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Asthma, Bronchiolitis, and Pnemonia Tintinalli Chapt 123-124. April 18th 2005 Mark Rodkey, M.D., FAAP Scott Gunderon, D.O.

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Presentation on theme: "Asthma, Bronchiolitis, and Pnemonia Tintinalli Chapt 123-124. April 18th 2005 Mark Rodkey, M.D., FAAP Scott Gunderon, D.O."— Presentation transcript:

1 Asthma, Bronchiolitis, and Pnemonia Tintinalli Chapt April 18th 2005 Mark Rodkey, M.D., FAAP Scott Gunderon, D.O.

2 Asthma Chronic disease of the tracheobronchial tree characterized by airway obstruction, inflammation, hyperresponsiveness, mucous plugging and edema. Chronic disease of the tracheobronchial tree characterized by airway obstruction, inflammation, hyperresponsiveness, mucous plugging and edema. Recurrent wheezing which responds to bronchodilators. Recurrent wheezing which responds to bronchodilators.

3 Epidemiology 4.8 million children 4.8 million children 40% increase in last decade 40% increase in last decade Risk factors Risk factors Family Hx Family Hx African/American, Asian, Hispanic African/American, Asian, Hispanic Low birth weight Low birth weight Urban household Urban household Low income Low income

4 Pathophysiology Three classifications: Three classifications: extrinsic IgE mediated extrinsic IgE mediated intrinsic infection induced intrinsic infection induced mixed (both IgE and infection) mixed (both IgE and infection)

5 Pathophysiology Less than 2 years old Less than 2 years old viral triggers viral triggers Over 2 Over 2 allergens and irritants are triggers allergens and irritants are triggers

6 Pathophysiology Bronchoconstriction Bronchoconstriction due to histamine and leukotriene release due to histamine and leukotriene release Airway mucosal edema/plugging Airway mucosal edema/plugging

7 Pathophysiology Obstruction Obstruction Air trapping Air trapping Hyperventilation, lowers PaCO2 Hyperventilation, lowers PaCO2 Respiratory failure raises PaCO2 Respiratory failure raises PaCO2

8 Pediatric Anatomy Higher risk for respiratory failure from asthma than adults because of anatomic differences Higher risk for respiratory failure from asthma than adults because of anatomic differences Compliance of infant rib cage and immature diaphragm Compliance of infant rib cage and immature diaphragm paradoxical respiration paradoxical respiration increased work of breathing and fatigue increased work of breathing and fatigue

9 Pediatric Anatomy Less elastic recoil Less elastic recoil more prone to atelectasis more prone to atelectasis increases V/Q mismatch increases V/Q mismatch Thicker airway wall Thicker airway wall greater bronchoconstriction greater bronchoconstriction

10 Pediatric Anatomy Obstruction more likely Obstruction more likely Collapse of lung segments Collapse of lung segments Compensatory mechanisms may mask the extent of dyspnea Compensatory mechanisms may mask the extent of dyspnea

11 Evaluation Before H&P!!!! Before H&P!!!! ABC’s! ABC’s! Shock (respiratory) Shock (respiratory) Oxygen Oxygen β2 agonist β2 agonist

12 Evaluation Peak expiratory flow rate (PEFR) Peak expiratory flow rate (PEFR) pre and post treatments (age 8) pre and post treatments (age 8) values are in liters per minute values are in liters per minute based on child’s height based on child’s height < 50% indicates severe obstruction < 50% indicates severe obstruction < 25% indicates possible hypercarbia < 25% indicates possible hypercarbia

13 Evaluation ABG ABG Impending respiratory failure Impending respiratory failure Hypoventilating Hypoventilating PEFR < 30% of predicted PEFR < 30% of predicted Not responding to treatment Not responding to treatment Disposition (PICU vs RNF) Disposition (PICU vs RNF) Pulse Oximetry Pulse Oximetry Expired CO2 Expired CO2

14 Clinical Evaluation! Respiratory effort Respiratory effort tachypnea, grunt, flare, retractions tachypnea, grunt, flare, retractions air hunger air hunger altered activity altered activity altered mental status altered mental status Forced breath (blow hand) Forced breath (blow hand) recite alphabet in one breath recite alphabet in one breath response to treatment response to treatment

15 Chest X-ray first wheeze first wheeze poor response to treatment poor response to treatment fever fever chest pain chest pain considering FB, pneumo considering FB, pneumo hyperinflation flattened diaphragm barrel-chest PBT atelectasis

16 Differential pneumonia pneumonia FB FB Cystic Fibrosis Cystic Fibrosis BPD BPD CHF (Congenital Heart Disease) CHF (Congenital Heart Disease) Croup Epiglottitis Retropharyngeal abscess Bacterial tracheitis GERD

17 Treatment β2 receptor agonists--albuterol β2 receptor agonists--albuterol activates adenylate cyclase activates adenylate cyclase increases cyclic adenosine monophosphate increases cyclic adenosine monophosphate bronchial smooth muscle relaxation bronchial smooth muscle relaxation binding intracellular calcium to endoplasmic reticulum binding intracellular calcium to endoplasmic reticulum

18 Treatment Xopenex - R isomer of albuterol Xopenex - R isomer of albuterol Salmeterol is a long acting β2 agonist Salmeterol is a long acting β2 agonist NOT indicated in acute setting NOT indicated in acute setting reduces need for Albuterol reduces need for Albuterol

19 Treatment Epinephrine Epinephrine 0.01mL/kg of 1:1000 up to 0.3 mL (0.5?) SQ 0.01mL/kg of 1:1000 up to 0.3 mL (0.5?) SQ 3cc nebulized 3cc nebulized Racemic epi Racemic epi 0.5 mL nebulized 0.5 mL nebulized helps reduce edema? helps reduce edema?

20 Treatment Terbutaline Terbutaline more β2 selective than epi more β2 selective than epi 0.01 mL/kg 1mg/mL, max 0.25 mL 0.01 mL/kg 1mg/mL, max 0.25 mL 5-10 mcg/kg SQ or IV 5-10 mcg/kg SQ or IV may cause myocardial ischemia, tachycardia may cause myocardial ischemia, tachycardia

21 Treatment Corticosteroids (Prednisone, Solumedrol) Corticosteroids (Prednisone, Solumedrol) 1-2 mg/kg/day PO or IV 1-2 mg/kg/day PO or IV Anticholinergics (Atrovent) Anticholinergics (Atrovent) prevents bronchoconstriction induced by guanosine monophosphate prevents bronchoconstriction induced by guanosine monophosphate IV fluids IV fluids Magnesium sulfate Magnesium sulfate not much supporting evidence in Pediatrics not much supporting evidence in Pediatrics

22 Bronchiolitis

23 Bronchiolitis Inflammation of bronchioles Inflammation of bronchioles Usually refers to children under 2 who have a viral URI with some intrathoracic symptoms (wheeze, cough, tightness) Usually refers to children under 2 who have a viral URI with some intrathoracic symptoms (wheeze, cough, tightness)

24 Epidemiology Prevalence late October to May Prevalence late October to May RSV 50-70% RSV 50-70% Influenza Influenza Parainfluenza Parainfluenza

25 RSV Direct contact with secretions Direct contact with secretions Self inoculation hands to eyes and nose Self inoculation hands to eyes and nose Infectious on countertops for > 6 hours Infectious on countertops for > 6 hours Shed up to 9 days in the respiratory tract Shed up to 9 days in the respiratory tract Nasal discharge, pharyngitis, cough Nasal discharge, pharyngitis, cough Fever up to 40C Fever up to 40C Peak symptoms at 3 to 5 days Peak symptoms at 3 to 5 days

26 Physical findings tachypnea, tachycardia, conjunctivitis, retractions, prolonged expiration (I:E), wheezing, hypoxemia tachypnea, tachycardia, conjunctivitis, retractions, prolonged expiration (I:E), wheezing, hypoxemia

27 Evaluation similar to asthma similar to asthma swab nose for RSV, Influenza swab nose for RSV, Influenza CXR CXR

28 Treatment Suction airway Suction airway O2 O2 β2 agonist β2 agonist Albuterol Albuterol Racemic Epi Racemic Epi Epinephrine Epinephrine

29 Treatment Atrovent? Atrovent? Atropine? Atropine? dries secretions dries secretions Steroids? Steroids? for family Hx of asthma for family Hx of asthma

30 Treatment Ribavirin? (Guidance of PICU) Ribavirin? (Guidance of PICU) Pulmonary Disease Pulmonary Disease Cystic Fibrosis Cystic Fibrosis RDS RDS Congenital Heart Disease Congenital Heart Disease

31 Bronchiolitis 70% of children who wheeze in the ED are smoking (passively or actively) 70% of children who wheeze in the ED are smoking (passively or actively)

32 Pneumonia

33 Pneumonia Goals Goals Identify causes of Pneumonia in children Identify causes of Pneumonia in children Describe Respiratory Distress in Pneumonia Describe Respiratory Distress in Pneumonia Review Treatment for Pneumonia Review Treatment for Pneumonia Pediatric Emergency Medicine Pediatric Emergency Medicine

34 Pneumonia Infection within the lung Infection within the lung Viral Viral Bacterial Bacterial Fungal Fungal

35 Epidemiology 40/1000 in preschool children (U.S.) 40/1000 in preschool children (U.S.) 9/1000 in 10 year olds (U.S.) 9/1000 in 10 year olds (U.S.) Mortality < 1% in industrialized nations Mortality < 1% in industrialized nations 5 million deaths under 5years annually in developing countries 5 million deaths under 5years annually in developing countries Fall/Spring—parainfluenza Fall/Spring—parainfluenza Winter—respiratory syncytial virus Winter—respiratory syncytial virus Winter—influenza Winter—influenza Bacterial more common in the winter Bacterial more common in the winter

36 Risk Factors Asthma/RAD/Bronchio litis Asthma/RAD/Bronchio litis Immunocompromise Immunocompromise Previous Insult to Lungs Previous Insult to Lungs Abnormal Anatomy (Immotile Cilia) Abnormal Anatomy (Immotile Cilia) Cystic Fibrosis, Sickle Cell... Cystic Fibrosis, Sickle Cell... Prematurity Malnutrition Low Socioeconomic Status Cigarette Smoke Day Care Foreign Body

37 Pathophysiology Aspiration of infective particles into the lower respiratory tract Aspiration of infective particles into the lower respiratory tract Suppression of normal defenses after viral infection Suppression of normal defenses after viral infection Coexistent viral and bacterial pathogens in children in ¡Ã50% of cases Coexistent viral and bacterial pathogens in children in ¡Ã50% of cases

38 Etiologic Agent Birth to 1 month Birth to 1 month Viruses: CMV Viruses: CMV group B streptococcus, E coli, Klebsiella, Listeria group B streptococcus, E coli, Klebsiella, Listeria 1 to 24 months 1 to 24 months Viruses: RSV, parainfulenza, influenza, adenovirus Viruses: RSV, parainfulenza, influenza, adenovirus Bacteria: Strep pneumoniae, strep pyogenes, staph aureus, H. influenza Bacteria: Strep pneumoniae, strep pyogenes, staph aureus, H. influenza

39 Etiologic Agent 2 to 5 years 2 to 5 years Viruses: Influenza, adenovirus Viruses: Influenza, adenovirus Bacteria: Strep pneumoniae Bacteria: Strep pneumoniae 5 to 18 years 5 to 18 years Viruses: RSV, adenovirus Viruses: RSV, adenovirus Bacteria: Mycoplasma, Strep pneumoniae, Chlamydia pneumoniae Bacteria: Mycoplasma, Strep pneumoniae, Chlamydia pneumoniae

40 Special Concerns Staph aureus Staph aureus rapid progression, abscesses rapid progression, abscesses Grp A Strep Grp A Strep invasive, necrotizing fasciitis, empyema invasive, necrotizing fasciitis, empyema Gram neg bacilli Gram neg bacilli recently hospitalized patients recently hospitalized patients

41 Special Concerns B. pertussis B. pertussis paroxysmal cough paroxysmal cough C. trachomatis C. trachomatis maternal exposure, conjunctivitis maternal exposure, conjunctivitis M. pneumoniae M. pneumoniae rash (Erythema Multiforme) rash (Erythema Multiforme)

42 Special Concerns RSV mortality rate RSV mortality rate Congenital Heart up to 35% Congenital Heart up to 35% Congenital Heart w/ Pulmonary HTN up to 70% Congenital Heart w/ Pulmonary HTN up to 70%

43 Symptoms cough cough fever fever chest pain chest pain fatigue fatigue gasping gasping tachypnea apnea abdominal pain nausea

44 Findings respiratory distress respiratory distress tachypnea, grunting, flaring, retracting tachypnea, grunting, flaring, retracting abnormal auscultatory findings??? abnormal auscultatory findings??? cyanosis cyanosis chest X-ray - infiltrates chest X-ray - infiltrates

45 CXR Findings Viral Viral diffuse interstitial infiltrates diffuse interstitial infiltrates Bacterial Bacterial consolidated, lobar consolidated, lobar Mycoplasma Mycoplasma diffuse diffuse

46 Lab CBC CBC elevated WBC, left shift elevated WBC, left shift Blood Culture Blood Culture Cold Agglutins Cold Agglutins Sputum Culture Sputum Culture ABG ABG May help with placement May help with placement RSV RSV Influenza Influenza

47 Appearance History is not as useful History is not as useful Examination is paramount Examination is paramount Observation Observation vigorous crying vigorous crying playful playful quiet is bad! quiet is bad!

48 Signs of Respiratory Distress Tachypnea Tachypnea Retractions Retractions Flaring Flaring Grunting Grunting Abdominal Breathing (seesaw) Abdominal Breathing (seesaw) Bradypnea Bradypnea Signs of Respiratory Distress Signs of Respiratory Distress Wheezing Wheezing Stridor 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

49 Evaluation of Respiratory Distress High Expired CO2 High Expired CO2 CXR CXR Soft Tissue Neck X-ray Soft Tissue Neck X-ray Response to Treatment Response to Treatment Pulse Oximetry???? Pulse Oximetry???? should not guide acute treatment decisions should not guide acute treatment decisions misleading misleading inaccurate inaccurate

50 Treatment Position/Support/Maintain Airway Position/Support/Maintain Airway Wipe Nose! Wipe Nose! Remove Foreign Bodies Remove Foreign Bodies Oxygen Oxygen Cool Mist (H2O or NS?) Cool Mist (H2O or NS?)

51 Antibiotics? Birth to 1 month - Amp + Gent, Cefotaxime Birth to 1 month - Amp + Gent, Cefotaxime 1 to 24 months - Amoxil, cephalosporin 1 to 24 months - Amoxil, cephalosporin 2 to 5 years - Amoxil, cephalosporin 2 to 5 years - Amoxil, cephalosporin over 5 years - Zithromax, Biaxin over 5 years - Zithromax, Biaxin Resistant S. pneumoniae - vancomycin Resistant S. pneumoniae - vancomycin

52 Antibiotics? Viral Viral support support acyclovir? acyclovir? ribavirin? ribavirin?

53 Treatment Beta agonist Beta agonist IVF (except cardiogenic and resp?) IVF (except cardiogenic and resp?) 10-20cc/kg 10-20cc/kg normal saline or Ringer’s normal saline or Ringer’s never sugar in bolus (unless calculated) never sugar in bolus (unless calculated) Oxygen & Albuterol Oxygen & Albuterol

54 Intubation Cardio/Respiratory Failure Cardio/Respiratory Failure Uncompensated Shock Uncompensated Shock Unable to maintain airway ** Unable to maintain airway ** ETT size ETT size age/4 + 4, insert 3 x size of tube age/4 + 4, insert 3 x size of tube small fingernail small fingernail nares nares

55 Disposition - Admit Hypoxia Hypoxia < 3 months old < 3 months old Shock Shock Dyspnea Dyspnea Activity Level Activity Level Extensive ED Treatment Extensive ED Treatment

56 Complications Viral pneumonia Viral pneumonia resolve spontaneously without specific Tx resolve spontaneously without specific Tx Bacterial pneumonia Bacterial pneumonia dehydration, bronchiolitis obliterans, apnea dehydration, bronchiolitis obliterans, apnea pleural effusions, empyemas, pneumothorax, pneumatoceles, development of additional infectious foci pleural effusions, empyemas, pneumothorax, pneumatoceles, development of additional infectious foci

57 Cases Case 1 Case 1 16 month old boy, respiratory distress 16 month old boy, respiratory distress RR 40, HR 140, T 39.2C RR 40, HR 140, T 39.2C Rash Rash Case 2 Case 2 7 year old boy, cough 7 year old boy, cough RR 20, HR 105, T 38.2C RR 20, HR 105, T 38.2C Hx TE Fistula, Cleft Palate, RAD Hx TE Fistula, Cleft Palate, RAD

58 Cases Case 3 Case 3 6 day old boy, respiratory distress 6 day old boy, respiratory distress RR 64, HR 160 RR 64, HR 160 Case 4 Case 4 9 month old boy, respiratory distress, shock 9 month old boy, respiratory distress, shock RR 60, HR 170, T 37.5 RR 60, HR 170, T 37.5 green nasal d/c green nasal d/c

59 Cases Case 5 Case 5 3 month old boy, CPR 3 month old boy, CPR RR 0, HR 0 RR 0, HR 0 Case 6 Case 6 5 year old boy, cough, fever, rash 5 year old boy, cough, fever, rash RR 20, HR 100, T 38.7C RR 20, HR 100, T 38.7C

60 Cases Case 7 Case 7 2 year old boy 2 year old boy Cough, fever Cough, fever Tachypnea, retracting, grunting, flaring Tachypnea, retracting, grunting, flaring Lungs clear Lungs clear RR 42, HR 140, T 38.3C RR 42, HR 140, T 38.3C Case 8 Case 8 4 year old boy, Down Syndrome 4 year old boy, Down Syndrome Cough, Fever, Tachypea Cough, Fever, Tachypea Grunting, Flaring, Retracting Grunting, Flaring, Retracting RR 32, HR 120 RR 32, HR 120

61 Cases Case 9 Case 9 13 year old boy 13 year old boy Cough, Fever, Tachypea, Chest Pain Cough, Fever, Tachypea, Chest Pain Grunting, Flaring, Retracting Grunting, Flaring, Retracting Decreased BS on Left Decreased BS on Left RR 32, HR 120 RR 32, HR 120 Case 10 Case year old boy, Christmas Day 14 year old boy, Christmas Day Cough, Fever Cough, Fever RR 18, HR 96 RR 18, HR 96 WBC 4.0 WBC 4.0

62 Cases Case 11 Case 11 8 year old girl, 5 year old boy, siblings 8 year old girl, 5 year old boy, siblings Cough, Fever, Tachypea Cough, Fever, Tachypea Lungs clear Lungs clear Case 12 Case month old girl, Situs TOGA Diaphrag Hernia 10 month old girl, Situs TOGA Diaphrag Hernia Cough, Fever, Tachypea Cough, Fever, Tachypea Grunting, Flaring, Retracting Grunting, Flaring, Retracting RR 48, HR 160 RR 48, HR 160

63 Cases Case 13 Case 13 4 year old boy 4 year old boy Cough, Fever, Tachypea Cough, Fever, Tachypea Coarse BS Coarse BS RR 48, HR 120, T 38.6C RR 48, HR 120, T 38.6C Case 14 Case month old boy 14 month old boy Cough, Fever, Tachypea Cough, Fever, Tachypea Clear BS Clear BS RR 48, HR 120, T 39C RR 48, HR 120, T 39C

64 Summary Recognize Respiratory Distress Recognize Respiratory Distress Low Threshold to Consider Pneumonia Low Threshold to Consider Pneumonia Treatment for Respiratory Distress, then Pneumonia Treatment for Respiratory Distress, then Pneumonia Normal Breath Sounds Normal Breath Sounds DO NOT R/O PNEUMONIA! DO NOT R/O PNEUMONIA!


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