Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants...
Transcript of Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants...
![Page 1: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/1.jpg)
Acute Respiratory Distress in Infants and Children
Mantosh S. Rattan, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati College of Medicine
![Page 2: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/2.jpg)
Etiologies of respiratory distress
Common radiographic presentations
Cases presenting through the Emergency Department
![Page 3: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/3.jpg)
3-month-old previously healthy female
Mild congestion and decreased oral intake for 24 hrs.
Transferred to ED after being seen in local urgent care
Tachypnea with grunting
Hypoxic
Afebrile
![Page 4: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/4.jpg)
Large cardiopericardial silhouette
Fissural thickening
Ill defined pulmonary vasculature
Lower lobe atelectasis (left > right)
![Page 5: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/5.jpg)
Volume overload L to R shunts
Valvular insufficiency
Systemic AV communication
Pressure overload Outflow or inflow obstruction
Disorders affecting the inotropic state Myocarditis, electrolyte disturbances, hypoxia, acidosis,
cardiomyopathies, coronary artery lesions, metabolic derangements, septic shock
Alterations in the chronotropic state SVT, VT, complete heart block
![Page 6: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/6.jpg)
Age is critical
Drop in pulmonary vascular resistance (falls in the first 3 months of life)
Ventricular septal defect (VSD)
Patent ductus arteriosus (PDA)
Anomalous left coronary artery from the pulmonary artery (ALCAPA)
![Page 7: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/7.jpg)
Isolated VSD 2-6/1,000 live births
20% CHD Second to BAV
Small VSDs Asymptomatic
Excellent long term prognosis
Moderate/Large VSD Trial of medical therapy
Uncontrolled HF Surgical repair
![Page 8: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/8.jpg)
Centers for Disease Control and Prevention
![Page 9: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/9.jpg)
Functionally closed within 48 hrs. after birth Most authorities consider patent ductus abnormal ˃
3 months
Term infants 1 in 2,000 births
Hemodynamic impact of PDA determined by magnitude of shunting Flow resistance of the ductus arteriosus Length
Narrowest diameter
Overall shape and configuration
![Page 10: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/10.jpg)
![Page 11: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/11.jpg)
Anomalous left coronary artery from the pulmonary artery
AKA Bland-Garland-White syndrome
1 in 300,000 live births
Usually isolated
![Page 12: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/12.jpg)
Spectrum of pathophysiologic changes that take place after birth in patients
with ALCAPA
Peña E et al. Radiographics 2009;29:553-565
©2009 by Radiological Society of North America
![Page 13: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/13.jpg)
![Page 14: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/14.jpg)
![Page 15: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/15.jpg)
![Page 16: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/16.jpg)
![Page 17: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/17.jpg)
Primary cardiomyopathy
Dilated
Hypertrophic
Restrictive
Secondary
Arrhythmogenic
Ischemic
Toxic
Infiltrative
Infectious
![Page 18: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/18.jpg)
![Page 19: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/19.jpg)
ECHO
Severely dilated LV
Severely depressed LV systolic performance
EF 15%
No VSD/PDA
Normal coronaries
Cardiac catherization
Endomyocardial biopsy
Active myocarditis
![Page 20: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/20.jpg)
Inflammation of cardiac muscle
Myocellular damage heart failure
Causes Infectious (most common cause in pediatrics) Viral (enterovirus, adenovirus, parvovirus, HHV-6)
Toxic
Autoimmune
Mean age of Dx 9.2 years Bimodal distribution Between 6 and 12 months of age (infancy)
16 years of age (adolescence)
![Page 21: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/21.jpg)
![Page 22: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/22.jpg)
![Page 23: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/23.jpg)
![Page 24: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/24.jpg)
10-month-old boy with recurrent respiratory distress
Seen in the ED with admissions at the ages of 5, 7, 8, and now at 10 months
Born after full term gestation and had received all routine immunizations
No pets in the house
Father, maternal grandmother, paternal grandfather, and sibling with asthma
![Page 25: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/25.jpg)
With each admission retractions, cough, and tachypnea with fine crackles were described on physical exam with O2 sat between 85-90% on room air
Each time, his condition improved with supplemental oxygen, prednisolone, nebulizer treatments, and antibiotics
d/c home after 5 to 7 days following each admission
![Page 26: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/26.jpg)
• Symmetric hyperinflation • Parahilar opacities
![Page 27: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/27.jpg)
Reactive airway disease
Not unusual in infants and can be seen in up to 19% of children
Many names including transient early wheeze
Underlying cause small airways of infants
With infection airway diameter ↓ = wheeze
Gradually resolves with growth of airways
Hyperinflation and wheeze are characteristic
Persistent fine crackles and prolonged hypoxemia are not consistent with RAD
![Page 28: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/28.jpg)
Congenital heart disease Clinically confined to the respiratory system Normal auscultatory exam
Immunodeficiency No true documented infections
No history of recurrent/incompletely cleared Otitis
Sinusitis
Pharyngitis
Conjunctivitis
Normal growth
![Page 29: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/29.jpg)
Diffuse/Interstitial Lung Disease
In pediatric patients, a diagnosis of ILD is considered when the child has (chILD syndrome):
Respiratory symptoms(cough, rapid breathing, exercise intolerance)
Signs (resting tachypnea, adventitious sounds, retractions, clubbing, FTT)
Hypoxemia
Diffuse abnormalities on CXR or CT
75% cases are manifested before 1 year of age
![Page 30: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/30.jpg)
Disorders more prevalent in infancy
Diffuse developmental disorders
Alveolar growth abnormalities
Pulmonary interstitial glycogenosis (PIG)*
Neuroendocrine cell hyperplasia of infancy (NEHI)*
Surfactant dysfunction disorders
*Specific conditions of undefined etiology
![Page 31: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/31.jpg)
Acinar dysplasia
Congenital alveolar dysplasia
Alveolar capillary dysplasia with misalignment of pulmonary veins
Term infants present in the immediate neonatal period Rapid progressive respiratory failure
Severe pulmonary HTN
Universally fatal (1 case of successful lung transplant)
![Page 32: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/32.jpg)
![Page 33: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/33.jpg)
Most common cause of diffuse lung disease in infancy
Impaired alveolarization
Lobular simplification
Fewer and larger alveoli
Deficient septation and vascularization
![Page 34: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/34.jpg)
Prenatal
Reduced in utero thoracic space
CDH, oligohydramnios, CPAM/seqeustration, skeletal dysplasia
Postnatal
Chronic neonatal lung disease/”new” BPD
Extremely premature neonates
Arrested or delayed alveolar and pulmonary vascular development
CHD, genetic disorders (trisomy 21, filamin A X-linked gene), primary idiopathic
![Page 35: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/35.jpg)
Prematurity Congenital chylothorax
CHD Trisomy 21
![Page 36: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/36.jpg)
Unknown etiology ? Reactive feature that associates with conditions related
to lung development and injury*
Glycogen-laden mesenchymal cells in alveolar interstitium Patchy or diffuse
Particularly common in alveolar growth abnormalities Patchy PIG present in 40% of lung biopsies having lung
growth abnormalities*
Most common in neonates (immediately or soon after birth) and very young infants
*Deutsch et al (2007) Am J Respir Crit Care Med 176
*Deutsch GH, Young LR (2010) Pediatric Radiology 40
![Page 37: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/37.jpg)
PIG with alveolar growth abnormality
PIG in a patient with aortic coarctation
![Page 38: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/38.jpg)
Genetic mutations in proteins involved in surfactant metabolism
ABCA3
Surfactant protein B (SP-B)
Surfactant protein C (SP-C)
GM-CSF-Rα
Thyroid transcription factor 1 (TTF-1)
Solute carrier 747
![Page 39: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/39.jpg)
Autosomal recessive mutations in SP-B Severe respiratory distress within hours of birth
Unresponsive to exogenous surfactant or ECHMO
Fatal within a few months without lung transplant
Autosomal recessive ABCA3 and inherited/spontaneous autosomal dominant SP-C mutations Variable expression
Acute severe respiratory distress to chronic diffuse lung disease in children or adults
![Page 40: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/40.jpg)
ABCA3 mutation Surfactant protein C mutation
![Page 41: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/41.jpg)
INSPIRATION EXPIRATION
![Page 42: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/42.jpg)
# pulmonary neuroendocrine cells Within bronchiolar epithelium
Bombesin stain
Lack of inflammatory cells
Usually presents in infancy Tachypnea
Hypoxemia
Crackles
↑ Symptoms with viral respiratory infections
Infant PFT Significant air trapping and airway obstruction
![Page 43: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/43.jpg)
Treatment
Supportive
O2 supplementation
Nutritional support
Bronchodilators/Corticosteroids
Only beneficial during treatment of superimposed viral infxn
No reported deaths
![Page 44: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/44.jpg)
Radiography Hyperinflation
Resembles RAD/bronchiolitis
CT Air trapping
Geographic ground-glass opacities Middle lobe
Lingula
Paramediastinal
Characteristic symptoms, CT findings, and infant PFT for NEHI Forego lung biopsy
![Page 45: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/45.jpg)
5-year-old fully immunized otherwise health girl
Fever
Tachypnea (RR 60s)
Hypoxia (Sp02 85% RA)
![Page 46: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/46.jpg)
Differential Diagnosis
Age
Neonatal or beyond
Clinical symptoms
Position of mediastinal structures
![Page 47: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/47.jpg)
Ipsilateral mediastinal displacement
Lung collapse
Severe respiratory symptoms
DDx
Endobronchial foreign body
Mucus plug (asthma, surgery)
Endobronchial tumor
Extrinsic bronchial compression
Radiography
Interrupted bronchus
+- pneumomediastinum/subcutaneous gas
![Page 48: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/48.jpg)
Aspirated chicken obstructing left main bronchus
![Page 49: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/49.jpg)
![Page 50: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/50.jpg)
![Page 51: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/51.jpg)
Mucoepidermoid carcinoma
![Page 52: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/52.jpg)
![Page 53: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/53.jpg)
Necrotic left hilar adenopathy → Mycobacterium Avium
![Page 54: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/54.jpg)
Necrotic left hilar adenopathy → Mycobacterium Avium
![Page 55: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/55.jpg)
DDx
Isolated pleural effusion
Congenital malformations (secondary infection)
Pneumonia with pleural effusion
Tumor
Imaging
US extremely useful
Detect and characterize pleural effusion
Characterize consolidation
Potentially differentiate tumor from consolidation
![Page 56: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/56.jpg)
![Page 57: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/57.jpg)
Pleuropulmonary Blastoma
![Page 58: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/58.jpg)
T-Cell Lymphoma
![Page 59: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/59.jpg)
![Page 60: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/60.jpg)
![Page 61: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/61.jpg)
![Page 62: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/62.jpg)
Uncommon but increasing complication of community acquired pneumonia
Staphlococcus aureus, Streptococcus pneumoniae most common
Lung necrosis and cavitation
Microangiopathic changes
Thrombosis of intrapulmonary blood vessels
![Page 63: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/63.jpg)
US similar to CT in detection of lung necrosis and lung abscess*
Increased lung water in inflammation
Renders parenchyma visible
Hepatization
Dynamic air bronchogram
Altered echogenicity and vascularity
Necrosis
*Kurian J et al. AJR Dec 2009
![Page 64: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/64.jpg)
15-year-old male with sudden onset sharp left chest pain
SOB at rest and with minimal exertion with no improvement overnight prior to arrival at ED
![Page 65: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/65.jpg)
![Page 66: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/66.jpg)
Primary
No underlying lung disease that would predispose to air leak
Asthenic body habitus
Increased transpulmonary pressure
Valsalva manuever
Diving/military flying
![Page 67: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/67.jpg)
Secondary
Complication of underlying lung disease
Asthma
CF
Necrotizing pneumonia
ILD
![Page 68: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/68.jpg)
![Page 69: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/69.jpg)
Etiology
Mechanical stress highest at lung apices
Larger alveoli
More negative intrapleural pressures
Alveolar rupture forming air collection beneath visceral pleura (bleb)
Rupture of apical subpleural bleb PTX
Pleural porosity
Replacement of mesothelial cells in the pleura by porous inflammatory cell layer air leakage
![Page 70: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/70.jpg)
Resolved left PTX with chest tube
3 week f/u no symptoms
Repeat radiograph showing bi-apical irregularity
![Page 71: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/71.jpg)
Returns to ED 3 months later
New sudden onset right chest pain and SOB
Pain started after coughing
![Page 72: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/72.jpg)
Substantial residual PTX when placed to water seal
CT chest to “evaluate parenchyma”
![Page 73: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/73.jpg)
![Page 74: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/74.jpg)
Right greater than left apical “blebs” and left apical “lines”
![Page 75: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/75.jpg)
Ipsilateral apical blebs identified in 28% of children (13-19 years) with PSP
Published adult series varies from 56% to 88%
78% of the imaged events with blebs ipsilateral to the PTX also showed contralateral blebs
100% of the identified lesions in the apical subpleural regions
Limited CT confined to upper zones ↓ radiation exposure
Guimaraes C, Donnelly L et al. Pediatric Radiology (2007)
![Page 76: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/76.jpg)
Linear opacities seen at the apices of the lungs on the cephalad most axial images
56% of pts with PSP and 28% of age and gender matched controls
? Normal variant
Should not be confused with apical blebs
Guimaraes C, Donnelly L, et al. Pediatric Radiology (2007)
![Page 77: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/77.jpg)
Goals
Treat acute episode
Prevent recurrence
Recurrence
Following first episode between 50-60%
Children tx with O2 or chest tube
Higher than rates reported in adults
Currently no evidence to support the use of CT and subequent surgical intervention in first episodes of PSP*
*Robinson P.D et al. Pediatric Respiratory Reviews (2009)
![Page 78: Acute Respiratory Distress in Infants and · PDF fileAcute Respiratory Distress in Infants and Children ... electrolyte disturbances, hypoxia, ... Nutritional support](https://reader031.fdocuments.net/reader031/viewer/2022022002/5a909a027f8b9a7f398e18ab/html5/thumbnails/78.jpg)
Clinical presentation of CHD is often age dependent…don’t forget ALCAPA
Keep DLD in the back of your mind when seeing infants with repeat “viral/RAD”
Ultrasound is your friend…especially with thoracic infections More commonly being used for lung evaluation PTX
Alveolar/interstitial syndromes
Limit chest CT to apices in primary spontaneous PTX