* 2yo child presents to the ED with her parents because of high fever and difficulty swallowing. Parents state the child was healthy but awoke with a fever of 104F, hoarse voice, and difficulty swallowing. On exam, patient is sitting in tripod position (trying to straighten the airway for easier breathing), drooling, expiratory stridor, nasal flaring, and retractions of the suprasternal notch, supraclavicular and intercostal spaces.
* Epiglottitis is inflammation of the epiglottis, causes airway obstruction, is an airway emergency. * Children with epiglottitis look sicker than croup children. Epiglottitis usually seen in older kids. * Epiglottitis has less stridor, less barky cough, more drooling, more air hunger, higher fever than croup. * Epiglottitis most commonly caused by H. influenzae type B, incidence greatly decreased due to immunization. * Usually nobody else ill in the household.
* Look for sudden onset of high fever, dysphagia, drooling, muffled voice, and tripod positioning. * Exam shows respiratory distress, air hunger.
* This is an emergency. Do not send this child off to x-ray with a technician or the parents. Do not struggle with this patient to lay them down and look at their throat, because their airway can close while you are examining it. * When looking at a lateral film of the neck, the soft tissue structure should never be wider than the vertebral body. * To find epiglottis on lateral film, find the hyoid bone and look straight back. Thumbprint sign is when the inflamed epiglottis is so thick it looks like a thumbprint. Exam shows a cherry-red epiglottis.
* Management, next best step, is secure an airway. Once the airway is secure, you are safe. Now you can give antibiotics and treat the patient.
* Diagnosis is made on clinical and physical findings, as well as visualization of the enlarged epiglottis as you are intubating the patient (done by experts in endotracheal intubation and tracheostomy). Airway is usually obtained in the operating room under controlled conditions if possible.
* Treatment for antibiotics is third generation cephalosporins. Keep the patient intubated for a couple of days, about 48-72h after starting antibiotics.
* A tongue blade should never be used to examine the pharynx of a patient with epiglottitis. They will get laryngospasm and the airway will close and they can die.
* DDx include croups, abscess, foreign body. Complications include death.
Respiratory: Asthma
* 6yo boy presents to his physician with end-expiratory wheezing scattered throughout the lung fields. He is noted to have nasal flaring, tachypnea, and intercostal retractions. These symptoms are triggered by changes in the weather. There is a family history of asthma and atopic dermatitis. He has never been intubated or admitted to the pediatric ICU. His last hospitalization for asthma was 6mo ago, he takes medicine only when he starts to wheeze.
* Asthma is a reversible obstructive airway disease. Symptoms come and go. It affects both small and large airways. * If you think of your airways as a pipe organ cause there are different sizes, you get different pitches of wheezing. * Three components of asthma are bronchospasm (muscles constrict), mucus production, airway edema.
* Obstruction caused during asthma attack increases airway resistance and decreases FEV1 and flow rates. * Lungs will be hyperinflated and premature airway closure (air trapping).
* Take a deep breath and let half out, then take another deep breath and let half out, continuing this will not last long in a healthy person (try it for yourself). That’s what an asthmatic feels like due to air trapping.
* Etiology is unknown, does run in families, can be related to the environment, lots of different factors involved such as endocrine, immunologic, infectious.
* Presentation varies for asthma. Acute attacks and insidious attacks.
* Asthma has a tight “bronchospastic” cough. Wheezing is the hallmark of asthma. * Not everyone that has asthma wheezes and not everyone that wheezes has asthma. * Top three causes of chronic cough are asthma, post-nasal drip, and GERD.
* Some people will have cough that is worse at night, or cough worse with exercise, or with cold weather, of after being exposed to smoke, or when cutting grass, and so on.
* Asthma has wheezing, dyspnea, and a prolonged expiratory phase (to make room for next breath). * See symptoms of respiratory distress, accessory muscle use, nasal flaring, intercostal retractions. * Can complain of abdominal pain due to use of these muscles for breathing, like doing lots of sit ups.
* Liver and spleen may be palpable on physical exam because diaphragm pushes them down with hyperinflation. * Clubbing is not a hallmark sign of asthma, they oxygenate well be asthma attacks so no clubbing.
* No single diagnostic test for asthma. Usually clinical diagnosis.
* Peripheral smear can show eosinophilia (NAACP mnemonic). Sputum will have eosinophilia also.
* Allergy skin testing can help. Exercise testing in older children can help. Response to bronchodilators helps. Pulmonary function testing (PFT) before and after bronchodilators is helpful, but not pathognomonic. * X-rays show hyperinflation, flattened diaphragm, ribs more horizontal and maybe further apart, atelectasis particularly in the right middle lobe, peri-hilar inflammation. Also to rule out other parts of DDx.
* No need to get CXR on patient every time they get an asthma exacerbation. For first time get a CXR to rule out a mass. If fever, CXR to rule out pneumonia.
* Blood gases are not done routinely on asthma patients. However, sicker patients get ABGs. Initially, patients are hyperventilation so PCO2 low-normal. As attack progresses, PCO2 rises. At late stage, pH drops because you’ve used up all the buffers.
* Best treatment is to avoid triggers if patient knows what they are. Daily management of the asthmatic varies. * Categories are acute, mild-intermittent, mild-persistent, moderate-persistent, severe-persistent.
* Acute attack of asthma managed with bronchodilators (usually beta2 agonists), oxygen, and steroids.
* Mild-intermittent asthma is symptoms occurring less than twice a week. Nocturnal symptoms (e.g. coughing). These patients do not need daily medications. Use short-acting inhaled beta2-agonists when symptoms.
* Mild-persistent means symptoms occur more than twice a week, nocturnal symptoms more than twice a month. Need daily medications, such as cromolyn (mast cell stabilizer), nedocromil (stopped in 2008), or inhaled steroids. These days (2010), leukotriene antagonists (montelukast, zafirlukast, zileuton) have largely replaced cromolyn. Inhaled corticosteroids used as drug of choice for maintenance therapy. Beta2 agonist for break through.
* Moderate-persistent is more frequent symptoms and wheezing between exacerbations. Use inhaled corticosteroids, long-acting beta2-agonists, and short-acting beta2-agonists for breakthrough.
* Severe-persistent asthma is daily symptoms with more frequent hospitalizations. Use inhaled corticosteroids, long- acting beta2-agonists, and short-acting beta2-agonists for breakthrough. Leukotriene receptor antagonists daily for maintenance therapy as well.
* Treatment of exercise-induced asthma is using beta2-agonists prior to exercise. Giving a beta2-agonist like albuterol after an attack starts (trying to play catch-up) can be a dangerous game.
* Complications of asthma include pneumothorax, respiratory distress, death.
* Causes of wheezing include asthma, foreign body, Loeffler syndrome (pulmonary eosinophilia), cystic fibrosis, bronchiolitis.
Respiratory: Bronchiolitis
* 6mo presents with a three day history of URI, wheezy cough, and dyspnea. Exam shows temp of 39C, 60/min, nasal flaring, accessory muscle use, is air hungry, and O2 sat at 92%.
* Bronchiolitis most commonly caused by respiratory syncytial virus (RSV). Usually seen under age of 2yo. * Generally upper respiratory symptoms prior to developing coughing and wheezing.
* Bronchiolitis is not really a bronchoconstrictive disease, more inflammatory. Since these children under the age of 2 have narrower airways, they can get into trouble with airway resistance and lower respiratory tract infections. * Causes include parainfluenza, mycoplasma, adenovirus, and second-hand smoke predisposes.
* History of upper respiratory tract infections, developing fevers, rattling cough with respiratory distress. * Exam shows rapid breathing, wheezing and crackles possible, respiratory distress signs.
* Little children with bronchiolitis can get apneic and cyanotic because they are getting tired.
* X-rays usually reveal hyperinflation, peri-hilar atelectasis, viral pneumonitis or streaking, all not specific. * CBC usually normal. Best test to diagnose RSV bronchiolitis is a nasopharyngeal wash.
* Quick fluorescence antibody of wash, if shows nothing then can culture.
* Treatment is supportive for mild cases, humidified air (clean vaporizer daily), bronchodilator trial. * Some patients with bronchiolitis have a component of asthma, so those would respond to bronchodilators. * Some centers will give aerosolized epinephrine, can be helpful.
* Corticosteroids are not indicated. Antibiotics are not necessary because it is viral.
* Hospitalize if sick, like breathing very fast or lower than 95% sats for an infant. Hospitalize premature babies or babies less than 3mo. Worst stage of disease is 3-5 days in, so if kid is pretty sick at day 2 you should observer in the hospital. Patients with chronic lung disease of congenital heart disease should be hospitalized due to greater risk. Hospitalize any baby with respiratory rate > 60/min or PO2 < 60 on room air.
* Some children do well after getting suctioned out, e.g. nasal suctions.
* Ribavirin is aerosolized, can be used for patients with impending respiratory failure, immunodeficiencies, bronchopulmonary dysplasia, neuromuscular diseases, congenital heart disease.
* Mortality from RSV bronchiolitis is < 1%. Death can occur from prolonged apneic episodes or due to dehydration. Dehydration because they do not feed due to constant breathing and due to respiratory water loss.
* At risk babies can receive monoclonal antibodies as prevention. RSV IV immunoglobulin not used anymore. Palivizumab used now, monoclonal antibody against RSV given IM once a month during peak season (winter, November to March). High financial cost for this treatment.
* Patients with congenital heart disease go not get IV or IM monoclonal antibody against RSV. * DDx includes asthma.
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