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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 treecharacterized by airway obstruction,inflammation, hyperresponsiveness, mucous

plugging and edema.

Recurrent wheezing which responds tobronchodilators.

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 asthmathan adults because of anatomic differences

Compliance of infant rib cage and immaturediaphragm 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 extentof dyspnea

Evaluation

Before H&P!!!!

ABC’s!

Shock (respiratory) Oxygen

β2 agonist

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

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 totreatment

fever chest pain

considering FB, pneumo

hyperinflation

flattened diaphragm

barrel-chest

atelectasis

Differential

pneumonia

Cystic Fibrosis

CHF (Congenital HeartDisease)

Epiglottitis

Retropharyngeal abscess

Bacterial tracheitis

Treatment

β2 receptor agonists--albuterol activates adenylate cyclase

increases cyclic adenosine monophosphate

bronchial smooth muscle relaxation

binding intracellular calcium to endoplasmicreticulum

Treatment

Xopenex - R isomer of albuterol

Salmeterol is a long acting β2 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 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

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

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

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

Treatment

Suction airway

β2 agonist Albuterol

Racemic Epi

Epinephrine

Treatment

Atrovent?

Atropine? dries secretions

Steroids? for family Hx of asthma

Treatment

Ribavirin? (Guidance of PICU)

Pulmonary Disease

Cystic Fibrosis RDS

Congenital Heart Disease

Bronchiolitis

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

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

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 developingcountries

Fall/Spring — parainfluenza

Winter — respiratory syncytial virus

Winter — influenza Bacterial more common in the winter

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

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

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

Grp A Strep invasive, necrotizing fasciitis, empyema

Gram neg bacilli recently hospitalized patients

Special Concerns

B. pertussis paroxysmal cough

C. trachomatis maternal exposure, conjunctivitis

M. pneumoniae rash (Erythema Multiforme)

Findings

respiratory distress tachypnea, grunting, flaring, retracting

abnormal auscultatory findings???

cyanosis

chest X-ray - infiltrates

CXR Findings

Viral diffuse interstitial infiltrates

Bacterial consolidated, lobar

Mycoplasma diffuse

CBC elevated WBC, left shift

Blood Culture

Cold Agglutins Sputum Culture

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

Soft Tissue Neck X-ray

Response to Treatment

Pulse Oximetry????

should not guide acute treatment decisions misleading

inaccurate

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 Ringer’s

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

Disposition - Admit

Hypoxia

< 3 months old

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

Case 1 16 month old boy, respiratory distress

RR 40, HR 140, T 39.2C

Case 2

7 year old boy, cough RR 20, HR 105, T 38.2C

Hx TE Fistula, Cleft Palate, RAD

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

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

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

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

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

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, thenPneumonia

Normal Breath Sounds

DO NOT R/O PNEUMONIA!

asthma bronchiolitis p nemo nia

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