Download Pediatric Pulmonary Pearls

Pediatric Pulmonary Pearls
Terrence W. Carver, Jr., M.D.
Children’s Mercy Hospitals and Clinics
Medical Director of Respiratory Care and
Pulmonary Medicine
Associate Professor of Pediatrics
University of Missouri-Kansas City
© The Children's Mercy Hospital, 2016
Disclosures
• Many medications used in pediatric
patients are not specifically approved by
the FDA.
• Many medications used in cystic fibrosis
(CF) patients are not specifically approved
by the FDA.
Educational Objectives
• Review management of (some) pulmonary
concerns encountered in primary care
practice.
– Recognize a typical clinical scenario for
foreign body aspiration.
– Review evaluation for hemoptysis in a noncystic fibrosis patient.
– Evaluation of a pediatric patient with chronic
cough.
Selfish Goal
• My goal is to get invited back!
Foreign Body Aspiration
• Typical presentation (acute)
– Toddler
– Cough/choke episode
– Unilateral wheeze
Foreign Body Aspiration
• O2 saturation and respiratory rate
• Retractions/distress
• CXR
• Lateral decubitus views
– Air trapping
What’s wrong with this
picture?
Foreign Body Aspiration
• Witnessed
• Suspected
• Possible
Foreign Body Aspiration
• Solid/particulate
– ENT or Surgery for rigid bronchoscopy
• NPO
• Write checks that I don't cash.
• Oils/Volatiles
– Supportive care and oxygen (likely admission)
• Not bronchoscopic removal
New Hemoptysis—non CF
• Amount and color
– Bright red blood, clots, blood streaked mucus
• Source
– Lung, nose, GI
• Bronchitis/pneumonia
• Epistaxsis
• Liver disease, GERD
New Hemoptysis—non CF
• Urine output/blood
– Pulmonary/Renal Syndrome
• Rash, abnormal joints, chronic/recurrent
fever
– Rheumatologic
New Hemoptysis—non CF
• CXR findings and oxygen saturation
• CBC and reticulocyte count
• PT/PTT/LFTs/platelet count
• Guaiac stool
• Urinalysis/BUN/creatinine
– Blood and casts
Umm…Dr. Segeleon…
New Hemoptysis—non CF
• CT Chest with contrast or CT angiogram
• Bronchoscopy/BAL
• P and C-ANCA, RF, ANA, ESR, CRP, type
and cross, brain natriuretice peptide, Ddimer, sputum culture/AFB/TB evaluation?
• Echocardiogram
New Hemoptysis—non CF
• Consults; "Who you gonna call?"
– Rheumatology, Renal, ID, Surgery, ENT, GI
•
•
•
•
Positive pressure ventilation
Lung biopsy
Lung resection
Blood transfusion
Stridor
• Think airway (ENT)
• Laryngomalacia
• Recurrent croup
• Vocal Cord Dysfunction (VCD)
Laryngomalacia
• Infant
• Growing well and no distress
– Some chest wall retractions esp. supine
• If more severe consider subglottic
stenosis, laryngeal papillomatosis, others
• Scope (ENT) if suspicious for others or
severe
Recurrent Croup
• Rule out anatomic abnormality (ENT)
• Occasionally responds to "reactive airway
disease" medications (Pulmonary)
– Trial of inhaled corticosteroids
Vocal Cord Dysfunction
• Adolescent
• Type A personality
• Stress related (games vs. practice)
• Confused with exercise induced asthma
– Dysphonia, throat/neck vs. chest, choking sensation
– Video on cell phone
• Speech Therapy for breathing exercises
Chronic/Recurrent Cough
• History
– How long
– When
• AM/PM
• While asleep
– Associated feeding
• Good growth or failure to thrive
Chronic/Recurrent Cough
• Triggers
– Upper respiratory tract infections, allergies,
exercise,cold air, etc.
• Seasonal
– Previous steroids
Chronic/Recurrent Cough
• Symptoms of GERD/aspiration
• Family history of cystic fibrosis, asthma, or
allergic rhinitis
• Vocal Cord Dysfunction with “wheeze” but
normal oxygen saturation
Chronic/Recurrent Cough
• Asthma
– Early morning around 0200-0500
• GERD
– Feeding/chest rattle
– Family often says "wheeze"
Chronic/Recurrent Cough
• Allergic Rhinitis/Sinusitis
– On awakening
• Aspiration
– Cough/choke with po feeds vs. silent aspiration
• CF
– Loose
– Difficulties gaining weight
Chronic/Recurrent Cough
• Vascular ring
– Stridor, dysphagia
• Immune dysfunction
– Other sites of infection, failure to thrive
• Habit
– Loud, honking, resolves with sleep
Chronic/Recurrent Cough
• TB
– Weight loss, night sweats
• Large tonsils/upper airway obstruction
– Hard to judge
• Primary cilia dyskinesia
– recurrent sinusitis and otitis media, situs
inversus, respiratory difficulties as term
newborn
Chronic/Recurrent Cough
• Vitals and oxygen saturation
• Exam of nose and lungs, etc.
• Type of cough
• Any stridor
Chronic/Recurrent Cough
• Labs
– CXR
– UGI
– Sweat test
• Newborn screening began:
– MO 7/1/07
SD 6/1/05
– KS 7/1/08
NE 1/1/06
What’s wrong with this
picture?
Chronic/Recurrent Cough
• TST
• Immune evaluation
• Swallow study
• pH probe
• CT Chest with contrast
Chronic/Recurrent Cough
• Bronchoscopy/BAL
– Anatomy
– Lipid laden macrophages
Chronic/Recurrent Cough
• Cilia biopsy by ENT
– Structure typically but not function
Pneumothorax
• First or recurrent
• Same side
• Connective tissue disease
• CT Chest (with contrast)
– Blebs
• Surgery consult
What’s wrong with this
picture?
Tracheostomy & Cough
• Color, amount of sputum
• Increased suctioning
• Fever
• Acts sick
• Increased oxygen need
Tracheostomy & Cough
• Previous organisms and sensitivities
• Previous antibiotics that helped or didn’t
• Ever Pseudomonas or MRSA
Tracheostomy & Cough
• Vitals and oxygen saturation
• Type and size of tracheostomy
• Breath sounds
• CXR compared to previous
Home Ventilator
• Similar to tracheostomy
• Ventilator settings and times of day used
• Cuffed vs. uncuffed tubes
• Blood gas evaluation and bicarbonate
level from basic metabolic panel
Tracheostomy Concerns
• ENT generally
– Too big
– Too small
– Can’t get back in
• Critical vs. inconvenient
• Cuff problems
Snoring/Obstructive Sleep
Apnea
• ENT
• Large tonsils/adenoids
• Needs Polysomnogram (PSG aka Sleep
Study)
– Sleep or Pulmonary Clinic
• Consider admit
Pectus Excavatum
• Pulmonary Fuction Testing
• Surgery Clinic
• Cardiology Clinic
– Exercise study
CF with Cough
• Color and amount of sputum
• Change in taste--anaerobes
• Fever--not typically noted
• Associated symptoms
– Fatigue
– Weight loss
– URI
CF with Cough
• History of ABPA (Allergic
Bronchopulmonary Aspergillosis)
• Other pertinent history
• Home medications
• Last antibiotic course/dosing
• Last admit therapy--especially if admitting
CF with Cough
• Oxygen saturation
• Fever--atypical for standard exacerbation
• Respiratory rate/distress
• Breath sounds
– Crackles
– Reduced air movement
– Wheeze uncommon
CF with Cough
• Previous culture results
• CXR results compared to previous
• Other labs
– WBC, RSV, Influenza
– Pulmonary function tests with reduced FEV1
Pseudomonas aeruginosa
•
•
•
•
Frequent pathogen
Resistance pattern important
Consider ciprofloxan (Cipro)
Often admit for IV antibiotics
– Ceftazidime and tobramycin unless resistant
MRSA
• Increased incidence in CF not unlike overall
community
• Decreased survival
• Consider linezolid (Zyvox) or Bactrim
• Medication interactions
CF with Cough
• What does family want?
– Home antibiotics
– Admit
– Repeat sputum or throat culture
CF with Hemoptysis
• Amount, color
– < 5 ml vs. more
– Bright red blood vs. streaks in mucus
• New or many times
• Can patient tell where the bleeding is
coming from?
CF with Hemoptysis
• Home medications
– ADEK
• Other recent history
– Pulmonary exacerbation
• Other pertinent history
– Liver disease/portal HTN
CF with Hemoptysis
• Oxygen saturation
• Respiratory rate/distress
• Breath sounds
– Crackles
– Reduced air movement
– Wheeze
CF with Hemoptysis
• PT
• PTT
• CBC
• Liver function testing
• Type and cross for PRBC transfusion
CF with Hemoptysis
• CXR compared to previous
• Bronchiectasis
CF with Hemoptysis
• Positive pressure ventilation
• Bronchial artery embolization
• Lung resection
• Stop NSAIDS
• FFP and/or vitamin K
CF with Hemoptysis
• Hold airway clearance
• Antibiotics
• PRBC transfusion
CF with Hemoptysis
• What does family want?
– Home antibiotics
– Admit
– Repeat sputum or throat culture
CF with Abdominal Pain
• Location and duration
• Lack of stooling
• With eating (constipation, DIOS)
• Spitting up (GERD)
• Hematemesis (liver disease)
CF with Abdominal Pain
• Home medications
• Previous history
– Meconium ileus (adhesions/bowel
obstruction)
• Previous KUB/abdominal ultrasound
• Previous liver enzymes
CF with Abdominal Pain
• Considering (more likely)
– DIOS (Distal Intestional Obstructive
Syndrome)
– Constipation
– Missing enzymes
– GERD
CF with Abdominal Pain
• Considering (less likely)
– Gall stones
– Portal hypertension
– Liver disease
– Pancreatitis
• Pancreatic sufficient
CF with Abdominal Pain
• Exam
– Tenderness
– Mass
• Palpable stool
– Rebound
CF with Abdominal Pain
• KUB
• Abdominal ultrasound
• Liver enzymes
• Lipase/amylase
• PT
CF with Abdominal Pain
• GI or Surgery services
– Cautious with narcotics
• Enema
• GoLYTELY po or NG
• Increase constipation medications
– MiraLax
– Fluids
CF with Abdominal Pain
• What does the family want?
– Trial of therapy at home
– Admit
Suggested Reading
• Kendig’s and Chernick's Disorders of the
Respiratory Tract in Children, 8th ed., 2012.
• Respiratory Disease in Children: Diagnosis and
Management, ed. Loughlin and Eigen, 1994.
• Care of the Child with a Chronic Tracheostomy;
Am J Respir Crit Care Med. 2000;161:297-308
• Management of Spontaneous Pneumothorax;
Chest. 2001;119:590-602
Suggested Reading
• Cystic Fibrosis Pulmonary Guidelines Chronic
Medications for Maintenance of Lung Health; Am
J Respir Crit Care Med. 2007;176:957-969
• Cystic Fibrosis Pulmonary Guidelines
Pulmonary Complications: Hemoptysis and
Pneumothorax; Am J Respir Crit Care Med.
2010;182:298-306
Suggested Reading
• Association Between Respiratory Tract
Methicillin-Resistant Staphylococcus aureus and
Survival in Cystic Fibrosis; JAMA.
2010;303(23):2386-2392
• Update on treatment of pulmonary
exacerbations in cystic fibrosis; Current Opinion
in Pulmonary Medicine. 2006;12:440-444
Suggested Reading
• Guidelines for Evaluating Chronic Cough in
Pediatrics: ACCP Evidenced-Based Clinical
Practice Guidelines; Chest. 2006;129:260S283S
• Recommendations for the assessment and
management of cough in children; Thorax.
2008;63:1-15
Suggested Reading
• UpToDate, April 2016.
• Clinical Practice Guidelines From the
Cystic Fibrosis Foundation for
Preschoolers With Cystic Fibrosis,
Pediatrics. 2016;137(4):e20151784
• https://tools.cff.org/aboutcf/testing/newbor
nscreening/screeningforcf/