Lecture 1: Pulmonology Flashcards
1
Q
derangements of breathing in pediatrics
A
- respiratory disease is the most common reason for pediatric hospitalization
- hallmark distinction of airway noise
- upper airway obstruction - stridor
- lower airway obstruction - wheeze
- air trapping and prolonged expiratory phase can occur in either upper or lower obstruction
2
Q
nasal obstruction
A
- Newborns and young infants are obligate nasal breathers
- Significant respiratory distress can occur
- Can also lead to difficulty feeding
3
Q
oxygenation vs. ventilation
A
- ventilation and oxygenation occur independent from one another
- processes compromise each function differently
- both may be affected by severe obstruction
- Oxygenation affected first
4
Q
respiratory rate varies with age
A
- age
- infant
- 1-3 years
- 4-6 years
- 7-14
- 14-18
- respiratory rate
- 24-38
- 22-30
- 20-24
- 16-24
- 14-20
- always count respiratory rate over 60 seconds
- *Periodic breathing*
5
Q
respiratory exam
A
- observe over time since external stimuli may influence the exam
- do not be afraid to palpate and undress patient
- tachypnea is the most sensitive sign of pneumonia in children
- stridor is most commonly inspiratory, monophasic, noise
- Can be inspiratory, expiratory or fixed depending on the cause
- wheezing is continuous sound caused by turbulent flow in narrow airways
- Pitch can identify the part of airway involved
- rales (crackles) are fine, interrupted sounds that suggest pulmonary parenchymal disease
- Rhonchi are coarse, interrupted sounds that suggest large airway disease
- Egophany CAN be used in children who can follow instruction
6
Q
respiratory distress in children
A
- children mount a progressive effort with worsening compromise
- first, tachypnea
- then, further labored breathing
- retractions
- abdominal (“subcostal”)
- intercostal
- supraclavicular
- nasal flaring
- grunting
- attempt to maintain area for gas exchange by providing extra end expiratory pressure
- retractions
- positioning
- upright (gravity aids diaphragmatic contraction)
- tripodding (allows more efficient scalene and intercostal work)
- sniffing position (opens upper airway)
7
Q
cyanosis
A
- Blue discoloration of skin due to hypoxemia
- Central cyanosis occurs first
- Perioral/lips/tongue
- Trunk
- Extremities
- Poor prognostic factor for severity of disease
- Usually prompts admission to the hospital
8
Q
plain chest film
A
- good screening test for parenchymal or pleural disease
- poor test of pulmonary function
- upright film at limit of inspiration is best
- often difficult in small children, may require repeat of film
- radiography tech often forgets to compensate for child size when determining exposure
- lateral films very useful for evaluation of retrocardiac space
9
Q
arterial blood gas
A
- useful measure of pulmonary function
- even more useful if serial measurements allow description of trends
- worrying findings include
- rising pCO2 over 45 mmHg (respiratory acidosis)
- decreasing pO2 less than 85mmHg (hypoxemia)
- acidemia (uncompensated acidosis)
- Capillary and venous blood gases are easier to obtain, but pO2 is less helpful
- no utility of pO2 in venous blood gases
10
Q
pneumonia
A
- = Infection of alveolar spaces
- Viruses
- Bacterial pneumonia
11
Q
viral etiologies of PNA
A
- Respiratory Syncytial Virus (bronchiolitis)
- Rhinovirus (bronchiolitis)
- Human Metapneumovirus (bronchiolitis)
- Influenza Virus
- Parainfluenza Virus
- Adenovirus
- Herpes Simplex Virus
- Varicella Virus
12
Q
bacterial etiologies of PNA
A
- Neonate 0-2 months
- Group B Strep
- E. Coli
- Chlamydia trachomatis
- Infant 2 months to 24 months
- Streptococcus Pneumonae
- Group A Streptococci, other streptococci
- Haemophilus Influenza
- Staphyloccocus
- Toddler/School Age
- Streptococcus Pneumonae
- Staphylococcus
- Mycoplasma
13
Q
When to suspect PNA
A
- History- fever, cough difficulty feeding, fussiness, chest pain
- Physical Exam- TACHYPNEA, fever, rales, wheezes, decreased breath sounds
- Labs
- CBC, blood culture- Leukocytosis, Pathogen capure only 10-12 percent (hospitalized patient)
- CXR- “gold standard”
- Rapid Antigen Testing- available for RSV, Influenza, sometimes adenovirus, parainfluenza
- Titers- Mycoplasma, HSV
14
Q
tachypnea in PNA: definition
A
- Younger than 2 months: > 60 breaths/min
- Two to 12 months: > 50 breaths/min
- One to 5 years: > 40 breaths/min
- > 5 years: > 20 breaths/min
15
Q
viral PNA tx
A
- Supportive Care
- Hydration
- Oxygen
- Positioning/Nutrition
- Anti-Viral Agents
- Influenza- Tamiflu
- HSV- Acyclovir for systemic disease
- Varicella- VZIG prophylaxis for immunocompromised exposure
- Antibiotics
16
Q
Bacterial PNA tx
A
- Treatment- empiric tx
- Neonate- GNR=> Cephalosporin
- Staph=>Vancomycin
- Infant- Strep Pneumo=>Ampicillin
- Children- Strep Pneumo=>Ampicillin
- Mycoplasma=>Azithromycin
- Staph=> Clindamycin
- Staph (bad infection) => Vancomycin
- Neonate- GNR=> Cephalosporin
17
Q
complications of PNA
A
- Pleural effusion
- Empyema
- Treatment
- Sometimes still just antibiotics
- Can require surgical drainage and chest tubes
- Most often Strep pneumo and Staph aureus
18
Q
phase of stridor
A
- Inspiratory
- Above the thoracic inlet
- Expiratory
- Below the thoracic inlet
- Biphasic
- Fixed lesions
19
Q
stridor ddx
A
- laryngeal papillomatosis
- laryngeal trauma
- larygomalacia
- viral croup
- epiglottitis
- bacterial tracheitis
- anaphylaxis
- vocal cord paralysis
- vocal cord dysfunction
- foreign body
- subglottic stenosis
- retropharyngeal abscess
- congenital anomalies
- Pierre-Robin sequence
- neuromuscular disease
- Hemangioma
- Vascular rings/slings
- Tracheal stenosis
20
Q
croup
A
- respiratory illness (inflammation of larynx and surrounding airways) that manifests in young children with
- hoarse voice
- dry, barking cough
- inspiratory stridor
- most commonly viral
- fever and cough
- steeple sign
21
Q
viral croup
A
- typically 6 years of age and younger
- occurs any time of year
- most commonly late fall and winter
- symptoms typically worse at night
- 2nd and 3rd nights usually the worst
- most commonly parainfluenza viruses
- also
- influenza A and B
- adenovirus
- respiratory syncytial virus (RSV)
- diagnosis based on clinical findings
- screen all patients with stridor for immunization history, recent choking or foreign body aspiration, food allergies
- plain films only useful if atypical presentation
- pulse oximetry usually normal in viral croup unless a severe case
- if main airway is compromised to the point of hypoxemia, inpatient monitoring is warranted
- visualization of epiglottis not usually indicated unless concern for epiglottitis (drooling, toxic-appearing)
22
Q
treatment of viral croup
A
- cool mist
- home shower “steam”
- car ride with windows down
- cool water humidifiers
- systemic corticosteroids
- onset of action is several hours after dose
- no demonstrable benefit for more than two daily doses of dexamethasone
- nebulized racemic epinephrine
- benefit is transient
- for severe cases
- endotracheal intubation (avoided if possible)
- helium-oxygen mixture
23
Q
cystic fibrosis
A
- defect in the cystic fibrosis transmembrane conductance regulator resulting in a deficiency in chloride ion transport, causing abnormal fluid secretion
- secretions, including mucus, are thick and tenacious
- multi-organ involvement including chronic pulmonary disease and exocrine pancreatic insufficiency
- autosomal recessive
- most prevalent in northern Europeans
- Caucasians 1 in 2,500
- African-Americans 1 in 17,000
- Asians 1 in 90,000
24
Q
diagnosis of cystic fibrosis
A
- newborn genetic screening
- family history
- sweat chloride
- functional test
- most sensitive
- DNA testing
- less sensitive
- can only screen for known mutations
25
clinical presentation of cystic fibrosis
* meconium ileus & chronic constipation
* prolonged jaundice (biliary obstruction)
* failure to thrive
* signs of malabsorption
* Pancreatic insufficiency
* bulky, foul smelling stools
* greasy or oily stools
* recurrent lung disease
* Tastes “salty”
* Smell of pseudomonas aeruginosa (common pathogen)
26
management of cystic fibrosis
* chronic recurrent and indolent pneumonias
* recurrent infections contribute to airway and lung parenchymal changes
* bronchiectasis
* asthma
27
diagnosis of cystic fibrosis
* Newborn Screen
* Sweat Chloride testing
* DNA mutation testing
* Tests for most common mutations in CFTR gene
28
treatment of cystic fibrosis
* systemic and inhaled antibiotic therapy
* airway clearance measures, assist patient with decreasing chronic inflammation clearance and prevent chronic infection
* Albuterol
* Chest physiotherapy
* Cough Assist
* Nutrition
* pancreatic enzyme replacement
29
obstructive sleep apnea
* spectrum of disorders where obstruction of airflow results in increased respiratory effort and frequent sleep arousal, increased respiratory effort, hypoventilation, and (sometimes) hypoxemia
* may progress on to
* pulmonary hypertension
* cor pulmonale (right heart changes and ultimately failure)
* sleeping difficulties
* frequent sleep arousals
* increased sleeptime respiratory effort
* daytime hypersonmonlence impairing school performance
* less common in children than in adults
* snoring
* common in pediatric population
* ~15% of children have habitual snoring on history
* peak incidence age 4-8 years
* History
* Screen for OSA by asking
* “Does your child snore”
* exam
* “allergic shiners”
* allergic rhinitis
* tonsillar and adenoidal hypertrophy
* hyponasal speech
30
diagnosis of obstructive sleep apnea
* Polysomnography (gold standard)
* monitors oxygenation and ventilation during sleep
* gas challenges to determine source of apnea
* central vs. obstructive
* also
* lateral neck film to evaluate airway
* EKG to screen for right ventricular hypertrophy
31
medical managment for temporary relief if sleep study is unremarkable
* medical management for temporary relief if sleep study is unremarkable
* treat allergic rhinitis
* treat tonsillitis
* surgical management
* tonsillectomy and adenoidectomy
* palatouvuloplasty (less common)
32
differential diagnosis for wheezing
* bronchiolitis
* pneumonia
* aspiration
* laryngotracheomalacia
* vascular rings
* airway stenosis or Web
* paratracheal adenopathy
* mediastinal mass
* airway foreign body
* BPD/BOOP
* cystic fibrosis
* vocal cord paralysis
* vocal cord dysfunction
* cardiovascular disease (CHF)
* asthma
33
bronchiolitis cause
* most common cause of acute hospital admissions for infants less than 2 years of age during the winter months
* most common cause
* RSV (respiratory syncytial virus)
* infects about ~1/3 of all children every year
* immunity is not long-lasting
* other causes
* influenza, parainfluenza, adenovirus, metapneumovirus
* pathogenesis
* infection and inflammation of the lower airways
* obstruction results from edema, mucus plugging
34
presentation of bronchiolitis
* begins much like a typical upper respiratory infection
* fever
* rhinorrhea
* cough
* Often progressing to lower airway disease
* lower airway secretions =\> wheezing, rales, coarse breath sounds, worsening cough
* tachypnea
35
diagnosis of bronchiolitis
* RSV and influenza enzyme immunoassay
* may be useful for cohorting if performed rapidly
* CXR - hyperinflation, atelectasis, multifocal (and often shifting) infiltrates
* CBC - commonly normal, may show mild lymphocytosis consistent with viral illness
36
prevention of bronchiolitis
* Prevention (RSV infects at high rate)
* hand-washing
* RSV intravenous immune globulin
* palivizumab
* given to high-risk groups during RSV season each year
37
treating bronchiolitis
* no curative therapy
* supportive care
* oxygen
* hydration IV fluids/frequent feedings
* pulmonary toilet (nasal suction, airway clearance, positioning)
* Monitoring
* Assess risk factors (prematurity, chronic lung disease, other underlying pulmonary disease)
* Apnea risk
38
foreign body presentation
* Obstruction =\> emergency airway management
* Upper Airway =\> stridor, drooling
* Lower Airway =\> wheezing
* Late Presentation =\> infection, chronic changes, abscess
39
foreign body diagnosis
* History, Physical Exam, CXR to screen
* Gold Standard to rule in or rule out
* Bronchoscopy
40
atopic disease
* Asthma
* Atopic dermatitis (eczema)
* Allergic rhinitis (hay fever)
41
asthma
* asthma is the most common chronic disease of childhood
* despite technologic advances, morbidity has increased
* asthma management has significantly changed over the past decade
* health disparities issues abound in asthma
* African-Americans have a disproportionate amount of disease burden for asthma
* Certain zip codes are disproportionately affected
* airway hyperresponsiveness to triggers
* disease of excess inflammation, all processes narrow lumen of airway
* inflammatory cell infiltration
* mucus plugging
* shedding of airway epithelium
* mast cell activation
* bronchoconstriction
* widespread small airway constriction and obstruction impairs air movement, particularly during exhalation
* air trapping evident on exam and chest plain films
* tidal volume reduced as patient must inspire again before exhaling sufficient volume
42
asthma symptoms and signs
* baseline symptoms may be very subtle and clinically hard to diagnose
* mild asthma exacerbation
* cough
* wheeze
* exercise intolerance
* chest congestion
* moderate asthma exacerbation
* dyspnea
* chest tightness
* labored breathing
* severe asthma exacerbation
* mental status changes
* may become paradoxically unlabored when entering respiratory failure
* cyanosis
* pulsus paradoxus
43
treatment of asthma
* treatment of acute exacerbation
* systemic corticosteroids
* mainstay of therapy
* impairs new inflammation
* inflammation present in airways needs time to “burn out”
* β2-agonist (albuterol) – briefly impairs small airway smooth muscle bronchoconstriction
* ipratropium – inhaled atropine analog (anticholinergic) for large airway dilation
* supportive care (oxygen, hydration)
44
asthma diagnosis
* no specific laboratory findings
* hypoxia with significant airway compromise
* or with significant atelectasis
* chest plain films
* lung hyperinflation
* atelectasis related to airway plugging
* peribronchial thickening/cuffing
* pulmonary function testing
* reveal small airway disease
* methacholine challenge
* FEV1 reduced, FEV25-75 reduced
* improvement with administration of β-agonist
45
treatment of severe cases of asthma
* parenteral β2-agonist (terbutaline)
* parenteral epinephrine
* parenteral magnesium
* parenteral theophylline
* mechanical ventilation generally avoided, but if necessary:
* ketamine plus halothane anesthesia with helium-oxygen mixture
46
chronic asthma treatment
* education
* medications
* inhaled corticosteroids
* long-acting β2-agonist – associated with increased risk of death
* leukotriene modifiers
* mast cell stabilizers (cromolyn)
* environment modification
* Hepa filters
* _smoking_
* dust mite control
* pets
* reduction of exacerbating factors
* identify triggers and find ways to avoid them
* treatment of reflux, sinusitis, allergic rhinitis
* stress reduction
* influenza vaccine
47
larger treatment goals of asthma
* anti-inflammatory agents
* individualized management plans
* reduction of risks must be ongoing
* early diagnosis and vigilant monitoring with utilization of latest treatment modalities
48
albuterol administration
* Nebulization
* Mask/spacer
