Stridor
Most common cause of stridor in the newborn.
Laryngomalacia
- Inspiratory stridor due to luminal narrowing of laryngeal cartilage.
- Usually heard by 2 weeks of age, more pronounced with agitation or laying down.
- Confirmed with awake flexible laryngoscopy. Most can just be wait and watch, but refer if causing feeding issues, and/or nighttime obstructive hypoxia. Resolves around 12-24 months old.
3 causes of acute wheezing.
Asthma, bronchiolitis, and foreign body.
- most common of acute and recurrent wheezing is asthma.
Most common cause of epiglottitis in the U.S.
nontypeable H flu.
- Followed by Strep pneumo, strep pyogenes GABHS, and Staph aureus.
- epiglottitis is differentiated from croup by its more toxic appearance and rapid onset.
Diagnose this: abrupt onset of cough in a child while eating or playing.
Foreign body aspiration.
- But, can have history of chronic, wet cough in a young child (there can be delays in diagnosis up to > 1 month).
- On CXR- obstructive asymmetric hyperinflation is usually seen in bronchial foreign body cases, but 10-25% can have normal CXR.
4 signs of impending respiratory failure on exam
Any of these:
- little or no air movement
- retractions, nasal flaring
- tachypnea
- looking anxious, jittery, not wanting to lay down
- cyanosis, extreme fatigue, altered mental status, loss of consciousness
In the neonatal period, this is associated with increased risk of vocal cord paralysis.
What is difficult vaginal delivery?
- Stretching of the neck during delivery can cause damage to the recurrent laryngeal nerve.
-Can also occur due to aberrant great vessel or CNS lesions, including Arnold- Chiari malformation, posterior fossa tumor, and hydrocephalus, or iatrogenic (CT, thyroid, TEF repair surgery complications).
- Presents with toddler/newborn with weak cry and hoarse/raspy voice.
Most common causes of chronic wheezing.
Asthma, allergies, GERD, infectious, and obstructive sleep apnea.
Most common cause of bacterial tracheitis
Staph aureus.
- Usually follows viral URI, and does not involve the epiglottis.
- Presents with high fever, brassy/productive cough, and rapid deterioration
- Treat with 3rd gen cephalosporin, or vanco.
Diagnose this- chronic cough, wheezing, apnea, and recurrent pneumonia
Aspiration- oral or gastric secretions are inhaled into the lungs.
- If aspiration pneumonia, preferred treatment is amox-clav/amp-sulbactam
Describe the changes noted on O2 and CO2 with acute respiratory acidosis.
O2 desaturation and elevated CO2
- typically, we see issues with oxygenation prior to changes with CO2. This is why a hypoxemic child with "normal" CO2 gas exchange will improve with simple nasal cannula supplemental O2.
Laryngeal webs are most commonly seen with this syndrome.
- Identified by testing for 22q11 gene deletions.
- Laryngeal webs develop from abnormal recanalization of structures around laryngeal inlet
17 year old with asthma presents with: cough, wheezing, URI
- One ER visit due to asthma exacerbation 2 years ago.
- PFT: FEV 1 74%, FEV1/FVC 79%, change after bronchodilator to FEV 1 35%
What is asthma severity?
Moderate persistent asthma.
- >/= 12 years of age, FEV1 > 60% but < 80% is defined range of moderate persistent asthma.
List the types (3) of high risk patients that qualify for palivizumab
1. infants and children < 24 months with chronic lung disease within 6 months of start of of RSV season.
2. Infants < 29 weeks in their 1st winter
3. Children < 24 months with hemodynamically significant cyanotic and acyanotic congenital heart disease
Most common presentation of a patient with cryptogenic organizing pneumonia (COP)
Numerous episodes of "bronchitis" that respond to antibiotics and then recur.
- COP is a rare disease with various causes. The alveolar septa are thickened by chronic inflammatory cell infiltrate, as well as Type II cell hyperplasia of alveolar septa.
If a patient has low O2 and elevated CO2, what airway management options should be considered?
noninvasive ventilation using BiPAP. or intubation for mechanical ventilation. If that fails, escalate to ECMO
- Only supplemental oxygenation will not suffice, because elevated CO2 will not improve with just oxygen support.
What is exercise, irritants, and emotional stress?
- Patients may present with respiratory distress, stridor (inspiratory), and/or difficulty swallowing.
- Unlike asthma, patients don't respond to albuterol.
Asthma medication that increases risk of GER
What is theophylline?
- Reduces lower esophageal sphincter tone, resulting in increased risk of GER.
What are the current scheduled recommendations for pnuemococcal vaccines (PCV 13,PPSV23)- immunocompetent and immunocompromised.
PCV 13 at 2,4,6, and 12-15 months of age. Then, PPSV23 at least 8 weeks later to children 2-18 years of age with immunocompromising conditions (2nd dose may be required 5 years later for immunocompromised conditions, but not chronic conditions).
Most common cause of bronchiolitis obliterans
Most commonly occurs following a LRTI, particularly with adenovirus serotype 3,7, or 21.
- BO is when small bronchi and bronchioles are obstructed intraluminal masses of fibrous tissue.
Main factors that control ventilation vs oxygenation on mechanical ventilation
oxygenation- PEEP, FiO2
Ventilation- tidal volume and respiratory rate
What treatment option can be used in patients who have refractory vocal cord dysfunction?
Botulinum toxin
- Use when speech therapy, breathing exercises, and decreased exposure to airway irritants does not work.
What is the main difference between treatment in 0-4 year olds and > 4 year olds in step 3 of asthma management?
>4: daily and prn combination low dose ICS fomoterol (SMART therapy)
What are the extrapulmonary manifestations of Mycoplasma pnuemoniae- list at least 4.
Hemolytic anemia, splenomegaly, erythema multiforme (and SJS), arthritis, pharyngitis, tonsillitis, and neurologic changes-- especially confusion
Pathophysiology of bronchiectasis and diagnostic criteria.
Pathophys: Dilation of bronchi due to destruction of airway elastin. Bronchi become damaged during infection/inflammation and become distorted.
Diagnosis is based on airway dilatation, bronchial wall thickening seen on chest high resolution computed tomography (gold standard).
Look for kids with chronic productive cough, wheezing, recurrent infections, and CLUBBING of the fingers (VERY COMMON).
- Etiology can include CF, chronic aspiration, alpha-1 antitrypsin deficiency, dysmotile cilia, immunodeficiencies, and allergic bronchopulmonary aspergillosis.
O2 saturation of hemoglobin molecule at a certain PaO2 is dependent on what 3 factors and what factors shift the oxyhemoglobin curve to the right?
Temperature, 2,3-DPG level (phos levels), and pH status.
- Right shift: decreased affinity for Hgb (thus, a decreased O2 uptake by Hgb) due to increased temperature, acidosis (decreased pH, PaCO2), and increased phos (2,3 DPG)