Asthma, Bronchiolitis, and Pnemonia

Tintinalli Chapt 123-124. April 18th 2005

Mark Rodkey, M.D., FAAP Scott Gunderon, D.O.

Asthma

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

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

Pathophysiology

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

Pathophysiology

Less than 2 years old

viral triggers

Over 2

allergens and irritants are triggers

Pathophysiology

Bronchoconstriction

due to histamine and leukotriene release

Airway mucosal edema/plugging

Pathophysiology

Obstruction Air trapping Hyperventilation, lowers PaCO2 Respiratory failure raises PaCO2

Pediatric Anatomy

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

Pediatric Anatomy

Less elastic recoil

more prone to atelectasis increases V/Q mismatch

Thicker airway wall

greater bronchoconstriction

Pediatric Anatomy

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

Evaluation

Before H&P!!!! ABCs! Shock (respiratory) Oxygen 2 agonist

Evaluation

Peak expiratory flow rate (PEFR)

pre and post treatments (age 8) values are in liters per minute based on childs height

< 50% indicates severe obstruction < 25% indicates possible hypercarbia

Evaluation

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

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

Chest X-ray

first wheeze poor response to treatment fever chest pain considering FB, pneumo

hyperinflation flattened diaphragm barrel-chest PBT atelectasis

Differential

pneumonia FB Cystic Fibrosis BPD CHF (Congenital Heart Disease)

Croup Epiglottitis Retropharyngeal abscess Bacterial tracheitis GERD

Treatment

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

Treatment

Xopenex - R isomer of albuterol Salmeterol is a long acting 2 agonist

NOT indicated in acute setting reduces need for Albuterol

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?

Treatment

Terbutaline
more 2 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

Treatment

Corticosteroids (Prednisone, Solumedrol)

1-2 mg/kg/day PO or IV
prevents bronchoconstriction induced by guanosine monophosphate

Anticholinergics (Atrovent)

IV fluids Magnesium sulfate

not much supporting evidence in Pediatrics

Bronchiolitis

Bronchiolitis

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

Epidemiology

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

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

Physical findings

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

Evaluation

similar to asthma swab nose for RSV, Influenza CXR

Treatment

Suction airway O2 2 agonist Albuterol Racemic Epi Epinephrine

Treatment

Atrovent? Atropine?

dries secretions for family Hx of asthma

Steroids?

Treatment

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

Bronchiolitis

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

Pneumonia

Pneumonia

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

Pneumonia

Infection within the lung Viral Bacterial Fungal

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 developing countries Fall/Springparainfluenza Winterrespiratory syncytial virus Winterinfluenza Bacterial more common in the winter

Risk Factors

Asthma/RAD/Bronchio litis Immunocompromise Previous Insult to Lungs Abnormal Anatomy (Immotile Cilia) Cystic Fibrosis, Sickle Cell . . .

Prematurity Malnutrition Low Socioeconomic Status Cigarette Smoke Day Care Foreign Body

Pathophysiology

Aspiration of infective particles into the lower respiratory tract Suppression of normal defenses after viral infection Coexistent viral and bacterial pathogens in children in 50% of cases

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

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

Special Concerns

Staph aureus

rapid progression, abscesses

invasive, necrotizing fasciitis, empyema recently hospitalized patients

Grp A Strep

Gram neg bacilli

Special Concerns

B. pertussis

paroxysmal cough
maternal exposure, conjunctivitis rash (Erythema Multiforme)

C. trachomatis

M. pneumoniae

Special Concerns

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

Symptoms

cough fever chest pain fatigue gasping

tachypnea apnea abdominal pain nausea

Findings

respiratory distress

tachypnea, grunting, flaring, retracting

abnormal auscultatory findings??? cyanosis chest X-ray - infiltrates

CXR Findings

Viral

diffuse interstitial infiltrates

consolidated, lobar diffuse

Bacterial

Mycoplasma

Lab

CBC

elevated WBC, left shift

Blood Culture Cold Agglutins Sputum Culture ABG May help with placement RSV Influenza

Appearance

History is not as useful Examination is paramount Observation

vigorous crying playful quiet is bad!

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

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

Treatment

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

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

Antibiotics?

Viral
support acyclovir? ribavirin?

Treatment

Beta agonist IVF (except cardiogenic and resp?)

10-20cc/kg normal saline or Ringers never sugar in bolus (unless calculated)

Oxygen & Albuterol

Intubation

Cardio/Respiratory Failure Uncompensated Shock Unable to maintain airway ** ETT size

age/4 + 4, insert 3 x size of tube small fingernail nares

Disposition - Admit

Hypoxia < 3 months old Shock Dyspnea Activity Level Extensive ED Treatment

Complications

Viral pneumonia

resolve spontaneously without specific Tx

Bacterial pneumonia
dehydration, bronchiolitis obliterans, apnea pleural effusions, empyemas, pneumothorax, pneumatoceles, development of additional infectious foci

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

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

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

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

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

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

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

Summary

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