Peds Pulmonary



Differentials

Wheezing

Apnea of prematurity (AOP)


Asthma

  • Diagnostic:
    •  spirometry
  • Management:
    • A-drenergics (Albuterol)
    • S-teroids
    • T-heophylline
    • H-ydration (IV)
    • M-ask (Oxygen)
    • A-ntibiotics
  • Stepwise therapy, multiple drug classes:
    • Inhaled corticosteroids (↓morbidity, unchanged course)
    • Leukotriene modifiers ([1] Leukotriene receptor antagonists, [2] leukotriene synthesis inhibitors)
    • Long acting beta-2 agonists (Formoterol, Salmeterol)
    • Theophylline (becoming outdated)
    • Biologics (anti-IgE; Omalizumab)
    • Short-acting beta-2 agonists (albuterol)
    • Anticholinergics (Ipratropium)
    • Oral corticosteroids (avoid prolonged use)
  • Trigger Reduction Tactic:
    • Viral upper resp. infection
    • ↓Exposure; flu vaccine
    • Smoke (tobacco, wood)
    • Quit smoking (parents and caregivers); alternate heating
    • Dust mites
    • Bedding encasements and cleaning
    • Animal Dander
    • Air filters, separation from pets
    • Cockroach allergens
    • Pesticides, crack sealants
    • Indoor Mold
    • Cleaners, dehumidifiers

Bronchiolitis


Bronchopulmonary dysplasia (BPD)

  • Path:
    • chronic lung disorder characterized by bronchiolar metaplasia and interstitial fibrosis
    • a chronic lung disease that develops in newborns as a consequence of the treatment of IRDS with oxygen and positive pressure ventilation for a primary lung disorder
  • Etiology:
    • 1) precise cause is unknown
      • 2) common factors include:
      • a. low gestational age
      • b. mechanical ventilation with high airway pressure
      • c. high oxygen concentration
      • d. history of IRDS
    • 2)PMH – premature
  • Presentations:
    • cyanosis
  • Physical Exam:
    • intercostal retractions
    • increased respiratory pattern >60/min
    • Breath sounds:
      • 1) wheezes
      • 2) rhonchi
      • 3) crackles
      • 4) expiratory grunting
    • 1) nasal flaring
      2) substernal retractions
      3) abdominal distention (seesaw breathing)
CXR - Bronchopulmonary dysplasia
Pulmonological / CC BY-SA
  • Primary assessment:
    • 1) mature infant who requires mechanical ventilation and doesn’t improve
      2) continued need for high oxygen concentrations
      3) signs of respiratory distress (tachypnea, retractions)
  • Diagnosis:
    • CXR:
      • 1) initially resembles IRDS then progresses to atelectasis, follow by cyst-like areas of hyperluency which increase in later stages
    • ABG:
      • acute alveolar hyperventilation with hypoxemia, develop hypercarbia later

  • Management:
    • A. oxygen therapy
    • B. pulmonary hygiene
    • C. mechanical ventilation for ventilatory failure
    • D. ventilation and oxygenation should be maintained at the lowest possible level
    • E. drug therapy: bronchodilators may be helpful
    • F. monitor fluid balance
    • G. surgical ligation of PDA for infants who are difficult to wean
    • H. weaning from mechanical ventilation should be a slow, gradual process that involves higher concentrations of oxygen for prolonged periods of time after extubation. Infants may go home with oxygen therapy.
    • I. supportive care to relieve symptoms of respiratory distress and heart failure
    • J. maintain blood gas values: PaO2 55-70torr, PaCO2 45-60 torr, and pH 7.25-7.40
    • K. minimize mean airway pressure
    • L. extubation can be done at ventilator rates between 5-15 breaths/min
    • M. avoid endotracheal CPAP, because of the increased airway resistance and work of breathing that can be created.

Common cold


Croup (laryngotracheitis)


Cystic Fibrosis (CF)


Osmosis / CC BY-SA

Cystic Fibrosis Symptoms
Blausen 0286 CysticFibrosis
BruceBlaus. / CC BY

Epiglottitis


Med Chaos / CC0

Foreign body aspiration


IRDS (Infant Respiratory Distress Syndrome)

  • Path:
    • Primarily a disease of preterm infants
    • deficiency of pulmonary surfactant in an immature lung
    • noncompliant, stiff lungs that are structurally immature that contain an insufficient surfactant
    • amount of pressure needed to open alveoli increase
    • promotes hypoxemia, hypercarbia and then persistent pulmonary HTN
  • Presentation:
    • presents with prematurity (almost always), tachypnea, nasal flaring, expiratory grunting, intercostal, subxiphoid, and subcostal retractions, cyanosis, and diminished breath sounds
  • Treatment:

Meconium Aspiration Syndrome (MAS)

  • Path:
    • Respiratory disease of term, postterm, and SGA newborns caused by inhalation of meconium or meconium-stained amniotic fluid into the lungs;
  • Presentation:
    • mild to severe respiratory distress, hyperexpansion of the chest, hyperinflated alveoli, and secondary atelectasis.
    • Seen in 5% of newborns with meconium stained amniotic fluid
    • Aspiration -.> airway obstruction -> respiratory distress
  • Meconium effects on the lungs:
    • Ball-valve effect
    • Chemical irritation
    • Predisposition for infection
    • Inhibition of production + function of surfactant
    • Often seen with primary pulmonary hypertension of the newborn (↑pulmonary vascular resistance)
MekAsp w 1d 1.3.51.0.7.1277489803.56708.9039.46848.34134.21565.59325
Kinderradiologie Olgahospital Klinikum Stuttgart
/ CC BY-SA
  • Diagnosis:
    • X-ray: infiltrates, streaking, ↑A-P diameter, flattened diaphragm
  • Management:

Newborn respiratory distress syndrome

  • Feature:
    • Premature babies
      • Inadequate surfactant concentrations
      • Preterm
      • Respiratory Distress Syndrome (“Hyaline Membrane Disease”)
    • Full-term
      • Primary Pulmonary Hypertension of the Neonate (PPHN)
      • Meconium Aspiration Pneumonia
    • Preterm and full-term
      • Transient Tachypnea of the Newborn
      • Bacterial Sepsis (Group B Streptococcus)
  • Lab Evaluation:
    • Chest X-Ray:
      • Parenchymal pattern determination, ?pneumothorax, cardiac morphology
    • Arterial Blood Gas:
      • Acid-base disturbance, the extent of hypercapnia/hypoxia
      • Complete Blood Count:
      • H+H, white count, platelet count (?DIC)
    • Blood Culture:
      • Recovery of offending microbe
    • Blood Glucose:
      • Hypoglycemia, stress hyperglycemia
    • Echocardiogram:
      • Interrogation of murmur or PPHN, cardiomegaly, structural heart disease
  • Management:

Peritonsillar abscess


Peds Pneumonia


  • About:
    • An inflammation of lung parenchyma
    • Viruses are the most common agents in infants
    • Mycoplasma pneumoniae most common in children
    • Bacterial PNA, bugs isolated from blood: strep pneumo, H. flu, Staph aureus in infants, debilitated pts, and adolescents with widely disseminated disease
    • Predisposition to bacterial pna: aspiration, immunodeficiency, congenital anolamies (TE fistula, cleft palate) abnormal mucus clearance (CF, ciliary dysfunction ie Kartagener’s, bronchiectasis), CHF.

Bacterial Pneumoniae
  • Microbiology by Age Group:
    • ≤1 month:
      • Group B StrepE. coli, Gram (-) bacilli, S. pneumoniae
    • 1-3 mos:
      • Febrile
      • RSV and other viruses
      • Afebrile
      • C. trachomatisM. hominisU. urealyticum, CMV, B. pertussis
    • 3 months to 5 years:
      • RSV + other viruses, S. pneumoH. influenzae (type b, non-typeable),
    • 5-18y:
      • M. pneumoniae, S. pneumoniae, C. pneumoniae
    • ≥18y:
      • M. pneumoniae, S. pneumoniae, C. pneumoniae, H. influenzae (type b, non-typeable)influenza, adenovirus
  • Presentation:
    • High fever, chills, wheeze, cough, dyspnea, consolidation (auscultatory findings)
  • Physical Exam:
    • Dullness to percussion à segmental infiltrates
  • Complications:
    • empyema & septicemia
    • Sicklers are particularly susceptible to overwhelming pneumococcal infections.
  •  

  • Preschool kids (60 days – 5 years)
    • Streptococcus pneumoniae and Haemophilus influenzae
    • Treat with:
      • amoxicillin 
      • 2nd – azithromycin or clarithromycin
  • School-age kids (5-18) 
    • Mycoplasma pneumoniae and Chlamydia pneumoniae
    • Treat with:
      • azithromycin

Pneumococcal Pneumoniae
  • Presentation:
    • only signs may be fever + tachypnea.
  • Treatment:
    • Penicillin

Haemophilus influenza
  • About:
    • also lobar pna.
    • Distinguished from pneumococcal pna by more indolent course and inadequate response to penicillin.
  • Treatment:
    • Abx include amox or amp PO but if PO inadequate may require IV amp.
    • 20% of H. flu is resistant to amox/amp, use Augmentin or IV cephalosporin.

Staph Pneumoniae
  • Presentation:
    • most common in first year, usually unilateral, abscess, tissue destruction, overwhelming
      septicemia.
  • 2 typical features:
    • pneumatocele
    • rapid progression.
    • Empyema with thick purulent fluid is a hallmark.
  • Treatment:
    • chest tube for drainage

Mycoplasma Pneumoniae
  • Presentation:
    • #1 cause of adolescent pna (25-35%). Incubation period is 2-3 weeks.
    • Sx of headache, malaise, fever, cough. WBC and diff usually normal, “cold agglutinins” may be + after 1st week of illness. CXR looks worse than the pt.
    • Can be fulminant in SS dz pts.
    • Assoc with bullous myringitis
  • Treatment:
    • Erythromycin.

Chlamydia trachomatis
  • Presentation:
    • contracted from birth thru infected vagina, usually presents at 1-2 months with low grade fever, machine gun or “staccato cough”. Increased eosinophils on differential.
    • cxr will have diffuse interstitial infiltrate.
    • 50% have proceeding conjunctivitis.
  • Dx:
    • by giemsa stain of conjunctival inclusion bodies.
  • Treatment:
    • Erythromycin.

Bordetella pertussis
  • Presentation:
    • 2000-4000 cases per year in US.
    • Is an encapsulated gram-negative rod, infects ciliated epithelium of upper respiratory tract.
    • Pertussis toxin increases adenylate cyclase, organism also synthesizes and exports adenylate cyclase.
  • Association:
    • apnea
  • 3 stages of clinical dz:
    1. Catarrhal phase:
      1. lasts 2 weeks, coryza with increased mucus and secretions, sx similar to cold
    2. Paroxysmal phase:
      1. usually lasts 1-2 weeks but up to 4 weeks, consists of paroxysms of hacking cough with copious mucus followed by inspiratory ” whoop” air rushes past narrowed glottis.
    3. Convalescent phase:
      1. can last for months.
  • Dx:
    • PCR
    • culture on Bordet-gengou medium (high % of blood) ID by agglutination with specific antiserum or by fluorescent Ab staining.
  • Treatment:
    • Supportive: hydration, oxygen if needed
    • Abx erythromycin, clarithromycin, azithromycin, TMP-SMX (halts spread, does NOT hasten recovery)
    • close contacts – azithromycin
    • Adults  should get Tdap as a single booster dose
    • Contraindications to giving pertussis vaccine:
      • previous hx of serious reactions to vaccine (temp >105 or severe swelling at the injection site) seizure disorder or other significant neurological disorder
    • Indication for admission:
      • age <4-6 months, resp distress, toxic appearing, dehydration, vomiting if not taking PO’s, social factors, immunocompromised patients, esp sickler’s, CF patients
    • Indic for d/c home:
      • not hypoxic, good sats on room air, good PO intake, good UOP, negative bcx

Viral PNA
  • MC cause:
    • RSV, parainfluenza, influenza A & B
  • Presentation:
    • Cough, wheeze, stridor
    • Less prominent fever
    • Mucosal congestion, upper airway inflammation
  •  Diagnosis:
    • CXR: diffuse infiltrates and hyperinflation

Primary ciliary dyskinesia


Reactive Airway Disease


Retropharyngeal abscess


Transient tachypnea of the newborn (TTN)


Tuberculosis


Upper Respiratory Infections (Viral – URI)

  • Management:
    • OTC cough/cold medications NOT recommended, especially < 4 yo
    • Buckwheat honey
    • Pelargonium sidoides (geranium) extract (Umcka Coldcare)
    • Nasal saline irrigation
    • Vapor rub (> 2Yo)
    • Zinc sulfate
    • don’t use antibiotics

Reference

  • Blausen.com staff (2014). “Cystic Fibrosis” Medical gallery of Blausen Medical 2014. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436.