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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.

asthma
Asthma
  • Chronic disease of the tracheobronchial tree characterized by airway obstruction, inflammation, hyperresponsiveness, mucous plugging and edema.
  • Recurrent wheezing which responds to bronchodilators.
epidemiology
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
Pathophysiology
  • Three classifications:
    • extrinsic IgE mediated
    • intrinsic infection induced
    • mixed (both IgE and infection)
pathophysiology5
Pathophysiology
  • Less than 2 years old
    • viral triggers
  • Over 2
    • allergens and irritants are triggers
pathophysiology6
Pathophysiology
  • Bronchoconstriction
    • due to histamine and leukotriene release
  • Airway mucosal edema/plugging
pathophysiology7
Pathophysiology
  • Obstruction
  • Air trapping
  • Hyperventilation, lowers PaCO2
  • Respiratory failure raises PaCO2
pediatric anatomy
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 anatomy9
Pediatric Anatomy
  • Less elastic recoil
    • more prone to atelectasis
    • increases V/Q mismatch
  • Thicker airway wall
    • greater bronchoconstriction
pediatric anatomy10
Pediatric Anatomy
  • Obstruction more likely
  • Collapse of lung segments
  • Compensatory mechanisms may mask the extent of dyspnea
evaluation
Evaluation
  • Before H&P!!!!
  • ABC’s!
  • Shock (respiratory)
  • Oxygen
  • β2 agonist
evaluation12
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
evaluation13
Evaluation
  • ABG
    • Impending respiratory failure
    • Hypoventilating
    • PEFR < 30% of predicted
    • Not responding to treatment
    • Disposition (PICU vs RNF)
    • Pulse Oximetry
    • Expired CO2
clinical evaluation
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

Chest X-ray
differential
pneumonia

FB

Cystic Fibrosis

BPD

CHF (Congenital Heart Disease)

Croup

Epiglottitis

Retropharyngeal abscess

Bacterial tracheitis

GERD

Differential
treatment
Treatment
  • β2 receptor agonists--albuterol
    • activates adenylate cyclase
    • increases cyclic adenosine monophosphate
    • bronchial smooth muscle relaxation
    • binding intracellular calcium to endoplasmic reticulum
treatment18
Treatment
  • Xopenex - R isomer of albuterol
  • Salmeterol is a long acting β2 agonist
    • NOT indicated in acute setting
    • reduces need for Albuterol
treatment19
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?
treatment20
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
treatment21
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
bronchiolitis23
Bronchiolitis
  • Inflammation of bronchioles
  • Usually refers to children under 2 who have a viral URI with some intrathoracic symptoms (wheeze, cough, tightness)
epidemiology24
Epidemiology
  • Prevalence late October to May
  • RSV 50-70%
  • Influenza
  • Parainfluenza
slide25
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
Physical findings
  • tachypnea, tachycardia, conjunctivitis, retractions, prolonged expiration (I:E), wheezing, hypoxemia
evaluation27
Evaluation
  • similar to asthma
  • swab nose for RSV, Influenza
  • CXR
treatment28
Treatment
  • Suction airway
  • O2
  • β2 agonist
  • Albuterol
  • Racemic Epi
  • Epinephrine
treatment29
Treatment
  • Atrovent?
  • Atropine?
    • dries secretions
  • Steroids?
    • for family Hx of asthma
treatment30
Treatment
  • Ribavirin? (Guidance of PICU)
  • Pulmonary Disease
  • Cystic Fibrosis
  • RDS
  • Congenital Heart Disease
bronchiolitis31
Bronchiolitis
  • 70% of children who wheeze in the ED are smoking (passively or actively)
pneumonia33
Pneumonia
  • Goals
    • Identify causes of Pneumonia in children
    • Describe Respiratory Distress in Pneumonia
    • Review Treatment for Pneumonia
    • Pediatric Emergency Medicine
pneumonia34
Pneumonia
  • Infection within the lung
  • Viral
  • Bacterial
  • Fungal
epidemiology35
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/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
pathophysiology37
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
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 agent39
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
Special Concerns
  • Staph aureus
    • rapid progression, abscesses
  • Grp A Strep
    • invasive, necrotizing fasciitis, empyema
  • Gram neg bacilli
    • recently hospitalized patients
special concerns41
Special Concerns
  • B. pertussis
    • paroxysmal cough
  • C. trachomatis
    • maternal exposure, conjunctivitis
  • M. pneumoniae
    • rash (Erythema Multiforme)
special concerns42
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

Symptoms
findings
Findings
  • respiratory distress
    • tachypnea, grunting, flaring, retracting
  • abnormal auscultatory findings???
  • cyanosis
  • chest X-ray - infiltrates
cxr findings
CXR Findings
  • Viral
    • diffuse interstitial infiltrates
  • Bacterial
    • consolidated, lobar
  • Mycoplasma
    • diffuse
slide46
Lab
  • CBC
    • elevated WBC, left shift
  • Blood Culture
  • Cold Agglutins
  • Sputum Culture
  • ABG
  • May help with placement
  • RSV
  • Influenza
appearance
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

Signs of Respiratory Distress
evaluation 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
treatment50
Treatment
  • Position/Support/Maintain Airway
  • Wipe Nose!
  • Remove Foreign Bodies
  • Oxygen
  • Cool Mist (H2O or NS?)
antibiotics
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
antibiotics52
Antibiotics?
  • Viral
    • support
    • acyclovir?
    • ribavirin?
treatment53
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
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
Disposition - Admit
  • Hypoxia
  • < 3 months old
  • Shock
  • Dyspnea
  • Activity Level
  • Extensive ED Treatment
complications
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
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
cases58
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
cases59
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
cases60
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
cases61
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
cases62
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
cases63
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
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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