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Peds Blueprint: Pulmonology

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What is the leading cause of illness in children and adults?
Respiratory tract infections
URIs are above the ____. LRIs include the ____, _____, and _____.
Above the larynx; Include the trachea, bronchi, and pulmonary structures
What diseases are included under the umbrella of URIs?
Pharyngitis
Sinusitis
Common cold
Most common causes of the common cold?
Rhinovirus (50%)
Coronavirus (20%)
Other viruses (the rest)
What is acute bronchiolitis?
Inflammation of the bronchioles (airways <2mm). MC in infants. MC time is Fall through Spring.
What is the most common cause of acute bronchiolitis?
Respiratory Syncytial Virus (RSV)
Other causes: Parainfluenza, adenovirus, rhinovirus
What are clinical features of acute bronchiolitis?
URI symptoms (rhinorrhea - lots of green mucus!, sneezing, low-grade fever)
Wheezing - often called "happy wheezer"
Respiratory distress
Signs of respiratory distress?
Nasal flaring
Tachypnea
Retractions
Diagnostic studies for acute bronchiolitis?
CBC - usually normal
Nasal washings for RSV culture and antigen assay - often done in infants
Management of acute bronchiolitis?
Consider hospitalization and Ribavirin (especially if a preemie or severely ill)
Supportive care - nebulized albuterol, IV fluids, antipyretics, chest physiotherapy, humidified O2
O2 sat >95%
What is prophylaxis for RSV and when is it indicated?
Palivizumab (Synagis) IM for preemies (<32 weeks) or with chronic lung disease and <2 years old. Given monthly throughout the RSV season.
What is Croup?
AKA acute viral laryngotracheobronchitis. Affects children most commonly between 6 months to 5 years.
What is the most common cause of croup? Other causes?
Parainfluenza virus types 1 and 2 is MC
Other: RSV, adenovirus, influenza, rhinovirus
What are clinical findings of croup?
Harsh, barking, seal-like cough
Inspiratory stridor
Hoarseness
Aphonia
Low-grade fever
Rhinorrhea
What is the classic finding on a PA neck Xray with croup?
Steeple sign - subglottic narrowing
How do you differentiate croup from epiglottitis?
Lateral neck film
How do you treat croup?
Mild croup - supportive care
Moderate-severe: Dexamethasone, humidified air, nebulized racemic epi
What is epiglottitis?
Infection of epiglottis - medical emergency! Can be caused by virus or bacteria. MC in children aged 2-7
What vaccine has helped decrease the incidence of epiglottitis in children?
Hib
Clinical presentation of epiglottitis?
Sudden onset of fever, respiratory distress, severe dysphagia, drooling, and muffled voice
Mild stridor with little or no coughing
Tripoding
Diagnostic studies for epiglottitis?
Direct visualization - caution bc may be fatal in children
CBC and blood cultures
Lateral neck Xray
What is the classic Xray findings with epiglottitis?
Thumbprint sign - swollen epiglottis
Management of epiglottitis?
Secure airway
Broad-spectrum Cephalosporin (Cefotaxim, Ceftriaxone) for 7-10 days
Dexamethasone
What is asthma?
Disease of chronic inflammation leading to airway narrowing and increased mucus production. Triggered by allergens, irritants, cold air, exercise.
What are the three characteristics of asthma?
1. Obstruction
2. Bronchial hyperactivity
3. Inflammation of airway
What is the strongest predisposing factor to asthma?
Atopic triad: asthma, eczema, allergic rhinitis
Risk factors for mortality due to asthma?
African american
Previous hx of intubation
>2 ED visits in a year
Use of 2 SABA canisters in a month
Use of systemic steroids
Inability to perceive SOB
What is the pathogenesis of asthma?
There is an initial inflammatory event which involves the degranulation of presensitized mast cells. Mast cells then release inflammatory mediators (histamines, cytokinds, leukotrienes, and platelet activating factors). This all leads to edema, mucus production, and bronchospasms.
How is asthma classified?
Based on frequency of symptoms and PFTs:
Intermittent
Mild Persistent
Moderate persistent
Severe persistent
Classification of asthma
What are clinical features of asthma?
Classic: wheezing, cough, dyspnea, sputum production
Pts are asymptomatic between episodes
Important elements of history to ask in a patient with asthma?
Current symptoms and frequency
Presence of nocturnal sx
Triggers
Previous treatments
Past hospitalizations
Use of steroids
Previous intubations
PE findings with asthma?
Tachypnea
Tachycardia
Accessory muscle use
Nasal flaring
Tracheal tugging
Abdominal breathing
DDx with asthma in children?
Bronchiolitis - will be acute, not chronic
Cystic fibrosis - GI symptoms, growth disturbances, recurrent sinus infx, PNA
Croup - not chronic
Epiglottitis - not chronic
Bronchitis - not chronic
FB aspiration - not chronic
DDx of asthma in adults?
COPD - onset is in adulthood
CHF - onset is in adulthood
Airway obstruction exists when the peak flow is <___% of predicted value based on patient's age, gender, height
80%
Stepwise approach for managing asthma
What meds are for short acting control of asthma?
Short acting beta agonist (SABA)
Ipratropium Bromide
Systemic steroids
What meds are for long acting control of asthma?
Inhaled corticosteroids
Long acting beta agonist (LABA)
Cromolyn, Nedocromil
Leukotriene modifier agonists
Theophylline
Step 1 of asthma tx?
SABA prn (albuterol) - bronchodilators
SE of bronchodilators?
Flushing
Tremors
Tachycardia
Step 2 of asthma tx?
Preferred: low dose inhaled corticosteroid (ICS)
Alternative: Cromolyn or Nedocromil, Leukotriene modifiers, Theophylline
SE of inhaled steroids?
Oral candidiasis
Growth stunting (with high dose ICS)
Step 3 of asthma tx?
Preferred: Low dose ICS + LABA (Salmeterol) OR medium dose ICS
Alternative: Low dose ICS + leukotriene receptor agonist (LTRA), theophylline, or zileuton
Purpose of LABAs?
For management of nocturnal sx and exercise induced asthma. Never used as monotherapy.
Step 4 asthma tx?
Preferred: medium dose ICS + LABA
Alternative: medium dose ICS + LTRA, theophylline, or zilueton
Step 5 of asthma tx?
High dose ICS + LABA AND consider omalizumab for pts with allergies
Step 6 of asthma tx?
High dose ICS + LABA + oral steroids AND consider omalizumab
When are anticholinergics used in asthma?
For severe exacerbations [Ipratropium (Atrovent)]
What is the cornerstone of therapy for all asthma patients?
Education
Environmental control
Management of cormorbidities
Consider immunotherapy
What is Cystic fibrosis?
An autosomal recessive disorder that results in abnormal production of mucus by almost all exocrine glands which causes obstructive lung disease. Median survival is 31.
What complications are CF patients at a higher risk for?
GI tract malignancies
Osteopenia
Arthropathies
What are clinical features of CF?
Cough with excess sputum
Decreased exercise tolerance
Sinus pain
Purulent nasal discharge
Steatorrhea
Diarrhea
Abdominal pain
What are physical signs of CF?
Clubbing of fingers
Increase AP chest diameter
Apical crackles
Diagnostic studies for CF?
ABG - will show hypoxemia and compensated respiratory acidosis in advanced disease
PFTs - mixed obstructive and restrictive pattern
CXR - hyperinflation, peribronchial cuffing, mucous plugs, bronchiectasis, increased interstitial markings
CT - bronchiectasis
SWEAT CHLORIDE TEST (>60) on 2 occasions<---- diagnostic test of choice
What is bronchiectasis?
Condition where bronchi and lung tissues are damaged and cannot clear mucus. Can be congenital (CF) or acquired (TB, fungal infections, etc)
Management of CF?
Comprehensive multidisciplinary therapy improved control of symptoms and increases chance of survival. Therapies include clearance of airway secretions, reversal of bronchoconstriction, treatment of respiratory infections, replacement of pancreatic enzymes, and nutritional and psychosocial support.
What are differentiating features of PNA and bronchitis?
PNA are more likely to have a high fever, more dyspnea, chills, chest pain, and hypoxia.
What is pneumonia?
Inflammation of the alveoli or interstitium of the lung caused by microorganisms. It's the primary cause of mortality from infectious disease
What is community acquired pneumonia (CAP)?
PNA acquired from the home or a non-hospital environment
What are common bacteria that cause CAP?
Strep pneumo <----MC
H. influenzae
Moraxella catarrhalis
Staph aureus
Klebsiella pneumo
What viruses cause CAP?
Influenza
RSV
Adenovirus
Parainfluenza
What pathogen is most likely to cause PNA in Children<1 year? Children >1 but <2?
Children<1 year - RSV
Children >1 but <2 - Parainfluenza
What are clinical features of CAP?
1-10 day hx of increasing cough, purulent sputum, SOB, tachycardia, pleuritic chest pain, fever or hypothermia, sweats, and rigors
What are PE findings with CAP?
Altered breath sounds
Dullness to percussion
What is the most common cause of PNA in all types?
Strep pneumo
Diagnostic studes for CAP?
Sputum gram stain or culture
CXR <---- study of choice
Procalcitonin
Tx for PNA in neonates?
Ampicillin+Gentamicin for 10-21 days
Tx for PNA in children from 2 months to 5 yo?
80-90mg/kg/day for 7-10 days of Amoxicillin
Tx for PNA in 3 week old-4 month old?
Erythromycin for 10 days
Alternate: Azithromycin
Prevention of PNA?
Prevnar (PCV-13) - given in 4 doses between 2 months-18 months
Pneumovax (PPSV-23) - indicated for children >2 with chronic lung disease, sickle cell, etc or if they have not previously gotten the Prevnar
Booster shots are needed every 6 years
What population is most affected by swallowing foreign bodies?
Children from 18 to 48 months of age account for around 80% of all cases of ingested foreign bodies
What are clinical features of a swallowed FB in children?
In children, the history can be unclear. Signs and symptoms can include refusal or inability to eat, vomiting, gagging and choking, stridor, neck or throat pain, and drooling. A high degree of suspicion is necessary for unwitnessed ingestions in children, especially in those <2 years of age
What warrants an endoscopy with a swallowed FB?
Sharp objects
Multiple FBs
Button batteries
Perforation
Coin at the level of the cricopharyngeus muscle in a child
Airway compromise
Presence of a foreign body for >24 h
What diagnostic studies are helpful for swallowed foreign bodies?
Expiratory radiography
Bronchoscopy
How do you manage a swallowed FB?
Watch and wait if possible
Heimlich maneuver
Surgery
What is the most common cause of respiratory distress in a preemie infant?
Hyaline membrane disease
What is Hyaline membrane disease?
Deficiency of surfactant
What are clinical features of Hyaline membrane disease?
Respiratory distress in an infant
Diagnostic studies for hyaline membrane disease
CXR - will show air bronchograms, diffuse bilateral atelectasis with ground glass appearance, doming of the diaphragm
Tx for hyaline membrane disease
Synchronized intermittent mandatory ventilation should be used
Administration of exogenous surfactant in the delivery room as prophylaxis or rescue in established hyaline membrane disease