Wheezing Infant, Pneumonia

Front 1

Difference in wheezing and stridor

Back 1

Wheezing: expiratory > inspiratory
Stridor: inspiratory > expiratory

Front 2

What causes wheezing?

Back 2

Something that narrows the airway lumen.

Front 3

intrinsic cause of wheezing: defn

Back 3

In the airway or the airway itself.

Front 4

Bronchiolitis: defn

Back 4

Clinical syndrome in child <2 yo with tachypnea, chest retractions, and wheezing.

May or may not have fever, cyanosis, or respiratory distress

Front 5

Main cause of croup

Back 5

one of the parainfluenzae viruses

Front 6

Most serious RSV infections occur between ______ and ______.

Back 6

6 weeks and 2 years of life

Front 7

#1 cause of bronchiolitis

Back 7

Respiratory syncytial virus (RSV)

Front 8

When do most RSV infections occur?

Back 8

between october and may with peak in January and February

Front 9

Physical findings of upper respiratory tract infection

Back 9

otitis; inflamed nasal mucosa, nasal flaring

Front 10

Physical findings of lower respiratory tract infection

Back 10

wheezing; coarse or fine crackles; respiratory distress

Front 11

Which children with bronchiolitis need admission?

Back 11

1) Young age (<3 months or ex-preemies)

2) Hypoxemia (O2 sats <95%)

3) underlying cardiopulmonary illness

4) Prior h/o wheezing illness requiring admission

5) H/o apnea, cyanosis

Front 12

High risk patients for bronchiolitis

Back 12

1) Premature

2) Bronchopulmonary dysplasia

3) Congenital heart disease

4) Cell-mediated immunodeficiency (SCID, HIV)

5) transplant patients

6) malnutrition

7) neuromuscular disease

Front 13

Tx for bronchiolitis (hospitalized)

Back 13

1) Oxygen

2) IV fluids

3) nasopharyngeal toilette

4) NO empiric abx!

5) Bronchodilators (there are some responders and some non-responders)

6) Corticosteroids?

Front 14

Prevention of bronchiolitis

Back 14

1) Hand washing

2) RSV vaccine - in the works

3) Ig preps

Front 15

Long term sequelae of bronchiolitis

Back 15

up to half of kids with it will have recurrent wheezing, especially with viral URIs

Front 16

What predicts development of persistent wheezing/asthma?

Back 16

frequent wheezing during the first three years plus:

1) Parent with asthma
2) Eczema

(less major factors):

Allergic rhinitis
Wheezing apart from colds
Eosinophilia

Front 17

How long do RSV infections last?

Back 17

2-3 weeks. Also infected child with RSV spreads it to half other family members on average.

Front 18

Most effective thing to protect patients from RSV

Back 18

hand washing

Front 19

Which breath sound:

Non-musical, discontinuous
Originate from the popping open of small airways and alveoli

Back 19

crackles (aka rales, crepitations)

Front 20

Which breath sound:

Gurgling noises during inhalation or exhalation
Originate when a larger airway is partially obstructed from secretions, mucosal swelling, or tumor tissue pressing on the passage

Back 20

Rhonchi

Front 21

Differential Diagnosis of theWheezing Infant

Back 21

Anatomic – intrinsic or extrinsic
Asthma
Bronchiolitis
Wheezing Associated with Respiratory Illness
GE reflux ± aspiration
Cystic fibrosis (CF)
Foreign body - airway or esophageal
Bronchopulmonary dysplasia (BPD)
TB - adenopathy and endobronchial disease
Ciliary dyskinesia syndrome

Front 22

What is Bronchopulmonary dysplasia (BPD)?

Back 22

chronic lung disorder that is most common among children who were born prematurely, with low birthweights and who received prolonged mechanical ventilation to treat respiratory distress syndrome.

There is inflammation and scarring in lungs.

Front 23

Non pulmonary causes of wheezing

Back 23

1) salicylate poisoning

2) Congestive heart failure (may be superimposed with infection)

3) Viral myocarditis

Front 24

In the child less than two years of age, it refers to a clinical syndrome characterized by tachypnea, chest retractions, wheezing, and air-trapping on exam or x-ray.
The patient may or may not have fever, cyanosis, and severe respiratory distress.

Back 24

Bronchiolitis

Front 25

The #2 cause of bronchiolitis (1st is RSV)

Back 25

one of the Parainfluenzae viruses

Front 26

what will be seen in CXR in infant bronchiolitis?

Back 26

hyperinflation, atelectasis, air space disease (pneumonia).

Front 27

infectious exudative inflammation of the distal portions of lung (terminal airways, alveolar spaces, and interstitium)

Back 27

pneumonia

Front 28

What are the two causes of almost all pneumonia?

Back 28

1) Aspiration of contaminated oropharyngeal secretions

2) Inhalation of airborne bacteria or viruses

Front 29

integrated system of ciliated cells and their secretions that push the mucus layer towards the mouth

Back 29

mucociliary escalator

Front 30

Clinical presentation of acute pneumonia

Back 30

1) Fevers and chills
2) Cough with sputum
3) Dyspnea
4) Chest pain (especially when it's peripheral)

Front 31

Clinical presentation of SEVERE pneumonia

Back 31

Confusion or disorientation
Hypothermia
Hypotension
Tachypnea
Hypoxia

Uremia (BUN ≥20)
Multilobar infiltrates on chest radiograph
Thrombocytopenia, Leukopenia

Front 32

CURB-65 as a severity scoring tool for pneumonia: advantages and disadvantages

Back 32

Pros: Easy to use
Confusion
Delirium
Uremia
BUN > 20 mg/dl
Respiratory rate >30 breaths/minute
Blood pressure
Systolic blood pressure < 90 mmHg
65
Cons: doesn't consider comorbities

Front 33

What does CURB-65 mean?

Back 33

Confusion
Uremia
Respiratory rate (fast)
Blood pressure (low)
65 - age over 65

Front 34

Pneumonia Severity Index (PSI)severity scoring tool for pneumonia: advantages and disadvantages

Back 34

Pros: complete and thorough, considers comorbities
Cons: complex to use

Front 35

The pneumonia Pathogen isolated in roughly ___ of cases

Back 35

half

Front 36

Most common pneumonia causing bacteria

Back 36

Streptococcus pneumoniae
Chlamydophlia pneumoniae
Haemophilus influenzae
Mycoplasma pneumoniae
Legionella species
Staphylococcus aureus

Front 37

How does gas exchange change in pneumonia?

Back 37

If one lung is full of inflammatory exudate it can't participate in gas exchange. All air goes to other lung.

The pCO2 will decrease by about half in the good lung and the pO2 will increase by the same amount pCO2 goes down (to 120 torr). But arterial oxygen content will change vey little becaseu oxygen sat was already 100% when pO2 was 100 torr.

Front 38

Features of typical pneumonia

Back 38

High grade fever
Rigors
Cough productive of purulent sputum
Radiograph with lobar consolidation
Pathogens
S pneumoniae
H influenzae
Moraxella catarrhalis

Front 39

Features of atypical pneumonia

Back 39

Dry cough
Diffuse patchy lung findings
Pathogens
Legionella species
Mycoplasma  pneumoniae
C pneumoniae
Viruses

Front 40

T/F The resulting pO2 systemically when one lung is consolidated is the sum of pO2 from the two lungs divided by 2

Back 40

F

Front 41

To minimize shunt fraction, pulmonary vasculature responds by undergoing _____

Back 41

hypoxic vasoconstriction

Front 42

Why does pCO2 go lower when one lung is consolidated?

Back 42

Because the person will be hyperventilating to prevent hypoxemia

Front 43

Dx of pneumonia

Back 43

Examine sputum (should see WBCS)

Do blood cultures (bacteremia)

Front 44

Interstitial pattern of pneumonia suggests _____ etiology

Back 44

viral

Front 45

Alveolar-filling pattern of pneumonia suggests _____ etiology

Back 45

Bacterial

Front 46

Lobar distribution pattern of pneumonia suggests _____ etiology

Back 46

pneumococcal or Klebsiella

Front 47

How is pneumonia treated?

Back 47

Figure out from the epidemiology what are the most likely organisms to be causing the pneumonia in your patient, then give empiric abx that cover all the organisms.

Front 48

Complications of pneumonia

Back 48

lung abscess, empyema (infected pleural effusion)

Front 49

Prevention of pneumonia

Back 49

pneumococcal vaccine

flu vaccine

Front 50

90-95% of lobar pneumonia is caused by ________

Back 50

S. pneumoniae

Front 51

Bronchopneumonia: defn

Back 51

Pneumonia centered around small airways

Front 52

Four stages of untreated pneumonia evolution

Back 52

1) Congestion
2) Red hepatization
3) Grey hepatization
4) resolution

Front 53

Where is the bacterial pneumonia exudate primarily found?

Back 53

In alveolar spaces and distal bronchioles

Front 54

What is in the bacterial pneumonia exudate?

Back 54

Edema fluid
Red cells
Leukocytes (principally neutrophils)
Fibrin

Front 55

What causes the red hepatization?

Back 55

The sludging and extravasation of red cells, causing lung tissue to look like liver tissue

Front 56

What causes the gray hepatization?

Back 56

migration of neutrophils and fibrin and alveolar spaces fil with them. There's less edema fluid now.

Front 57

What happens in the resolution stage of pneumonia?

Back 57

Exudate is cleared from alveolar spaces by coughing and macrophage activity. Lung returns to normal appearance.

Front 58

Empyema: defn

Back 58

Extension of infection to pleura

Front 59

Organization: defn

Back 59

Replacement of exudate by fibroblasts.

Exudate stays in the alveolar space while fibroblasts are recruited and lay down collagen. The collagen then replaces the alveolar space.

Front 60

Lung abscess: defn

Back 60

necrotizing loss of lung tissue that's replaced by pus

Front 61

Two patterns of viral infections of lung

Back 61

1) Bronchitis, bronchiolitis

2) Pneumonia (affects gas exchange)

-Acute interstitial pneumonia
-Necrotizing bronchopneumonia
-Focal parenchymal necrosis