Respiratory Emergencies Flashcards
(126 cards)
1
Q
what causes pertussis
A
bordetella pertussis
2
Q
describe the incubation period of pertussis and how its spread
A
- Incubation 1-3 weeks, longer than most URIs
- Highly contagious; person to person via aerosolized droplets
3
Q
what does pertussis toxin cause
A
Pertussis toxin causes sloughing of the trachea, inflammation and paralysis of the respiratory cilia, and interference with clearing of respiratory tract
4
Q
A 5 month old infant is brought to the ED with a 5 day history of a cough The parents state he has had episodes of not breathing for up to 10 seconds during coughing spells and has turned blue around his mouth. Child is not vaccinated, secondary to “autism” concerns
Vital signs: RR 30 HR 140, pulse oximetry 94%, temp 98.8 R. Pulm: no wheezes, rales, or diminished breath sounds noted
A
pertussis “whooping cough”
**cough cough cough puke”
5
Q
characteristics of pertussis
A
- Mean duration of cough is 36-48 days (paroxsymal coughing spells that lasts for months)
- Coughing may lead to vomiting, incontinence, choking, syncope, rib fractures or possibly carotid artery dissection.
- Infants can get secondary bacterial pneumonia leading cause of death or encephalopathy
6
Q
describe the stages of pertussis
A
Catarrhal stage: sneezing, low grade fever, cough. Most infectious at this time. 1-2 weeks.
Paroxysmal stage: burst of numerous rapid coughs, then whooping on inspiration. May become cyanotic during attack. Post tussive emesis. 1-6 weeks; may last 10 weeks
Convalescent stage: paroxysms recur when ever the patient gets a respiratory infection. 2-3 months
7
Q
clinical dx of pertussis
A
- CDC definition is 14 days of continuous cough with either:
- Paroxysms of cough
- Inspiratory whoop
- Post-tussive emesis
- Apnea, w/ or w/o cyanosis (infants less than 1 yr.) (**cyanosis in babies)
8
Q
labs for pertussis
A
Culture and PCR
- culture sensitivity is highest in first two wks.
- Between 2-4 wks, both culture and PCR are options; PCR is quite a bit faster (culture takes 7 days)
- Serology if over 4weeks of cough
*treat presumptively in ED– no rapid test to dx
9
Q
tx of pertussis
A
- Isolation- Patient must remain in isolation until abx course is completed
- Macrolides (Zpack) for patient and close contacts advised
- Acellular pertussis vaccines available.
-Recommended one time in combination with dT – DTaP (less than 7yo) or Tdap (less than7 yo)
011-12 yrs; 13-18 yrs; or 19-65 yrs
10
Q
pertussis prevention
A
- Vaccinate
- Infants get vaccine at 2,4,6 months; 15-18mo; then 4-6yrs
- Waning immunity over time, but even at 5 years, still have 70% immunity
- Upper case “T” means there is about the same amount of tetanus in DTaP, Tdap and Td.
- Upper case “D” and “P” means there is more diphtheria and pertussis in DTaP than in Tdap and Td; lower case letters (“d” “p”) means there is less.
11
Q
A 30 year old male presents to your clinic with the c/c of a cough for two weeks. He has had mild URI symptoms which have resolved but still has a cough keeping him up at night. Cough is nonproductive. He does not smoke, and has no other medical problems.
Vital signs normal. Pulmonary exam: occasional wheezes bilaterally. Remainder of his exam is normal
A
bronchitis
*usually clinical dx
12
Q
cause of bronchitis
A
usually fever
13
Q
presentation of bronchitis
A
- Usually no fever
- no abnl vitals
- Acute cough less than 2wks
- No h/o chronic lung disease
- NL CXR
- No crackles/rhonchi
14
Q
tx of bronchitis
A
sx management
- Nasal steroid (flonase)
- Bronchodilator (albuterol to help w/ wheezing)
- Cough suppressant (vicodin– anti-tussive)
- Smoking cessation
- Anti tussives
- **Antibiotics only if treating pertussis (Zpack)
*take cough suppressant at night to get sleep but what to get some sleep so cough it up during day
15
Q
phase of cough
A
- Deep inspiration
- Closure of glottis with rapid increase in pleural pressure
- Opening release of glottis with explosive release of pressure
Defense Mechanism:
Clears secretions and inhaled particles
16
Q
common causes of acute cough
A
- Inflammation- bronchitis, pneumonia
- Irritation- Environmental pollutants
- Bronchospasm
- Other-PE, ACE- I and ARBs
17
Q
common causes of chronic cough
A
- Inflammation- Bronchitis, pollution, chronic aspiration
- Irritation- Cigarettes, cancer, Post nasal drip
- Bronchospasm- Asthma, CHF
- Other- psychogenic, ACE-I and ARBs
18
Q
4 common types of cough
A
- dry
- barking
- stridor
- wet cough
19
Q
evaluation of cough
A
- History of constant throat clearing or swallowing associated with post nasal drip
- CXR most common finding is normal (r/o FB, CHF, pleural effusion)
- Always think FB in peds
- PFT’s
- Bronchoscopy
- Lung biopsy
20
Q
tx of benign cough/bronchitis
A
- Tincture of time
- Bronchodilators if wheezing; steroids prn
- Smoking cessation
- Anti-tussives
- Anesthetize peripheral irritant receptors- Benzonatate (tessalon pearls- non-narcotic option)
- Increase threshold of cough center- Dextromethorphan or Narcotics - Expectorants - guaifenesin
- Humidification
- Fluids
21
Q
An 18 year old male comes to your urgent care with his mom with the complaint of coughing up blood. He has had a productive cough and sinus congestion for 7 days. Today he noticed blood tinged sputum, then coughed up a clot the size of a quarter
Vital signs: normal. On exam he has no focal findings on HEENT, Pulmonary or cardiac exam.
A
Hemoptysis
22
Q
what is hemoptyss
A
- Expectoration of blood from the lungs or bronchotracheal tree
- 90% from the bronchial arteries
23
Q
MOST common causes of hemoptysis
A
- Main extrathoracic cause is nosebleeds
- Bronchitis is most common pulmonary cause
-Good history taking required to distinguish between hemoptysis and hematemesis; may be difficult
24
Q
causes of hemoptysis
A
- Bronchitis 30-60%
- Lung cancer 20-30%
- Pulmonary embolus
- Hemoptysis in 30% of patients - Tuberculosis
- Leading cause in 3rd world countries
25
evaluation of hemoptysis
1. Quantify the amount of bleeding
2. Look for extra thoracic sources of bleeding
3. CXR 20-46% have normal CXR
4. Chest CT
5. Sputum analysis
6. Bronchoscopy
*Sputum analysis and bronchoscopy occur in patient or outpatient; not timely testing to affect ED management
26
tx of hemoptysis
1. ABC’s
- Pulse oximetry, B/P
- Airway management may be difficult, want to protect unaffected lung from bleeding
2. Hospitalize for >25 cc hemoptysis
3. May need Type and cross, transfusion if massive bleed
4. Evaluation of abnormal CXR findings
5. Antibiotics if indicated
6. Cough suppression
27
6 year old old male is brought to the ED with cough and fever and myalgias for three days. Immunizations UTD. No GI sx. Temp is 101.4 F, HR 156, RR 32. His left TM is erythematous and bulging with middle ear purulence. Rhinorrhea, watery eyes. Neck is supple, lungs CTA, Abd is soft, extremities well perfused.
influenza
28
presentation of flu
1. abrupt onset of Fever 101-103F,
2. chills/rigors;
3. HA,
4. myalgias,
5. generalized malaise.
6. Dry cough.
7. Fever last 2-4d; other sx’s last 3-7 d.
8. Kids under 13 years of age may have more GI symptoms.
29
most common complications of influenza
1. OM in kids;
2. bronchitis,
3. bacterial pneumonia,
4. myocarditis,
5. encephalitis
30
whats the difference between flu and sepsis
both fever, tachypnea,
-always have on ddx
*have good history!
31
when is flu most common
- 20% of the population affected by Influenza every year.
| - Northern hemisphere flu season is Nov-March
32
who is most at risk for flu complications
1. Asthmatics and COPD
2. Elderly
3. Children under 2 concerning; under 1 year old their hospitalizations rates are equal to elderly, pregnant women
33
describe the incubation and time course of flu
1. Incubation period 18-72 hours depending on inoculum load
| 2. Viral shedding complete in 7 days except for kids up to two weeks
34
dx studies of influenza
1. only PCR and viral culture can specify the strain
2. Most rapid kits can detect A versus B
- Done with a nasal swab
*In an epidemic testing may not be warranted; swab is 85% sensitive at best
35
influenza evaluation and tx
1. Rapid flu swab: +/-
2. Imaging – not recommended, unless concern for secondary PNA (hypoxia, dyspnea)
3. IVF – if feeling badly, not taking PO
4. Consider “other” causes of FLS (pyelo)
*Zofran, tylenol, fluids, turn lights off
36
anti-viral tx of flu
1. Best effects if used less than 48 hours of symptom onset. Clinical treatment ok
2. Neuraminidase inhibitors (oseltamivir, zanamivir) work on both Flu A and B
3. Amantidine derivatives only for Flu A
ex. Tamiflu
37
side effects of Oseltamavir (Tamiflu)
vomiting, nausea
38
Dosing of Oseltamavir (Tamiflu)
over 40 kgs : 75 mg Bid X 5 days
less than 40 kgs : weight based dosing
Prophylactic dose is just once a day, 75 mg qd for adults,x10days, and weight based for smaller
39
indications for Zanamivir
- Treatment of influenza age 7 years +
- Prophylaxis in 5 years +
Not recommended in asthmatics/ COPD due to possible bronchospasm
**inhaled tx (poor oral bioavaility)
40
anti-viral tx meds
1. Tamiflu (oselatamavir)
2. Zanamivir (inhaled form)
3. Adamantadine Derivatives (only for influenza A NOT B)
41
side effects of Amantadine
HA, insomnia, hallucinations, dizziness, depression
42
Flu tx summary
1. In season, treat clinically
2. Initiate within 48 hours
3. Tamiflu often causes GI distress/V/D
4. Illness is shortened by 1day w/ txmt, and can present secondary infections
5. If high risk, tx even after onset >2d
- pregnant women
- over 65yo and under 2yo
- chronic resp conditions (COPD/ Asthma)
- immunosuppressed
43
what high risk pts should you tx for flu
If high risk, tx even after onset over 2d
- pregnant women
- over 65yo and under 2yo
- chronic resp conditions (COPD/ Asthma)
- immunosuppressed
44
Mrs. Jones is a 50 year old non smoking female with the complaint of a fever of 102 F, productive blood tinged cough, chills, myalgia, and weakness for 3 days. She started feeling more short of breath today and came in for evaluation.
Vital signs: B/P 110/68, RR 22, HR 100, temp 101 F, pulse oximetry 91%
Pulmonary exam shows decreased breath sounds and rhonchi in the R lower lung field
CXR:
community acquired pneumonia
45
7th most common cause of death in adults
community acquired pneumonia
* Leading cause of death due to infectious disease
* 4 million diagnosed annually, ¼ hospitalized
46
typical causes of community acquired pneumonia
```
Streptococcus pneumonia (#1),
H. influenza,
Staph aureus,
Moraxella;
Klebsiella
```
47
atypical causes of community acquired pneumonia
Mycoplasma (#1), Legionella, B.pertussis, Chlamydia
48
compare the presentation of typical vs atypical pneumonia
typical: present with abrupt fever,productive cough, purulent sputum, sob, pleuritic CP
atypical: Slower onset, cough w/o sputum, more likely have extrapulmonary sx ST, rash, HA, renal
* 20% of adults in CO w/ a cough over 2-3 weeks have pertussis
49
*20% of adults in CO w/ a cough over 2-3 weeks have ___
pertussis
50
presentation fo Strep pneumo pneumonia
- sudden onset,
- rigors,
- bloody/rusty brown sputum,
- high fever,
- chest pain
- 25% will develop pleural effusion
51
common causative organism in pts w underlying lung dz (CF, COPD)
H. influenza
52
presentation of legionella pneumonia
- self limited disease to multi-system organ failure.
- GI symptoms usually proceed cough, more ill than -CXR shows
*Spread by water droplets - associated with misting machines, fountains, whirlpool, showers
53
presentation of mycoplasma pneumonia
- cough, sore throat, headache, diarrhea, retrosternal CP, bullous myringitis incubation 16-30 days
- Most common atypical organism
- ‘military recruits, school children/college age’ – easily spread in areas of close contact
54
presentation of Chlamydia pneumonia
- ST, hoarseness and headache as well as pulm sx, laryngitis common
- Outbreaks in nursing homes and among military recruits
55
criteria for HCAP
1. Residence in a SNF
2. Hospitalization w/in last 90 days
3. IV/wound care/dialysis w/in past 30 days
*“potentially” higher risk of multi drug resistant organisms
56
clinical findings of pneumonia
1. Hypotension, tachypnea, hypoxia, tachycardia in sick patients
2. Fever
3. Inspiratory crackles* (alveolar fluid)
4. Rhonchi
5. Wheezing
6. Diminished breath sounds
7. Rigors and sweats
57
diagnostic tests for pneumonia
1. CXR
2. sputum cultures
- 10-30% of patients do not produce sputum
- Useless if already on antibiotics
3. ABG-- if pt looks poorly
4. blood cultures
58
describe pneumonia CXR findings and associated dx
Lobar: Strep pneumo
Diffuse patchy infiltrate, multi lobar: S.aureus, H.inf
Interstitial pattern: Mycoplasma, Legionalla
Cavitary lesions, air-fluid levels: Pseudomonas, TB
*It has been taught that lobar consolidation is due to the "typical" bacteria, and interstitial infiltrates are due atypicals and viruses.
59
Radiographic resolution of pneumonia occurs in
50% at 2 weeks, 65% at 4 weeks, and 75 % at 6 weeks
60
when would you get blood cultures for pneumonia
1. If sick (and inpatient) cultures can guide Abx
2. Mandatory for ICU patients (CMS)
- Prior to Abx administration
- Abx within 6 HOURS of arrival in ED
3. Unnecessary on patients going home
- Leads to overuse of abx (false positive cultures)
61
Diagnostic test on the horizon for pneumonia
1. Procalcitonin
- Higher value (over 0.25mcg/L) seems to correlate with greater disease severity and higher likelyhood of bacterial dz
2. CRP
- over 40 more likely bacterial
62
who needs to be in isolation
- Ideally anyone with a fever and cough should be given a mask or placed in an isolation room
- Mask goes on the patient
ex. pneumonia
63
when do you admit to the hospital for respiratory dz
1. Hypoxia
2. Immunocompromise
3. Ill Appearing
4. Extremes of age
5. Co morbid diseases
6. Curb-65, PSI
64
what is CURB-65
```
C-confusion
U-Urea over 7mmol/L
R- RR over 30/minute
B-B/P less than 90/60
65-Age over 65 years old
```
65
outpatient management of pneumonia
1. Healthy, no recent Abx use:
- Macrolide (ie, Azithromycin) OR Doxycycline
- -PCN, Cephalosporins: no activity against atypicals
2. Co-morbidities (chronic lung, liver, renal dz, DM, Etoh, etc
- Respiratory fluoroquinolone (ie, Levo) OR
- Beta-lactam + macrolide (ie, HD Amox + Azithro)
3. 1st line tx in peds is amoxicillin bc they get different bugs
66
inpatient management of pneumonia
- Dual therapy with a B-lactam and Macrolide (Ceftriaxone and Azithromycin)
- Resp Fluoroquinolone (ie, Levo)
*Most studies support Antibiotics within 6 hours of arriving at the hospital translate into shorter LOS. Do not delay treatment waiting on Culture results.
67
A 22 year old female comes to the ED during an asthma attack. She’s had URI symptoms for 4 days. Tonight she has been using her albuterol inhaler every 1-2 hours without any relief. She is on inhaled steroids at home.
Vital signs: B/P 100/60, HR 110, RR 24, temp 99.5 F, 92%
Exam: Anxious sitting upright in bed. Lungs-diminished bilaterally with scattered wheezes
asthma
68
Average asthmatic spends __ days in bed and __ days of restricted activity per year
5.8 days
15 days
69
what is the most prevalent chronic dz in children
asthma
*Asthma prevalence has slowed from previous decades, but still rising
70
pathophysiology of asthma
- Inflammation and REVERSIBLE airway obstruction
- Triggers of asthma cause mast cell degranulation leading to
1. Increased vascular permeability
2. Mucosal edema
3. Bronchial smooth muscle contraction, and reduction of airway diameter
4. Mucus production
71
risk factors for death by asthma
1. Previous severe exacerbations, ie, ICU admission, intubation
2. Two or more hospitalizations in past yr
3. Using over 2 canisters of short acting beta agonist per month
4. over 3 ED visits for asthma in the past yr
5. Low socioeconomic status, inner city residence
72
compare the cough of asthma, croup and bronchioloitis
Squeeky exhaled– wheeze- asthma
Squeeky inhale-- stridor – croup (Upper airway)
Wheezing w/ cough under 2-3 y/o– bronchiolotiis
73
presentation of asthma
Classic presentation is dyspnea, coughing and wheezing with prolonged expiratory phase
74
considerations for asthma
1. Trigger
2. Duration of symptoms
3. Prehospital treatments
4. Previous steroid use, hospitalizations, intubations
5. Baseline PEFR
6. how often you use inhaler
75
asthma PE
1. Vital signs: Pulse oximetry measures blood oxygen saturation, but no ventilation
2. Speaking ability
3. Accessory muscle use, retractions
4. Auscultation- wheezing, decreased air movement; silent chest is ominous (too tight for noise)
76
complications of asthma
PTX
| pneumonia
77
ddx for wheezes
1. asthma
2. Pneumonia
3. Bronchitis
4. Croup
5. COPD
6. CHF
7. PE
8. Allergic reactions
9. FB aspiration
78
evaluation/ work up of asthma
1. PEFR- Pretreatment PEFR over 40% of predicted indicates severe obstruction
2. CXR
- Usually performed in first time wheezers
- Focal findings on Exam
- Failure to improve with treatment
3. ABG- sick patients PEFR less than 25%
- Provides information about respiratory acidosis and hypercapnia
4. EKG in any patient with cardiac condition
79
tx of asthma exacerbation
1. All patients get cardiac monitor, pulse oximeter, and BP monitoring
2. If moderate/severe: IV access
3. B-agonists: Albuterol
“continuous albuterol neb” ~1 hr
4. steroids
80
describe the use of albuterol for asthma
- albuterol nebulizer x3, + atrovent
- nebulizer treatments (or MDI w spacer)
- Consider 1 hour continuous if no better
- Patient should be on a monitor, given secondary tachycardia, hypertension, palps
81
cornerstone of tx for asthma exacerbation
steroids- Studies show patients who do not get steroids are the ones who return to the hospital
82
describe steroid use in asthma exacerbation
Delay in anti-inflammatory effect for 4-6 hr
- Oral does 40-60 mg prednisone
- 1-2mg/kg usually max out at 60 mg
- IV dose 125 mg Methylprednisolone
- New recommendations: add inhaled steroid to oral steroid in patients going home
83
other meds for asthma exacerbation
Magnesium sulfate, 1-2 mg IV
- Used in severe exacerbations
- Smooth muscle relaxer/ bronchodilation
Heliox (80% helium 20% oxygen)
- less dense than O2, may add to nebs
- decreases airway resistance
84
when do you intubate
Absolute indications:
1. coma and respiratory arrest
2. Otherwise clinical changes suggest need:
3. Increased work of breathing
4. Increased PCO2
5. decreased PO2
6. decreased mental status
Ketamine: good induction agent for asthmatics - bronchodilates
85
when can you discharge w/ asthma exacerbation
- Patients who feel better, are not hypoxic, tachypnic, and have clear lungs
- Can check PEFR; prefer over 60%
- On B-2 agonist and oral steroids, 4-5d.
*All patients should be rechecked in 1-3 days
86
when do you admit for asthma exacerbation
- Admit patients with PEFR under 40% or no clinical improvement
- PEFR between 40-60% clinical judgment
*All patients should be rechecked in 1-3 days
87
CXR:
| lung hyperinflation with flattened hemidiaphragms, and often a very vertically oriented heart
emphysema
88
common EKG changes in COPD?emphysema
1. RAD ( heart “rotates” with R heart hypertrophy);
2. incomplete or complete RBBB (usually due to RVH;
3. rsRprime in V1) / Right atrial enlargement (Tall P waves);
4. low QRS voltage (due to hyperinflation of the lungs)l POOR R wave PROGRESSION in the chest leads, (due to downward displacement of the diaphragm resulting in vertical heart position;
5. R wave is usually bigger than the S wave by V3/V4)
89
COPD cardinal sx
dyspnea, chronic cough, sputum production
90
describe the 2 forms of COPD exacerbation
Chronic Bronchitis -productive cough over 3 months duration for more than 2 years
Emphysema-destructive permanent enlargement of the air spaces distal to the terminal bronchioles with loss of normal structure
*Both cause progressive airway obstruction and may have some reversible airway hyper reactivity
91
weakened and collapsed air sacs w/ excess mucus
emphysema
92
4th Leading cause of death in the US
| Only cause which is increasing in incidence
COPD
*Tobacco accounts for 90% of cases
COPD prevalence is rising globally, and linked closely with cigarettes
93
Second most common cause of permanent disability in people over 40 y.o.
COPD
94
describe acute copd exacerbation
"an acute worsening of the patients normal daily respiratory symptoms leading to a change in medication”
- Increase in cough frequency and severity
- Increase in sputum volume or character
- Increased dyspnea
During exacerbations inflammation, bronchospasm, and mucus hypersecretion lead to airway narrowing, VQ mismatch and hypoxemia
95
triggers for acute copd exacerbation
mostly URIs (70%); remainder is pollution or unknown
96
presenting hx of acute copd exacerbation
History of worsening cough, change in sputum production, hemoptysis, worsening DOE and at rest
97
PE of acute copd exacerbation
1. Tripod posture- JVD
2. Pursed lip breathing- Peripheral edema
3. Accessory muscle use- AMS
4. Asymetry of lung sounds
5. Diaphoresis
98
evaluation of copd exacerbation
1. Pulse oximetry-May have chronic hypoxia
2. PEFR
- Relatively unchanged during exacerbations
- May be useful if airway reactivity is present
3. CXR
4. ABG- Likely abnormal, clinical picture is most helpful.
5. Consider EKG and monitor
6. Sputum culture- not reliable
99
copd tx objectives
1. Relieve hypoxemia
2. Alleviate reversible bronchospasm
3. Treat the underlying etiology of the exacerbation
100
tx of copd exacerbation
1. Oxygen
- Nasal cannula up to 6L; NRB mask if needing more
- Goal SaO2 88-92% -
- -Risk of prompting worsening hypercapnia with excess supplemental oxygen
2. Bronchodilators
- Recommendation of B2–agonists every 30-60 minutes; likely “continuous neb”
- Use atrovent as well
3. Abx
4. steroids
5. NPPV
6. Mucolytics/expectorants- no data to support their evidence
101
what Abx would you use w/ copd exacerbation
- Initiate in moderate to severe cases
- Doxycycline, Azithromycin, Augmentin; Levofloxacin if hospitalized and concern for pseudomonas
- Treat between 7-10 days
102
what steroids do you use w/ copd exacerbation
- Prednisone 40-60mg PO or Solumedrol 125mgIV
- Increased PEFR and decreased relapse rate at 72 hours
- Optimal dose and duration is uncertain but no benefit beyond 2 weeks; usually 5 days of rx
103
who w/ copd exacerbation should be hospitalized
*Not every exacerbation requires hospitalization
Criteria for admission
1. AMS
2. Co morbid conditions
3. Inability to eat or sleep due to dyspnea
4. Inability to walk between rooms if previously mobile
5. Social situations
6. Worsening hypoxemia
7. No response to outpatient management
104
signs of respiratory distress
1. Tachypnea
2. Tripod posture
3. Use of accessory muscles
4. Diminished breath sounds
5. Altered mental status
6. Hypoventilation
7. Hypoxia
8. Physical exhaustion
105
evaluation/ tx of respiratory distress
- Consultation with your attending physician is imperative
- Patients require advanced airway management i.e. intubation
- Consider non invasive airway management i.e. BIPAP
106
asthma exacerbation management- stable
1. Albuterol/ atrovent -”continuous neb”
2. Steroids
3. Reasses s/p treatment
- CXR only if concern for secondary infection or not improving
- If improved (normal RR, clear lungs, no hypoxia) : d/c with : 1.) albuterol inhaler qid prn 2.) Prednisone 40-60mg qd for 5 d total
107
if asthma exacerbation is no better after initial tx then:
Reasses – if still wheezing/ feeling no better
1. repeat neb
2. MgSO4 1-2mg over 30 min
3. ? VBG, NPPV
4. Consider other etiologies: HF, FB, PE, PNA, ARDS…
5. consider admission
108
3 yo girl, presents at 2 am w/mom. 3 days of cough, runny nose, got much worse this evening. Barky, stridorous
croup
109
presentation of croup
1. 6mo-3 years
2. Viral, self limited
3. 1-5 day prodrome of cough/coryza, then onset of:
- Inspiratory stridor
- Barky cough
- hoarseness
*clinical dx
110
cxr:
| steeple sign- narrowing of upper trachea
croup
111
croup managment
-Tx is directed towards decreasing airway edema
Decision:
- Mild sx: tx and d/c home
- Moderate/severe: require prolonged observation vs admission
112
tx of mild croup
- Oral dex .15-.6mg/kg
- Mgmt at home:
- Steamy showers
- A car ride in the cold night air
- Return precautions
113
tx of moderate/sever croup
1. Allow parent to hold child and comfort
2. Humidified air/oxygen
- Blow by vs on face
3. Dexamethasone PO, IM or IV
4. Racemic epinephrine via nebulizer
5. Observe and reassess after 3-4 hours
114
what is mild croup
No stridor at rest
Barky cough
Hoarse cry
No increased WOB
115
what is moderate croup
Stridor at rest
Mild retractions
No agitation
116
what is severe croup
Anxious, agitated, pale fatigued, increased WOB
117
when do you admit croup- laryngotracheobronchitis
1. Persistent hypoxia
2. Recurrent symptoms after 3 hours
3. increased WOB (stridor at rest, tachypnea, retractions)
4. over 2 rounds of epi
* Pearl – give the IV version PO, tastes better
* Pearl: no difference between nebulized or racemic epi ; may be repeated q 15-20 min
118
who is most effected by bronchiolitis
- Affects 20- 30% of infants
- Most common LRI infection in first two year of life
- Peaks Nov-March
- Inc risk if:
- premature <37week
- Chronic lung dz, immunocompromised
119
what causes bronchiolitis
RSV nmber 1 cause
120
what does bronchiolitis cause
1. Airway inflammation and edema
2. Increased mucus production
3. bronchospasm
121
how do you dx bronchiolitis
1. Commonly preceeded by 1-3 d of URI sx
- Congestion, cough, runny nose, wheezy
2. Nasal flaring, accessory muscle use
3. decreased PO ,low grade fever
4. under 2yo commonly
122
tx of bronchiolitis
1. APNEA and DEHYDRATION are of great concern
- Assess hydration
- Oxygen prn
2. Suction**** KEY
3. No routine testing – RSV, CXR, etc.
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management of bronchiolitis
"nothing cures this disease and very little improves it”
| Management is primarily palliative - “suction” – kids
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deposition of bronchioloitis
Inpatient if hypoxic, tachypnic, poor PO/dehyrated, inc WOB, co-morbidities
d/c home w/ good discharge instruction
Suction breakfast lunch and dinner
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why do kids under 2 most often get bronchiolitis
Kids under 2 get it because they are obligate nose breathers. Mucous clogs their noses and drains into lungs.
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additional notes on bronchioliti s
1. Albuterol: 25% get better, more likely if h/o of asthma, eczema, etc.
2. Steroids: controversial, but since so many ped respiratory diseases get better, many give it –especally if asthma h/o eczema
3. RSV: usually not needed, unless the child is going to be admitted, as inpatient team will want to know
