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139 Cards in this Set
- Front
- Back
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What can bronchospasms present as? |
Cough, chest pain, shortness of breath, fatigue with exertion, expiratory wheeze, and chest tightness
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What are some things that can cause airway obstruction? |
-presence of obstructing material (secretions, tumor or foreign body) -Mucal thickening -Contraction of smooth muscle (spasms) -Extrinsic compression |
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What are differential causes of wheezing in children and infants? |
-Asthma (especially with recurrent wheeze) -Allergies -GERD -Infections (bronchiolitis, bronchitis, PNA) -Obstructive sleep apnea -Heart failure _Bronchopulmonary dysplasia (Uncommon and can be seen in premature infants who have been on a ventilator) |
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A patient with recurrent respiratory infections needs to be evaluated for? |
Immunodeficiencies (2 main types): -Inherited -Acquired (HIV) -Make sure to refer to allergist/immunologist |
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What are signs and symptoms of an immunodeficiency |
–8ormore new ear infections in a year –Twoor more serious sinus infections –Persistentoral candidiasis –Twoor more months on antibiotics without improvement –Theneed to clear infections with IV antibiotics–Recurrentpneumonia –Failureto thrive –Twoor more deep skin infections |
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If you are trying to diagnose asthma, what is important to ask in the history? |
Asthma, eczema (atopic dermatitis) and allergies |
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What is the appearance of air hunger? |
Sitting forward, trying to suck in air. Can be accompanied with nasal flaring. |
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What lung sound is associated with wheezing? |
Prolonged expiratory phase |
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What will the lung sounds sound like with upper respiratory involvement? |
Noisy breathing, snoring, stridor, and rhonchi |
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What will the lung sounds sound like with lower respiratory involvement? |
-Presence of crackles/rales, rhonchi, wheezing, prolonged expiratory phase, and possible diminished breath sounds |
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In regards to pulse oximetry, what are different percentages for severity? |
-Greater than 95% is WNL -90 to 95% is moderate oxygen compromise -Less than 90% severe lack of oxygen |
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When should you order a chest xray with wheezing? |
Order a chest xray (PA and lateral) with the first episode of wheezing, other pulmonary disorders (PNA, CHF) and if the child is less than 1 year old with persistent wheezing. |
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What are some asthma changes that can be seen on xray? |
-Can be normal xray findings -May show hyperinflation of lungs -Flattening of the diaphragm (associated with chronic inflammation and associated with accessory muscle use) -Peribronchial thickening -With or without atelectasis |
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When should you order a CT scan for sinusitis? |
-Facial swelling -Acute sinusitis unresponsive to 48 hours of antibiotics -Toxic appearing child -Recurring or chronic sinusitis -Chronic unresponsive asthma |
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What are different kinds of allergy work up for asthma? |
Skin testing (refer to allergist) -ImmunoCap or RAST testing |
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When should you order a sweat test? |
For suspected cystic fibrosis -Measures the sodium in the skin CF has >2.5 times the normal amount |
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What is the gold standard for diagnosing asthma in children? |
Pulmonary function test-Spirometry is the gold standard for diagnosing asthma in children older than 4 years of age Can be done: -Done at the time of initial assessment -Can be done after treatment is initiated and symptoms are stabilized to document attainment of near "normal" airway function -During period of progressive or prolonged loss of asthma control -At least every 1 to 2 years to assess maintenance |
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What is a peak expiratory flow? |
-Diagnostic test -Assesses control and evaluates effectiveness of beta agonist treatment in children 4 and up -Use these values for the asthma action plan as the reference value -Use during exacerbations to help determine the severity of the exacerbations and guide therapeutic decisions |
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What is the most likely cause of recurrent wheezing in children younger than 5 years? |
Asthma |
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What is asthma characterized by? |
Airway inflammation airflow obstruction (caused by airway edema and mucus secretion and smooth muscles hyperplasia causes airway remodeling) airway hyperresponsiveness (triggered by bronchospasms) |
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What is the etiology of asthma? |
•Asthmais the leading serious chronic illness of children in the U.S. •Themost common chronic disease of childhood •Effectsmore than 5 percent of the U.S. population younger than 18 year –In2006 an estimated 6.8 million children under 18 years were diagnosed withasthma –Highestprevalence in children 5-17 years of age. Decreases with age –Theprevalence has increased 75% over the past 20 years |
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What race is asthma prevalent? |
25% higher among American Indian or Alaska children -60% higher among blacks -140% higher among Puerto Rican children relative to white children -Could be due to access to medical care and more exposure to environmental factors |
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What are risk factors for persistent wheezing and predisposition to asthma in infants? |
-Frequent symptoms in the first 12 months of life -Eczema -Elevated IgE levels -Maternal history of asthma -Maternal smoking |
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When should you suspect asthma in children? |
URI trigger 85% of wheezing episodes -3 or more episodes of otitis media -PNA -Atopic dermatitis -Family history of asthma -Laryngotracheitis -Allergic rhinitis -Any wheezing in the first 3 years -Sinusitis and family history -Recurrent wheezing in the first 6 years |
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What is the classic presentation of asthma? |
Common asthma symptoms include: coughing, especially at night, wheezing, shortness of breath, chest tightness, pain or pressure, and fatigue with exertion |
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What is the unusual presentation of asthma? |
-Chest tightness and difficulty breathing in the early morning hours -Constant sighing -Rapid breathing, fatigue, difficulty sleeping, anxiety, difficulty concentration, chronic dry, non productive cough |
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Aside from a chest xray and allergy testing, what else can you do to diagnose asthma? |
Spirometry to demonstrate obstruction and assess reversibility -Done in children older than 5 years old -Reversibility is determined either by: an increase in FEV1 of more than or equal to 12% from baseline, increase of greater than or equal to 10% of predicted FEV1, and after inhalation of short acting bronchodilator |
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What are additional pulmonary studies for asthma? |
Pulmonary function studies and broncho-provocation with methacholine, histamine, cold air or exercise challenge |
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What is pulmonary function studies? |
–Measurementof lung volumes and evaluation of respiratory loops may be needed if there is aquestion about possible coexisting COPD, Vocal cord dysfunction or possiblecentral airway obstruction |
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What is broncho-provocation with methacholine, histamine, cold air or exercise challenge? |
If asthma is suspected and spirometry is normal or near normal -A positive test is consistent with asthma -Negative test may be more helpful to rule out asthma |
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What 3 things are needed to diagnosis asthma? |
-Episodic symptoms of airflow obstruction or airway hyperresponsiveness are present -Airflow obstruction is at least partially reversible -Alternative diagnoses are excluded |
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What is needed to determine if an infant or child needs intiation of long term control therapy? |
If 4 or more episodes of wheezing in the past year that lasted more than 1 day and affected sleep and who have either 1 of the following: -Parent with history of asthma -Physician's diagnosis of atopic dermatitis -Evidence of sensitization to aeroallergens OR 2 of the following: -Evidence of sensitization to fods -Greater or equal 4% peripheral blood eosinophilia -Wheezing apart from colds |
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If you are diagnosing a 5 year old or older with asthma, what would they demonstrate with a spirometry? |
-Demonstrate obstruction and assess reversibility -Reversibility is determined either by: an increase in FEV1 or greater than or equal to 10% of predicted FEV1 -After inhalation of short acting bronchodilator **Spirometry is needed to establish a diagnosis of asthma** |
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According to the NHLBI key indicators for considering a diagnosis of asthma, what do you need a history of for asthma? |
History of: -Cough (worse at night), recurrent wheeze, recurrent difficulty in breathing, recurrent chest tightness -Symptoms occur or worsen in the presence of (exercise, viral infection, animals, house dust, changes in weather, laughing or crying hard, menstrual cycles) -Symptoms occur or worsen at night (awakens the patient) |
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What is needed to determine asthma control? |
-Determine the asthma severity (before treatment) -Assess asthma control (goal is the lowest level of treatment needed to maintain control) -Classifying severity of asthma exacerbation (mild, moderate, severe, and respiratory arrest immanent) |
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Describe Step 1 Mild Intermittent for a 0 to 4 year old |
Daytime S/S: Symptoms are less > or equal to 2 per week, asymptomatic and normal PEF between exacerbations, requires SABA 2 days a week. No interference with normal activity Night time S/S: 0 |
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Describe Step 2 Mild Persistent for a 0 to 4 year old |
Daytime S/S: Symptoms >2 per week but <1 time per day. Requires SABA >2 days per week but <1 per day. Exacerbations may affect activity Night time S/S: 1 to 2 times a month |
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Describe Step 3 Moderate Persistent for 0 to 4 year old. |
Daytime S/S: daily symptoms, daily use of inhaled SABA. Some limitations. Exacerbations affect activity >2 per week. May last days. Night time S/S: 3 to 4 times a month |
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Describe Step 4 Severe Persistent for 0 to 4 year old. |
Daytime S/S: Throughout the day. Requires SABA several times a day. Extremely limited physical activity. Frequent exacerbations Night time: >1 time a week Lung function: FEV1 <60% predicted |
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Describe Step 1 Mild Intermittent in 5 to 11 year old. |
Daytime S/S: Symptomsless than or equal to 2 per weekAsymptomatic and normal PEF betweenexacerbationsRequires SABA(Short acting beta2agonists) 2 days per weekNo interference with normalactivity Night time: <2 or equal to 2 times a month Lung function: FEV1 >80% predicted. Normal FEV1 between exacerbations |
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Describe Step 2 Mild Persistent in 5 to 11 year old. |
Daytime: Symptoms >2/wk but <1time /dayRequiresSABA >2days/wk. but <1/dayExacerbationsmay affect activity Night time: 3 to 4 times/month Lung function: FEV1 >80% predicted |
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Describe Step 3 moderate persistent in 5 to 11 year olds. |
Daytime: Daily symptoms, daily use of SABA, some limitation of normal activity Night time: >1 time a week but not nightly Lung function: FEV 60-80% predicted |
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Describe Step 4 Severe persistent in 5 to 11 year olds. |
Daytime: Throughout the dayRequires SABA several times a dayExtremely limited physical activityFrequent exacerbations NIght time: Often 7 times/week Lung function: FEV1 <60% predicted |
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Describe the asthma control and adjusting therapy in a 0 to 4 year old if well controlled. |
Symptoms: < or equal to 2days/week Night time wakening: < or equal to 1 time/month Activity interference: None SABA: < or equal to 2 days/week PO steroids: 0-1 per year Recommended action: Maintain current treatment and follow up every 1 to 6 months. Consider step down if controlled for 3 months |
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Describe the asthma control and adjusting therapy in a 0 to 4 year old if not well controlled. |
Symptoms: >2 days/ week Night time waking: > 1 time per month Activity interference: Some limitation SABA: >2 days per week PO steroids: 2 to 3 times per year Recommended action: Step up(1 step) and reevaluate in 2-6 weeks.If noclear benefit in 4 -6 wks, consider alternative diagnoses oradjusting therapy |
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Describe the asthma control and adjusting therapy in a 0 to 4 year old if poorly controlled. |
Symptoms: throughout the day Night time waking: >1 time per week Activity interference: Extremely limited SABA: Several times per day PO steroids: >3 per year Recommended action: Consider short course of oral systemiccorticosteroidsStep up (1-2 steps) and reevaluate in 2weeks. If no clear benefit in 4-6 weeks consider a different diagnosis |
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Describe the asthma control and adjusting therapy in a 5 to 11 year old if well controlled. |
Symptoms: < or equal to 2 days/week Night time waking: < or equal to 1 time/month SABA: < or equal to 2 days/week Lung function: 80% predicted or personal best PO steroids: 0 to 1 per year Recommended action: Maintain current step. follow up every 1 to 6 months. Step down if well controlled for at least 3 months |
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Describe the asthma control and adjusting therapy in a 5 to 11 year old if not well controlled. |
Symptoms: >2 days/week or multiple times on < than or equal to 2 days/month Night time waking: > or equal to 2 times/month SABA: > or equal to 2 days/week Lung function: 60-80% PO steroids: > or equal to 2 per year Recommended action: Step up at least 1 step, reevaluate in 2 to 6 weeks. Use alternative treatment for side effects |
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Describe the asthma control and adjusting therapy in a 5 to 11 year old if very poorly controlled. |
Symptoms: Throughout the day Night time waking: >2 times per week SABA: Several times per day Lung function: <60% PO steroids: > or equal to 2 per year Recommended action: Consider short burst of systemic corticosteroids. Step up 1 to 2 and reevaluate in 2 weeks |
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If a patient has mild classification for the severity of asthma exacerbation, how would you describe it? |
Symptoms can happen while walking and can lie down Talks in: Sentences Alertness: May be agitated Respiratory rate: Increased Accessory muscle use: Usually not Wheezing: Moderate often only at end expiratory Pulse: Normal PEF: > 70% PaO2: Normal PCO2: <42mmhG Pulse ox: >95% |
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If a patient has moderate classification for the severity of asthma exacerbation, how you would describe it? |
Symptoms: While at rest. Infants will have a soft, short cry and feed less. Prefers to sit Talks in: Phrases Alertness: Usually agitated Respiratory rate: Increased Accessory muscle use: Common Wheezing: Loud, exhalation Pulse: Increased PEF: 40 to 69% PaO2: >60mm Hg PCO2: <42mmHg Pulse Ox: 90-95% |
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If a patient has severe classification for the severity of asthma exacerbation, how would you describe it? |
Symptoms: While at rest. Infant stops feeding and sits upright Talks in: Words Alertness: Usually agitated Respiratory rate: Increased Accessory Muscle use: Usually Wheezing: Loud, inhalation, and exhalation Pulse: Increased PEF: <40% PaO2: <60mmHg PCO2: >42mmhg (possible respiratory failure) Pulse ox: <90% |
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What is the goals of treatment for asthma? |
•Chroniccontrol •Maintainnormal activity levels and exercise•Maintainnear normal pulmonary function•Preventacute episodes of asthma •Minimizeemergency department visits and hospitalizations •Avoidadverse effects of asthma medications |
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What are some short acting beta agonists? (SABA) |
-Albuterol (ProAir, proventil, ventolin) --Regular use on a daily basis means poor control -Levalbuterol (HFA, Xopenex) |
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When you need quick control, what can you prescribe on top of the albuterol inhaler? What is the dosage? |
Methlprednisolone Short burt of 1-2mg/kg/day divided to every day to twice a day for 3 to 10 days until peak flow is 70% |
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What are some inhaled corticosteroid medications for long term control? |
Mometasone, budesonide, fluticasone, beclomethasone, and ciclesonide |
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What are examples of inhaled corticosteroids + LABA medications for long term control? |
Fluticasone/Salmeterol Budesonide/formeterol Mometasone/formeterol |
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Describe the stepwise method and what medications are included in the stepwise method for 0 to 4 year olds. |
Step 1: SABA PRN Step 2: Low dose ICS + cromolyn or moteleukast Step 3: Medium dose ICS Step 4: Medium dose ICS + LABA or monteleukast Step 5: High dose ICS + Laba or monteleukast Step 6: High dose ICS + LABA or monteleukast + oral corticosteroid |
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What can signify the need to step up treatment in any age group? |
Frequent use of SABA may indicate the need to step up treatment Use of SABA >2 days a week (usually means poor control in 5 to 11 year olds) |
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Describe the stepwise method and what medications are included in the stepwise method for 5 to 11 year olds. |
Step 1: SABA PRN Step 2: Low dose ICS +cromolyn or singulair Step 3: Low dose ICS + LABA or low dose ICS with either singular, theophylline, or medium dose ICS Step 4: Medium dose ICS + LABA or Medium dose ICS + singular or theophylline Step 5: High dose ICS + LABA or High dose ICS + singulair or theophylline Step 6: High dose ICS + LABA + oral steroid |
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Describe the stepwise method and what medications are included in the stepwise method for 12 years and older. |
Step 1: SABA PRN Step 2: Low dose ICS or cromolyn, Singulair Step 3: Low dose ICS plus LABA or Low dose ICS plus singular, theophylline, or zileuton Step 4: Medium dose ICS + LABA or Medium dose ICS + singulair, theophylline, or zileuton Step 5: High dose ICS + LABA and consider omalizumab Step 6: High dose ICS + LABA+ steroid |
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How long should you follow up with an asthmatic patient? |
Follow up monthly until controlled then every 6 months. If stable after 3 months, try to reduce therapy by 25 to 50% |
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What is allergic rhinitis and how is it diagnosed? |
Inflammation of the nasal epithelium -Second most common atopic disorder (asthma #1) -Diagnosed in presence of rhinorrhea, nasal pruritis, congestion, and sneezing |
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What is the subjective data for allergic rhinitis? |
Nasal congestion, mouth breathing, snoring, nasally speech, itchy nose, palate, pharynx, and eyes, sneezing, hoarseness, rhinorrhea, red eyes, postnasal discharge, and night cough |
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Describe some objective data for allergic rhinitis in the eyes, ears, mouth and nose. |
Eyes: Dennie lines and morgan fold, cobble stone appearance palpebral conjunctiva Ears: asses for otitis media and serous otitis Nose: Assess for pale to purplish color and edema (boggy) nasal mucosa membranes, clear thin watery nasal discharge, will have nasal crease: horizontal crease across the lower third of nose, presence of nasal polyps Mouth: Cobblestone appearance of the pharynx, mouth breather and assess for tonsilar hypertrophy |
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What is Dennie lines or Morgan fold? |
Extra groove in lower eyelid, conjunctivitis, and dark circles |
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How is allergic rhinitis diagnosed? |
Characteristic symptoms and clinical findings -History of atopy in child or family -Presence of eosinophils on nasal smear -Referrals for skin allergy testing -Serologic testing for IgE antibody to specific allergens (RAST, ImmunoCAP test) |
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How do you manage allergic rhinitis? |
-Avoidance of the offending allergen -Oral antihistamines (first generation: sedating benadryl and second generation: Nonsedating: Loratidine, cetirizine) -Nasal antihistamines -Nasal irrigations -Leukotrienes: Singular -Intranasal corticosteroids (Flonase, Nasonex) |
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What is the best nasal irrigation to use? |
1/4 teaspoon of salt in 8 ounces of water -Washes away irritants -Moistens the mucosa |
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What should you be cautious with when using nasal decongestants? |
-Helpful to relieve nasal congestion but short term use only. -Can cause rebound rhinorrhea if used for more than 3 to 5 days -Children younger than 2 years old should not be given decongestants |
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What is the most common upper respiratory infection in children? |
The common cold: Acute viral rhinitis -Children have 6 to 12 colds per year -30 to 40% are caused by rhinoviruses -Average duration is 1 week |
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What are subjective data for upper respiratory infection (the cold). |
-Sudden onset of clear or mucoid rhinorrhea -Nasal congestion -Sneezing -Sore throat -Cough -Possible fever (especially in children less than 5 years old) |
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What are some objective data for upper respiratory infection (the cold)? |
Nose, throat, and tympanic membranes may appear red and inflamed |
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What other objective data for other types of viruses? (Epstein-Barr virus, Adenovirus, Enteroviruses, herpesvirus) |
Epstein-Barr: possible exudate on tonsils Adenovirus: possible exudate on tonsils with cervical lymphadenopathy Enteroviruses: Possible vesicles or ulcers on the tonsillar pillars Herpesvirus: Ulcers anteriorly and cervical lymphadenopathy |
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How do you treat upper respiratory infections? |
-Acetaminophen or ibuprofen for fever or pain. -Humidification for relief of congestion and cough -Nasal saline drops with suction to relieve mucous -Avoid OTC medication in children under 4 years -Antihistamines do not work in relieving cold symptoms -Fluids (water) -Humidification (clean properly every 3 days) -Bulb syringe (gentle nasal irrigation) -Normal saline nasal drops |
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What over the counter medications have been withdrawn from children? |
Antihistamines Antitussives (dextromethorphan) Expectorant (guaifenesin) Decongestant (pseduophedrine) |
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What are signs and symptoms of respiratory distress? |
-Tachypnea -Drooling -Grunting respirations (Ominous sign of impending respiratory failure) -Tripod position (Upright, leaning slightly forward, mouth open and with head, neck and jaw thrust forward) -Nasal flaring -Use of accessory muscles -Increased restlessness -Apprehension -Agitation -Cyanosis -Drowsiness to coma |
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What are 3 symptoms needed to diagnose rhinosinusitis? |
-Purulent nasal discharge -Nasal obstruction -Facial pain, pressure or fullness lasting between 10 days and 4 weeks |
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What are common bacteria of rhinosinusitis? |
S. pneumoniae, H. influenzae, and Moraxella catarrhalis |
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What are signs and symptoms of rhinosinusitis? |
Primary symptoms: purulent rhinorrhea, facial pain, and nasal obstruction Suggestive signs and symptoms: Headache, fever, fatigue, maxillary dental pain, cough, decreased ability to smell, ear pressure or fullness Additional key issues: Cough worse at night, periorbital cellulits, and occasional malodorous breath or ears feel full |
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How do you diagnose rhinosinusitis? |
Usually diagnosed without imaging based on signs, symptoms, and clinical findings -CT Scan is usually done if facial swelling and acute rhinosinusitis is unresponsive to 48 hours of antibiotics, child has a toxic apperance, chronic or recurrent rhinosinusitis, and chronic unresponsive asthma |
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What is the management for acute rhinosinusitis? |
-Most acute rhinosinusitis resolve without antibiotics in about 4 weeks -Amoxicillin (80 to 90mg/kg/day) -Augmentin, Cefpodoxime If allergic to amoxicillin, can use azithromycin |
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What is chronic sinusitis? |
Symptoms persisting for at least 12 weeks -Risk factors: anatomic blockage, irritant and allergen exposure, defects in mucocilliary function, immunodeficiency, and chronic infection with bacterial viruses or fungi |
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What is stridor and What are some diseases that can cause stridor? |
-High pitched wheezy sound in the upper airway -Epiglottitis, laryngotracheobronchitis "infectious croup", bacterial tracheitis, diptheria, and foreign body |
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What is epiglottitis and who is at risk? |
-Acute inflammation of the epiglottis and the supraglottic larynx caused by the Haemophilus influenzae bacteria, neisseria meningitides or streptococcus. -CHildren between 1 and 5 years old affected -Rare event secondary to the Haemophilus Influenzae conjugate vaccine |
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What are signs and symptoms of epiglottitis? |
–Suddenescalating high fever –dysphagia and drooling –muffled voice and sore throat –inspiratoryretractions, cyanosis and soft stridor –“looksill” –Mayprogress to total airway obstruction and respiratory arrest |
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How do you diagnose epiglottitis? |
-Direct visualization of the epiglottis
-Epiglottis will be cherry red and swollen |
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How do you treat epiglottis? |
-Endotracheal intubation in children -Blood cultures -IV antibiotics for 2 to 3 days follow by 10 day course of oral antibiotics -Cephalosporin to cover H. influenzae and Streptococcus species |
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What is laryngotracheitis (Croup)? |
-Swelling and erythema of the lateral walls of the trachea below the vocal cords -Results in rapid, acute upper airway obstruction at the larynx -Harsh, barking cough Effects children less than 6 years old. Most common between 6 and 36 months |
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What causes croup? |
Viral Parainfluenza type 1 is the most common cause Can also be caused by influenza, metaphenumovirus, adenovirus, and rhinovirus -Incubation period is 3 to 6 days and lasts 5 days |
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What is the clinical presentation of croup? |
-Recent history of URI before onset of stridor -Fever within the first 24 hours -Intermittent stridor (mild to moderate "barky cough") -Symptoms worse at night -Gradual onset of symptoms 2 to 3 days -May or may not have sore throat -Improvement within a few days if you have viral croup |
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What will the physical exam of croup look like? |
•Slightdyspnea, tachypnea and retractions•Mild,brassy or barking cough •Stridor–Highpitched, harsh sound from turbulent air flow, inspiratory •Fever,low grade or elevated •Substernal andchest wall retraction in severe case •Prolongedinspiration |
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How is croup diagnosed? |
-Based on history and clinical findings -X ray of neck and chest -Classic pattern: subglottic narrowing will show "steeple sign" on posterioranterior views |
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What are some differential diagnosis for croup? |
-Epiglottitis -Acute spasmodic croup (no signs of infection) -Foreign body aspiration -Retropharyngeal abscess -Extrinsic compression from tumors |
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How do you manage croup? |
-Humidified air -Cold, night air is helpful to decrease inflammation -Nebulized epi (short term benefits for 2 hours, can lead to rebound swelling several hours later, and close cadriorespiratory monitoring) -Corticosteroids (helpful to decrease inflammation, also short term. Dexamethasone 0.6mg/kg or Pulmicort respules nebulizer) -Cold medication is not helpful |
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When should you consider hospitalization with croup? |
Respiratory distress -Rate between >60 breaths per minute -Exhibiting stridor at rest -Temperature greater than 102.2F |
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What is bacterial tracheitis (membranous croup)? |
-Acute bacterial infection of the upper airway
-Does not involve the epiglottis -Usually seen between the ages of 3 and 10 -Usually follow an URI -Begins with croup episode but becomes infected with S. aureus (most common), H. influenzae or M. catarrhalis |
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What are clinical findings to bacterial tracheitis? |
–Brassycough, High fever (greater than 102 F) –Rapidlydeteriorates –Copiouspurulent sputum –Looksill –Slowercourse than Epiglottis, normal appearing epiglottis. –CBC: elevated WBC with a left shift |
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How do you manage bacterial tracheitis? |
–Hospitalization –Intubationor tracheostomy to bypass tracheal swelling –Oxygen –Antibioticsto cover S. aureus –Mostchildren become afebrile in 48 to 72 hours |
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What is foreign body aspiration and the difference between a large foreign body versus small objects? |
-Onset of sudden episode of coughing without the signs of respiratory infection -Large foreign body can occlude the upper airway and cause suffocation -Small objects in the lower respiratory tract may not produce symptoms for days to weeks -Common causes: hot dogs, peanuts, small coins, popcorn, hard candy, and small toys |
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What are some clinical findings to foreign body aspiration? |
–Chokingalong with inability to vocalize or cough –Cyanosiswith marked distress –Drooling,stridor –Abilityto vocalize (partial obstruction) –Hemoptysis,dyspnea, wheezing -Wheezingthat does not respond to bronchodilators |
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What is the treatment for foreign body aspiration in the upper airway and lower airway? |
Upper airway: Allow the choking patient to continue to cough to remove the foreign body or use the AHA recommendations (5 back blows, 5 chest compressions, etc.) Lower airway: Bronchoscopy to remove the object |
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How will you diagnose foreign body aspiration?
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Chest x-ray (not as helpful) -Chest fluroscopy -Bronchoscopy |
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When does acute bronchitis occur? |
Most commonly occurs after a viral infection (rhinovirus, RSV, influenza, parainfluenza, and adenovirus |
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What is chronic bronchitis? |
Productive cough lasting more than 3 months. Usually related to asthma, allergies, CF, and cigarette smoking |
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What are the symptoms of bronchitis? |
-Mild URI symptoms, rhinitis, and pharyngitis -Dry hacking cough that begins 3 to 4 days after onset of rhinitis, cough becomes more productive after a few days, wheezing -Older patients c/o chest pain which worsens with coughing -Younger children may have post-tussive vomiting -Normal temperature or low grade fever |
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What are some differential diagnosis for bronchitis and how do you rule it out? |
-Asthma: patten of wheeze, no fever -Bronchiectasis: Recurrent pulmonary infections, irritability, poor growth -Congenital heart disease: heart murmur, signs of CHF, and poor growth -Sinusitis: Purulent rhinitis lasting weeks, headache, and facial dental pain -Foreign body aspiration -GERD: barium swallow shows reflux into esophagus |
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How do you diagnose bronchitis? |
Chest xray will be normal CBC: Shows elevated neutrophils (Bacterial infection) C reactive protein: Elevated (Bacterial infection) |
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How do you treat bronchitis? |
-Supportive care -Antibiotics -Humidified air -Chest physiotherapy (if productive cough and coarse crackles) |
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When should you avoid cough suppressants? |
Avoid cough suppressants in children with a productive cough |
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What kind of antibiotics would you use to treat bronchitis? |
Bronchitis is usually viral, but if not: Azithromycin for 5 days or erythromycin for 14 days |
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When should you follow up with bronchitis? |
If they are coughing for 2 weeks If the cough worsens If the fever persists or worsens If in respiratory distress |
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What is bronchiolitis? |
Viral illness that lasts 1 to 3 days and that causes inflammation leading to obstruction of the small respiratory airways. -Leading cause of hospitalizations for infants -Can be caused by RSV or other viruses |
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What is the clinical presentation of bronchiolitis? |
Initially: URI Gradual development of respiratory distress -Noisy, raspy breathing with wheezing -Low grade to moderate fever -Decreased appetite Infants may just show apnea |
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What are the physical findings of bronchiolitis? |
-Paroxysmal wheezing (usually at night) -Crackles -High respiratory rate(60-80 breaths per minute) -Signs of respiratory distress (nasal flaring, grunting, retractions, cyanosis, prolonged expiration) |
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What are diagnostic tests for bronchiolitis? |
Chest x-ray to rule out pneumonia -RSV wash for rapid testing -Viral cultures of nasal washing to confirm other viruses |
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How do you treat bronchiolitis? |
Supportive care -Increase fluids (pedialyte, breast milk, or formula) to prevent dehydration -Humidified air to loosen sticky mucus -Avoid smoke exposure -Antipyretics for fever -Elevate of the child to a sitting position at a 30 to 40 degree angle -Can try nebulizer |
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What is pneumonia? |
Lower respiratory tract infection -Consolidation of the alveolar spaces involving airways and parenchyma -Bacterial PNA is caused by streptococcus -Mycoplasma PNA causes "walking" PNA (atypical) |
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When does viral pneumonia occur in a child? |
-Most common between 2 and 3 years old |
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When does bacterial pneumonia occur in a child? |
More common in children over 5 years old -Mycoplasma PNA is leading cause in school age children and adolescents |
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What are the symptoms of viral pneumonia? |
Onset may be acute or gradual, progresses more slowly -Nasal congestion, coryza, and cough -Hoarseness, wheezing, rapid/shallow respirations -Lower respiratory S/S develop slowly -Can have fever -Nontoxic apperance |
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What are the symptoms of bacterial pneumonia in an infant? (S.pneumonia) |
Initially: mild URI, unilateral conjunctivitis, abrupt fever to 104F, mild cough, diarrhea, vomiting Progresses: restlessness, apprehension, nasal flaring, rapid shallow respirations, grunting, abdominal distention, cough may be absent |
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What are the symptoms of bacterial pneumonia in older children and adolescents? (S.pneumonia) |
-Onset abrupt with rigors and fever 102-104 -Appears ill -Headache -Anorexia, nausea, vomiting, diarrhea, abdominal pain -Dyspnea, pleuritic pain, cough -Alternating restlessness and drowsiness |
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What are the symptoms of mycoplama pneumoniae? (walking pneumonia) |
-Slow onset -Malaise, transient arthritis -Persistent dry, hacking cough -Sore throat often followed by hoarseness -Low grade temperature and chills |
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What are objective findings to viral pneumonia? |
-Can be non-toxic appearing -Tachypnea, cough, diffuse bilateral wheezing, decreased breath sounds -Supresternal, intercostal, substernal retractions -Cyanosis |
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What are objective findings to bacterial S. pneumoniae in infants? |
-Tachypnea, nasal flaring, grunitng, retractions, diminished breath sounds, crackles, wheezing
-Fever, tachycardia, air hunger, cyanosis |
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What are objective findings to bacterial S. pneumoniae in older children ? |
-Diminished breath sounds over the affted lung -Dullness to percussion over consolidation -Productive cough -bloody, rust tinged sputum -crackles, wheezing, splinting of respirations on affected side -Fever, nuchal rigidity -Drowsiness, restlessness -Respiratory distress |
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What are objective findings to bacterial M. pneumoniae? |
-Fever -Diminished breath sounds, coarse, harsh breath sounds, and fine crackles -May have a macular rash, erythematous macular rash -Cervical lymphadenopathy, conjunctivitis, and otitis media |
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What will the physical exam show for pneumonia in general? |
-Elevated respiratory rate, accessory muscle use, wheeze or crackles, retractions, tachypnea, decreased tactile and vocal fremitus, diminished breath sounds -Dullness plus fine and crackling rales on the affected side |
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Describe the cough and sputum color in bacterial pneumoniae |
Dry, hacking and productive cough -Rust color sputum or bloody sputum |
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What are the physical findings in atypical pneumonia? |
URI symptoms, low grade fever, dry cough with scant sputum -Minimal changes or harsh breath sounds and rhonchi -Rhinorrhea not common |
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How do you diagnose pneumonia? |
Viral: CXR will show diffuse infiltrates Bacterial: blood cultures, WBC, S pneumoniae will show lobar consolidation and S. aureus will show bronchopneumonia Atypical: Interstitial infiltrates, patchy inflammatory changes |
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What is the treatment for bacterial pneumonia? |
Infants younger than 4 to 6 months are usually hospitalized -Acetaminophen -Antibiotic treatment: Amoxicillin or augmentin, azithromycin |
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What is the treatment for atypical pneumonia (M. pneumoniae)? |
Erythrmycin or azithromycin Acetaminophen |
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What is cystic fibrosis? |
-Autosomal recessive genetic multisystem disorder that affects exocrine function -Defective gene results in unusually thick, sticky mucus that obstructs glands, ducts, damages tissues (pulmonary, GI, endocrine/metabolic, and reproductive) -Obstructs the pancreas and stops natural enzymes from helping the body break down and absorb nutrients -Clogs the lungs and leads to infection |
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What are signs and symptoms of cystic fibrosis? |
-Salty, tasty skin -Persistent coughing -Frequent lung infections -Wheezing or shortness of breath -Poor growth/weight gain in spite of a good appetite -Frequent greasy, bulky stools or difficulty in bowel movements |
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How and what are the results of a diagnostic test for cystic fibrosis? |
-Positive sweat test (Measures the amount of chloride in the sweat) -Sputum culture -Pulmonary functions test -Liver function test -Stool 72 hour fecal fat test -Chest X-ray/CT Scan |
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What is the most common cause of bronchiectasis in children? |
Cystic fibrosis |
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How do you manage CF? |
-Supportive care -Organ transplant if severe -Medications: -Bronchodilators (Albuterol, ipratropium) -Nebulized hypertonic saline -Oral corticosteroids -Antibiotics to treat respiratory infections -Pancreatic enzyme supplements |
