Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Asthma, Bronchiolitis, and Pnemonia Tintinalli Chapt 123-124. April 18th 2005 Mark Rodkey, M.D., FAAP Scott Gunderon, D.O. Asthma Chronic disease of the tracheobronchial tree characterized by airway obstruction, inflammation, hyperresponsiveness, mucous plugging and edema. Recurrent wheezing which responds to bronchodilators. Epidemiology 4.8 million children 40% increase in last decade Risk factors Family Hx African/American, Asian, Hispanic Low birth weight Urban household Low income Pathophysiology Three classifications: extrinsic IgE mediated intrinsic infection induced mixed (both IgE and infection) Pathophysiology Less than 2 years old viral triggers Over 2 allergens and irritants are triggers Pathophysiology Bronchoconstriction due to histamine and leukotriene release Airway mucosal edema/plugging Pathophysiology Obstruction Air trapping Hyperventilation, lowers PaCO2 Respiratory failure raises PaCO2 Pediatric Anatomy Higher risk for respiratory failure from asthma than adults because of anatomic differences Compliance of infant rib cage and immature diaphragm paradoxical respiration increased work of breathing and fatigue Pediatric Anatomy Less elastic recoil more prone to atelectasis increases V/Q mismatch Thicker airway wall greater bronchoconstriction Pediatric Anatomy Obstruction more likely Collapse of lung segments Compensatory mechanisms may mask the extent of dyspnea Evaluation Before H&P!!!! ABC’s! Shock (respiratory) Oxygen β2 agonist Evaluation Peak expiratory flow rate (PEFR) pre and post treatments (age 8) values are in liters per minute based on child’s height < 50% indicates severe obstruction < 25% indicates possible hypercarbia Evaluation ABG Impending respiratory failure Hypoventilating PEFR < 30% of predicted Not responding to treatment Disposition (PICU vs RNF) Pulse Oximetry Expired CO2 Clinical Evaluation! Respiratory effort tachypnea, grunt, flare, retractions air hunger altered activity altered mental status Forced breath (blow hand) recite alphabet in one breath response to treatment Chest X-ray first wheeze poor response to treatment fever chest pain considering FB, pneumo hyperinflation flattened diaphragm barrel-chest PBT atelectasis Differential pneumonia FB Cystic Fibrosis BPD CHF (Congenital Heart Disease) Croup Epiglottitis Retropharyngeal abscess Bacterial tracheitis GERD Treatment β2 receptor agonists--albuterol activates adenylate cyclase increases cyclic adenosine monophosphate bronchial smooth muscle relaxation binding intracellular calcium to endoplasmic reticulum Treatment Xopenex - R isomer of albuterol Salmeterol is a long acting β2 agonist NOT indicated in acute setting reduces need for Albuterol Treatment Epinephrine 0.01mL/kg of 1:1000 up to 0.3 mL (0.5?) SQ 3cc nebulized Racemic epi 0.5 mL nebulized helps reduce edema? Treatment Terbutaline more β2 selective than epi 0.01 mL/kg 1mg/mL, max 0.25 mL 5-10 mcg/kg SQ or IV may cause myocardial ischemia, tachycardia Treatment Corticosteroids (Prednisone, Solumedrol) Anticholinergics (Atrovent) 1-2 mg/kg/day PO or IV prevents bronchoconstriction induced by guanosine monophosphate IV fluids Magnesium sulfate not much supporting evidence in Pediatrics Bronchiolitis Bronchiolitis Inflammation of bronchioles Usually refers to children under 2 who have a viral URI with some intrathoracic symptoms (wheeze, cough, tightness) Epidemiology Prevalence late October to May RSV 50-70% Influenza Parainfluenza RSV Direct contact with secretions Self inoculation hands to eyes and nose Infectious on countertops for > 6 hours Shed up to 9 days in the respiratory tract Nasal discharge, pharyngitis, cough Fever up to 40C Peak symptoms at 3 to 5 days Physical findings tachypnea, tachycardia, conjunctivitis, retractions, prolonged expiration (I:E), wheezing, hypoxemia Evaluation similar to asthma swab nose for RSV, Influenza CXR Treatment Suction airway O2 β2 agonist Albuterol Racemic Epi Epinephrine Treatment Atrovent? Atropine? dries secretions Steroids? for family Hx of asthma Treatment Ribavirin? (Guidance of PICU) Pulmonary Disease Cystic Fibrosis RDS Congenital Heart Disease Bronchiolitis 70% of children who wheeze in the ED are smoking (passively or actively) Pneumonia Pneumonia Goals Identify causes of Pneumonia in children Describe Respiratory Distress in Pneumonia Review Treatment for Pneumonia Pediatric Emergency Medicine Pneumonia Infection within the lung Viral Bacterial Fungal Epidemiology 40/1000 in preschool children (U.S.) 9/1000 in 10 year olds (U.S.) Mortality < 1% in industrialized nations 5 million deaths under 5years annually in developing countries Fall/Spring—parainfluenza Winter—respiratory syncytial virus Winter—influenza Bacterial more common in the winter Risk Factors Asthma/RAD/Bronchio litis Immunocompromise Previous Insult to Lungs Abnormal Anatomy (Immotile Cilia) Cystic Fibrosis, Sickle Cell . . . Prematurity Malnutrition Low Socioeconomic Status Cigarette Smoke Day Care Foreign Body Pathophysiology Aspiration of infective particles into the lower respiratory tract Suppression of normal defenses after viral infection Coexistent viral and bacterial pathogens in children in ¡Ã50% of cases Etiologic Agent Birth to 1 month Viruses: CMV group B streptococcus, E coli, Klebsiella, Listeria 1 to 24 months Viruses: RSV, parainfulenza, influenza, adenovirus Bacteria: Strep pneumoniae, strep pyogenes, staph aureus, H. influenza Etiologic Agent 2 to 5 years Viruses: Influenza, adenovirus Bacteria: Strep pneumoniae 5 to 18 years Viruses: RSV, adenovirus Bacteria: Mycoplasma, Strep pneumoniae, Chlamydia pneumoniae Special Concerns Staph aureus Grp A Strep rapid progression, abscesses invasive, necrotizing fasciitis, empyema Gram neg bacilli recently hospitalized patients Special Concerns B. pertussis C. trachomatis paroxysmal cough maternal exposure, conjunctivitis M. pneumoniae rash (Erythema Multiforme) Special Concerns RSV mortality rate Congenital Heart up to 35% Congenital Heart w/ Pulmonary HTN up to 70% Symptoms cough fever chest pain fatigue gasping tachypnea apnea abdominal pain nausea Findings respiratory distress tachypnea, grunting, flaring, retracting abnormal auscultatory findings??? cyanosis chest X-ray - infiltrates CXR Findings Viral Bacterial diffuse interstitial infiltrates consolidated, lobar Mycoplasma diffuse Lab CBC elevated WBC, left shift Blood Culture Cold Agglutins Sputum Culture ABG May help with placement RSV Influenza Appearance History is not as useful Examination is paramount Observation vigorous crying playful quiet is bad! Signs of Respiratory Distress Tachypnea Retractions Flaring Grunting Abdominal Breathing (seesaw) Bradypnea Signs of Respiratory Distress Wheezing Stridor Poor Air Exchange Skin Color Change in Level of Consciousness Change in Depth of Breathing (volume) Change in I:E Positioning Tripod Sniffing Air Hunger Evaluation of Respiratory Distress High Expired CO2 CXR Soft Tissue Neck X-ray Response to Treatment Pulse Oximetry???? should not guide acute treatment decisions misleading inaccurate Treatment Position/Support/Maintain Airway Wipe Nose! Remove Foreign Bodies Oxygen Cool Mist (H2O or NS?) Antibiotics? Birth to 1 month - Amp + Gent, Cefotaxime 1 to 24 months - Amoxil, cephalosporin 2 to 5 years - Amoxil, cephalosporin over 5 years - Zithromax, Biaxin Resistant S. pneumoniae - vancomycin Antibiotics? Viral support acyclovir? ribavirin? Treatment Beta agonist IVF (except cardiogenic and resp?) 10-20cc/kg normal saline or Ringer’s never sugar in bolus (unless calculated) Oxygen & Albuterol Intubation Cardio/Respiratory Failure Uncompensated Shock Unable to maintain airway ** ETT size age/4 + 4, insert 3 x size of tube small fingernail nares Disposition - Admit Hypoxia < 3 months old Shock Dyspnea Activity Level Extensive ED Treatment Complications Viral pneumonia resolve spontaneously without specific Tx Bacterial pneumonia dehydration, bronchiolitis obliterans, apnea pleural effusions, empyemas, pneumothorax, pneumatoceles, development of additional infectious foci Cases Case 1 16 month old boy, respiratory distress RR 40, HR 140, T 39.2C Rash Case 2 7 year old boy, cough RR 20, HR 105, T 38.2C Hx TE Fistula, Cleft Palate, RAD Cases Case 3 6 day old boy, respiratory distress RR 64, HR 160 Case 4 9 month old boy, respiratory distress, shock RR 60, HR 170, T 37.5 green nasal d/c Cases Case 5 3 month old boy, CPR RR 0, HR 0 Case 6 5 year old boy, cough, fever, rash RR 20, HR 100, T 38.7C Cases Case 7 2 year old boy Cough, fever Tachypnea, retracting, grunting, flaring Lungs clear RR 42, HR 140, T 38.3C Case 8 4 year old boy, Down Syndrome Cough, Fever, Tachypea Grunting, Flaring, Retracting RR 32, HR 120 Cases Case 9 13 year old boy Cough, Fever, Tachypea, Chest Pain Grunting, Flaring, Retracting Decreased BS on Left RR 32, HR 120 Case 10 14 year old boy, Christmas Day Cough, Fever RR 18, HR 96 WBC 4.0 Cases Case 11 8 year old girl, 5 year old boy, siblings Cough, Fever, Tachypea Lungs clear Case 12 10 month old girl, Situs TOGA Diaphrag Hernia Cough, Fever, Tachypea Grunting, Flaring, Retracting RR 48, HR 160 Cases Case 13 4 year old boy Cough, Fever, Tachypea Coarse BS RR 48, HR 120, T 38.6C Case 14 14 month old boy Cough, Fever, Tachypea Clear BS RR 48, HR 120, T 39C Summary Recognize Respiratory Distress Low Threshold to Consider Pneumonia Treatment for Respiratory Distress, then Pneumonia Normal Breath Sounds DO NOT R/O PNEUMONIA!