Asthma Bronchiolitis p Nemo Nia
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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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Asthma
Chronic disease of the tracheobronchial treecharacterized by airway obstruction,inflammation, hyperresponsiveness, mucous
plugging and edema.
Recurrent wheezing which responds tobronchodilators.
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Epidemiology
4.8 million children
40% increase in last decade
Risk factors Family Hx
African/American, Asian, Hispanic
Low birth weight Urban household
Low income
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Pathophysiology
Three classifications: extrinsic IgE mediated
intrinsic infection induced
mixed (both IgE and infection)
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Pathophysiology
Less than 2 years old viral triggers
Over 2 allergens and irritants are triggers
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Pathophysiology
Bronchoconstriction due to histamine and leukotriene release
Airway mucosal edema/plugging
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Pathophysiology
Obstruction
Air trapping
Hyperventilation, lowers PaCO2 Respiratory failure raises PaCO2
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Pediatric Anatomy
Higher risk for respiratory failure from asthmathan adults because of anatomic differences
Compliance of infant rib cage and immaturediaphragm paradoxical respiration
increased work of breathing and fatigue
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Pediatric Anatomy
Less elastic recoil more prone to atelectasis
increases V/Q mismatch
Thicker airway wall greater bronchoconstriction
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Pediatric Anatomy
Obstruction more likely
Collapse of lung segments
Compensatory mechanisms may mask the extentof dyspnea
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Evaluation
Before H&P!!!!
ABC’s!
Shock (respiratory) Oxygen
β2 agonist
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Evaluation
Peak expiratory flow rate (PEFR) pre and post treatments (age 8)
values are in liters per minute
based on child’s height
< 50% indicates severe obstruction
< 25% indicates possible hypercarbia
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Evaluation
ABG Impending respiratory failure
Hypoventilating
PEFR < 30% of predicted
Not responding to treatment
Disposition (PICU vs RNF)
Pulse Oximetry
Expired CO2
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Clinical Evaluation!
Respiratory effort tachypnea, grunt, flare, retractions
air hunger
altered activity
altered mental status
Forced breath (blow hand) recite alphabet in one breath
response to treatment
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Chest X-ray
first wheeze
poor response totreatment
fever chest pain
considering FB, pneumo
hyperinflation
flattened diaphragm
barrel-chest
PBT
atelectasis
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Differential
pneumonia
FB
Cystic Fibrosis
BPD
CHF (Congenital HeartDisease)
Croup
Epiglottitis
Retropharyngeal abscess
Bacterial tracheitis
GERD
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Treatment
β2 receptor agonists--albuterol activates adenylate cyclase
increases cyclic adenosine monophosphate
bronchial smooth muscle relaxation
binding intracellular calcium to endoplasmicreticulum
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Treatment
Xopenex - R isomer of albuterol
Salmeterol is a long acting β2 agonist NOT indicated in acute setting
reduces need for Albuterol
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Treatment
Epinephrine 0.01mL/kg of 1:1000 up to 0.3 mL (0.5?) SQ
3cc nebulized
Racemic epi 0.5 mL nebulized
helps reduce edema?
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Treatment
Terbutaline more β2 selective than epi
0.01 mL/kg 1mg/mL, max 0.25 mL
5-10 mcg/kg SQ or IV
may cause myocardial ischemia, tachycardia
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Treatment
Corticosteroids (Prednisone, Solumedrol) 1-2 mg/kg/day PO or IV
Anticholinergics (Atrovent) prevents bronchoconstriction induced by guanosine
monophosphate
IV fluids
Magnesium sulfate not much supporting evidence in Pediatrics
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Bronchiolitis
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Bronchiolitis
Inflammation of bronchioles
Usually refers to children under 2 who have a viral URI with some intrathoracic symptoms(wheeze, cough, tightness)
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Epidemiology
Prevalence late October to May
RSV 50-70%
Influenza Parainfluenza
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RSV
Direct contact with secretions
Self inoculation hands to eyes and nose
Infectious on countertops for > 6 hours Shed up to 9 days in the respiratory tract
Nasal discharge, pharyngitis, cough
Fever up to 40C Peak symptoms at 3 to 5 days
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Physical findings
tachypnea, tachycardia, conjunctivitis,retractions, prolonged expiration (I:E), wheezing, hypoxemia
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Evaluation
similar to asthma
swab nose for RSV, Influenza
CXR
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Treatment
Suction airway
O2
β2 agonist Albuterol
Racemic Epi
Epinephrine
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Treatment
Atrovent?
Atropine? dries secretions
Steroids? for family Hx of asthma
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Treatment
Ribavirin? (Guidance of PICU)
Pulmonary Disease
Cystic Fibrosis RDS
Congenital Heart Disease
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Bronchiolitis
70% of children who wheeze in the ED aresmoking (passively or actively)
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Pneumonia
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Pneumonia
Goals Identify causes of Pneumonia in children
Describe Respiratory Distress in Pneumonia
Review Treatment for Pneumonia
Pediatric Emergency Medicine
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Pneumonia
Infection within the lung
Viral
Bacterial Fungal
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Epidemiology
40/1000 in preschool children (U.S.) 9/1000 in 10 year olds (U.S.)
Mortality < 1% in industrialized nations
5 million deaths under 5years annually in developingcountries
Fall/Spring — parainfluenza
Winter — respiratory syncytial virus
Winter — influenza Bacterial more common in the winter
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Risk Factors
Asthma/RAD/Bronchiolitis
Immunocompromise
Previous Insult to Lungs Abnormal Anatomy
(Immotile Cilia)
Cystic Fibrosis, SickleCell . . .
Prematurity
Malnutrition
Low Socioeconomic
Status Cigarette Smoke
Day Care
Foreign Body
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Pathophysiology
Aspiration of infective particles into the lowerrespiratory tract
Suppression of normal defenses after viralinfection
Coexistent viral and bacterial pathogens inchildren in ¡Ã50% of cases
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Etiologic Agent
Birth to 1 month Viruses: CMV
group B streptococcus, E coli, Klebsiella, Listeria
1 to 24 months Viruses: RSV, parainfulenza, influenza, adenovirus
Bacteria: Strep pneumoniae, strep pyogenes, staph
aureus, H. influenza
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Etiologic Agent
2 to 5 years Viruses: Influenza, adenovirus
Bacteria: Strep pneumoniae
5 to 18 years Viruses: RSV, adenovirus
Bacteria: Mycoplasma, Strep pneumoniae, Chlamydia
pneumoniae
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Special Concerns
Staph aureus rapid progression, abscesses
Grp A Strep invasive, necrotizing fasciitis, empyema
Gram neg bacilli recently hospitalized patients
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Special Concerns
B. pertussis paroxysmal cough
C. trachomatis maternal exposure, conjunctivitis
M. pneumoniae rash (Erythema Multiforme)
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Findings
respiratory distress tachypnea, grunting, flaring, retracting
abnormal auscultatory findings???
cyanosis
chest X-ray - infiltrates
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CXR Findings
Viral diffuse interstitial infiltrates
Bacterial consolidated, lobar
Mycoplasma diffuse
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Lab
CBC elevated WBC, left shift
Blood Culture
Cold Agglutins Sputum Culture
ABG
May help with placement
RSV Influenza
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Appearance
History is not as useful
Examination is paramount
Observation vigorous crying
playful
quiet is bad!
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Signs of Respiratory Distress
Tachypnea Retractions
Flaring
Grunting
Abdominal Breathing(seesaw)
Bradypnea
Signs of Respiratory Distress
Wheezing 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
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Evaluation of Respiratory Distress
High Expired CO2
CXR
Soft Tissue Neck X-ray
Response to Treatment
Pulse Oximetry????
should not guide acute treatment decisions misleading
inaccurate
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Antibiotics?
Birth to 1 month - Amp + Gent, Cefotaxime
1 to 24 months - Amoxil, cephalosporin
2 to 5 years - Amoxil, cephalosporin
over 5 years - Zithromax, Biaxin
Resistant S. pneumoniae - vancomycin
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Antibiotics?
Viral support
acyclovir?
ribavirin?
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Treatment
Beta agonist
IVF (except cardiogenic and resp?) 10-20cc/kg
normal saline or Ringer’s
never sugar in bolus (unless calculated)
Oxygen & Albuterol
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Intubation
Cardio/Respiratory Failure
Uncompensated Shock
Unable to maintain airway **
ETT size age/4 + 4, insert 3 x size of tube
small fingernail
nares
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Disposition - Admit
Hypoxia
< 3 months old
Shock
Dyspnea
Activity Level
Extensive ED Treatment
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Complications
Viral pneumonia resolve spontaneously without specific Tx
Bacterial pneumonia dehydration, bronchiolitis obliterans, apnea
pleural effusions, empyemas, pneumothorax,pneumatoceles, development of additional infectious
foci
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Cases
Case 1 16 month old boy, respiratory distress
RR 40, HR 140, T 39.2C
Rash
Case 2
7 year old boy, cough RR 20, HR 105, T 38.2C
Hx TE Fistula, Cleft Palate, RAD
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Cases
Case 3 6 day old boy, respiratory distress
RR 64, HR 160
Case 4 9 month old boy, respiratory distress, shock
RR 60, HR 170, T 37.5
green nasal d/c
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Cases
Case 5 3 month old boy, CPR
RR 0, HR 0
Case 6 5 year old boy, cough, fever, rash
RR 20, HR 100, T 38.7C
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Cases
Case 7 2 year old boy
Cough, fever
Tachypnea, retracting, grunting, flaring Lungs clear
RR 42, HR 140, T 38.3C
Case 8 4 year old boy, Down Syndrome
Cough, Fever, Tachypea Grunting, Flaring, Retracting RR 32, HR 120
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Cases
Case 9 13 year old boy
Cough, Fever, Tachypea, Chest Pain
Grunting, Flaring, Retracting Decreased BS on Left
RR 32, HR 120
Case 10 14 year old boy, Christmas Day
Cough, Fever RR 18, HR 96 WBC 4.0
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Cases
Case 11 8 year old girl, 5 year old boy, siblings Cough, Fever, Tachypea
Lungs clear
Case 12 10 month old girl, Situs TOGA Diaphrag Hernia
Cough, Fever, Tachypea Grunting, Flaring, Retracting
RR 48, HR 160
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Cases
Case 13 4 year old boy Cough, Fever, Tachypea Coarse BS
RR 48, HR 120, T 38.6C
Case 14 14 month old boy
Cough, Fever, Tachypea Clear BS RR 48, HR 120, T 39C
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Summary
Recognize Respiratory Distress
Low Threshold to Consider Pneumonia
Treatment for Respiratory Distress, thenPneumonia
Normal Breath Sounds
DO NOT R/O PNEUMONIA!