Lower Respiratory Disorders

1. Lower Respiratory Disorders Debbie King NP June 2010

2. Croup • An acute upper airway obstruction typically caused by a virtual infection of the larynx • Etiology/Patho • Parainfluenza • Other causes • RSV, Influenza, rubeola, adenovirus, mycoplasma • Inflammation of the entire airway is usually present, edema formation in the subglottic space is responsible for the predominant signs of upper airway obstruction • Most common in children 3 months to 6 years of age • Males more often affected than females • Peaks during late fall and winter • With temperature changes

3. Croup • Signs and Symptoms • Low grade fever • Rapid onset of “barky” cough • Symptoms worse at night • Improvement with cool night air

4. Croup • Differential Diagnosis • Bacterial infections of upper respiratory tract • Laryngotracheomalacia • Foreign body aspiration • Acute laryngeal edema • Severe asthma

5. Croup • Physical Findings • Inspiratory stridor • Brassy, barky cough • Dyspnea • Chest sounds are usually clear

6. Croup • Diagnostic Tests/Findings • White blood cell count- normal or elevated • Pulse oximetry • Radiographic image of airway (steeple sign) • Viral cultures of nasopharyngeal secretions

7. Croup • Management/Treatment • Mild disease • Outpatient care • Family education • Steam to cool • Stridor • Moderate to severe • Hospitalize for supportive care • 1 to 5% requite intubation • Medication • Dexamethasone 1mg/ml 0.6mg/kg x 1dose • Nebulized racemic epinephrine • Corticosteroid Orapred 15/5 2mg/kg/bid x 2day

8. Laryngomalacia • A benign congenital disorder • Cartilaginous support for the supraglottic structures is underdeveloped • Most common cause of persistent stridor in infants in first 6 weeks of life • Stridor is worse in supine position and with increased activity such as feedings • Is also worse with URIs

9. Laryngomalacia • Associated with slight Ox desaturation during sleep • May be associated with GERD • Improves with age • Resolved by age 2 • DX confirmed by direct laryngoscopy • With inspiratory- collapse of epiglottis • No treatment is needed • Except is rare severe cases, surgery may be warranted

10. Tracheomalacia • Definition • Cartilaginous framework of the airway is inadequate to maintain airway patency • Cartilage of infants is soft, so all have some degree of collapse • May be an isolated condition • Maybe associated with • Tracheoesophageal fistula or vascular ring • May involve part or all of trachea

11. Tracheomalacia • Signs and symptoms • Coarse wheezing • Prolonged expiratory phase • Croupy cough • Increased symptoms with agitation, excertion or infection • Workup • To be done by an ENT • Bronchoscopy • Barium swallow • Treatment based on severity

12. Foreign Body Aspiration • Inhalation of foreign body that lodges in upper trachea or lower airways • Etiology/Incidence • Food or object • 80% are <3 years of age • 2/3 of cases are males

13. Foreign Body Aspiration • Signs and Symptoms • Sudden violent cough with gagging • History of witnessed choking • May be asymptomatic if object is not obstructing airway • Differential Diagnosis • Acute phase • Chronic phase

14. Foreign Body Aspiration • Physical Findings • Rarely still coughing • Unilateral wheezing and decreased breath sounds on side of aspiration • Voice changes • If foreign body persists, bronchiectasis and abscess formation is likely

15. Foreign Body Aspiration • Diagnostic Tests/Findings • Pulse oximetry • Chest radiograph • Expiratory chest, decubitus, or fluoroscopy • Management/ Treatment • Institute cardiopulmonary resuscitation if needed

16. Foreign Body Aspiration • Immediate transport to hospital for evaluation and removal • Refer to endoscopy team • May need antibiotics • Chest radiograph in 6 to 8 weeks

17. Epiglottitis • Medical emergency • Caused by H. Flu • Rarely by strep pneumonia, Strep pyogenes, Neisseria meningitides, staphylococci • Inflammation and swelling of the supraglottic structures • Can develop rapidly • Can lead to life-threatening upper airway obstruction • Rarely seen since intro of H. flu vaccine

18. Epiglottitis • Signs and symptoms • Sudden onset of fever • Dysphagia • Drooling • Muffled voice • Inspiratory retractions • Cyanosis • Soft stridor • Sit in sniffing dog position (tripod)

19. Epiglottitis • Test • X-ray shows a classic thumbprint sign • But obtaining x-ray slows treatment • Best to observe epiglottitis in surgery • Cultures of blood and epiglottis • Treatments • Endotracheal intubation • O2 • IV antibiotics for 2-3 days • Prognosis • Rapid resolutions with correct diagnosis and treatment • Recurrence is not common

20. Bronchitis • Acute- transient inflammation of larger lower airways • Chronic- symptoms persist for more than 2 weeks progresses from dry to productive • Etiology/Incidence • Most commonly viral • Bacterial causes • Most common in winter and early spring

21. Bronchitis • Signs and Symptoms • Initial phase includes symptoms of upper respiratory illness • Cough dry at first • May have pain with cough

22. Bronchitis • Differential Diagnosis • Asthma • Allergic disease • Pneumonia • Gastroesophageal reflux • Inhalation or irritants • Cystic fibrosis • Immune deficiency • Chronic sinusitis • Immotile cilia syndrome • Foreign body aspiration • Airway deformity

23. Bronchitis • Bacterial Causes • Corynebacterium diphtheriae • Gram positive • Treatment • Antitoxin • EES and procaine penicillin G • Rifampin or clindamycin if allergic to above • Mycoplasma pneumoniae • Bacteria without a cell wall • Treatment • Observe • Tetracycline or a macrolide

24. Bronchitis Bacterial causes continued • Bordetella pertussis • Gram negative • There is also a parapertussis • Treatment • EES • Mycobacterium tuberculosis • Gram positive • No cell wall-waxy coating • Treatment • Rifampicin or Isoniazid for 6-12 months

25. Bronchitis • Physical Findings • Brassy cough • Coarse breath • Rhonchi on auscultation • May have tracheal tenderness • Diagnostic Tests/Findings • Based on history and physical • Radiograph of chest may be normal • White count is normal/or slightly high with virus • Pulmonary function tests may be normal

26. Bronchitis • Management/Treatment • Avoidance of irritants • Expectorants rarely used • Increase fluid intake • Bronchodilators • Inhaled steroids • Antibiotics for bacterial causes

27. Bronchiolitis • An acute viral infection of the smaller airway • Etiology/Incidence • RSV- Sept-March • Causes common cold symptoms in older children and adults • palivizumab (brand name Synagis) given for at risk babies • Parainfluenza • GERD • Recurrent bronchiolitis • Trial Prevacid • Mid-winter to early spring (usually) • Almost all children have it at least once before age 3

28. Bronchiolitis • Signs and symptoms • Congestion • thick mucus that causes gagging • Makes eating very difficult • Cough • Low-grade fever • Work of breathing • May present as apnea

29. Bronchiolitis • Differential diagnosis • Bacterial or chlamydia pneumonia • Aspiration pneumonia • Asthma • Foreign body aspiration • Retropharyngeal abscess • Salicylate poisoning

30. Bronchiolitis • Physical Findings • Rhinorrhea • Nasal flaring • Retracting • Wheezing • Vital signs • Hypoxia • fever

31. Bronchiolitis • Diagnostic Tests/Findings • Based on history and physical • Chest radiograph • Pulse oximetry • White blood cell count • Usually normal • May have mild lymphocytosis • Viral culture with rapid diagnostic techniques

32. Bronchiolitis • Management/Treatment • Oxygen therapy • Best therapy • Fluid and nutritional support • Nebulized 3% hypertonic saline • May provide symptom relief • Bronchodilators • Limited, if any benefit • Corticosteroids • Rarely used, research indicates steroids are not helpful • Ribavirin (an anti-viral) may be used with caution- inpatient only • Limited value per the research • RSV IGIV for prophylaxis

33. NEW YORK (Reuters Health) - Children who start swimming before the age of 2 may be at increased risk of a common infant lung infection, and possibly asthma and respiratory allergies later in life, a new study suggests. Health January 2010 The findings, reported in the European Respiratory Journal, add to evidence that exposure to chlorinated pools may affect children's respiratory health -- particularly if they have a family history of asthma or respiratory allergies like hay fever. Experts have suspected that the air quality around pools, particularly indoor ones, is to blame. When the chlorine used to disinfect pools combines with swimmers' sweat, saliva or urine, irritating chlorine byproducts are formed, and over time these chemicals may damage the airways. In the new study, Belgian researchers found that infant swimming -- whether in indoor or outdoor pools -- was linked to a heightened risk of bronchiolitis. Bronchiolitis is an infection of the lungs' small airways, usually caused by the respiratory syncytial virus, that is common in infants. In this study, infant swimmers who developed the infection were also at increased risk of developing asthma or respiratory allergies by kindergarten.

34. Pneumonia • Infectious- infection which involves small airways in children • Aspiration- caused by ingestion of food, saliva, or gastric content into air passages

35. Pneumonia • Etiology/ Incidence • Common viral agents- RSV • Newborns- most common bacterial causes group B strep, gram-negative enteric bacilli • Infant and young children < 6 years- streptococcus pneumoniae is primary cause • Older children and adolescents- streptococcus pneumoniae most likely • Aspiration pneumonia occurs in specific settings • 4% preschool children

36. Pneumonia • Signs and Symptoms • Cough • Fever • Chest pain • May have change in level of activity • May have nasal flaring • May be retracting • Signs of generalized toxicity • May have abdominal complaints • Increased respiratory rate • May be one of only two symptoms in a child under 3 years

37. Pneumonia • Differential Diagnosis • Atelectasis • Foreign body aspiration • Gastric aspiration • Asthma • Cystic fibrosis • Tuberculosis • Bronchitis • Pertussis • RSV • Neoplasm

38. Pneumonia • Physical Findings- will have some or all listed below • Ill appearing or Not • Even septic • Vital signs abnormal • Fever, tachypnea, tachycardia. BP changes • Nasal congestion • Wheezing • Crackles on inspiration • Localized dullness to percussion • Decreased breath sounds • Increased capillary refill time • Abdominal pain with palpation

39. Pneumonia • Diagnostic Tests/Findings • Chest radiograph • Atelectasis • Viral usually begins with scattered perihilar and peribronchial infiltrations • Bacterial- patchy infiltrates in infants, hilar adenopathy, pleural effusion • Acute aspiration usually develops in portion of lung that is dependent at time of aspiration

40. Pneumonia • White blood cell count may or may not elevate • Viral cultures of nasopharyngeal secretions • Blood cultures • Sputum cultures • Positive cold agglutinin screen or titer > 1:32 suggestive of Mycoplasma Pneumonia • Pulse oximetry- decreased O2 saturations

41. Pneumonia • Management/Treatment • Antimicrobial treatment based on etiology • Amoxil, Augmentin, Omnicef, Rocephin, Vancomycin-for inpatient • If viral, just supportive care is needed • Bronchodilators and chest physiotherapy may improve airway clearance • Flu vaccine for those with chronic illness • Other supportive therapy may include additional fluids and/or oxygen • Can progress rapidly and should be monitored • Prognosis • Survival rate is high • Mortality rate from uncomplicated pneumococcal pneumonia is less than 1%

42. Pleurisy, Pleural Effusion and Empyema • Pleurisy- inflammation of the pleural lining • Pleural Effusion- accumulation of fluid in pleural space • Empyema- inflammation and purulent exudate

43. Pleurisy, Pleural Effusion and Empyema • Etiology/Incidence • Often caused by disease process else where in the body • Parapneumonic effusions • Signs and Symptoms • Chest pain • High fever • Shortness of breath

44. Pleurisy, Pleural Effusion and Empyema • Differential diagnosis • Tuberculosis • Neoplasm • Connective tissue disorder • Sarcoidosis • Physical Findings • Unilateral decrease in chest expansion during inspiration • Splinting toward the affected side • Dullness to percussion

45. Pleurisy, Pleural Effusion and Empyema • Diagnostic Tests • Chest radiograph • Thoracentesis for evaluation of the pleural liquid • Mantoux test- PPD • CBC • Blood cultures • Pulse oximetry

46. Pleurisy, Pleural Effusion and Empyema • Management/Treatment • May involve treatment of an underlying systemic illness

47. Cystic Fibrosis • Defective epithelial chloride transport results in dehydrated viscous secretion which obstruct the exocrine ducts • This glue-like mucus builds up and causes problems in many of the body's organs, especially the lungs and the pancreas. People who have cystic fibrosis can have serious breathing problems and lung disease. They can also have problems with nutrition, digestion, growth, and development. There is no cure for cystic fibrosis and the disease generally gets worse over time

48. Cystic Fibrosis • Signs and Symptoms • Extremely viscid meconium • Weight loss despite voracious appetite • Recurrent respiratory infections • Liquid, large, foul smelling stools • Frequent flatulence • Recurrent wheezing • Salty-tasting skin • Heat prostration

49. Cystic Fibrosis • Differential Diagnosis • Asthma • Immunologic deficiencies • Antitrypsin deficiency (rare) • Airway abnormalities • Gastroesophageal reflux

50. Cystic Fibrosis • Physical Findings • Respiratory • Chronic cough • May cough up blood • Altered lung exam • Increased work of breathing • Increased anteroposterior diameter of chest • Dyspnea on exertion • Recurrent otitis media • Chronic rhinorrhea • Nasal polyps • Clubbing –rounding and flattening of the fingers