Asthma, Bronchiolitis, and Pnemonia Tintinalli Chapt 123-124. April 18th 2005 Mark Rodkey, M.D., FAAP Scott Gunderon, D.

1. Asthma, Bronchiolitis, and Pnemonia Tintinalli Chapt 123-124. April 18th 2005 Mark Rodkey, M.D., FAAP Scott Gunderon, D.O.

2. Asthma • Chronic disease of the tracheobronchial tree characterized by airway obstruction, inflammation, hyperresponsiveness, mucous plugging and edema. • Recurrent wheezing which responds to bronchodilators.

3. 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

4. Pathophysiology • Three classifications: • extrinsic IgE mediated • intrinsic infection induced • mixed (both IgE and infection)

5. Pathophysiology • Less than 2 years old • viral triggers • Over 2 • allergens and irritants are triggers

6. Pathophysiology • Bronchoconstriction • due to histamine and leukotriene release • Airway mucosal edema/plugging

7. Pathophysiology • Obstruction • Air trapping • Hyperventilation, lowers PaCO2 • Respiratory failure raises PaCO2

8. Pediatric Anatomy • Higher risk for respiratory failure from asthma than adults because of anatomic differences • Compliance of infant rib cage and immature diaphragm • paradoxical respiration • increased work of breathing and fatigue

9. Pediatric Anatomy • Less elastic recoil • more prone to atelectasis • increases V/Q mismatch • Thicker airway wall • greater bronchoconstriction

10. Pediatric Anatomy • Obstruction more likely • Collapse of lung segments • Compensatory mechanisms may mask the extent of dyspnea

11. Evaluation • Before H&P!!!! • ABC’s! • Shock (respiratory) • Oxygen • β2 agonist

12. 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

13. Evaluation • ABG • Impending respiratory failure • Hypoventilating • PEFR < 30% of predicted • Not responding to treatment • Disposition (PICU vs RNF) • Pulse Oximetry • Expired CO2

14. 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

15. first wheeze poor response to treatment fever chest pain considering FB, pneumo hyperinflation flattened diaphragm barrel-chest PBT atelectasis Chest X-ray

16. pneumonia FB Cystic Fibrosis BPD CHF (Congenital Heart Disease) Croup Epiglottitis Retropharyngeal abscess Bacterial tracheitis GERD Differential

17. Treatment • β2 receptor agonists--albuterol • activates adenylate cyclase • increases cyclic adenosine monophosphate • bronchial smooth muscle relaxation • binding intracellular calcium to endoplasmic reticulum

18. Treatment • Xopenex - R isomer of albuterol • Salmeterol is a long acting β2 agonist • NOT indicated in acute setting • reduces need for Albuterol

19. 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?

20. 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

21. 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

22. Bronchiolitis

23. Bronchiolitis • Inflammation of bronchioles • Usually refers to children under 2 who have a viral URI with some intrathoracic symptoms (wheeze, cough, tightness)

24. Epidemiology • Prevalence late October to May • RSV 50-70% • Influenza • Parainfluenza

25. RSV • 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

26. Physical findings • tachypnea, tachycardia, conjunctivitis, retractions, prolonged expiration (I:E), wheezing, hypoxemia

27. Evaluation • similar to asthma • swab nose for RSV, Influenza • CXR

28. Treatment • Suction airway • O2 • β2 agonist • Albuterol • Racemic Epi • Epinephrine

29. Treatment • Atrovent? • Atropine? • dries secretions • Steroids? • for family Hx of asthma

30. Treatment • Ribavirin? (Guidance of PICU) • Pulmonary Disease • Cystic Fibrosis • RDS • Congenital Heart Disease

31. Bronchiolitis • 70% of children who wheeze in the ED are smoking (passively or actively)

32. Pneumonia

33. Pneumonia • Goals • Identify causes of Pneumonia in children • Describe Respiratory Distress in Pneumonia • Review Treatment for Pneumonia • Pediatric Emergency Medicine

34. Pneumonia • Infection within the lung • Viral • Bacterial • Fungal

35. 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 developing countries • Fall/Spring—parainfluenza • Winter—respiratory syncytial virus • Winter—influenza • Bacterial more common in the winter

36. Asthma/RAD/Bronchiolitis Immunocompromise Previous Insult to Lungs Abnormal Anatomy (Immotile Cilia) Cystic Fibrosis, Sickle Cell . . . Prematurity Malnutrition Low Socioeconomic Status Cigarette Smoke Day Care Foreign Body RiskFactors

37. Pathophysiology • Aspiration of infective particles into the lower respiratory tract • Suppression of normal defenses after viral infection • Coexistent viral and bacterial pathogens in children in ¡Ã50% of cases

38. 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

39. 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

40. Special Concerns • Staph aureus • rapid progression, abscesses • Grp A Strep • invasive, necrotizing fasciitis, empyema • Gram neg bacilli • recently hospitalized patients

41. Special Concerns • B. pertussis • paroxysmal cough • C. trachomatis • maternal exposure, conjunctivitis • M. pneumoniae • rash (Erythema Multiforme)

42. Special Concerns • RSV mortality rate • Congenital Heart up to 35% • Congenital Heart w/ Pulmonary HTN up to 70%

43. cough fever chest pain fatigue gasping tachypnea apnea abdominal pain nausea Symptoms

44. Findings • respiratory distress • tachypnea, grunting, flaring, retracting • abnormal auscultatory findings??? • cyanosis • chest X-ray - infiltrates

45. CXR Findings • Viral • diffuse interstitial infiltrates • Bacterial • consolidated, lobar • Mycoplasma • diffuse

46. Lab • CBC • elevated WBC, left shift • Blood Culture • Cold Agglutins • Sputum Culture • ABG • May help with placement • RSV • Influenza

47. Appearance • History is not as useful • Examination is paramount • Observation • vigorous crying • playful • quiet is bad!

48. 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 Signs of Respiratory Distress

49. Evaluation of Respiratory Distress • High Expired CO2 • CXR • Soft Tissue Neck X-ray • Response to Treatment • Pulse Oximetry???? • should not guide acute treatment decisions • misleading • inaccurate

50. Treatment • Position/Support/Maintain Airway • Wipe Nose! • Remove Foreign Bodies • Oxygen • Cool Mist (H2O or NS?)