Respiratory Diseases Summary MBBS

8/6/2019 Respiratory Diseases Summary MBBS

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Common Respiratory

ProblemsIn

Children

Common Respiratory

ProblemsIn

Children


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4 months old4 months old

One day history ofOne day history of

excessive cryingexcessive crying

Sent home with theSent home with the

diagnosis of windydiagnosis of windycolic with anticolic with anti--

spasmodicsspasmodics

Next day:Next day:

Grunting, respiratoryGrunting, respiratorydistress, fever.distress, fever.

Admitted ,oxygen, IVAdmitted ,oxygen, IV

ceftriaxone.ceftriaxone.

Case 1:


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Case (contd)Case (contd)

Second day:Second day:

Mother felt better butMother felt better but

continues to becontinues to be

tachypnoeic, chesttachypnoeic, chestindrawing, feverindrawing, fever

persisting.persisting.

Vancomycin addedVancomycin added

with oxygenwith oxygen


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Case (contd)Case (contd)

Third dayThird day Severe respiratorySevere respiratory

distressdistress

Pus drained through waterPus drained through water

seal drainageseal drainage Antibiotics contd.Antibiotics contd.

Discharged after 2 wk.Discharged after 2 wk.

Strepto.pneumoniae isolated


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16 month old boy with wheeze

Initial Vitals: HR 160

RR 60

BP 88/50

Temp 38

O2sat on RA 89%

Case 2


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You do your pediatric triage

Appearance Crying, distressed, looking

around, moving all 4 limbs

Breathing (work of) Laboured, chest caving in,

+++indrawing

Circulation ColourOK, N cap refill


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What would you like to do now?

Oxygen by mask applied, IV attempt started and

pt now on cardiac monitor

Airway No stridoraudible, no obvious secretions

Breathing +++ wheeze with little airentry bilat

(inspiratoryAND expiratory)

Circulation Warm extrem, PPP, cap refill 2 secs


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Oxygen

Salbutamol nebulizer

IV Access established orders?

CXR done / pending

ABG report

Venous Gas pH 7.35

pCO2 38pO2 125

Normal ABG values are: pO2 of 80Normal ABG values are: pO2 of 80--100 mmHg; pCO2 of100 mmHg; pCO2 of

3535--45 mmHg; pH of 7.3545 mmHg; pH of 7.35--7.45; and SaO2 of 957.45; and SaO2 of 95--100%100%


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History:

Has had a cold foralmost 2 days now(mild fever, decreased energy / appetite with cough

and runny nose)

Started getting wheezy this morning

No history of exposure to allergens, inhalants

orFB aspiration

Family History of Asthma / no smokers / no pets

Otherwise healthy with no known allergies


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Continuous Salbutamol nebulizer

for15 mins has little effect

Still indrawing

RR 65

Still alert and looking around, crying

Additional treatment?

IV steroids Methylprednisolone 1 mg/kg IV / IM

Continue Salbutamol

Considerracemic Epinephrine (0.5 mls)


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Repeat Venous Gas about 30 mins later

pH 7.15

pCO2 55pO2 120

Eyes rolling back, little crying now

What do you want to do?

Drugs? Tube Size?

Ketamine 1-2 mg/kg IV

Atropine 0.01 mg/kg IV (min 0.1 mg)

Succinyl 1 mg/kg IV

4 4.5 tube




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OtherOptions

IV Magnesium 25 mg/kg (max 2 gm)

IV Epinephrine

IV Salbutamol

Inhalational Anesthetics

Methylxanthines

Heli - Ox


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DifferentialDiagnosis ofWheezing

H + N Vocal cord dysfunction

Chest AsthmaBronchiolitis

Foreign BodyAspiration

CVS Congestive Heart FailureVascularRings


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Pediatric Asthma Guidelines

MILD Nocturnal cough

Exertional SOB

Increased Salbutamol use Good response to Salbutamol

O2 sat > 95%

PEF > 75% (predicted / personal best)

O2

Salbutamol

Considerpo Steroids

Symptoms

Pre - Treat

Treatment


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MODERATE Normal mental status

Abbreviated speech

SOB at rest

Partial relief with Salbutamol and required > than q 4h

O2 sat 92%-95%

PEF 50-75% (predicted / personal best)

O2 100%

Salbutamol

Systemic corticosteroids

Consideranticholinergic

Symptoms

Pre - Treat

Treatment

Pediatric Asthma Guidelines


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Asthma Guidelines

SEVERE Altered mental status Difficulty speaking

Laboured respirations

Persistant tachycardia

No prehospital relief with usual dose Salbutamol

O2 saturation


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Asthma Guidelines

Symptoms

Pre - Treat

Treatment

NEARDEATH Exhausted , Confused

Diaphoretic

Cyanotic, Decreased respiratory effort, APNEA

Falling heart rate

O2 saturation


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18 mo Girl with 24 hrHx of coughing with drooling

Hx: Has had an URTI forabout a week and was

getting mildly betteruntil yesterday. She

developed a feverand the cough got harsher.

Still drinking but not interested in solids

Vomited once last night

Started drooling this morning

CASE 3


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T39.1 degrees rectally, P170, R28, BP 100/66

Appearance alert, awake, not toxic, in no acute distress

Did not appearto preferupright ora forward leaning position

EENT Moist MM, slight erythema of oropharynx,

nasal crusting, N TMs, no rash / petechiae,

no drooling

Supple neck

Chest Clearwhen resting

Mild inspiratory stridorwith crying

Rest of the exam N

Physical Exam


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DDx?

Croup

Epiglottitis

Bacterialtracheitis

RetroPharygeal

abcess

Foreign Body

aspiration

Otherthings on DDx of

Inspiratory Stridor

Laryngeal Web

TEF

DiptheriaAirway thermal injury

Subglottic stenosis

Peritonsillarabcess

GERD

Esophageal FB

Laryngeal fracture

Laryngeal cyst

Lymphoma


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Soft tissue lateral

neckradiograph


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Lymph nodes between the posteriorpharyngeal wall

and the prevertebral fascia

gone by 3 4 yrs of life

drain portions of the nasopharynx and the posterior

nasal passages

may become infected and progress to breakdown

of the nodes and to suppuration

Retropharyngeal Abscess


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ETIOLOGY

Complication of bacterial pharyngitis

Less frequently

- extension of infection from vertebral osteomyelitis

Group A hemolytic streptococci, oral anaerobes,

and S. aureus


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Recent orcurrent history of an acute URTI

Abrupt onset:

High feverwith difficulty in swallowing

Refusal of feeding

Severe distress with throat pain

Hyperextension of the head

Noisy, often gurgling respirations

Drooling

Typically


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Soft Tissue Neck Film

Patient position MILD EXTENSION

Positive Film - Retropharyngeal soft tissue > the width

of the adjacent vertebral body

- may see airin the retropharynx

On Exam

Nasopharynx Bulging forward of the soft palate andnasal obstruction

Oropharynx Bulging of posteriorphyaryngeal wall

or

Not visualized


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Complications

Abscess rupture - aspiration of pus.

Lateral extension - present externally on the side of the neck

Dissection along fascial planes into the mediastinum

Death may occurwith aspiration, airway obstruction,erosion into majorblood vessels, ormediastinitis.


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Treatment

Ceftriaxone 75mg/kg/day/divided Q 12 hrly

Clindamycin 20-30 mg/kg/day divided Q8H

(if pre-fluctuant phase)

Decadron 0.6 mg/kg

Airway management

Surgical decompression


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17 month old male with a one-hourhistory

of noisy and abnormal breathing

Normal now but at the time, parents thought he was

quite distressed.

Now, he is able to speak and drink fluids without difficulty

CASE 4


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VS T36.8, P200 (crying), R28 (crying), O2 sat 99%

Alert with no signs ofrespiratory distress

Able to speak, had no cyanosis, no drooling,

no dyspnea

H+N No obvious swelling, bleeding, FB seen

Chest Mild wheezing with ? mild inspiratory stridor

What would you like to do now???


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Soft Tissue

Neck View


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CXR (PA)


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Next?

Expiratory

CXR


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Inspiratory View Expiratory View


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RightDecub

View


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Foreign Body Aspiration

More common with food than toys

Highest risk between 1 and 3 years old

(immature dentition no molars, poorfood control)

Common foods = peanuts, grapes, hard candies

Some foods swell with prolonged aspiration

(may even sprout)


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ClinicalManifestations

Typically

Acute respiratory distress (now resolved orongoing)

Witnessed choking period

Uncommonly

Cyanosis and resp arrest

Symptoms: cough, gag, stridor, wheeze, drool,

muffled voice


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Investigations

Xrays

Lateral neck

Chest inspiratory, expiratory, decubitus views

Expiratory views

Overinflation (partial obstruction with inspiratory flow)

Volume loss with mediastinal shift towards obstructed

side (partial obstruction with expiratory flow)

Atelectasis (complete obstruction)


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Decubitus views

Normal Smallervolumes and elevated diaphragm

on side down

Abnormal Hyperinflation ornormal volumes indecub position

If suspected Need a bronchoscope to rule out orremove Foreign Body


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CASE 5

2 yo Boy with BarkyCough for2 days

Runny nose, decreased appetiteNot himself

No PMHx / FHx of significance

Shots UTD

Othersibs with similarURTIs


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Temp 38.9

HR 140

O2 sat 98% (drops to 90% when he crys)

RR 40 (mild indrawing)

On Exam

Irritable, crying, good colour

H & N sl erythema of throat, no pus

N TMs, small cervical nodes

Chest Barky cough, inspiratory stridor

No wheeze noted


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Diagnosis?

Racemic Epinephrine 0.5 ml dose

? Dexamethasone now orlater

Re Assess in 30 minutes

No improvement with 1st dose of epinephrine



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IV Ceftriaxone PLUS Cloxacillin

Consult Pediatric ICU / Pulmonary

forBronch / Intubation

Re Examine

Ongoing Inspiratory StridorCries when trachea is examined


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Bacterial tracheitis

An acute bacterial infection of the upperairway capable

of causing life-threatening airway obstruction

Staph aureus most commonly(parainfluenza, Moraxella catarrhalis, H. influenzae, anearobes)

Most pts less than 3 years old

Usually follows an URTI (esp laryngotracheitis)

Mucosal swelling at the level of the cricoid cartilage,

complicated by copious thick, purulent secretions


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Brassy cough

High fever

Toxicity" with respiratory distress

(may occurimmediately oraftera few days of

apparent improvement)

Failed response to CROUP TREATMENT

(mist, intravenous fluid, racemic epinephrine)

CLINICALMANIFESTATIONS


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Antibiotics (good Staph coverage)

Intubation ortracheostomy is usually necessary

? Decadron

Treatment


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Pediatric Pneumonia

Neonate Bacteria more frequentE. coli, Grp B strep, Listeria, Kleb

1 3 mo Chlamydia trachomatis (unique)

Commonly viral (RSV, etc.)B. Pertussis

1 24 mo S. pneumonia, Chlamydia pneum

Mycoplasma pneumonia

2 5 yrs RSV

Strep pneumonia, Mycoplasma, Chlam


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Severe Pneumonia:

Staph aureus

Strep pneumonia

Grp. A strepHIB

Mycoplasma pneumonia

Pseudomonas ifrecently hospitalized


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History:

Infants < 3 months Tachypnea, cough, retractions,

grunting, isolated feveror

hypothermia, vomiting, poor

feeding, irritability, orlethargy

As age increases, symptoms are more specific

Fever and chills, headacheCough or wheezing

Chest pain, abdominal distress,

neck pain and stiffness


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Physical Exam

Tachypnea is the best single indicator of pneumonia

Age in months Upperlimit of Normal RR

< 2 60

2-12 50

> 12 40


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Treatment

Neonates Ampicillin + Gentamycin / Cefotaxime

1 3 mo Erythromycin 10 mg/kg IV Q6H

1 24 mo Cefuroxime 50 mg/kg IV Q8H (not ICU)Ceftriaxone 50-75 mg/kg IV Q24H

and Cloxacillin 50 mg/kg IV Q6H (ICU)

3 mo 5 yrsCeftriaxone / ErythroClarithro / Azithro (outpt Tx)


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Respiratory Failure inRespiratory Failure inChildrenChildren


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Respiratory failure: where is theRespiratory failure: where is the

defect?defect?

Ventilation

DiffusionPerfusion

Abnormal oxygen

carrying capacityfailure of

cellular oxygen

uptake


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Types ofRespiratory FailureTypes ofRespiratory Failure

Type I failure, alsoType I failure, also

known asknown as

normocapnic ornormocapnic or

nonnon--ventilatoryventilatoryfailure, is indicatedfailure, is indicated

by hypoxemia (lowby hypoxemia (low

pO2 ) with a normalpO2 ) with a normal

or low pCO2.or low pCO2.

It is commonly due toIt is commonly due to

ventilation/perfusionventilation/perfusion

(V/Q) abnormalities.(V/Q) abnormalities.

Other causes include:Other causes include:impaired diffusionimpaired diffusion

across the alveolaracross the alveolar--

capillary membranecapillary membrane

(as occurs with(as occurs withpulmonary fibrosispulmonary fibrosis

and shunting)and shunting)


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Type II failure:Type II failure:

An elevated pCO2An elevated pCO2

is the hallmark ,is the hallmark ,

also known asalso known as

ventilatory orventilatory or

hypercapnichypercapnic

failure.failure.

It is generally theIt is generally the

result of alveolarresult of alveolar

hypoventilation,hypoventilation,

increased dead spaceincreased dead space

ventilation, orventilation, or

increasedC

O2increasedC

O2production. Otherproduction. Other

causes are factorscauses are factors

that impair the centralthat impair the central

ventilatory drive in theventilatory drive in thebrainstem, restrictbrainstem, restrict

ventilation, orventilation, or

increase CO2increase CO2

production.production.


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Causes of Type I FailureCauses of Type I Failure

V/Q abnormaltitiesV/Q abnormaltities Pneumonia,Pneumonia,

meconium aspiraton,meconium aspiraton,Pulmonary oedema.Pulmonary oedema.

Cyanotic heartCyanotic heartdiseasedisease

DiffusionDiffusionabnormalitiesabnormalities Interstitial fibrosisInterstitial fibrosis

Inadequate systemicInadequate systemicblood flowblood flow ShockShock

Inadequate oxygenInadequate oxygencarrying capacitycarrying capacity Severe anemia,Severe anemia,

methhemoglobinemiamethhemoglobinemia

Inadequate cellularInadequate cellularuptake:uptake: Cyanide poisioningCyanide poisioning


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Type II Failure: alveolarType II Failure: alveolar

hypoventialtionhypoventialtion

Neuromuscular:Neuromuscular:

CNS disease, GBCNS disease, GB

Syndrome.Syndrome.

Respiratory muscleRespiratory muscledisordersdisorders

Muscular dystrophyMuscular dystrophy

Chest wall / pleura:Chest wall / pleura:

Pliable chest,Pliable chest,

pneumothorax, pleuralpneumothorax, pleural

effusioneffusion

Airway disorders:Airway disorders:

Croup.Croup.

Pulmonary diseasePulmonary disease

Bronchiolitis,Bronchiolitis,pneumonia, asthmapneumonia, asthma

Increased CO2Increased CO2

production:production:

Sepsis, fever, burnSepsis, fever, burn


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In children, respiratory failure most often isIn children, respiratory failure most often is

due to diseases of the lungs.due to diseases of the lungs.

CNS disorders that lead to respiratoryCNS disorders that lead to respiratory

failure are:failure are:Control abnormalities that cause Type IIControl abnormalities that cause Type II

(hypercapnic) respiratory failure and(hypercapnic) respiratory failure and

usually present without signs andusually present without signs and

symptoms of respiratory distress (such assymptoms of respiratory distress (such as

dyspnea, retractions, or tachypneadyspnea, retractions, or tachypnea

A 16A 16 ld f l i i th ED ftld f l i i th ED ft


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A 16A 16--yearyear--old female arrives in the ED afterold female arrives in the ED after

the SLC result. No other history is availablethe SLC result. No other history is available

because the friends who brought him to thebecause the friends who brought him to theED left.ED left.

The vital signs are:The vital signs are:

Temperature (T) = 96Temperature (T) = 96F;F;

Pulse (P) = 90 beats/min;Pulse (P) = 90 beats/min;

Respiratory rate (R)Respiratory rate (R) = 6 breaths/min;= 6 breaths/min;

Blood pressure (BP) =120/80 mmHg; andBlood pressure (BP) =120/80 mmHg; and

Pulse oxygen saturation is 76% on room air.Pulse oxygen saturation is 76% on room air.


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Arterial blood gasArterial blood gas

(ABG) is: pH = 7.13;(ABG) is: pH = 7.13;

pO2 = 52; pCO2 = 81;pO2 = 52; pCO2 = 81;

HCO3 = 26; andHCO3 = 26; and

oxygen saturation =oxygen saturation =

75% on room air.75% on room air.

Glasgow coma scale: 4.Glasgow coma scale: 4.

Shallow respiration.Shallow respiration.

Pinpoint pupil.Pinpoint pupil.

Lungs and heart areLungs and heart are

normalnormal




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ProblemProblem

This patient has hypercapnia and hypoxia.This patient has hypercapnia and hypoxia.

Of the physiologic events in respiration,Of the physiologic events in respiration,

diffusion, transport, and the tissue/cellulardiffusion, transport, and the tissue/cellular

uptake of oxygen are normal, butuptake of oxygen are normal, but

ventilation is impaired.ventilation is impaired.

Pin point pupil points to the poisoningPin point pupil points to the poisoning

probably narcotic drug.probably narcotic drug.


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An 8An 8--yearyear--old male muscularold male muscular

dystrophydystrophyEamination revealsEamination revealsrhinorrhea and excessiverhinorrhea and excessivesecretions in thesecretions in theoropharynx.oropharynx.

There are scatteredThere are scatteredrhonchi in the lungsrhonchi in the lungsbilaterally. There is nobilaterally. There is nocyanosis.cyanosis.

The neurologic exam isThe neurologic exam is

consistent with hisconsistent with hisdiagnosis of musculardiagnosis of musculardystrophy with muscledystrophy with muscleweaknessweakness

His vital signs are:His vital signs are:

T = 100.2T = 100.2F;F;

P = 120 beats/min;P = 120 beats/min;

R = 12 breaths/min; andR = 12 breaths/min; and

BP = 100/70 mmHg; andBP = 100/70 mmHg; and

Weight = 20 kg.Weight = 20 kg.


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The ABG is: pH = 7.17;The ABG is: pH = 7.17;

pO2 = 46; pCO2 = 78;pO2 = 46; pCO2 = 78;

HCO3 = 32; and O2HCO3 = 32; and O2

saturation = 71% onsaturation = 71% onroom air.room air.

This patient has TypeThis patient has Type

II hypercapnicII hypercapnic

respiratory failurerespiratory failure

secondary to failure ofsecondary to failure ofthe respiratorythe respiratory

muscles from amuscles from a

primary muscleprimary muscle

disorder.disorder.




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A 4A 4--monthmonth--old female withold female with

breathing difficulties.breathing difficulties.

Her vital signs are:Her vital signs are:

T = 103.5T = 103.5 F;F;


R = 64 breaths/min;R = 64 breaths/min;BP = 80/50 mmHg; andBP = 80/50 mmHg; and

Pulse oxygen saturationPulse oxygen saturation= 82% in room air= 82% in room air

Prematurity (30 weeks),Prematurity (30 weeks),respiratory distressrespiratory distresssyndrome requiring asyndrome requiring aventilator. She also had aventilator. She also had a

congenitalcongenitalgastrointestinal problemgastrointestinal problemrequiring surgery at 6requiring surgery at 6weeks of age and hasweeks of age and hascontinued to havecontinued to have

gastrointestinal problems.gastrointestinal problems.She hasShe hasbronchopulmonarybronchopulmonarydysplasiadysplasia

Small for her ageSmall for her age


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Small for her age.Small for her age.

Respiratory distress withRespiratory distress with

retractions, grunting,retractions, grunting,

flaring, head nodding.flaring, head nodding.Skin is pale, sweaty, andSkin is pale, sweaty, and

cyanotic with delayedcyanotic with delayed

capillary fill. There arecapillary fill. There are

rales in both lung fields.rales in both lung fields.The chest roentgenogramThe chest roentgenogram

shows diffuse bilateralshows diffuse bilateral

infiltrates.infiltrates.

The ABG on room airThe ABG on room air

is: pH = 7.61; pO2 =is: pH = 7.61; pO2 =

56; pCO2 = 24; HCO356; pCO2 = 24; HCO3

= 27; and oxygen= 27; and oxygensaturation is 78%.saturation is 78%.



A 2A 2--monthmonth--old is brought to the ED withold is brought to the ED with


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A 2A 2 monthmonth old is brought to the ED withold is brought to the ED with

a chief complaint of not eating fora chief complaint of not eating for

several days.several days.Vital signs are:Vital signs are:

T = 36.8T = 36.8C (R);C (R);


R = 58 breaths/minR = 58 breaths/min

BP = 55/30 mmHg;BP = 55/30 mmHg;

andandPulse oxygenPulse oxygen

saturation is 78% onsaturation is 78% on

room air.room air.

O/E tachypnea,O/E tachypnea,

retractions, andretractions, and

cyanosis. The lungscyanosis. The lungsare clear. The heart isare clear. The heart is

tachycardic with notachycardic with no

murmurs. The livermurmurs. The liver

edge is down 2 cm.edge is down 2 cm.The abdomen is nonThe abdomen is non--

tender. There is notender. There is no

edema and no rash.edema and no rash.


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ABG drawn on 100%ABG drawn on 100%

FiO2 showsFiO2 shows

essentially no changeessentially no changefrom the room airfrom the room air

blood gas: pH = 7.48;blood gas: pH = 7.48;

pO2 = 64; pCO2 = 35;pO2 = 64; pCO2 = 35;

HCO3 = 23; and O2HCO3 = 23; and O2saturation is 79%.saturation is 79%.

An initial ABGAn initial ABG

reveals: pH = 7.48;reveals: pH = 7.48;

pO2 = 62; pCO2 = 34;pO2 = 62; pCO2 = 34;and HCO3 = 23.and HCO3 = 23.




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A 5A 5--yearyear--old male is seen for a cough ofold male is seen for a cough of

several days duration that is not improvingseveral days duration that is not improving

O/E: sitting up andO/E: sitting up and

leaning forward.leaning forward.

wheezing bilaterally.wheezing bilaterally.

Tachypnic withTachypnic withintercostal retractions.intercostal retractions.

Three continuousThree continuous

salbutamol aerosolssalbutamol aerosols

were given bywere given bynebuliser.nebuliser.

Vital signs are:Vital signs are:

T = 96.8T = 96.8F (O);F (O);

P = 170 beats/min;P = 170 beats/min;R = 44 breaths/min;R = 44 breaths/min;

andand

Pulse oximetry is 94%Pulse oximetry is 94%

on room air.on room air.


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His lungs are clear,His lungs are clear,

no wheeze or rales,no wheeze or rales,

and no retractions. Heand no retractions. He

has dry mucoushas dry mucousmembranes and palemembranes and pale

skin with tenting.skin with tenting.

Vital signs are now:Vital signs are now:

T = 96.8T = 96.8F (O);F (O);


R = 16 breaths/min;R = 16 breaths/min;

BP = 65/40 mmHg;BP = 65/40 mmHg;

andand

Pulse oxygenPulse oxygensaturation = 86% onsaturation = 86% on

room air.room air.


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First ABG ; pH = 7.52;First ABG ; pH = 7.52;

pO2 = 58; pCO2 = 24;pO2 = 58; pCO2 = 24;

HCO3 = 14; andHCO3 = 14; and

oxygen saturation =oxygen saturation =88% on room air.88% on room air.

The second ABGThe second ABG

shows: pH = 7.12;shows: pH = 7.12;

pO2 = 68; pCO2 = 70;pO2 = 68; pCO2 = 70;

HCO3 = 14; andHCO3 = 14; andoxygen saturation isoxygen saturation is

90% on 100% FiO2.90% on 100% FiO2.

Normal ABG values are: pO2 of 80-100 mmHg; pCO2 of 35-45

mmHg; pH of 7.35-7.45; and SaO2 of 95-100%


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Treatment: Acute Respiratory FailureTreatment: Acute Respiratory Failure

Hypoxemia is more dangerous than hypercarbia.Hypoxemia is more dangerous than hypercarbia.

Administration of supplemental oxygenAdministration of supplemental oxygenVentilatory supportVentilatory support

Extracorporial Membrane Oxygenation (ECMO)Extracorporial Membrane Oxygenation (ECMO)

Never use bicarbonates unless lung can exhaleNever use bicarbonates unless lung can exhale

Documents

Respiratory Diseases Summary MBBS