Peds Pulmonary

Differentials

Wheezing

• Wheezing in infants:
  • Bronchiolitis and bronchopulmonary dysplasia are the most common
    
  • Foreign body aspiration, certain inherited disorders, anatomic anomalies of airway
• Wheezing in peds 1 to 4:
  • Viral induced and asthma are the most common
    
  • Foreign body aspiration, inherited disorders, community-acquired pneumonia
• New onset wheezing in a toddler:
  • A high index of suspicion for foreign body aspiration
• Wheezing in peds 5 to 12:
  • Asthma most common
    
  • Vocal cord dysfunction, community-acquired pneumonia
• Wheezing in adolescence:
  • Asthma and vocal cord dysfunction are most common
    
  • Hypersensitivity pneumonitis

Apnea of prematurity (AOP)

• Path:
  • AOP is a common form of apnea in the newborn defined as a cessation of breathing effort that is longer than 20 seconds
  • Premature infants can spend up to 80% of their sleep time in REM sleep.
• Presentation:
  • absence of breathing greater than 20 seconds in infants less than 37 weeks
• Associated:
  • bradycardia; cyanosis
• Management:
  • Theophylline, caffeine, Doxapram, methylxanthine
  • If the infant does not respond to tactile stimulation give 40% oxygen or same level currently receiving
  • Chest compressions should begin if the heart rate is less than 80 or if the infant is hypotensive

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  • Theophylline (becoming outdated)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

Osmosis / CC BY-SA
National Heart, Blood, and Lung Institute / CC BY

Bronchiolitis

• Path:
  • A common, acute lower respiratory tract infection that primarily affects the small airways (bronchioles);
• Presentation:
  
  • MC infants < 1Yo
  • Course:
    • Incubation (4-6 days)
      
    • 3-7-day progression to noisy breathing, wheezing, increased work of breathing (WOB)
      
  • Sign:
    • prolonged expiratory phase, wheeze, nasal flaring, suprasternal retractions, air trapping + lung hyper-expansion
      
    • Grunting and cyanosis = severe disease
    • Rhinorrhea, pharyngitis, cough, wheezing, rhonchi, rales
• MC Cause: RSV
• Lab Imaging:
  • Monitoring with pulse oximetry
    
  • Rapid testing to verify etiology:
    • RSV, parainfluenza, influenza, adenovirus (nasal swab)
      
  • CXR:
    • hyperinflation, flattened diaphragm
      
    • Increased density pneumonia

Osmosis / CC BY-SA

• Diagnosis:
  • Antigen detection assays
• Treatment:
  • Supportive care
    
  • Oxygen administration as needed
  • Plenty of fluids (pedialyte, water, formula, breast milk)
    
  • Nasal saline and suction
    
  • Acetaminophen if necessary
    
  • Usually avoided: antibiotics, bronchodilators, corticosteroids
• Immunocompromised patients: use of antivirals (ribavirin) be recommended

X-ray of a child with RSV showing the typical bilateral perihilar
James Heilman, MD / CC BY-SA

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)

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

• Path:
  • can survive for hours outside the host, in dry air, droplets remain airborne for longer
•  Etiology:
  • Rhinovirus, coronavirus
• Transmission:
  • direct contact, droplets
  • mouth, eyes, or nose.
• Presentation:
  • sneezing, excessive nasal secretion, congestion
• Complications:
  • laryngitis, otitis media
•  Diagnosis:
  • common symptoms
•  Treatment:
  • cough suppressants, antihistamines
•  Prevention:
  • Wash hands often, avoid close contact with sick people, do not touch the face with unwashed hands

Croup (laryngotracheitis)

• Path:
  • most common infectious upper airway disorder;
  • parainfluenza virus but also RSV; viral;
• Presentation: 
  • 6 months to 3 yo;
  • URI for 5 days prior to seal like barking cough;
  • inspiratory stridor; respiratory distress; 
  • labored breathing and retractions if obstruction;

• Complication:
  • bacterial tracheitis
• Diagnosis:
  • xray shows steeple sign;
  • CBC with diff to rule out bacteria; respiratory panel;
• Treatment:
  • supportive treatment;
  • corticosteroids; aerosolized racemic epinephrine;
  • cool mist with mask

Frank Gaillard / CC BY-SA

Cystic Fibrosis (CF)

• Path:
  • Autosomal-recessive disease involving multiple organs, especially pancreas and lungs; most common lethal genetic disease in US; usually develop the obstructive disease (bronchiectasis), that leads to progressive respiratory failure and death;
• Presentation:
  • with chronic sinusitis, nasal polyps, persistent cough, persistent and productive cough, infection and inflammation of the lungs eventually leads to bronchiectasis, pancreatic insufficiency leading to malabsorption and FTT, meconium ileus
• Diagnosis:
  • 4 symptoms:
  • Meconium ileus
    
  • Respiratory symptoms
    
  • Failure to thrive
    
  • Evidence of meconium peritonitis prenatal ultrasound
• Indications for Sweat Testing:
  • Two weeks old and weight > 2kg
    
  • Positive screening of newborn
    
  • Meconium ileus
    
  • Older children and adults with suggestive symptoms
    
  • Siblings of patients with confirmed CF
• Sweat Chloride Test:
  • – 6 Months or Less:
    CF Possible = 30-59 mmol/L
    CF Likely = > or = 60 mmol/L
  • – > 6 Months:
    CF Possible = 40-59 mmol/L
    CF Likely = > or = 60 mmol/L
• Treatment:
  • Pancreatic enzyme supplementation
    
  • High calorie/protein/fat diet
    
  • Daily salt supplementation
    
  • Airway clearance
    
  • Antibiotics
    
  • Pulmozyme

Osmosis / CC BY-SA
Cystic Fibrosis Symptoms

BruceBlaus. / CC BY

Epiglottitis

• Path:
  • 2-7yo; preemies at risk;
  • sudden onset;
  • tripod position;dysphagia, drooling, dysphonia;
  • muffled voice;
  • distressed inspiratory effort;
  • see cherry red inflamed swollen epiglottis
• MC cause:
  • Group A Streptococcus, S. aureus, H. influenzae type b (unimmunized)

• Radiograph:
  • “thumb sign”
• Diagnosis:
  • visualization when placing an endotracheal tube
• Management:
  • endotracheal intubation to secure airway; IV ceftriaxone

Med Chaos / CC0

Foreign body aspiration

• Presentation:
  • 6 months to 5 yo; normal and not in distress;
  • sudden onset cough;
  • stridor, retractions, unilateral wheezing;
• Diagnosis:
  • xray

• Management:
  • wait for it to pass;
  • treat with endoscopic removal of the object

Samir at English Wikipedia / CC BY

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:
  • Nasal CPAP is the initial preferred intervention
    Surfactant replacement

Chest X-ray of a case of IRDS,
with fine granular opacities,
air bronchograms and bell-shaped thorax
Mikael Häggström, M.D. / CC0

• Prevention:
  • Prenatal administration of a single course of steroids to women in preterm labor or at risk of delivery within the next 7 days between 24-34 weeks gestation

Mikael Häggström, M.D. / CC0

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)

Kinderradiologie Olgahospital Klinikum Stuttgart
/ CC BY-SA

• Diagnosis:
  • X-ray: infiltrates, streaking, ↑A-P diameter, flattened diaphragm
• Management:

BruceBlaus / CC BY-SA

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:
  • Supportive measures + assisted ventilation
    
  • Surfactant therapy
    
  • Inhaled nitric oxide
    
  • If the above fail
    
  • Extracorporeal membrane oxygenation (ECMO) – modified heart-lung apparatus

Peritonsillar abscess

• Presentation:
  • over 10 yo;
  • GABHS;
  • biphasic onset with worsening; fever, drooling, dysphagia; sore throat;
  • muffled hot potato voice;
  • trismus;
• Physical Exam:
  • uvula deviates to the opposite side;
  • unilateral swollen tonsil;
  • cervical lymphadenopathy;
• Management:
  • penicillin and aspiration

James Heilman,MD, CC BY-SA 3.0, via Wikimedia Commons

Peds Pneumonia

Bacterial Pneumoniae

• 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

• Path:
  • situs inversus, chronic sinusitis, bronchiectasis
• Presentation:
  • mild respiratory distress, tachypnea, increased incidence of infections, chronic cough, symptoms increase over the course of the day
  • constantly runny nose, year-round nasal congestion, rhinosinusitis
  • defective Eustachian tube ciliary function leads to poor clearance, chronic otitis media, conductive hearing loss
• Association:
  • transposition of great vessels, pyloric stenosis, epispadias, congenital cardiac abnormalities, pectus excavatum, scoliosis

• Diagnosis:
  • nasal nitric oxide, measure mucociliary transport, assess ciliary motion and ultrastructure using HSVM and electron microscopy, genetic testing
• Management:
  • variable, symptomatic, monitoring is essential
  • Definitive dx: electron microscopic visualization of the missing dynein arm or radial spokes
• Prognosis:
  • normal lifespan in general, lung function declines over time, advise against smoking, may require surgical intervention for symptoms over time

Reactive Airway Disease

Retropharyngeal abscess

• Presentation:
  • under 6 yo;
  • staph aureus;
  • fever, muffled hot potato voice;
  • arching of neck;
  • odynophagia;
  • sore throat; drooling, toxic;
• Diagnosis:
  • X-ray shows increased retropharyngeal space;
  • CT scan;

• Treatment:
  • nafcillin, unasyn, ceftriaxone, clindamycin; surgical drainage of abscess

Retropharygneal abcess
James Heilman, MD / CC BY-SA

Transient tachypnea of the newborn (TTN)

• Path:
  • A condition that presents within the first few hours of life with tachypnea and other signs of respiratory distress (↑ O2 requirement and ABGs that do not reflect CO2 retention)
  • delay in the clearance of fetal lung fluid.
    • – Low levels of catecholamines circulating (necessary to alter the function of the ENaC channel to absorb excess fluid from the lungs)
      
    • – Pulmonary immaturity
      
    • – Mild surfactant deficiency
      
    • Decreased pulmonary compliance due to excess fluid
• Presentation:
  • Tachypnea (RR greater than 60/min), nasal flaring, grunting, intercostal/subcostal/suprasternal retractions, and on auscultation – crackles, diminished or normal breath sounds
• Risk Factors:
  • Maternal risk factors – delivery before 39 weeks, c-section without labor, gestational diabetes, and maternal asthma
    Fetal risk factors – male gender, prematurity, SGA, and LGA
•  Diagnosis:
  •  CXR:
    • small pleural effusion and perihilar streaking on x-ray.
• Management:
  • Supportive care while the retained lung fluid is absorbed (IV fluids, gavage oral feedings, supplemental O2, maintenance of thermoneutrality).
  • lasts more than 3 days:
    • CPAP

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.