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1

Stridor

Squeaky, whistlelike sound that results from turbulence between supraglottis and trachea
Extrathoracic obstruction Laryngomalacia
o CongenitalInspiratoryStridor "Noisy Breathing"
Worse in supine
Relieved when standing up or prone
Exacerbated by crying/feeding
o Softeningandweaknessoflaryngealcartilage
Collapses the airway o Dx
Laryngoscopy
Omgea shaped epiglottis
Collapse of the supraglottic structures w/ inspiration
Croup
Foreign body aspiration
Retropharyngeal Abscess
o Fever, drooling, dysphagia, neck pain, stridor
o Dx
CT
Vascular Rings
o PersistentStridor
o Branch of aortic arch encircles the trachea & esophagus
o Biphasic stridor and feeding difficulties
From tracheal or esophageal enacement o Improves w/ neck extension

2

Wheezing, rhonchi, and rales due to narrowing/congestion of bronchioles

o Expiratory Wheezing
Intrathoracic obstruction Asthma
Bronchiolitis
o Crackles or Rales
Parenchymal Disease
Pneumonia
Pulmonary edema
o ↑ S2
↑ Pulmonary Pressure

3

Tracheitis

o Bacterial
S. aureus most common cause Hx of recent URI
Previous viral laryngotracheobronchitis (croup, inspiratory stridor)
Follows w/ acute elevation in temperature, trouble breathing, change
to biphasic stridor (expiratory & inspiratory) Brassy cough, high fever, respiratory distress
Tx for croup (mist & racemic epinephrine) don’t help
Tx
Secure airway (intubation) IVABx

4

Epiglottitis

o Acute inflammation and edema
o Mostcommon2-7y/o
o Causes
HIB
Blood culture will be + 90%
Unvaccinated typically
GAS (β Hemolytic), Moraxella
o Sx
Rapid upper airway obstruction
Can cause Resp Arrest
High Fever (~104°)
Muffled Speech
Inspiratroy stridor
Dysphagia w/ drooling
Sitting forward in tripod position w/ neck hyper extension
o Signs
“Thumbprint” on lateral xray
Cherry Red epiglottis
o Tx
2nd/3rd Generation Cephalosporin
Rifampin prophylaxis for non-immunized if HIB
1st step Have sterile environment and skilled personal for
nasotrachealintubation

5

Croup (Laryngotracheobronchitis)

o Inflammation/Edema of Subglottic Larynx, Trachea, &Bronchi
o Types
Viral
Most common, 3m to 3y, Late Fall/Winter
Spasmodic
Preschool children, Secondary to Hypersensitivity
o Viral Croup
Causes
Parainfluenza (most), RSV, Adenovirus, Influenza Viral Prodrome for 2-3d (rhinorrhea, low grade fever)
Followed by inspiratory stridor (means upper airway/extrathoracic) & cough, fever
o BarkyCough Stridor worsens at night
AP XR “Steeple Sign” (Subglottic Narrowing) o SpasmodicCroup
Acute onset, mainly at night
Recurs & Resolves w/out Tx
o Tx
NO ALBUTEROL (can worsen) If stridor @ rest
Systemic Corticosteroids
o Dexamethasone(↓edema)
O2 w/ humidified air (Cool Mist/Air) Resp Distress
Racemic Epinephrine Aerosol
o Always try trial of epi before intubation o α:Vasoconstriction»↓Edema
o β: Smooth muscle relaxation of air way

6

Asthma

o Decreased Expiratory Flow
o Sx
Nocturnal Cough (#1), wheezing (usually expiratory, really severe if
inspiratory), dyspnea
o AsthmaTriadFamilyHx
Eczema (atopic), Allergic Rhinitis, and Asthma
o Classification&Tx
Mild Intermittent
2 Daytime per week
1 night time per week
Options
o Medium-dose corticosteroids + short acting β-agonist
o Low-dosecorticosteroidsandalong-actingβ-agonist
Severe persistent
Continual Sx?
High-dose inhaled steroids + as long-acting β-agonists + oral steroids
o Tx
If oral thrush from inhaled steroids, rinse mouth after If signs of impeding respiratory failure
∆MS, silent chest (not moving air bilaterally), hypoxemia (low pO2), CO2 retention (acidosis)
Intubation w/ mechanical ventilation

7

Bronchiolitis

o Inflammation/obstruction of the bronchioles by viral infection
o Most Common Lower Respiratory Infection of First 2y
o NovtoApril(winter)
o Significant in those w/ chronic lung disease, CHD, prematurity
o Causes
RSV (most), Parainfluenza, Adenovirus, Rhinovirus, Influenza
o Sx
Initial gradual URT Sx
Rhinorrhea, nasal congestion, fever, cough Progression
Tachypnea
Scattered fine rales /coarse breath sounds(crackles), wheezing
Palpable liver & spleen
o From Hyperinflation
Hypoxemia (respiratory failure) & Apnea (esp.

8

Pneumonia

o Infection & Inflammation of the Lung Parenchyma
o Cough, fever, tachypena, abnormal chest auscultation
Rales
Heard in Pneumonia & CHF
Wet or Crackly inspiratory breath sounds o Duetoalveolarfluid/debris
Wheezing
o Causes
0 to 3m
Congenital Infections
Intrapartum (First few days of life)
o GBS (Most), Gram – Rods (E. coli), Listeria o HSV
IV Acyclovir
Postpartum
o RSV
Afebrile Pneumonitis
o Chlamydia trachomatis, Ureaplasma urealyticum Tx
o Ampicillin+Gentamicin(orCefotaxime) Viruses
3mto5y
o Adenovirus, influenza, parainfluenza, RSV (Not after 2y)
Bacteria
o Streppneumoniae
> 6y
Mycoplasma &Chlamydia (Walking Pneumonias)
Viruses (Not RSV)
Strep pneumoniae

9

Types of Pneumonia

Viral Pneumonia
URI Sx
o Rhinorrhea, nasal congestion, fever, cough
Interstitial infiltrates
WBC 20,000 (nΦ)
Complications
o Lungabscess(empyema)
Purulent infection in the pleural space
Typically w/ S. aureus, S. pneumoniae, S. pyogenes ↓ breath sounds on affected side
On CXR: Near complete whiteout
Tx
Vancomycin bc of varying resistances o TensionPneumothorax
Esp. S. aureus
Rupture of alveoli into pleural space from bacterial
toxins
Acute worsening
Tx
Insert needle into 2nd/3rd intercostals space at midclavicular line
Tx
o ABx

10

Chlamydia trachmatis

Most common cause of Afebrile Pneumonia
1-3m
Staccato Type Cough, dyspnea, NO Fever, Wheezing, rales/rhonchi
50% Hx of Conjunctivitis @ birth
Dx
o Erythromycin, CXR w/ Hyper inflation & Interstitial infiltrates (ground glass appearance: fine reticular opacities)
o DirectFluorescentAb
o Eosinophilia Tx
o Erythromycin

11

Mycoplasma Pneumoniae

Older children & adolescents
Widespread rales & rhonchi
o Physical exam is worse than would expect by history CXR
o Interstitialinfiltrates Dx
o + Cold Agglutinins, ↑IgM Mycoplasma Titer Tx
o Erythromycin or Azithromycin
Same as Chlamydia trachomatis in Afebrile Pneumonia

12

Pertussis

o WhoopingCough
o Immunization@12m
o

13

Allergic Rhinitis

o Can also cause Nasal Polyps from chronic inflammation
o Headache and Congestion, but not fever/purulent discharge (AcuteRhinitis)
o SeasonalVariability

14

Cystic Fibrosis

o Sx/Signs
Cough that starts off dry/hacking but progresses to productive
Meconium Ileus @ Birth
Bilious vomiting
Inspissated meconium consistency
If suspected, get XR first bc can identify air in peritoneum, a surgical
emergency
o Next contrast enema
Distal Colon will be small
Microcolon
Hyperosmolar enema may be therapeutic If fails, surgery
FTT, progressive Resp Insufficiency, Pancreatic Insufficiency (fat malabsorption → steatorrhea /foul smelling)
Gray stools
Fat vitamin deficiency
Nasal Polyps w/ chronic sinusitis
Headache, fever, cough (from postnasal drip), purulent discharge
Tender sinuses, unable smell, snoring
Opacification on CT of all sinuses by 8 y/o

↓ Expiratory Flow Rate (Consistent w/ obstructive 1st)
↓ Lung Vol. (Consistent w/ Restriction 2nd)
Rectal Prolapse
Jaundice, Biliary Cirrhosis
Recurrent Pneumonia
1st get S. aureus
2nd get P. aeruginosa (Transition around 20 y/o)
Hypoxemia
Digital Clubbing Hyponatremia
Increased salt loss in sweat
o Dx
Abnormal Sweat Chloride Test
o Pancreatic enzymere placement and fat vitamin supplements

15

Chronic Lung Disease

o O2 Dependent past 28d
o Most common in Prematures born w/ARDS
o Follows Acute Lung Trauma
Barotrauma from Mechanical Ventilation, Meconium Aspiration Syndrome, Infections
Followed by secondary lung injury (oxidants & proteases) Healing of lung tissue is abnormal
Both Restrictive (from tissue fibrosis) & Obstructive (from dysplastic narrowed airways) Lung Disease
o S/Sx
Diminished Oxygenation (↓ PaO2)
Hypercarbia (↑PaCO2)
Intermittent Tachypnea, wheezing, respiratory distress
Frequent Infection

16

Foreign Body Aspiration

o Laryngotracheal (Extrathoracic)
Inspiratory Stridor, Cough o Bronchial (Intrathoracic)
Asymmetrical lung findings on PE
Decreased air movement on affected side
Initially cough, drooling, and choking Later avoid feeding
Complete
Atelectasis
Partial Ball-Valve
Unilateral Emphysema
Hyperinflation
Localized Wheezing, Recurrent/Persistent Pneumonia
o Chest and Abdominal X-rays first
If negative and still symptomatic, Endoscopic Evaluation Normal Inhalation and Abnormal Expiration
One side will remain hyperinflated on expiration
o Partial ball valve obstruction, lets air in but not out
o Tx
Bronchoscope to remove if tracheal/bronchial obstruction Flexible Endoscopy for esophageal obstructions

17

Congenital Diaphragmatic Hernia

o Can DX w/ US (esp. when Hx of Polyhydramnios)
o Should be suspected in any full term infant w/ severe resp distress
Esp. w/ decreased breath sounds on one side
Severe respiratory acidosis
o Scaphoid (sunken) abdomen w/ Ipsilateral prominent chest
o Cardiac impulse is displaced and decreased breath sounds on opposite side o Prognosis is based on Lung Hypoplasia not size of defect
o Never bag mask, because will further distend the bowels
o CXR
Bowel air fluid level in thorax
o Tx
1st nasogastric suction to decompress the bowels 2nd intubation
Surgical Correction

18

Transient Tachypnea of Newborn (TTN)

Transient Tachypnea of Newborn (TTN)
o Early onset Tachypnea w/in 3h
w/ nasal flaring, grunting, retractions, cyanosis
o Relieved w/ supplemental O2
o Lungs are clear to auscultation
o Risk Factors
C-section
Absence of the “thoracic squeeze” and hormones from labor
o Research shows more likely related to hormones than the mechanical forces, primarily cortisol
o CXR
Temporary pulmonary edema
Perihilar Streaking in the interlobar Fissure
From excess fluid in the alveoli spilling over into the extra-alveolar interstitium
Hyperexpansion
o Flat diaphragm
Prominent pulmonary markings
o Resolves in 2 to 3d
o Corrects easily w/O2

19

Neonatal Pneumonia

o More common with premature, mothers w/ intrapartum fevers, PROM o S/SX
Respiratory Distress soon after birth, circulatory collapse, jaundice, poor feeding, abdominal distension, tachycardia, apnea, higher calorie requirement
o CXR
Nonspecific patchy infiltrates or bilateral alveolar densities w/ air
bronchograms

20

Persistent Pulmonary HTN of Newborn

o Tachypnea and Severe Cyanosis
o Murmur from Tricuspid insufficiency may be heard
o CXR
↓ Pulmonary Vasculature Markings

21

Meconium Aspiration

o Respiratory Distress soon after birth
o Pneumothorax/ mediastinum may result o CXR
Patchy infiltrates, Coarse Streaking, & Hyperinflation (Flattened Diaphragm, ↑AP Diameter)

22

Neonatal Respiratory Distress Syndrome (Hyaline Membrane Disease)

o Most important risk factors: Preterms & Infants of Diabetic Mothers
o S/Sx
Presents w/in minutes of birth w/ 25Tachypnea (RR > 60), duskiness, grunting, nasal flaring, retractions, shallow rapid breathing, and cyanosis
Cyanosis is minimally responsive to supplemental O2
Ex. 75% to 90%
o Decreased lung compliance, reduced lung volume, right-to-left shunt of blood
o Labs
Metabolic/Respiratory Acidosis CXR
Lung parenchyma w/ Fine Reticular Ground Glass Appearance and Air Bronchograms
Histological
Homogenous, acidophilic, granular membranes lining alveolar
ducts/alveoli
o Tx
Prophylactically giving Corticosteroids to help promote lung maturity Surfactant

23

Retinopathy of Prematurity (ROP)

o Risk Factor: Supplemental O2 & Prematurity

24

Risks w/ supplemental O2 in Preterms

o ROP
o PersistentPDA
o Intraventricular Hemorrhage
o Necrotizing Enterocolitis

25

SIDS & Apnea

o Apnea of Infancy
Unexplained cessation of breathing ≥ 20s
Or shorter if bradycardia, cyanotic, or hypotonia
Not expected in Term infants (unlike preterm) Investigate for congenital heart defects
o Apnea of Prematurity ≥ 20 s
50% of those born between 30 to 31 w and nearly all born less than 28w Immature Central Resp Control
Often associated w/ bradycardia and cyanosis
Tx
Methylxanthines (Stimulate)
o Caffeine & Theophylline
o Periodic Breathing
≥ 3 respiratory pauses for ≥ 3s w/in 20s
o SIDS

26

Phrenic Nerve Injury

o Cyanotic w/ S/Sx of Respiratory Distress Grunting, retractions, tachypena
o Risk factor Macrosomia/LGA (esp. infants of diabetic mothers)
o With accompanying Erb-Duchenne Palsy (e.g. ↓ tone in arm)
o CXR may appear normal
US will reveal asymmetric diaphragmatic motion “See Saw” motion

27

Hydrocarbon Aspiration

o Gasoline, kerosene, furniture polish
o S/Sx
Dyspnea, cyanosis, respiratory failure
o Charcoal is ineffective and emesis is contraindicated (further aspiration)
o Tx
Monitor
Symptomatic

28

Idiopathic Pulmonary Hemosiderosis (IPH)

o Chronic history of recurrent pulmonary insults
Fever, respiratory difficulty, wheezing, cyanosis, hemopytis (pulmonary
hemorrhage)
Occult blood from swallowed pulmonary secretions
Rapid clearing on repeat CXR
Chronic hypoxia: digital clubbing
o Hypochromic/
Microcytic anemia from Iron Deficiency
o Some have hypersensitivity to cow milk (HeinerSyndrome) o Dx
Bronchoalveolar Lavage
Hemosiderin-laden macrophages

29

Retropharyngeal abscesses

o Suppurative infection of lymph nodes between P. Pharyngeal Wall and Paravaterbal
Fascia
o Most common organism: S.aureus, GABHS, oral anaerobes o S/Sx
Hx of Pharyngitis
Abrupt onset of fever and severe sore throat (difficulty swallowing) Refusal of food, drooling, muffled voice (looks like epiglottis)
Fluctuant mass
o Dx
Bulge in the P. Pharyngeal Wall
o Tx
Incision & drainage
ABx

30

Congenital Cystic Adenomatoid Malformation

o Cystic mass causes improper development of bronchioles
Respiratory distress
Mass may compress lungs causing Pulmonary hypoplasia and shifting heart across midlines
Not to be confused w/ diaphragmatic hernia Cystic Mass is usually detected on US