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Asthma, Bronchiolitis, and Pnemonia Tintinalli Chapt 123-124. April 18th 2005 Mark Rodkey, M.D., FAAP Scott Gunderon, D.O. PowerPoint PPT Presentation


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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.

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Asthma, Bronchiolitis, and Pnemonia Tintinalli Chapt 123-124. April 18th 2005 Mark Rodkey, M.D., FAAP Scott Gunderon, D.O.

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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


first wheeze

poor response to treatment

fever

chest pain

considering FB, pneumo

hyperinflation

flattened diaphragm

barrel-chest

PBT

atelectasis

Chest X-ray


pneumonia

FB

Cystic Fibrosis

BPD

CHF (Congenital Heart Disease)

Croup

Epiglottitis

Retropharyngeal abscess

Bacterial tracheitis

GERD

Differential


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)

    • 1-2 mg/kg/day PO or IV

  • Anticholinergics (Atrovent)

    • 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


Asthma/RAD/Bronchiolitis

Immunocompromise

Previous Insult to Lungs

Abnormal Anatomy (Immotile Cilia)

Cystic Fibrosis, Sickle Cell . . .

Prematurity

Malnutrition

Low Socioeconomic Status

Cigarette Smoke

Day Care

Foreign Body

RiskFactors


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

    • rapid progression, abscesses

  • Grp A Strep

    • invasive, necrotizing fasciitis, empyema

  • Gram neg bacilli

    • recently hospitalized patients


Special Concerns

  • B. pertussis

    • paroxysmal cough

  • C. trachomatis

    • 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%


cough

fever

chest pain

fatigue

gasping

tachypnea

apnea

abdominal pain

nausea

Symptoms


Findings

  • respiratory distress

    • tachypnea, grunting, flaring, retracting

  • abnormal auscultatory findings???

  • cyanosis

  • chest X-ray - infiltrates


CXR Findings

  • Viral

    • diffuse interstitial infiltrates

  • Bacterial

    • 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!


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

Signs of Respiratory Distress


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!


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