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CLIPP 12: 10-month old with a cough
Terms in this set (63)
Etiology of Wheezing in Infants
Viral respiratory infex --> airway inflammation vs. Asthma (bronchodilators/seroids not useful in former.but may help if have very strong family hx of asthma)
Asthma pathophys (3)
1. Airway inflammation
2. Mucus hypersecretion, and
3. Reversible airflow obstruction due to bronchoconstriction.
(4. Maybe remodeling aka smooth muscle hyperplasia/hypertrophy in longstanding asthma)
- recurrent coughing and/or wheezing
- responsive to
) and to
- upper respiratory tract infections
- cold air,
- smoke exposure.
Dx of asthma
of asthma that
responds to therapy for asthma
no other identifiable cause
for wheezing has asthma by definition, regardless of age.
Asthma vs RAD
A significant proportion of children with wheezing that presents early in life
do not continue to wheeze beyond 2 to 3 years
of age, so some physicinas label them with RAD instead, but this is controversial
Signs of Respiratory Distress: Paradoxical breathing.
What is this a sign of?
Why does it happen?
More common in kids or older people, and why?
Paradoxical breathing = sign of very severe respiratory distress due to respiratory muscle fatigue.
- force of contraction generated by the diaphragm EXCEEDS ability of the chest wall muscles to expand the rib cage --> chest is drawn INWARD with inspiration, , ABDOMEN RISES due to downward displacement of abdominal contents.
Paradoxical breathing is seen more commonly in infants and young children than in older individuals due to the GREATER COMPLIANCE of the chest wall.
Signs of resp distress: Tachypnea
- What is hyperpnea? What 3 things can it be an indicator for?
- What is hypopnea? What can it result in?
Varies depending on the severity of the underlying process.
Hyperpnea (increased depth of respiration) without respiratory distress may suggest non- pulmonary condition
- extreme anxiety (hyperventilation syndrome).
Hypopnea (reduced tidal volume) increases the proportion of each breath used to ventilate dead space, so may result in hypoventilation even in the setting of a normal or elevated respiratory rate.
Signs of resp distress: Nasal flaring
- What does it indicate?
Nasal flaring (enlargement of both nares during inspiration) is seen in small children with significant respiratory distress and indicates that
accessory muscles are being used for respiration
Signs of resp distress: Head bobbing
- What is this an indication of?
- Why does this happen?
- When best observed?
- also due to use of the accessory muscles of respiration (in this instance, the neck strap muscles).
- with inspiration, the head bobs
owing to neck flexion caused by use of the neck strap muscles.
- best observed during sleep.
Signs of resp distress: Grunting
- What is this and how does it happen?
Grunting = forced expiration against a partially closed glottis
- thought to help infants generate the positive pressure necessary to stent airways open.
Reduced signs of respiratory distress: Is this always an indication that things are better? What can you do to tell?
respiratory muscle fatigue
will reduce the signs of respiratory distress even though a patient's condition is in fact deteriorating.
In this situation, a
blood gas may reveal elevation of PCO2
indicative of hypoventilation.
Bordatella pertussis: What are the 3 stages?
- How long is each stage?
- What are the symptoms of each stage?
- Do infants with whooping cough whoop?
Pertussis has a triphasic course:
1. catarrhal stage:
- 1-2 weeks
- upper respiratory tract infection symptoms.
2. paroxysmal stage
- 4-6 weeks
- repetitive, forceful coughing episodes followed by massive inspiratory effort, which results in the characteristic "whoop."
3. Convalescent stage:
- paroxysms of cough gradually decrease in frequency and severity as the convalescent stage is entered --> Episodic cough may persist for months.
Infants generally do not develop a "whoop" due to relative weakness of their inspiratory effort.
Bordatella pertussis complications:
- Do infants or older ppl get more complications?
- 2 complications infants can have.
Infants with pertussis tend to have more complications than older children with pertussis.
- difficulty feeding because of their cough,
- central nervous system complications such as apnea.
Bordatella pertussis immunization:
- Acellular pertussis vaccine recommended for whom?
- With full immunization, how effective is the immunization?
- What is another problem with the vaccine and what are the recommendations for fixing this?
- acellular pertussis vaccine is recommended for all children.
- However, even with full immunization, vaccine efficacy is only
protection from the vaccine wanes with time
such that many adolescents are unprotected from pertussis unless
as is currently recommended.
- Must be considered in any child with _________ and _________.
- In the rare cases of epiglottis that still happen in immunized populations, what 2 bugs is epiglottis due to? (2)
Epiglottitis is uncommon thanks to widespread immunization against HiB, but is important to consider in any child with stridor and respiratory distress.
- life-threatening emergency that has historically almost always been due to infection with Haemophilus influenzae type b (Hib)
- rare cases of epiglottitis still occur and, in immunized populations, are more commonly due to
staphylococcal or streptococcal
organisms than Hib.
Epiglottits most often in children what age?
between the ages of 2 and 5 years.
Epiglottitis signs and symptoms (6)
Most patients will appear toxic and may position their airway in a sniffing position (sitting, leaning forward, with neck hyperextended and chin protruding).
Epiglottitis emergent intervention:
- Where do you have to put the child and with whom?
- In the meantime do you disturb the child or try to look at stuff in their throat?
- acute airway obstruction may be imminent --> put pt in the OR with individuals skilled in airway management, usually an anesthesiologist and either a general surgeon or otolaryngologist.
- While awaiting these individuals, the child should not be disturbed or examined due to the risk of acute deterioration.
- Is an airway film indicated when you suspect epiglottitis?
- If you DO do an airway film, what two things will you see?
- Airway films are usually not indicated and may put the patient at risk.
- If done, the films may show
thickening of the epiglottis (the "thumb sign")
thickening of the aryepiglottic folds
- Consider in a child with ______ and _____, esp if they also have _______ or _______.
- Diagnosis is made by what on the pharynx?
- When should you be especially suspicioussssss?
- immunization has resulted in diphtheria being an uncommon disease in the U.S.
- Consider in a child with pharyngitis and a low-grade fever, particularly if stridor or hoarseness is present.
- diagnosis is made when the characteristic gray pseudomembrane is seen in the pharynx.
- suspicion should be raised if the child is not immunized.
What other 2 things can cause pharyngitis with dysphagia and stridor?
Retropharyngeal or parapharyngeal abscess
Extrinsic causes of wheezing can be caused by what 3 things?
Can be caused by anything causing extrinsic compression of an airway, including:
- a vascular ring or sling
- a mass or other lesion
- Due to airway narrowing _________ the thoracic inlet.
- Usually heard w inspiration or expiration? What about when obstruction is severe?
- Due to airway narrowing ABOVE the thoracic inlet.
- Usually heard with inspiration, but can be biphasic if obstruction is severe.
- Due to airway narrowing ________ the thoracic inlet.
- Usually heard w inspiration or expiration? What about when obstruction is severe? What about if obstruction is SUPER SEVERE??
Typically due to airway narrowing BELOW the thoracic inlet.
- With mild airway obstruction, wheezing is usually heard only in expiration. With increasing obstruction, wheezing may become biphasic and may even disappear altogether when obstruction is severe.
- Although typically diffuse, focal wheeze may be heard in some settings such as mucus plugging.
Wheezing can also be characterized as polyphonic or monophonic: Polyphonic wheeze is characterized by multiple pitches and is typical of asthma; monophonic wheeze is characterized by only a single pitch and is typical of focal airway obstruction.
Coarse, low-pitched rattling sounds heard best in expiration. Thought to be due to secretions and narrowing of airways.
Finer breath sounds heard on inspiration.
Associated with either fluid in the alveoli or with opening and closing of stiff alveoli (as in interstitial disease).
Sometimes described as either coarse or fine. (Coarse crackles are usually thought to be associated with purulent secretions in the alveoli as with pneumonia; fine crackles are often associated with pulmonary edema or interstitial lung disease.
The amount of air entry should be noted during every lung exam.
Decreased air entry can be a sign of consolidation, atelectasis, pneumothorax, pleural effusion or airway obstruction.
Bronchial breath sounds
Lower in pitch and more hollow-sounding than normal breath sounds. Caused by air moving through areas of consolidated lung.
Pneumonia is due to inflammation of the lung parenchyma. It is generally caused by microorganisms, but non-infectious causes include aspiration of gastric contents or hydrocarbons.
The most common cause of pneumonia in children is a respiratory virus, including:
Adenovirus RSV Parainfluenza Influenza
Bacterial infections are less common causes of pneumonia than viruses but tend to be more severe:
In the neonatal period, bacteria transmitted from the maternal genital tract must be considered, including Group B streptococcus, E.Coli, and Klebsiella.
Pneumonia due to Chlamydia pneumoniae usually presents with a staccato cough between 4 and 12 weeks of age.
Streptococcus pneumoniae is the most common bacterial cause of pneumonia in the U.S. among infants beyond the neonatal period and children up to 5 or 6 years of age.
In school-aged and older children, Mycoplasma pneumoniae is the predominant cause, followed by S. pneumoniae.
Signs and symptoms
The symptoms of viral pneumonia begin with a prodrome of upper respiratory tract infection symptoms including cough and rhinorrhea. The cough frequently progresses, and is accompanied by fever, tachypnea, and crackles on chest exam.
Bacterial pneumonia may present abruptly or be preceded by a viral prodrome. Presentation varies, depending on the age of the patient and the etiology, but typically fever, cough, and signs of respiratory distress (dyspnea, tachypnea, retractions, etc.) are present. On chest examination, crackles or decreased breath sounds may be noted.
Radiographic findings: Viral vs. bacterial pneumonia
Findings of viral pneumonia on chest x-ray are variable and may show diffuse or patchy interstitial infiltrates, hyperinflation and small pleural effusions.
Chest x-rays in bacterial pneumonia typically show airspace disease with lobar or segmental consolidation and air bronchograms.
Lab findings: Viral vs. bacterial pneumonia
In viral pneumonia, peripheral white blood cell counts tend to be normal or only slightly elevated.
Viral antigen testing of respiratory secretions may be helpful in making the diagnosis but is usually not necessary.
In bacterial pneumonia, peripheral white blood cell counts are usually elevated and have a neutrophilic predominance.
Treatment of pneumonia
Treatment of viral pneumonia
Treatment of viral pneumonia is supportive, and the majority of children recover without sequelae.
Treatment of bacterial pneumonia
Treatment of bacterial pneumonia includes appropriate antibiotics and supportive care. Prognosis for treated patients is usually excellent in previously healthy children, but varies depending on the bacterial etiology.
Acute bronchiolitis is a viral disease of the lower respiratory tract of infants and represents the most common cause of wheezing in infants.
It is characterized by bronchiolar obstruction due to edema, mucus, and cellular debris. Respiratory syncytial virus (RSV) is the most common cause, but other viruses such as influenza and parainfluenza may cause bronchiolitis as well.
There is a wide spectrum of disease. Most children initially have mild upper respiratory tract symptoms and often a fever of 38.5-39 C. Respiratory symptoms can progress to cough, wheezing, dyspnea and irritability.
Bronchiolitis radiographic findings
Chest radiographs may show hyperinflation, increased interstitial markings, peribronchial cuffing, and scattered atelectasis from bronchial obstruction.
Treatment of bronchiolitis is supportive, aimed at maintaining adequate oxygenation and hydration.
The use of additional therapies such as corticosteroids, bronchodilators, and hypertonic saline has been controversial, with some physicians adhering to the principle that they are ineffective and other believing that they can be helpful under certain circumstances (such as a strong family history of asthma).
Antibiotics may be indicated if there is evidence of secondary bacterial pneumonia.
Asthma is a disease of inflammation of the airways that results in airway obstruction.
Asthma is characterized by infiltration of inflammatory cells into the airway mucosa, mucus hypersecretion, and mucosal edema, accompanied by bronchoconstriction.
Clinically, patients may present with an acute exacerbation or with more chronic symptoms.
Acute presentations include cough, wheezing, tachypnea and dyspnea, with wheezing and diminished air exchange on chest exam. Although wheezing due to asthma is typically diffuse, focal wheeze may be heard in some settings such as mucus plugging. Signs of a
more severe exacerbation may include minimal air exchange and absence of wheezing due to poor airflow, cyanosis and pulsus paradoxus.
Chronic symptoms include recurrent episodes of dyspnea and/or cough.
Asthma radiographic findings
Chest x-ray findings in asthma include hyperinflation due to air trapping, increased interstitial markings and patchy atelectasis.
The primary goals of asthma therapy are to:
Reduce airway inflammation and Dilate the airways
Asthma acute exacerbation treatment
The mainstays of treatment for an acute episode are anti-inflammatory therapy with corticosteroids and bronchodilation with beta-2 agonists such as albuterol, together with supportive care for hypoxemia or dehydration.
Asthma mainenance therapy treatmetn
Choice of therapy for chronic asthma is based on the frequency, severity and type of symptoms, as well as by other comorbidities.
A common approach is to use an inhaled corticosteroid as a daily, controller medication, with an inhaled beta-agonist such as albuterol as needed for breakthrough symptoms.
Alternative and additional medications (such as montelukast) are also used under appropriate circumstances.
Prognosis is generally good but is highly dependent on ongoing medical management and patient adherence to therapy.
Asthma sequelae of foreign body aspiration
The most commonly aspirated foods include hot dogs, hard candy, nuts, grapes, and popcorn.
The composition of the foreign body determines the local tissue reaction. The fatty oils in aspirated food (such as peanuts) create a more severe pneumonitis than a similarly sized object made of plastic or metal, while a disc battery (such as a watch battery) may erode through the bronchial wall.
Foreign bodies that lodge in the upper airway (trachea and bronchi) can be immediately life-
threatening and are responsible for over 500 childhood deaths a year in the U.S. More than half of these deaths are in children under the age of 2 years.
Cough history: Fluid intake
This is an important question. Not only does it give you a sense of the child's hydration status, but it also provides information about her degree of breathing difficulty. Due to the need to coordinate breathing with sucking and swallowing, infants with respiratory distress or tachypnea often demonstrate some degree of distress with feeding, and they may require frequent pauses to catch their breath.
Another reason this is a useful question is that it helps assess for dysphagia. Infants and children with difficulty swallowing may have a pharyngeal or esophageal foreign body, or they may have an infection in the epiglottis, pharynx, tonsils or peritonsillar region. Finally, the presence of choking, coughing or gagging during feeds is suggestive of aspiration, as can occur with a laryngeal cleft or tracheoesophageal fistula.
Of note, many parents become alarmed when their children do not eat well during illnesses, but this is a common and generic response to illness and malaise. With some exceptions (e.g., diabetes), it is less important that a child is eating solid food over a brief period of time than it is that a child is drinking fluids. That said, it can be helpful to distinguish difficulty with solid foods from that with liquids because the clinical implications are different. Coughing with liquids is suggestive of aspiration, whereas dysphagia with solids is suggestive of narrowing the posterior oropharynx or esophagus.
Cough history: Fever
A history of a fever would make an infectious process more likely but would not rule out other processes.
Recurrence of fever several days into a respiratory illness can be seen with the development of superimposed bacterial pneumonia.
Cough history: Acute vs chornic
In any infant or child with a cough or wheezing, especially the first episode, it is important to find out if aspiration of a foreign body (e.g., toy parts, nuts, popcorn) is likely.
Even if there is no specific history of choking, foreign body aspiration always remains in the differential, particularly in infants and toddlers who tend to put everything in their mouths. In fact, most cases of foreign body aspiration in this age group are unwitnessed.
Cough history: Hoarse voice
Particularly important in toddlers and older children, as it helps sort out whether the reason for her cough and wheezing is due to a problem in the upper airway (especially the pharynx and larynx) or her lower airway. Problems of the larynx and pharynx such as pharyngitis, tonsillitis, epiglottitis and other infections often present with a hoarse or muffled voice or cry.
Problems isolated to the lower airway typically do not affect the quality of the voice or cry.
Cough history: barky cough + noises when breathing
A barky or seal-like cough would suggest a diagnosis of croup in a child this age.
Croup, or laryngotracheobronchitis, occurs throughout the year but is most common in winter months. It is most common in children 2-5 years of age.
It is usually due to a viral infection (most commonly Parainfluenza virus type 1) that begins with non-specific URI symptoms and progresses to some degree of airway obstruction. Children typically have a barky cough and may also develop inspiratory stridor.
With mild croup, inspiratory stridor may be heard only during agitation. As the severity of obstruction increases, inspiratory stridor may be present even at rest and may progress to include expiratory stridor as well in severe cases.
Parents or caregivers often use the term "wheeze" to refer to many different respiratory sounds. It is therefore important to determine the timing in the respiratory cycle both by history and by physical examination in order to distinguish between wheezing and stridor; wheezing is more likely to be expiratory whereas stridor is typically inspiratory, but both can be heard throughout the respiratory cycle in more severe cases.
Other symptoms: Ear infections, pneumonia, spitting up, chronic diarrhea, trouble gaining weight
It is important to gather information about other significant medical or developmental problems.
Birth history is very important because a child born prematurely may have underlying respiratory conditions such as bronchopulmonary dysplasia that contribute to cough and wheezing.
Asking about recurrent infections, stool pattern and difficulty gaining weight helps assess whether immunodeficiency or malabsorptive conditions such as cystic fibrosis may be present.
Asking about reflux symptoms is important in any child with a cough, although reflux usually contributes to a chronic rather than an acute cough.
Cough history: Immunizations
It is always important to know the immunization status of a child with a cough, because unimmunized or partially immunized children have a significantly higher risk of acquiring pertussis.
Differential diagnosis in 10 month old for cough + wheezing (3)
asthma, bronchiolitis, foreign body aspiration
Ddx in 10 month old for ACUTE cough
Allergic rhinitis, asthma, bronchiolitis, croup, foreign body aspiration, community-acquired pneumonia (CAP), pertussis, sinusitis, viral URI
Ddx in 10mo old for CHRONIC cough
CF, anatomic abnormality, GERD
Ddx in 10mo old for cough + fever
Bronchiolitis, Croup, CAP, Pertussis, sinusitis, Viral URI
Ddx in 10mo old for cough + rhinorrhea
Allergic rhinitis, pertussis (catarrhal stage), Sinusitis, Viral URI
Eval for foreigin body aspiration: CXR
PA and lateral chest films are a good choice as part of your initial workup, because you know she has asymmetric breath sounds and you want to see whether there are radiographic findings to account for the asymmetry.
Bilateral decubitus or inspiratory/expiratory chest films are used to evaluate whether obstruction of the larger airways, such as that due to a foreign body, is present.
Decubitus chest films are performed with the child lying on her side. The concept of the lateral decubitus film is that the dependent lung should deflate slightly compared to the non- dependent lung due to the effect of gravity. If each lung deflates slightly when dependent as expected, there is less likelihood of an obstruction in a large airway. If one side does not deflate as expected, this suggests an obstruction in a large airway.
The rationale for inspiratory/expiratory films is similar to that for decubitus films. The airway containing an obstruction does not allow the distal lung to deflate fully and results in asymmetric deflation with expiration. The advantage of decubitus films over inspiratory/expiratory films is that decubitus films do not require the patient to be able to hold a breath in inspiration or expiration. The disadvantage is that the abnormal finding, if present, is more subtle than on inspiratory/expiratory films.
These are the findings you would expect with an aspiration obstructing the right airway:
PA film (with the child in a sitting position): Right hemidiaphragm is flattened, suggesting unilateral hyperexpansion on the right.
Right decubitus: With child on her right side, the mediastinal structures remain in the midline, rather than shifting towards the right lung due to gravity, further demonstrating the fixed hyperinflation of the right lung.
Left decubitus: With child on her left side, the mediastinal structures shift towards the left lung as expected.
Hyperinflation is seen in those foreign body aspirations that result in a "ball valve" effect, in which the aspirated object creates a partial obstruction to airflow during inspiration but fully obstructs the airway during exhalation. The result is air trapping with each breath.
Alternatively, when an aspirated object causes a complete airway obstruction, the result is a total lack of airflow to the bronchus, which can lead to atelectasis and signs of volume loss on x-ray (e.g., mediastinal shift towards the affected side or elevation of the hemidiaphragm on the affected side).
Chest fluoroscopy (E) is an excellent radiographic test to evaluate for airway foreign body in an infant or toddler because it does not require the child to hold her breath. Also, it is a dynamic evaluation that allows visualization of the airways over several breaths rather than a single breath, as is the case with decubitus or inspiratory/expiratory films. However, it is performed with continuous and real-time imaging of the chest by the radiologist and is therefore generally available only during hours that a radiologist is immediately available. An additional drawback to fluoroscopy is the additional radiation typically administered during the test compared with plain films.
Soft tissue neck film
Soft-tissue neck films (A) are not the best choice at this time. Anna has no stridor to suggest croup or another supra- or subglottic abnormality.
Bronchoscopy (F) is typically not performed as the initial diagnostic test for foreign body given that it requires that a physician trained in the procedure is on-site with the necessary equipment. In most cases, some type of airway imaging (x-rays or fluoroscopy) is usually obtained first unless the history and exam are extremely suggestive of an aspirated foreign body.
Other causes of large airway obstruction
Other causes of large airway obstruction include airway tumors and extrinsic compression as may
Caretaker Resources on Toddler Safety
AAP clinical report: Office-Based Counseling for Unintentional Injury Prevention (http://pediatrics.aappublications.org/content/119/1/202.full.pdf) (2007)
Guide to Safety Counseling in Office Practice (http://www.aacpp.com/pdf/parents/English/Safety_for_everyone/TIPP-Guide.pdf) compiled by The Injury Prevention Program (TIPP)
The AAP's website HealthyChildren.org (http://www.healthychildren.org) also has information for parents and caretakers about child safety.
occur with lymphadenopathy. (These causes are more common in adults than children, however, and are rare causes of airway obstruction in infants. One exception is in children from areas in which tuberculosis is endemic, as TB may manifest as airway obstruction.)
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