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Pediatric Pulmonary

Issues and Diseases of the Pediatric Population

Disease/ConditionDefinitionPathophysiologySymptomsDiagnosis/TreatmentAges Most Commonly Affected Other Information
Acute Tracheitis (Bacterial) Most common upper airway infection in children. Results in airway edema, copious secretions & airway obstruction. Most commonly caused by Staphyloccocus aureus/methicillin-resistant Staphyloccocus aureus (MRSA). Results in airway edema, copious purulent secretions & airway obstruction that can be worsened by psuedomembrane & mucosal sloughing. Onset of symptoms may be sudden or may be preceded by a pre-existing viral upper respiratory tract infection or croup. Acute Presentation: tachypnea, stridor, hoarse voice, fever, cough, and/or increased secretions from mouth & nose. Management: immediate treatment w/ broad spectrum antibiotics (IV), endotracheal intubation & Corticosteroids. -There may be evidence of concurrent infections i.e. sinusitis, otitis, pneumonia or pharyngitis. Children w/ GERD are at an increased risk. Ages 1-12 yrs Potentially life-threatening. Increased morbidity can occur r/t respiratory & cardiopulmonary arrest, respiratory failure, pneumonia, septic/toxic shock, ARDS & MODS.
Epiglottitis The inflammation of the tissue that covers the trachea. When bacterial invasion of the mucosa with associated inflammation of the posterior base of the tongue, it leads to rapid development of edema that causes a life threatening obstruction of the upperairway. Sudden development of a high fever, irritability, sore throat, inspiratory stridor, severe respiratory distress. Tracheal intubation, IV broad spectrum antibiotics, and the use of corticosteroids. Ages 2-6 Acute epiglottitis is a life threatening emergency. Avoid disturbing the child and secure the airway.
Retropharyngeal Abscess Abscess in posterior pharyngeal wall. Can be caused by aerobic,anaerobic, or polymicrobial infection. Commonly caused by S.aureus/MRSA Streptococcus pyogenes, Anaerobes & Group A beta-hemolytic streptococci.Consequence of a nasopharyngeal infection or penetrating local injury to pharyngeal wall. Gradual onset of 2-5 days that may follow oral trauma or nasopharyngeal infection. Signs & Symptoms: fever, dysphagia, drooling, stridor, respiratory distress & stiff neck. IV antibiotics targeted to specific microorganism& occasional incision and drainage of abscess. >6 years. More commonly occurs in male children around 4 years of age.
Peritonsillar Abscess Abscess within or around tonsil. Abscess formation w/I or around tonsil commonly caused by Group A beta-hemolytic streptococci S aureus/MRSA May be abrupt onset. Symptoms similar to epiglottitis: severe sore throat, high fever, toxic appearance, muffled voice, drooling, sits erect & quietly may have trismus (lock-jaw). Diagnosis based on history and presenting symptoms. Physical finding will show contralateral deviation of the uvula w/tonsillar edema. Needle aspiration/biopsy is gold standard. Treatment: antibiotics, incision & drainage or tonsillectomy. >9 years
Bronchiolitis The inflammation of the bronchioles usually caused by a virus. A viral infection will cause inflammation and necrosis of the bronchial epithelium and cause destruction of ciliated epithelial cells. Infiltration of lymphocytes cause activation of eosinophils, neutrophils, and monocytes. Significant rhinorrhea that is followed by a tight cough over the next several days. Decreased appetite, lethargy, and fever occurs. Crackles can be heard on auscultation,there are chest retractions and tachypnea. Diagnosis occurs through observation of symptoms. Treatment include supportive care for mild cases and in severe cases, supplemental oxygen, increased hydration, inhaled hypertonic saline, and sometimes inhaled bronchodilators. Children younger than 2
Viral Pneumonia Infection & inflammation in the terminal airways & alveoli. Most commonly caused by RSV. Others: parainfluenza, Haemophilus influenza types A & B, coronaviruses, rhinoviruses, enteroviruses, hMPV, bocavirus & adenovirus. Acquired by direct contact, droplet or aersol.Results in edema, increased mucus & interstitial pneumonia. Infection of lower respire. tract-->destruction of ciliated epithelium of distal airway w/ sloughing of cellular material. Mild to high fever, cough, rhinorrhea, malaise, rales, rhonchi, or wheezing, variable radiographic pattern DX of viral etiology require laboratory confirmation (immunofluorescence tests). Viral penumonias most common in young children(2-3 X more likely in children than adults) & infection occurs in winter to early spring. * Infants for RSV & all ages for other strains of viral pneumonia. Community Acquired Pneumonia (CAP) is most global infection in the pediatric age group & leading cause of mortality & morbidity in infants.Risk Factors: age <2, overcrowded living conditions, winter, recent antibiotic trtmt, daycare & second-hand smoke.
Bronchiolitis Obliterans Fibrotic obstruction of the respiratory bronchioles and alveolar ducts secondary to intense inflammation. Fibrotic obstruction of the lung occurs secondary to intense inflammation. Cough, respiratory distress, and cyanosis. Inhaled corticosteroids, bronchodilators, antibiotics, and oxygen supplementation. It is relatively rare in children. It is a rare condition mostly associated with viral pulmonary infections.
Asthma A chronic inflammatory disorder of the airways involving bronchial hyperresponsiveness and airway obstruction marked by periodic attacks of wheezing, shortness of breath, a tight feeling in the chest, and a cough that produces mucus. An allergen binds to IgE on mast cells releasing histamine, leukotrienes,prostoglandinD2, plt activating factor, chemokines, and cytokines. At the beginning of an attack, the person will feel chest constriction, expiratory wheezing, dypsnea, non productive coughing, prolonged expriation, tachycardia, and tachypnea. Avoidance of allergens and irritants, the use of short acting beta agonists inhalers, antiinflammatory medications, inhaled corticosteroids, leukotriene agonists Asthma accounts for 5-10% of the population and 1/2 of those affected developed asthma in childhood. It is most common in people under the age of 18. Asthma is the most common chronic childhood condition. Asthma accounts for 1/4 of emergency room visits in the US.
Cystic Fibrosis An autosomal recessive disorder with defective epithelial chloride ion transport. Abnormal secretions cause obstucive problems in respiratory, GI, and reproductive tracts which contributes to chronic bacterial infections that causes chronic bronchiectasis that becomes widespread. Persistent cough or wheeze, sputum production, and recurrent or severe pneumonia. We can sometimes also see chronic sinusitis and nasal polyps. There are screening algorithms for CF. Treatment is focused on pulmonary health and nutrition. Pulmonary therapies will include chest physical therapy to promote mucus clearance, the use of antibiotics, bronchodilators, and nebulized DNase. The median age of diagnosis is 6 months of age. 75% of cases diagnosed before the age of 1. 10% of cases diagnosed after the age of 10. Approximately1000 new cases of CF are diagnosed each year.
Bacterial Pneumonia Bacterial pneumonias are less common and occur across all age group. Fungal/Anaerobic pneumonias are rare in children.
Pertussis "Whooping Cough" Acute respiratory illness caused by Bordtella pertussis Persistent respiratory illness presenting classically in four stages: incubation, catarrhal, paroxsymal, and covalescent. The disease is often characterized by a distinct coughing sound. Atypical presentation occurs more in infants and vaccinated people Incubation:7-10 days. Catarrhal:(1-2 wks) nonspecific 'cold' symptoms with progressing cough. Paroxsymal:(2-6 wks) severe 'whooping' cough that can cause gagging, vomiting, cyanosis, dypsnea. Convalescent:(wks-months) cough subsides. Clinical Diagnosis includes acute cough lasting 14 plus days with one or more of the following: paroxysms of cough, post-tussive vomiting, or inspiratory whoop. If known exposure has occured, only cough lasting 14 plus days is needed to diagnose. Any age can be affected but disease tends to be worse in young children and infants. If disease contracted after vaccination, symptoms tend to be less severe. Vaccination: DTaP (diptheria, tetanus, acellular pertussis) ages 0-6, given in 5 shot series. Tdap (same coverage as DTaP) ages adolescent (7) to adult as a booster, given in a single shot.
Enterovirus D83 and Rhinovirus (Common Cold) RNA virus responsible for a wide spectrum of diseases spread through the oral-fecal route. D86 and Rhinovirus (common cold) are the ones responsible for upper/lower respiratory illnesses. The infections are more often in the upper respiratory tract but can also present in the lower respiratory tract. Sinuses can also be affected. URI symptoms often hard to distinguish from other etiologies include sore throat, cough, coryza. Also see common cold symptoms such as runny nose, sinus congestion. Severe symptoms include dyspnea,hypoxia, perihilar infiltrates, and asthma exacerbations. Can run lab tests but often diagnosed by symptoms and seasonal presentation. Disease tends to be more common in summer and fall. Acute respiratory illness is often a clue. Also look for cluster of patients reporting same symptoms. Any one can be affected but infants, young children, and immunocompromised patients affected most often. This is due to the lack of immunity acquired by most adults. Have asthma exacerbation plan in place. Patients with asthma tend to experience more sever symptoms and may need hospital support more often.
Influenza A and B Acute respiratory illness caused by RNA virus and transmitted airborne via droplets. Often misunderstood to be a GI illness, this virus attacks the respiratory tract during the winter season. It is highly recommended that people get vaccinated during the fall, especially the elderly or people at high risk (ie-healthcare workers). Common symptoms include fever, chills, muscle aches, weakness, runny nose, headache (severe), sore throat, and generalized malaise. If GI symptoms are seen, it is often in children. Often the diagnosis is done through symptoms during the peak season, but a rapid nasal swab can be done to obtain confirmation. If positive, airborne/droplet precautions should be followed by healthcare workers. Any age can be affected, but the elderly and young children, infants, and immunocompromised are the most susceptible. High risk patients also include those with asthma, prematurity, and chronic illness. In healthy individuals, the flu is often self-limiting and acute, but higher mortality has been seen in past years with the strains H1N1 and H3N2, especially in children younger than 5 (even more in those <6mo) and if bacterial co-infection is present.
Respiratory syncytial virus A negative stranded RNA virus that causes viruses in the lungs and respiratory tract Inoculation of the virus occurs in respiratory epithelial cells of the upper respiratory tract. The virus spreads through cell to cell transfer along intracytoplasmic bridges or syncytia down the respiratory tract. fever, cough, tachypnea, cyanosis, retractions, wheezing, rales, rhinorrhea, ear ache, mild sore throat Diagnosis: CXR, WBC, auscultation of the lungs, a final diagnosis of nasal respiratory secretions. Treatment:IV fluids, humidified oxygen, nebulized treatments (albuterol or ribavirin), mechanical ventilation in very severe cases Young children and infants are the most common age, but RSV can affect any age infants to adults. RSV is more severe in infants and young children, presenting with pneumonia and bronchitis. Adults with RSV have less severe cold like symptoms.
Foreign Body Aspiration Aspiration of small objects such as legos, beads, coins, small magnets etc. Foods like nuts, sunflower seeds, popcorn, hot dog pieces Irritation and granulation cause inflammation and bronchial obstruction and can lead to pneumonitis and infection. Possible esophageal erosions or aortoesophageal fistuas can occur Coughing(could be unexplained and persistant) Choking, cyanosis, Wheeze= Lower airway occlusion Stridor= Upper airway occlusion XRAY can show atelectasis Antibiotics and removal of object that has been aspirated with bronchoscopy or pulmonary lobectomy (rare) 1-3 years 75% lodge in Main Bronchi producing wheezing Objects lodged in laryngeal or subglottic regions are dangerous because they can completely occlude airway
Angioedema Localized edema involving the deep, subcutaneous layers of skin or mucous membranes Environmental: Allergic reaction (ex: peanuts, cow's milk), angiotensis-converting enzyme inhibitors used for HTN or heart disease Inherited: Plasma protien C-1 inhibitor deficientcy (C-1 INH)-1 causing hereditary angioneurotic edema (rare) Begins with facial swelling around eyes and lips and progresses to airway swelling. In C-1 INH recurring attacks of angioedema involve sub Q tissues (limbs, genitals, face), abdominal and pelvic viscera. Laryngeal attacks are LIFE THREATENING. Allergic: epinephrine, antihistamines, corticosteroid C-1 INH: airway monitoring, hydration, pain relief, controle of nausea, administration of C-1 INH concentrates. Prevention includes antifibrinolytic agents and attenuated androgens. Allergic = All ages C-1 INH = 8-12 years Children with increased levels of Bradykinin in their system are able to mediate the adverse affects because bradykinin causes vasodilation, increased vascular permeability, and histamine release
Obstructive Sleep Apnea Breathing disorder characterized by prolonged partial, intermittent, or complete obstructive apnea that disrupts sleep patterns and normal ventilation Multifactorial causes adenotonsillar hypertrophy is most common cause - physical impingement on nasopharyngeal airway. OSA is increased in children with elevated serum levels of C-reactive protein and increased inflammation. Snoring, restlessness, labored breathing, sweating during sleep, gasping, sudden arousal. Neurobehavioral impairment, increased daytime sleepiness, impaired school work, increased CO2, hypoxemia. Gold standard Diagnosis: polysomnographic sleep study . Can remove tonsils or adenoids, decrease obesity, CPAP during sleep. 13% ages 3-6 years 2-3% middle school age Other causes of OSAS are: obesity orthodontic/craniofacial anomalies, neurologic disorders, allergies, asthma, poor motor tone of upper airways, abnormal arousal mechanisms
Croup (AKA laryngotrachobronchitis) Subglottic edema from infection. 85% of cases caused by a virus, most common parainfluenza. Also cuased by influenza A, RSV, rhinovirus, adenovirus, rubella. Atypical bacterial cause is Mycoplasma Pneumoniae. Mucous membranes of the subglottic space are loosely adhered to the underlying cartilage allowing accumulation of mucosal and submucosal edema caused by inflammation/infection reaction. Rhinorrhea, sore throat, low grade fever. Harsh, seal-like barking cough, hoarse voice, inspiratory stridor Most need no treatment. Treatment depends on severity determined by Westley Croup Score. Humidified air, Glucocorticoids (injected, oral, or nebulized), nebulized racemic epi, oxygen administration, Heliox (helium oxygen mixture) 6 months to 3 years of age Peaks at 2 years of age Cricoid cartilage is narrowest point of airway and when edematous causes increased WOB, negative intrathoracic pressure, exacerbation of collapse of upper airway.
Created by: NURPATHO