being hospitalized!!! May ultimately cause obstruction Coughing, tachypnea, labored breathing, hypoxia, irritability, poor feeding, vomiting, Wheezing, crackles on auscultation, VERY contagious Infants/toddlers - progressive URI Sxs leading to: Symmetrical wheezing and crackles Respiratory distress, hypoxia, trouble feeding, atelectasis (Severe) Older Children: mild Premies - worst prognosis! --> Risk factors for RSV: <6 mos or chronic heart or lung disease |
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Bronchiolitis Tx
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Hospitalize the following:
< 6 mos Hypoxic Apnea Tachypnea w/feeding problems w/rapid shallow breathing Marked respiratory distress Chronic lung/heart DZ Immunodeficiency Inpatients: Supportive --> suction, oxygen, hydration, Ribavirin (antiviral) Lab: RSV nasal swab Outpatient therapy: Supportive - hydration, nasal suctioning, monitoring Inhaled bronchodilator --> May NOT support this condition Albuterol OK if only thing available in office --> Consider Racemic Epi + Oral Dexamethasone x 5d --> BETTER combination than Albuterol!! DAILY F/U until improvement (usu 7 days) Prevention: Synagis (Palivizumab) - given Nov-April, EXPENSIVE 5 criteria: CHF, Chronic lung disease, premies Prog: predisposes to asthma/PNA |
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Cystic Fibrosis: Epidemiology
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Autosomal Recessive DZ - defect in gene on Ch 7 --> mutations in CFTR -->
Problems in salt and water movement across cell membranes --> leads to thick secretions and alters host defense in the lungs Syndrome of chronic sinopulmonary infxns, malabsorption and nutritional abnormalities. Abnormalities in hepatic, GI, male reproductive systems, and Lungs. Lung DZ = major cause of morbidity/mortality |
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Cystic Fibrosis:
Sxs |
Greasy, bulky, malodorous stools
Failure to thrive --> malabsorption from exocrine pancreatic insufficiency Recurrent respiratory infections Digital clubbing Bronchiectasis Sweat chloride > 60 mmol/L Newborns: possible meconium ileus; chronic airway infxn Signs: Productive cough, wheezing, recurrent PNA's, obtructive airway DZ, exercise intolerance, dyspnea, and hemoptysis Exacerbations: Increased cough and sputum Decreased exercise tolerance Malaise and anorexia Possible H/O: severe dehydration, hypochoremic alkalosis; unexplained bronchiectasis; rectal prolapse; nasal polyps; chronic sinusitis; and unexplained pancreatitis or cirrhosis. |
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CF
Labs, Dx and Tx |
LAB:
Sweat chloride concentration > 60 mmol/L in presence of one or more typical clinical features or family Hx Dx can be confirmed by a genotype w/2 DZ-causing mutagens Tx: Pt should be followed by a CF Foundation-accredited CF care center GI Tx: pancreatic enzyme supplementation Lung DZ Tx: airway clearance therapy and aggressive ABX Respiratory Tx: Bronchodilators, and anti-inflammatory therapies Recombinant Human DNA-ase, inhaled hypertonic saline, and inhaled: tobramycin//aztreonam/oral azithromycin |
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CF related Pathogens
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1st few months: Staph aureus, H. flu
Later in age: Pseudomonas aeruginosa --> causes severe PNA |
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Pertussis
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Bordatella
Highly communicable infxn of respiratory tract. Intense prolonged coughing spells increased incidence: 2000-present HIGH hospitalization rates VERY contagious 3 classes: 1. Catarrhal URI - 2 weeks --> minimal fever, escalating coughing spells 2. Paroxysmal Stage (2-6 wks) --> Dry, prolonged coughing spells, inspiratory whoop 3. Convalescent stage --> intensity and frequency decrease Infants: Choking, gagging, gasping, red face, flailing limbs --> usually no whoop! Post-tussive vomiting ID: w/nasal swab culture Complications: BronchoPNA (M/C), Apnea, atelectasis, OM, sudden death, seizures, subconjunctival hemorrhage, epistaxis, Cerebral edema due to hypoxia MGMT: timely vaccines, ABX (Azithro or Erythromycin), hospitalization if severe TDAP Vaccine After 5-10 y/o - wears out |
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Bronchopulmonary Dysplasia
(General description) |
Occurs in premature infants (30% of those <1000g) in FIRST WEEK of life!
Developmental D/O of the lung characterized by: decreased surface area for gas exchange, reduced inflammation, and a dysmorphic vascular structure Ambiguous Pathophysiology Required O2 therapy or mechanical ventilation w/persistent oxygen requirement at 36 wks gestational age or 28 days of life Persistent respiratory abnormalities |
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Definition of BPD
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O2 required for > 28 days
H/O Positive pressure ventilation continuous positive airway pressure gestational age Definition takes into account: pre-term and full-term newborns (both can be Dx'ed) Extremely pre-term that need minimal ventilator support, but develop O2 requirement; Newborns that die within the first few wks physio abnormalities and biochemical markers of lung injury present in 1st week of life |
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Tx of BPD
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Surfactant Therapy w/adequate lung recruitment
Short courses of postnatal Glucocorticoid therapy Longer courses --> RISK of cerebral palsy Inhaled CTSDs and B-adrenergic agonists Chronic or intermittent diuretic therapy (ADVERSE EFFECTS) if rales/persistent pulmonary edema K and Arginine Chloride supplements Dx Bronchoscopy to evaluate for structural lesions Management of pulmnary HTN --> keep O2 saturation at 93% --> ECG/Echo Hypercaloric formulas and gastrostomy tubes Routinely vaccine for Influenza |
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Cystic Fibrosis: Epidemiology
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Autosomal Recessive DZ - defect in gene on Ch 7 --> mutations in CFTR -->
Problems in salt and water movement across cell membranes --> leads to thick secretions and alters host defense in the lungs Syndrome of chronic sinopulmonary infxns, malabsorption and nutritional abnormalities. Abnormalities in hepatic, GI, male reproductive systems, and Lungs. Lung DZ = major cause of morbidity/mortality |
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Cystic Fibrosis:
Sxs |
Greasy, bulky, malodorous stools
Failure to thrive --> malabsorption from exocrine pancreatic insufficiency Recurrent respiratory infections Digital clubbing Bronchiectasis Sweat chloride > 60 mmol/L Newborns: possible meconium ileus; chronic airway infxn Signs: Productive cough, wheezing, recurrent PNA's, obtructive airway DZ, exercise intolerance, dyspnea, and hemoptysis Exacerbations: Increased cough and sputum Decreased exercise tolerance Malaise and anorexia Possible H/O: severe dehydration, hypochoremic alkalosis; unexplained bronchiectasis; rectal prolapse; nasal polyps; chronic sinusitis; and unexplained pancreatitis or cirrhosis. |
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CF
Labs, Dx and Tx |
LAB:
Sweat chloride concentration > 60 mmol/L in presence of one or more typical clinical features or family Hx Dx can be confirmed by a genotype w/2 DZ-causing mutagens Tx: Pt should be followed by a CF Foundation-accredited CF care center GI Tx: pancreatic enzyme supplementation Lung DZ Tx: airway clearance therapy and aggressive ABX Respiratory Tx: Bronchodilators, and anti-inflammatory therapies Recombinant Human DNA-ase, inhaled hypertonic saline, and inhaled: tobramycin//aztreonam/oral azithromycin |
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CF related Pathogens
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1st few months: Staph aureus, H. flu
Later in age: Pseudomonas aeruginosa --> causes severe PNA |
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Pertussis
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Bordatella
Highly communicable infxn of respiratory tract. Intense prolonged coughing spells increased incidence: 2000-present HIGH hospitalization rates VERY contagious 3 classes: 1. Catarrhal URI - 2 weeks --> minimal fever, escalating coughing spells 2. Paroxysmal Stage (2-6 wks) --> Dry, prolonged coughing spells, inspiratory whoop 3. Convalescent stage --> intensity and frequency decrease Infants: Choking, gagging, gasping, red face, flailing limbs --> usually no whoop! Post-tussive vomiting ID: w/nasal swab culture Complications: BronchoPNA (M/C), Apnea, atelectasis, OM, sudden death, seizures, subconjunctival hemorrhage, epistaxis, Cerebral edema due to hypoxia MGMT: timely vaccines, ABX (Azithro or Erythromycin), hospitalization if severe TDAP Vaccine After 5-10 y/o - wears out |
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Bronchopulmonary Dysplasia
(General description) |
Occurs in premature infants (30% of those <1000g) in FIRST WEEK of life!
Developmental D/O of the lung characterized by: decreased surface area for gas exchange, reduced inflammation, and a dysmorphic vascular structure Ambiguous Pathophysiology Required O2 therapy or mechanical ventilation w/persistent oxygen requirement at 36 wks gestational age or 28 days of life Persistent respiratory abnormalities |
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Definition of BPD
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O2 required for > 28 days
H/O Positive pressure ventilation continuous positive airway pressure gestational age Definition takes into account: pre-term and full-term newborns (both can be Dx'ed) Extremely pre-term that need minimal ventilator support, but develop O2 requirement; Newborns that die within the first few wks physio abnormalities and biochemical markers of lung injury present in 1st week of life |
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Tx of BPD
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Surfactant Therapy w/adequate lung recruitment
Short courses of postnatal Glucocorticoid therapy Longer courses --> RISK of cerebral palsy Inhaled CTSDs and B-adrenergic agonists Chronic or intermittent diuretic therapy (ADVERSE EFFECTS) if rales/persistent pulmonary edema K and Arginine Chloride supplements Dx Bronchoscopy to evaluate for structural lesions Management of pulmnary HTN --> keep O2 saturation at 93% --> ECG/Echo Hypercaloric formulas and gastrostomy tubes Routinely vaccine for Influenza |
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o Leukotriene
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receptor Antagonists (LTRA’s)
• Chronic asthma therapy • Preferred in combo w/ICS only • Alternative @ step 2 for all ages • Ex: • Montekulast (Singulair – age 1y+ • Zafirlukcast (Accolate – age 5y+ |
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o LABA”s Long acting B-agonists
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• Long term controller medication
• Not first line • Not for acute relief • Only used in combination w/inhaled corticosteroids!!! • Indicated for exercise induced bronchospasm (not preferred) Salmeterol (4+) or Formoterol (5+) |
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Salmeterol (Severent Diskus)
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– age 4yr+
o +Fluticasone (Advair Diskus) age 4+, o 100/50 dose |
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• Formoterol (Foradil Aerolizer)
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age 5+
o +Budesonide (Symbicort) – age 12+ o ***Combination drugs – LABA + CTSD |
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• Montekulast
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LTRA
Singulair = Age 1+ • Preferred in combo w/ICS only |
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• Zafirlukcast
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LTRA
Zafirlukast = Age 5+ • Preferred in combo w/ICS only |
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o Inhaled Corticosteroids
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• Long term anti-inflammator y controller
• PREFERRED @ all levels of persistent asthma therapy • Mono- or combination therapy • Potency • Table 38-5, p 1133 • Determine Low Dose • Absorption and Growth o CTSD’s can affect bone velocity and bone demineralization o Low dose – less likely to occur o Higher dose/severe cases – most likely NOT primary care and will see a specialist for dosages |
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• Budesonide Respules (Pulmicort)
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o Inhaled Corticosteroids
• – age 12 mos+ No other meds available for kids under 1 y/o – so this is actually unofficially used for kids under 12 mos too! |
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• Nebulized budesonide
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o Inhaled Corticosteroids
• approved age 1y+ • Nebulized meds better absorbed through the lungs • Maintenance meds |
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• Fluticasone/salmeterol
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o Inhaled Corticosteroids
• (Flovent HFA) • 4y/older ADVAIR inhaler • Maintenance medications |
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• Beclomethasone
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Inhaled Corticosteroids
(QVAR) HFA • approved age 5y/older |
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Dyspnea and PEF Values to assess severity in the office
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• Mild→ dyspnea with activity
• PEF>70% predicted or best • Moderate-→ dyspnea with rest, limited activity • PEF40-69% • Severe→ dyspnea at rest, limited conversation, can’t talk because it prevents them from taking deeper breaths • PEF<40% • Consider b-agonists, corticosteroids, Epinepherine • Life threatening→ can’t talk, sweating • PEF<25% • Refer to emergency |
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Acute Attack in Office:
Tx |
0.15mg/kg x3 of Nebulized Albuterol w/in 1 hr
OR Inhaled Albuterol(4-8)puffs x 3 doses w/in 1 hour OR Ipatropium bromide + SABA --> if unresponsive Consider IM DepoMedrol (steroid injxn) -> controls rebound attacks Monitor O2 saturation Monitor FEV1 or PEF Rx Oral Steroids 1-2 mg/kg (1-2mg/kg x 5 days --> Injxn for immed. Tx until pt can get PO Rx OTHER - Epi - Last resort 3 tx -> no improvement --> ER |
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Acute Exacerbation at Home
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0.05 mg/kg Nebulized Albuterol
Single dose Continue every 3-4 hours pen Albuterol every 20 mins up to 3x tx If better - continue albuterol every 1-4 hrs PRN Max dose = 10mg Albuterol Inhaler (MDI) 2-6 puffs (equiv to 1 puff nebulized) Q 20 mins, up to 3x in a row, then Q 1-4 Hrs Better? F/U in 1-2 days to reassess |
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Asthma:
Inhaler Spacer |
Use is required if <8y/o
--> to ensure proper delivery |
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Instruction of proper Albuterol inhalation
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• 1. Breath out/breath in
• Emphasize that they shake first, then exhale FULLY • 2. Spray on middle of breath in • 3. Hold 10 sec |
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Reactive Airway DZ
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• A “catch all” dx for patients who are wheezing due to colds, irritants, past RSV infection, etc
• These young children may be asthmatic • Use the API • Use the guidelines for initiating therapy • 2007 NIH Asthma Guidelines – Classifying Asthma |
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Extrathoracic D/o
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involve the supraglottic structures
(Above the glottis - opening btwn vocal cords in posterior larynx) |
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Outpatient Pneumonia Therapy
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• Outpatient Therapy – empiric basis
o Amox HD, Augmetnin, Ceftin (Cefuroxime), Omnicef (Cefdinir) o Erythromycin, Biaxin (clarifthromycin, ZIthromax • Zith – short duration, 1x day dosing • A lot of Strep Pneumo is resistant to the Macrolides • ONLY use in cases you suspect to be atypical!! o Rocephin (Ceftriaxone) • Gram + and – • For a rapid response to severe presentations o Follow up in 1-2 days |
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Pneumonia:
Who to hospitalize |
o Who to hospitalize
• Infants and toddlers • Respiratory distress • Low pulse ox • Pleural effusion • Poor feeding, dehydration • Poor home environment • Underlying disease |
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Recurrent Respiratory Papillomatosis
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S/S: Hoarseness, voice changes, croupy cough or stridor
--> leads to life threatening airway obstruction Age of onset: ~2-4 y/o Patho: Papillomas on larynx, usual benign warty growths M/C laryngeal neoplasm in kids Cause: HPV --> vertically acquired Labs: Laryngoscopy to Dx --> Visualize: Unilateral wart on larynx DDX: viral croup (+/- BC), extrathoracic obstruction Prevent w/HPV Vaccine Tx: surgical removal (Cryo/forceps --> difficult), spread/recurrence common Maintain airway until remission |
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Malacia of Airway
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Tracheomalaica or Bronchomalacia (deeper)
-Coarse, chronic wheezing, -Cough, stridor, -Recurrent illnesses, -Recurrent wheezing that DOES NOT respond to bronchodilators Radiographic changes -softening of cartilagenous framework -->inadeq. to maintain airway -Congenital or Acquired (LT intubation/premies) |
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Malacia of Airway
Dx |
Dx:
-Made by airway Fluoroscopy or bronchoscopy -Barium swallow may be used to R/o vascular compression --> May be assoc. w/developmental abnormalities: Fistula, Rings/Slings, Cardiac |
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Malacia of Airway
Tx |
Isolated condition: conservative tx, pt usu. improves w/age
--> primary repair of co-existing lesions (fistulas, rings) Severe: intubation or tracheostomy necessary --> airway will most likely still collapse below tip of artificial airway, requiring positive pressure ventilation |
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M/C serious acute respiratory illness in infants and young children
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Bronchiolitis
Worse in premies/ < 6 mos/ chronic heart/lung DZ Peaks in winter |
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CAP Tx
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Empiric ABX
Children < 5 y/o w/abnormal CXR/clinical findings: First line: Amox HD, Augmentin, Ceftin, Omicef (Allergic - 2nd gen Cephs (minor) or Macrolide (severe) ) 2. Suspect Atypicals: Macrolide - Erythromycin, (Clarith/Azith- short doses), Biaxin 3. Rocephin - Gm +/-; rapid response to severe cases NOTES: **S. pneumo is usually resistant to Macrolides **Children > 5yo are MORE likely to have atypical PNA so Macrolide=BEST **Distal sites of infxn common w/S. pneumo/H. influx (meningitis, OM, sinusitis |
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Top 3 bacterial causes of PNA in kids
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1) S. pneumo - most severe/MC pathogen overall, especially if <5 y/o, risk for complications
2) Chlamydial - C. trachomatis, M/C in early infancy, vertical transmission, More common if > 5y/o 3) Mycoplasma - More common > 5y/o |
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Sxs of Pneumonia
Neonates, 3 mos - 3 yrs 3 y/o+ |
Neonates: Nonspecific; high fever; apnea
3 mos - 3 yrs: fever, cough coarse breath sounds, rales/crackles Vomiting, Respiratory distress 3y/o + fever, cough dyspnea rales or wheezing --> Atypicals |
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Allergic Rhinoconjunctivitis
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Frequently co-exists w/asthma
Perennial, seasonal, or episodic Sxs: sneezing, itching, conjunctival injxn; loss of smell/taste; mouth breathing; snoring P/E: pale/blue turbinates; thin secretions; postnasal drip; congested cough; periorbital edema; infraorbital cyanosis (shiners) Cobblestoning, Eosinophilia Tx: Oral or Topical Antihistamines, Topical decongestants ( < 3days), If see nasal polyps --> refer to R/o cystic fibrosis!!!! |
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Viral Pneumonia (Atypical)
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Preceded by viral URI
Wheezing, rales, prominent Stridor Older: myalgia, malaise, HA Resp Distress: Cough, tachypnea, retractions, grunting, nasal flaring, Rapid viral dx tests from nasal secretions for high risk/epidemiolgy control Even if RSV, can have other pathogens also CXR: perihilar streaking, interstitial; peribronchial cuffing |
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Tx: Viral PNA
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Supportive care
--> May include ABX if can't definitively exclude bacterial H. influe: Immunize high risk pts and age 6mos-5yrs Hospitalize: severe, RSV, <3y/o, w/BPD/severe pulm d/o, immunocomp. Consider Ribarivin Respiratory isolation w/viral Can lead to croup or bacterial tracheitis/PNA Adenovirus --> bronchiolitis obliterans, bronchiectasis, chronic influenza --> bronchiectasis Possibly predisposed to Asthma! |
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Chlamydial PNA
Sxs and Facts |
CAP (5-20%)
Mild, asymptomatic, but can become serious C. trachomatis --> evolves gradually --> may appear well Infants infxn = epidemic in urban areas Sxs: Staccato cough (mimics Pertussis), Pharyngitis, Tachypnea, Rales (inspiratory), FEW wheezes, fever, Inclusion Conjunctivitis!!!*** Eosinophilia, +Ig Have or H/o rhinopharyngitis w/nasal d/c or OM |
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Chlamydia PNA
Labs and Tx |
Eosinophilia,
Hypxemia C. trachomatis - ID w/nasopharyngeal washing C. pneumoniae - serologic testing --> isolation difficult Hyperexpansion common (DESPITE ABSENCE OF WHEEZE), diffuse interstitial, & pathcy alveolar infiltrates Tx: Macrolide or sulfisoxazole Hospitalize if respirotary distress, or post-tussive apnea Prolonged O2 therapy in some pts |
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Atypical Pnemonia
Mycoplasma Presentation |
Common > 5y/o
Endemic or epidemic infx Long incubation period (2-3 ws) Sx onset = slow Lung = primary site, but extrapulmonary --> OME, OE, Tonsillitis, bullous myringitis Cough: dry @ onset, productive w/progression!!! HA/malaise |
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Atypical Pnemonia
Mycoplasma Labs/Tx |
Total and diff WBC: NORMAL
Complement fixation - sn/sp Cold hemaglutinin titer - elevated during acute Titers for M. pneumon. --> 4x increase in Antibodies --> confirm dx or PCR Middle lower lobes - interstitial Pleural Effusion EXTREMELY common Abx: Macrolide: 7-10 days, Alternative: Ciprofloxacin Complications: Extrapulmonary; CNS; Skin, Heart, Joints |
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Croup
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Fall and Winter
M/C: Parainfluenza virus aka Laryngotracheobronchitis -Edema in subglottic space, inflam. of entire airway -Upper resp Sxs -Barking cough + stridor (I) + hoarseness (E) -Progression, stridor at rest (mod), retractions/cyanosis (severe) Lateral neck XR: Steeple sign Mild/Mod: hydration (mist therapy), oral prelone(3D) minimal handling Severe: O2, nebulized racemic Epi, Epi HCL, Deamethason (IM,PO), Budesonide D/C if sxs resolve in 3 days Risk of respiratory failure |
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Indications for mechanical ventilation in a child in status asthmaticus
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PaO2 < 60mmHg despite O2 therapy
AND PaCO2>60mmHg (& rising more than 5mmHg/h) |
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Asthma Referral/Consultation indications
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REFER to asthma specialist:
If difficulty achieving or maintaining control < 5yo: moderate-persistent; OR if Step 3/4 (Consider at Step 2) >5yo: Step 4+, consider at step 3. Also recommended if considering allergen immunotherapy/anti IgE therapy |
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Infants Long Term Controller indications
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In the absence of persistent Sxs, long term controller therapy indicated for those w/risk factors and 4+ episodes of wheezing over the past year that lasted >1d
OR 2+ exacerbations in 6mo requiring systemic CTSD's. |
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mAPI
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Assess asthma dx for children <3yo
Recurrent Wheezing + 1 Major Criteria OR +2 minor criteria Major criteria: 1 parent w/asthma; atopic dermatitis; inhaled allergen sensitivity Minor: Wheezing w/o URI; food allergies; Eosinophilia >4% |
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Atopic March
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Sequential pattern Revealed in atopic kids:
Atopic Dermatitis --> Asthma --> Allergic Rhinitis |
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Most sensitive measure of severity/control
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FEV1/FVC
>0.85 is good < 0.85 = Obstructive Use if >5y/o |
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EPR 3
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Approved by NAEPP: National Asthma Education & Prevention Program
Guideline for most current classification of asthma Used to assess the severity/control of 3 age groups, based on Components of Severity Severity: Sxs (Inter, Persistent) - Directs therapy Control: Manifestations minimized. Assess each on F/U. How successful is tx? Key Domains: Impairment (Freq/limitations), Risks (Declines in Fx, Excerbations, Med Fx) |
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DDX: Acute Dyspnea
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Bronchiolitis
Croup Epiglottitis FB Aspiration |
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Vascular Rings/Slings
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VR: M/C vascular anomaly to compress the trachea or esophagus
VR: formed by a double aortic arch (MOST severe), R aortic arch w/L ligamentum arteriosum or patent ductus arterioles S - L Pulmonary artery branches off R pulmonary artery -Present in infancy -Sxs of chronic airway obstruction: stridor, coarse wheezing, croupy cough -Worse in supine position -Apnea -Respiratory arrest -Esophageal compression -Feeding difficulties (dysphagia/vomiting) -Chronic obstruction -Death |
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Vascular Rings/Slings
DDx/Tx |
DDx: R/o Croup (no wheeze/apnea +UR sxs), FB (unilateral abnorms), Airway malacia (+recurrent illnesses, but may be assoc. w/Rings/Slings!)
Imaging: Barium swallow - showing esophageal compression = mainstay of Dx (CXR/Echo - miss abnormalities) Further define Anatomy w/Angiography/CT w/contrast/MRI/MRA/Bronchoscopy Sig Sxs = surgical correction (double aortic arch) Usu improve following correction, may have mild persistent Sxs -->due to assoc. tracheomalacia |
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Bronchogenic Cysts
General/Sxs/Hx |
Middle mediastinum near carina, adjacent to major bronchi,
BUT can be found elsewhere in lung. 2-10 cm Thin walls, may contain pus, mucus or blood. Develop from abnormal lung budding of primitive foregut. May be seen w/other congenital pulmonary malformations. Can present acutely w/respiratory distress - early childhood --> d/t airway compression OR present w/Sxs of infection Chronic Sxs: -wheezing/cough -intermit. tachypnea -recurrent PNA -recurrent Stridor -May remain asymptomatic until adulthood --> Will eventually become symptomatic --> usu presents w/chest pain PE: often normal + P/E findings: tracheal deviation from midline decreased breath sounds percussion over involved lobe = hyper-resonant (air-trapping) |
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Bronchogenic Cysts
Labs/DDx/Tx |
DDx: Bronchiectasis, PTX, PNA
CT Scan = preferred imaging--> can differentiate solid versus cystic mediastinal masses --> can define the relationship to the airways and the rest of the lung -Barium swallow - shows communication w/GI tract -CXR: may show air trapping/hyperinflation/spherical lesion +/- fluid, BUT misses smaller lesions Tx: Surgical resection. Post-Op: pulmonary physiotherapy - prevents complications (atelectasis, of infxn distal to resection |
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M/C laryngeal neoplasm in kids
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Recurrent Respiratory Papillomatosis
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Recurrent Respiratory Papillomatosis
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Hoarseness, voice changes, croupy cough, or stridor
--> lead to life-threatening obstruction! Age of onset: 2-4 y/o -Patho: Papillomas on larynx, unusually benign, warty. M/C laryngeal neoplasm in kids Causative agent: HPV - possibly vertically acquired. Labs: Dx via laryngoscopy --> see unilateral "wart" on larynx DDx: viral croup (+/-BC) Extrathoracic obstruction (Hi-pitched stridor)-Croup, FB, VC Paralysis) |
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Recurrent Respiratory Papillomatosis
TX |
Dx: via laryngoscopy
Prevention: HPV vaccine Tx: surgical removal of lesions --> Difficult! Cryo/Forceps -->May spread down neck/bronchi Recurrence is common. :( Rx: intralesional cidofovir (Interferon) **Tracheostomy if respiratory arrest ***GOAL: Remission occurs in puberty --> maintain adequate airway until remission |
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Malacia of airway
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Patho: Congenital or Acquired, may be due to long-term intubation of premies
Cartilaginous framework of airway inadequate to maintain patency - All infants have this to SOME degree Sx: Coarse, cough, stridor Recurrent stridor that DOESN'T respond to bronchodilators Recurrent illnesses Radiographic Changes (Tracheomalacia or Bronchomalacia) |
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Malacia of airway
Dx/Tx |
Airway Fluoroscopy or bronchoscopy
Barium swallow used to R/o vascular compression --> May be associated w/developmental abnormalities (Rings/Slings) Tx: Conservative for isolated condition --> improves w/age Primary repair of co-existing lesions (fistulas/slings) Severe: intubation or tracheostomy - though airway will collapse below tip of artificial airway --> requiring positive pressure ventilation |
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Hyaline Membrane DZ
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M/C cause of respiratory distress in pre-term infants
(50% of those born at 26-28wks) Deficient surfactant production + surfactant inactivation by protein leaks in air spaces --> poor lung compliance --> atelectasis --> effort to expand --> respiratory distress Auscultation: air movement diminished despite vigorous effort CXR: bilateral atelectasis, air bronchograms of main airways, doming diaphragm, hypoexpansion/hypoinflation. "Ground Glass Appearance" Sxs: tachypnea, cyanosis, expiratory grunting Lab: Measure PaO2/SaO2, blood glucose, hct Tx: Surfactant replacement: -as prophylaxis in delivery room before dx -as a rescue agent w/in 2-4 hrs of birth (Survanta/Infasurf/Curosurf) W/progression: proteins that inhibit surfactant f(x) leak into air spaces--> Replacement Therapy becomes less effective Intubation, CPAP. Antenatal admin of CTSD's to the mother --> accelerates lung maturation --> 24 hrs prior to birth --> decreased mortality |
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Pertussis
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Increased incidence 2000-present
Patho: Bordatella Pertussis infects ciliated respiratory epithelium, releases pertussis toxins; Droplet communication 1)Catarrhal (1-3 wks) - URI sxs, slight fever + coryza (greatest infectivity) 2) paroxysmal - cough - 10 30, forceful, inspiratory whoop. vomiting, cyanosis, sweating, prostration and exhaustion after paroxysm. gagging/gasping/flailing/cyanosis/conjunctival hemorrhage 3) Convalescent Stage "Severe" Bronchitis" in infants. |
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Pertussis
Lab and Tx: |
Bloodwork may resemble lymphocytic leukemia
--> Leukocytosis w/lymphocytosis @ end of catarrhal stage @ 2 wks - nasopharyngeal swab or nasal wash - organism in respiratory tract @4-5 wks - cultures often (-) --> PCR has replaced culture (improved Sn/Dec time/cost) CXR: thickened bronchi/"shaggy" heart border Tx: Azithromycin - drug of choice --> some resistance reported to Macrolides CTSDs: decreased severity, BUT mask signs of bacterial superinfxn Albuterol - dec. severity but tacky Nutritional support Complications: BronchoPNA (M/C) w/left shift/high fever d/t superinfection (Paroxysmal Stage) Atelectasis Otitis Media Apnea/Sudden Death Seizures Chemoprophylaxis - family, esp <2yo (Azithromycin |
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Classification of Allergic Rhinoconjunctivitis
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Intermittent:
Sxs <4d/wk OR < 4wks Persistent: Sxs >4d/wk OR > 4wks Severity: Mild = w/out impairment of daily Fx/troubling Sxs Mod-Severe = W/impairment of daily activities OR w/troubling sxs |
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2nd Gen non-sedating Antihistamines
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Loratadine (2y/o+)
Cetirizine (6mos+) Azelastine (nasal + ophthalmic formulations) Indicated for Allergic Rhinoconjunctivitis |
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Mast Cell Stabilizers
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Intranasal Ipratropium = adjunct for rhinorrhea
Intranasal/Ophthalmic Cromolyn * Most effective if used prophylactically DAILY |
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Intranasal CTSD's
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Control allergic rhinitis if used chronically.
Mometasone/Fluticasone (>2yo) |
