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Pediatric Acute Care – Pulmonology Study Notes acute laryngotracheobronchitis (CROUP) - correct answer Peak 6 months to 3 years. Viral. PARA FLU, ADENOVIRUS, RSV Xray are not to document the diagnosis but rather to exclude other, more serious, causes of upper airway obstruction that require intervention. Best seen on frontal xray. inverted V or a church steeple laryngotracheobronchitis (croup) LTB - correct answer effects of Dexamethasone 0.6mg/kg steroids can be seen within 6 hours Diff from epiglottis = history of URI symptoms, barking cough* Peds: narrowest airway is at cricotracheal junction. laryngotracheobronchitis (CROUP) - correct answer Subglottic airway- larynx, trachea, and bronchi High in 3 months to 3 yrs. Parainfluenza** Symptoms can last for up to 1 week. Tx: Humidified air, fever control, one time dose of Dexamethasone 0.6mg/kg. Nebulized epineb. (0.5ml of2.25% in 3 ml of NS)- at risk for rebound for 4 hours post neb. Heliox 70-30 (improves laminar air flow through narrow airway) Epiglotitis - correct answer Hemophilus influenzae a paraflu, H flu ( nontypable) GAS, strep Pneumo toxic appearing. abrupt stridor, dysphagia, fever, restlessness The patients are typically older than those with croup; the classically described peak incidence occurs at age 3.5. Obtain a Lateral radiography of neck will reveal a large epiglottis with extension of the hypopharynx " thumb sign" Epiglotitis - correct answer pending cultures: 7-10 day course of 3rd gen cephalosporin + or - Vancomycin if MRSA is suspected.
Epiglottis - correct answer H influenza * cases reduced since invention of vaccine. Less likely causes : S.pneumo, s. aureus, B-hemo-strep. AP lateral neck "thumb sign" at epiglottis. Exudative tracheitis - correct answer purulent infection of the trachea in which exudative plaques form along the tracheal walls (much like those seen in diphtheria).6 to 10 years. Staph areus Hemangioma - correct answer Facial hemangiomas in the "beard" distribution have been associated symptomatic airway hemangiomas, which should raise the providers concern for airway compromise Subglottic stenosis - correct answer 3rd most common anomaly of larynx. Males* small cricoid cartilage with associated thickening of sub mucous layer. PE: May be NO sx until URI or cold. Stridor and barking cough. Often diagnosed with chronic laryngotracheobronchitis (CROUP). ** recurrent croup** red flag Dx made if lumen is < 4mm in term infant. Tx: Balloon dilation, tracheostomy, rib plasty. laryngomalacia - correct answer most common cause of stridor and congenital abnormality of larynx* males* Not necessarily in prematurity symptoms are absent at birth, arise @ 2-4w. inspiratory stridor worse when supine* poor feeding, GERD, Pt has normal cry and rarely respiratory distress. Dx: Awake laryngoscopy= elongated and laterally extended omega epiglottis, that falls posteriorly on itself on inspiration. collapse of aryepiglottic folds on inspiration 15 % will require trach. co-existing GERD worsens patho. Tx: Acid reflux precautions, OR for epiglottoplasty ( dividing aryepiglottic folds and trimming epiglottis) Tracheomalacia - correct answer trachea is floppy. collapsing during inspiration and expiration. Primary ( deformity of tracheal rings) secondary (vascular rings, TE fistula repair). PE: stridor, wheeze, barking cough. "drying spells" - reflex apnea with Cardiac arrest
Unasyn, clindamycin, or 3rd gen cephalosporin if improving change to oral for total of 10 days. foreign body aspiration - correct answer phase 1: immediate, chocking, gagging, coughing, cyanosis. phase 2: minutes to months asymptomatic phase 3: renewed symptomatic period: infection or inflammation. cough, wheezing, stridor, hemoptysis. PE findings: unilateral monophasic wheezing, cough, stridor. Asymmetry on inp and exp. CXR indicates air trapping. On lateral decubitus: mediastinum should shift toward gravity, failure to do so indicates air trapping. Tx: NEVER BLIND FINGER SWEEP! Abdominal /back thrust for infant and hemelich for peds. ** Ridgid bronch** Intrinsic vs extrinsic compression - correct answer If the radiographs suggest an intrinsic abnormality, bronchoscopy is the next procedure of choice. If the radiographs suggest an extrinsic compression, cross-sectional imaging is performed. T DOUBLE AORTIC ARCH - correct answer most common vascular ring. Anatomically, the two arches surround and compress the trachea anteriorly and the esophagus posteriorly. Symptoms shortly after birth. pulmonary sling - correct answer The resultant sling compresses the trachea. Pulmonary sling is the only vascular anomaly to course between the trachea and esophagus Right aortic arch with an aberrant left subclavian artery - correct answer INNOMINATE ARTERY COMPRESSION SYNDROME - correct answer IA. passes immediately anterior
to the trachea just inferior to the level of the thoracic inlet. On lateral radiography, there is indentation of the anterior aspect of the trachea at or just below the thoracic inlet. Tracheomalacia - correct answer tracheal wall softening related to abnormality of the cartilaginous rings of the trachea. It can be a primary or secondary condition and results in intermittent collapse of the trachea.e diagnosis cannot be made on a single static radiograph. However, lateral fluoroscopy or endoscopy can demonstrate dynamic changes in the caliber of the trachea, and they are diagnostic. The most common soft tissue masses in the trachea are hemangiomas, which most commonly occur in the subglottic region xray findings on foreign body aspiration - correct answer symmetric lung aeration, hyperinflation, oligemia, atelectasis, lung consolidation, pneumothorax, and pneumomediastinum. Most FB are non-radioopaque. ** The key radiographic feature is the lack of change in lung volume demonstrated at different phases of the respiratory cycle** Foreign body - correct answer Laryngeal or tracheal foreign bodies are far less common than bronchial foreign bodies** and usually present with abrupt stridor or respiratory distress. Radiographic findings include a radiopaque foreign body, soft tissue density within the airway, and loss of visualization
intermittently obstructing the airway. " kissing tonsils" kissing tonsils - correct answer CHAOS (Congenital high airway obstruction syndrome) - correct answer utero laryngeal atresia, subglottic stenosis, and head and neck masses obstructing the upper airway, most commonly lymphatic malformations or teratomas. EXIT strategy = head delivery during c-section with immediate intubation or tracheostomy. Situs solitus - correct answer normal configuration; it is associated with a 0.6% incidence of congenital heart disease. Situs inversus - correct answer the mirror image of normal and is associated with a 3% to 5% incidence of congenital heart disease. situs ambiguous - correct answer The major types of situs ambiguous include asplenia (bilateral right-sidedness) and polysplenia (bilateral right-sidedness). 100% incidence of CHD Position of aortic arch - correct answer Right-sided aortic arch is also a red flag for the presence of congenital heart disease TTN - correct answer C-section baby. Respiratory distress develops by 6 hours of age, peaks at 1 day of age, and is resolved by 2 to 3 days. combination of airspace opacification, coarse interstitial markings, prominent and indistinct pulmonary vasculature, fluid in the fissures, pleural effusion, and cardiomegaly (Fig. 3-2). Lung volumes are normal to increased.
Neonatal pneumonia - correct answer patchy, asymmetric perihilar densities and hyperinflation. hyaline membrane disease - correct answer 50% of preterm infants. decreased compliance, alveolar collapse, and increased surface tension. on xray: Lung volumes are low. There are bilateral granular opacities that represent collapsed alveoli interspersed with open alveoli. Because the larger bronchi do not collapse, there are prominent air bronchograms. Surfactant - correct answer increased risk for development of patent ductus arteriosus and pulmonary hemorrhage b-Hemolytic Streptococcal Pneumonia - correct answer most common neonatal* bilateral granular opacities and low lung volumes. Pulmonary Interstitial Emphysema - correct answer appears on radiographs as bubblelike or linear lucencies and can be focal or diffuse. associated with BPD Bronchopulmonary dysplasia - correct answer at end of the 2nd week of life, persistent hazy density appears throughout the lungs. Over the next weeks to months, a combination of coarse lung markings, bubblelike lucencies, and asymmetric aeration can develop. Viral pneumonia - correct answer peribronchial edema appears on radiography as increased peribronchial opacities—symmetric course markings that radiate from the hila into the lung Hyperinflation is evident on chest radiographs in children in the presence of
Acute Chest Syndrome - correct answer y fever, chest pain, hypoxia, and pulmonary opacities on chest radiographs. Radiography often shows segmental to lobar pulmonary opacities but can also be normal. There can be an associated increase in cardiomegaly. Bone scans may show rib infarcts. Cystic Fibrosis - correct answer demonstrates hyperinflation, increased peribronchial markings, mucus plugging, and bronchiectasis. The hilar areas can become prominent because of a combination of lymphadenopathy secondary to the chronic inflammation and enlarged central pulmonary arteries related to the development of pulmonary arterial hypertension 'Spinnaker sail sign' - correct answer pneumomediatstinum Metabolic alkalosis - correct answer is rare. Usual causes are pyloric stenosis, chronic diuretic use, and bicarbonate infusions. Heliox - correct answer a helium-oxygen mixture, has the theoretical benefit of improving laminar airflow through the restricted, inflamed airway found in patients with lower airway obstruction Reye's syndrome - correct answer Asprin at time of influenze illness. Presents with fever, convulsions. leathery and coma. Hallmark: fatty degeneration of liver with cerebral edema. Elevated serum AST with high serum ammonia levels. Negative CSF findings. Influenza - correct answer viral culture* may take up to 6 days for viral ID. Viral nucleic have > sensitivity than rapid PCR Tx: 1. Amantadanes ( Rimantadine and Amantidine) first 48. Ineffective for H1N1. Effective for FLU A only. OR 2. Neuraminidase inhiitors (Oseltamivir (PO), and peramivir (IV) ) effective against A and B. First Line tx for H1N1.
Human metapneumo virus - correct answer Similar to RSV/Flu. causes rhinitis, conjunctivitis, pharyngitis, asthma exacerbations, and Otitis. Tx is supportive. TB. - correct answer acid fast bacilli (Mycobacterium tuberculosis). Bacili can translocate to other organs = EPTB. children have higher risk of EPTB to lymphatics and meninges. Children under 10 are rarely contagious. progressive primary TB - correct answer presents with fever, moderate to severe cough, night sweats, abnormal or absent breath sounds over affected area. pulmonary TB - correct answer PRESENTS high fever, chest pain, SOB, effusions, decreased BS, or empyema. lymphatic TB - correct answer most common manifestation of extrapulm TB. Hallmark: unilateral discrete, firm, matted lymphadenopathy. Located in cervical (scrofula) nodes. CNS TB - correct answer most serious. < 2 years of age* can occur months after infection. military TB - correct answer NONSPECIFIC SYMPTOMS: malaise, fever, anorexia, weight loss. hepatomegaly, splenomegaly, respiratory distress, hypoxia, and pneumothorax TB diagnostics - correct answer A + TST with a - exam and - CXR is diagnostic for LTBI. definitive diagnosis with culture of sputum or gastric aspirate ( results take up to 10 weeks). May obtain PCR - Quantiferon Gold. TB - correct answer peds patients rarely present with TB sensitive symptoms. Always consider TB in failure to thrive or Fever of Unknown Origen (FUO) Bordetella pertussis - correct answer "whooping cough"- most common vaccine preventable disease in < 5 yr old. aerobic, non motile gram negative coccobacillus. resulting in mucopurulosanginous exudate in small airways. alveolar atelectasis, due to loss of surfactant, hypoxia then pulmonary htn. most contagious during the asymptomatic catarrhal stage.
- Transmission has already occurred by the time the hallmark cough is present. PAROXYSMAL cough, post tussive emesis, may last for 4-6 weeks. pertussis phases - correct answer 1. catarrhal ( non specific URI sx. most contagious phase.
- Paroxysmal : whoop (hurried and deep). post tussive emesis.
- progressive resolution of cough. pertussis aka
possible but not optimal alveolar period - correct answer week 36 to term. Here, further refinement of the terminal sacs and formation of the walls of the true alveoli occurColumnar cells within the alveolar wall differentiate into type I and type II cells. Type I cells provide the alveolar surface area necessary for gas exchange. Type II cells secrete surfactant A congenital diaphragmatic hernia - correct answer diaphragm fails to completely separate the pleuroperitoneal cavity into the abdominal and thoracic cavities. I in 2000 births tracheoesophageal fistula - correct answer communication between the trachea and esophagus results from incomplete division of the foregut into the respiratory and digestive systems occurs in I in 2500 supraglottic airway - correct answer The supraglottic airway includes the nose, the nasooropharynx, and the epiglottis Glottis area - correct answer The glottis includes the vocal cords, subglottic area, and cervical trachea. intrathoracic airway - correct answer includes the thoracic trachea, the mainstem bronchi, and the lungs Glottis - correct answer The infant's epiglottis is omega shaped and floppy. The epiglottis enters the anterior pharyngeal wall at a 45-degree angle and projects more posteriorly than in the older child Pulmonary Metabolism - correct answer pulmonary capillary circulation is uniquely suited for exercising a controlling influence on a number of circulating vasoactive
agents. These include activation of angiotensin I to angiotensin II; inactivation of bradykinin, serotonin, prostaglandin E (PGE), and PGF2 ; and partial inactivation of norepinephrine and perhaps histamine. In addition to modulating bronchial and pulmonary vascular diameter, the systemic effects of these agents include increased capiIlary permeability, platelet aggregation, and peripheral vasodilation. Central chemoreceptors - correct answer responsible for the dramatic increase in minute ventilation (VE) when Pacoz levels are elevated, are located in the medulla. Medullary chemoreceptors monitor H+ ion concentration of cerebrospinal fluid and brainstem interstitial fluid. Although H+ and HC03- ions are unable to cross the blood-brain barrier easily, CO readily penetrates and immediately hydrates to form carbonic acid (HZC03), which dissipates into H+ and HC03-. The concentration of H+ ions in the brain's interstitial fluid parallels Pacoz and acts as a stimulus to increase respirations. Dalton's law of partial pressures - correct answer The total pressure of a gas is equal to the sum of the pressures of the individual gases. For example atmospheric pressure is 760mmHg at sea level. Thus room air (21%), So room air exerts 21% of 760 to equal 160mmhg. keep in mind C. Water vapor reduces the partial pressure of inspired oxygen; so, 760 - 47 =713; 21% of 713 is 149.7 mmHg. alveolar gas equation - correct answer PA02 = PI02 - Pac02/RQ. In room air, at normal
- 6 mmHg. Intraalveolar pressure also becomes subatmospheric, and air moves in bulk flow f expiration - correct answer Expiration is a passive process in that the muscles of respiration relax and the size of the intrathoracic cavity decreases. When the muscles relax, the elastic properties of the lung followed by the elastic properties of the chest wall pull the thoracic cavity back to a resting position. As the size of the intrathoracic cavity decreases, intraalveolar pressure becomes supraatmospheric, and air moves in bulk flow from the alveoli to the atmosphere. Because of normal increased airways resistance during expiration, passi ve expiration requires more time than inspiration. Anatomic dead space - correct answer Normal anatomic dead space (nose pharynx, mouth, trachea) is approximately 2 ml/kg. Alveolar dead space - correct answer Refers to the volume of gas that fills alveoli whose perfusion is abnormally reduced or absent. Minute ventilation ( VE) - correct answer volume of air that moves in or out of the lungs per minute. Minute ventilation is the product of tidal volume and respiratory rate. Tital volume (Vt) - correct answer volume of air entering and leaving lungs during a single breath in a resting state, 6 to 8 mVkg ventilation perfusion mismatch V/Q - correct answer ventilation is greater than perfusion at the apex, and perfusion is greater than ventilation at the base. This results in an overall V/Q of 0.8. Characterized by a low V/0. ratio, a shunt refers to venous
blood that travels from the right to left side of the circulation without ever coming in contact with ventilated lung.. A capillary shunt occurs when alveolar-capillary blood flow comes in contact with nonventilating alveoli, for example, atelectasis, pneumonia, and pneumothorax = hypoxemia (A-aDoz) or PaozIFl02 ratio can be used to estimate the percent shunt. Chest percussion on exam - correct answer hyperresonant pitch in infant is WNL By age 6 a resonant pitch is WNL After age 6, hyperresonance may indicate the pathologic presence of air ( Pneumo) A resonant pitch before 6 years of age or a dull pitch thereafter indicates consolidation, for example, atelectasis, pneumonia, or pleural effusion Bronchophony - correct answer clarity and increase loudness of spoken words head through consolidation (pneumonia) Whispered pectoriloquy - correct answer auscultation of whispered words while stethoscope is placed over lung "99" Egophany - correct answer Infant airway - correct answer round chest until age 2. After 2 think obstructive pulmonary disease. compliant chest wall is great for ventilating a child, however, can cause easy collaopsible chest and decrease alveoli surface tension for a sick spontaneously breathing child. Pectus excavatum - correct answer NUSS pectus carinatum - correct answer Medulla oblongata - correct answer controls breathing by chances in hydrogen ion concentration (co2) and oxygen. It directs the pons to alter rate and depth. adenoids and tonsils - correct answer composed of lymph tissue, and tend to increase in size Peaking between 2-6 yrs, then recede in size.
round pneumonia - correct answer Round pneumonias tend to be >3 cm, solitary, and posteriorly located [60,61]. The most common bacterial etiology for round pneumonia is S. pneumoniae; additional bacterial causes include other streptococci, Haemophilus influenzae, S. aureus, and M. pneumoniae afebrile pneumonia of infancy - correct answer typically caused by C. trachomatis.hyperinflation with an interstitial process seen between two weeks and three to four months of life. presentation is one of insidious onset of rhinorrhea and tachypnea followed by a staccato cough pattern. + conjunctivitis. Peripheral eosinophilia may be present in infants with afebrile pneumonia of infancy infantile botulism - correct answer Raw honey* initial presentation may involve constipation, shortly followed by weakness, feeding difficulties, descending or global hypotonia, drooling, anorexia, irritability, and weak cry. Dx: isolation of C. botulinum spores from the stool Tx: human-derived botulism immune globulin Antibiotics are not recommended for infant botulism ARDS - correct answer 1) acute (exudative) sloughing of epithelial cells, neutrophil adherence, alveolar machrophages release cytokines interleukins and TNF. = protein rich fluid accumulation which destroys surfactant. Neutrophils release oxidants, proteases, leukotrienes and proinflammatory cells.
- Proliferative: type II cells 'clean up" produce surfactant, promote fluid transport, and proliferate the injured type I cells.
- Chronic fibrotic seen as early as 5-7 day p onset. promoted by IL-1* ARDS criteria - correct answer PAO2/FIO2 ration < 200 Acute onset bilateral infiltrates on CXR PA pressure M 18mmhg or no LA hypertension ALI criteria - correct answer PAO2/FIO2 ratio 20 0 - 300 Bilateral infiltrates on CXR acute onset
no LA hypertension and PA pressure < 18mmhg Causes of ARDS - correct answer Direct: pneumonia, aspiration of gastric contents, Near drowning, inhalation injury Indirect: Sepsis, burns, pancreatitis, trauma, transfusion reaction ARDS - correct answer in early phases, respiratory alkalosis may be noted. Tx: HFOV, NO, surfactant, Prone position. Arterial 02 content (CaA2) - correct answer (1.34 x Hgb x Sa02) + ( 0.003 x Pa02) Increasing HgB has most impact on CaO2! HFOV - correct answer allows for smaller tidal volumes
- higer MAP
- limited peak inspiratory pressures. Prone positioning - correct answer Improves V/Q mismatch by converting the more dependent segments of the lungs (bases) to areas where perfusion is better than ventilation. Air leak syndrome - correct answer intrapleural pressure is negative comparted to atmospheric, preventing lungs from collapsing or chest wall from springing back. asthma - correct answer initial phase : mast cells, T lymphocytes, macrophages, neutrophils and epithelial cells start inflame process. Histamine from mast cells causes mucosal edema, mucous plugs, and bronchospasm Late phase: May result in changes to FRC ( air trapping). congestion and infiltration resulting in respiratory insufficiency. Spirometry is needed to establish a diagnosis of asthma. Reversible airflow limitation and diurnal variation as measured by using a peak flow meter, for example: ·· Peak expiratory flow (PEF) varies 20 percent or more from PEF measurement on arising in the morning (before taking an inhaled short-acting beta2-agonist) to PEF measurement in the early afternoon (after taking an inhaled short-acting beta2-agonist). Asthma CXR - correct answer hyperinflation with flat diaphragm.
