Transcript Slide 1

Asthma, Bronchiolitis, and Pnemonia
Tintinalli Chapt 123-124.
April 18th 2005
Mark Rodkey, M.D., FAAP
Scott Gunderon, D.O.
Asthma
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Chronic disease of the tracheobronchial tree
characterized by airway obstruction,
inflammation, hyperresponsiveness, mucous
plugging and edema.
Recurrent wheezing which responds to
bronchodilators.
Epidemiology
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4.8 million children
40% increase in last decade
Risk factors
Family Hx
 African/American, Asian, Hispanic
 Low birth weight
 Urban household
 Low income
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Pathophysiology
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Three classifications:
extrinsic IgE mediated
 intrinsic infection induced
 mixed (both IgE and infection)
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Pathophysiology
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Less than 2 years old
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viral triggers
Over 2
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allergens and irritants are triggers
Pathophysiology
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Bronchoconstriction
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due to histamine and leukotriene release
Airway mucosal edema/plugging
Pathophysiology
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Obstruction
Air trapping
Hyperventilation, lowers PaCO2
Respiratory failure raises PaCO2
Pediatric Anatomy
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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
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Pediatric Anatomy
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Less elastic recoil
more prone to atelectasis
 increases V/Q mismatch
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Thicker airway wall
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greater bronchoconstriction
Pediatric Anatomy
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Obstruction more likely
Collapse of lung segments
Compensatory mechanisms may mask the extent
of dyspnea
Evaluation
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Before H&P!!!!
ABC’s!
Shock (respiratory)
Oxygen
β2 agonist
Evaluation
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Peak expiratory flow rate (PEFR)
pre and post treatments (age 8)
 values are in liters per minute
 based on child’s height
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< 50% indicates severe obstruction
< 25% indicates possible hypercarbia
Evaluation
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ABG
Impending respiratory failure
 Hypoventilating
 PEFR < 30% of predicted
 Not responding to treatment
 Disposition (PICU vs RNF)
 Pulse Oximetry
 Expired CO2
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Clinical Evaluation!
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Respiratory effort
tachypnea, grunt, flare, retractions
 air hunger
 altered activity
 altered mental status
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Forced breath (blow hand)
recite alphabet in one breath
 response to treatment
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Chest X-ray
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first wheeze
poor response to
treatment
fever
chest pain
considering FB, pneumo
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hyperinflation
flattened diaphragm
barrel-chest
PBT
atelectasis
Differential
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pneumonia
FB
Cystic Fibrosis
BPD
CHF (Congenital Heart
Disease)
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Croup
Epiglottitis
Retropharyngeal abscess
Bacterial tracheitis
GERD
Treatment
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β2 receptor agonists--albuterol
activates adenylate cyclase
 increases cyclic adenosine monophosphate
 bronchial smooth muscle relaxation
 binding intracellular calcium to endoplasmic
reticulum
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Treatment
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Xopenex - R isomer of albuterol
Salmeterol is a long acting β2 agonist
NOT indicated in acute setting
 reduces need for Albuterol
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Treatment
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Epinephrine
0.01mL/kg of 1:1000 up to 0.3 mL (0.5?) SQ
 3cc nebulized
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Racemic epi
0.5 mL nebulized
 helps reduce edema?
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Treatment
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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
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Treatment
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Corticosteroids (Prednisone, Solumedrol)
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Anticholinergics (Atrovent)
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1-2 mg/kg/day PO or IV
prevents bronchoconstriction induced by guanosine
monophosphate
IV fluids
Magnesium sulfate
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not much supporting evidence in Pediatrics
Bronchiolitis
Bronchiolitis
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Inflammation of bronchioles
Usually refers to children under 2 who have a
viral URI with some intrathoracic symptoms
(wheeze, cough, tightness)
Epidemiology
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Prevalence late October to May
RSV 50-70%
Influenza
Parainfluenza
RSV
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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
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tachypnea, tachycardia, conjunctivitis,
retractions, prolonged expiration (I:E),
wheezing, hypoxemia
Evaluation
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similar to asthma
swab nose for RSV, Influenza
CXR
Treatment
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Suction airway
O2
β2 agonist
Albuterol
Racemic Epi
Epinephrine
Treatment
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Atrovent?
Atropine?
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dries secretions
Steroids?
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for family Hx of asthma
Treatment
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Ribavirin? (Guidance of PICU)
Pulmonary Disease
Cystic Fibrosis
RDS
Congenital Heart Disease
Bronchiolitis
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70% of children who wheeze in the ED are
smoking (passively or actively)
Pneumonia
Pneumonia
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Goals
Identify causes of Pneumonia in children
 Describe Respiratory Distress in Pneumonia
 Review Treatment for Pneumonia
 Pediatric Emergency Medicine
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Pneumonia
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Infection within the lung
Viral
Bacterial
Fungal
Epidemiology
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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
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Asthma/RAD/Bronchio
litis
Immunocompromise
Previous Insult to Lungs
Abnormal Anatomy
(Immotile Cilia)
Cystic Fibrosis, Sickle
Cell . . .
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Prematurity
Malnutrition
Low Socioeconomic
Status
Cigarette Smoke
Day Care
Foreign Body
Pathophysiology
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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
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Birth to 1 month
Viruses: CMV
 group B streptococcus, E coli, Klebsiella, Listeria
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1 to 24 months
Viruses: RSV, parainfulenza, influenza, adenovirus
 Bacteria: Strep pneumoniae, strep pyogenes, staph
aureus, H. influenza
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Etiologic Agent
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2 to 5 years
Viruses: Influenza, adenovirus
 Bacteria: Strep pneumoniae
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5 to 18 years
Viruses: RSV, adenovirus
 Bacteria: Mycoplasma, Strep pneumoniae, Chlamydia
pneumoniae
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Special Concerns
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Staph aureus
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Grp A Strep
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rapid progression, abscesses
invasive, necrotizing fasciitis, empyema
Gram neg bacilli
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recently hospitalized patients
Special Concerns
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B. pertussis
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C. trachomatis
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paroxysmal cough
maternal exposure, conjunctivitis
M. pneumoniae
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rash (Erythema Multiforme)
Special Concerns
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RSV mortality rate
Congenital Heart up to 35%
Congenital Heart w/ Pulmonary HTN up to
70%
Symptoms
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cough
fever
chest pain
fatigue
gasping
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tachypnea
apnea
abdominal pain
nausea
Findings
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respiratory distress
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tachypnea, grunting, flaring, retracting
abnormal auscultatory findings???
cyanosis
chest X-ray - infiltrates
CXR Findings
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Viral
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Bacterial
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diffuse interstitial infiltrates
consolidated, lobar
Mycoplasma
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diffuse
Lab
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CBC
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elevated WBC, left shift
Blood Culture
Cold Agglutins
Sputum Culture
ABG
May help with placement
RSV
Influenza
Appearance
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History is not as useful
Examination is paramount
Observation
vigorous crying
 playful
 quiet is bad!
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Signs of Respiratory Distress
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Tachypnea
Retractions
Flaring
Grunting
Abdominal Breathing
(seesaw)
Bradypnea
Signs of Respiratory Distress
Wheezing
Stridor
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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
Evaluation of Respiratory Distress
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High Expired CO2
CXR
Soft Tissue Neck X-ray
Response to Treatment
Pulse Oximetry????
should not guide acute treatment decisions
 misleading
 inaccurate
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Treatment
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Position/Support/Maintain Airway
Wipe Nose!
Remove Foreign Bodies
Oxygen
Cool Mist (H2O or NS?)
Antibiotics?
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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?
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Viral
support
 acyclovir?
 ribavirin?
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Treatment
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Beta agonist
IVF (except cardiogenic and resp?)
10-20cc/kg
 normal saline or Ringer’s
 never sugar in bolus (unless calculated)
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Oxygen & Albuterol
Intubation
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Cardio/Respiratory Failure
Uncompensated Shock
Unable to maintain airway **
ETT size
age/4 + 4, insert 3 x size of tube
 small fingernail
 nares
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Disposition - Admit
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Hypoxia
< 3 months old
Shock
Dyspnea
Activity Level
Extensive ED Treatment
Complications
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Viral pneumonia
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resolve spontaneously without specific Tx
Bacterial pneumonia
dehydration, bronchiolitis obliterans, apnea
 pleural effusions, empyemas, pneumothorax,
pneumatoceles, development of additional infectious
foci
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Cases
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Case 1
16 month old boy, respiratory distress
 RR 40, HR 140, T 39.2C
 Rash
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Case 2
7 year old boy, cough
 RR 20, HR 105, T 38.2C
 Hx TE Fistula, Cleft Palate, RAD
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Cases
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Case 3
6 day old boy, respiratory distress
 RR 64, HR 160
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Case 4
9 month old boy, respiratory distress, shock
 RR 60, HR 170, T 37.5
 green nasal d/c
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Cases
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Case 5
3 month old boy, CPR
 RR 0, HR 0
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Case 6
5 year old boy, cough, fever, rash
 RR 20, HR 100, T 38.7C
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Cases
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Case 7
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2 year old boy
Cough, fever
Tachypnea, retracting, grunting, flaring
Lungs clear
RR 42, HR 140, T 38.3C
Case 8
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4 year old boy, Down Syndrome
Cough, Fever, Tachypea
Grunting, Flaring, Retracting
RR 32, HR 120
Cases
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Case 9
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13 year old boy
Cough, Fever, Tachypea, Chest Pain
Grunting, Flaring, Retracting
Decreased BS on Left
RR 32, HR 120
Case 10
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14 year old boy, Christmas Day
Cough, Fever
RR 18, HR 96
WBC 4.0
Cases
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Case 11
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8 year old girl, 5 year old boy, siblings
Cough, Fever, Tachypea
Lungs clear
Case 12
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10 month old girl, Situs TOGA Diaphrag Hernia
Cough, Fever, Tachypea
Grunting, Flaring, Retracting
RR 48, HR 160
Cases
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Case 13
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4 year old boy
Cough, Fever, Tachypea
Coarse BS
RR 48, HR 120, T 38.6C
Case 14
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14 month old boy
Cough, Fever, Tachypea
Clear BS
RR 48, HR 120, T 39C
Summary
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Recognize Respiratory Distress
Low Threshold to Consider Pneumonia
Treatment for Respiratory Distress, then
Pneumonia
Normal Breath Sounds
DO NOT R/O PNEUMONIA!