Lower Respiratory Disorders

1. Lower Respiratory Disorders Debbie King NP June 2006

2. Croup • An acute upper airway obstruction typically caused by a virual infection of the larynx • Etiology • Parainfluenza • Most common in children 3 months to 6 years of age • Males more often affected than females

3. Croup • Peak during late fall and winter • Signs and Symptoms • Low grade fever • Rapid onset of “barky” cough • Symptoms worse at night • Improvement with cool night air

4. Croup • Differential Diagnosis • Bacterial infections of upper respiratory tract • Laryngotracheomalacia (Look up) • Foreign body aspiration • Acute laryngeal edema • Severe asthma

5. Croup • Physical Findings • Inspiratory stridor • Brassy, barky cough • Dyspnea • Chest sounds are usually clear • Diagnostic Tests/Findings • White blood cell count- normal or elevated

6. Croup • Pulse oximetry • Radiographic image of airway (steeple sign) • Viral cultures of nasopharyngeal secretions • Management/Treatment • Mild disease • Outpatient care • Family education

7. Croup • Moderate to severe • Hospitalize for supportive care • 1 to 5% requite intubation • Medication • Dexamethasone 1mg/ml 0.6mg/kg x 1dose • Nebulized racemic epinephrine • Corticosteroid orapred 15/5 2mg/kg/bid x 2day • Isolation • prevention

8. Foreign Body Aspiration • Inhalation of foreign body that lodges in upper trachea or lower airways • Etiology/Incidence • Food or object • 80% are <3 years of age • 2/3 of cases are males

9. Foreign Body Aspiration • Signs and Symptoms • Sudden violent cough with gagging • History of witnessed choking • May be asymptomatic if object is not obstructing airway • Differential Diagnosis • Acute phase • Chronic phase

10. Foreign Body Aspiration • Physical Findings • Rarely still coughing • Unilateral wheezing and decreased breath sounds on side of aspiration • Voice changes • If foreign body is present persists, brochiectasis and abscess formation is likely

11. Foreign Body Aspiration • Diagnostic Tests/Findings • Pulse oximetry • Chest radiograph • Expiratory chest, decubitus, or fluoroscopy • Management/ Treatment • Institute cardiopulmonary resuscitation if needed

12. Foreign Body Aspiration • Immediate transport to hospital for evaluation and removal • Refer to endoscopy team • May need antibiotics • Chest radiograph in 6 to 8 weeks

13. Bronchitis • Acute- transient inflammation of larger lower airways • Chronic- symptoms persist for more than 2 weeks • Etiology/Incidence • Most commonly viral • Bacterial causes • Most common in winter and early spring

14. Bronchitis • Signs and Symptoms • Initial phase includes symptoms of upper respiratory illness • Cough • May have pain with cough • Differential Diagnosis • Asthma • Allergic disease • pneumonia

15. Bronchitis- differentials con’t • Gastroesophageal reflux • Inhalation or irritants • Cystic fibrosis • Immune deficiency • Chronic sinusitis • Immotile cilia syndrome • Foreign body aspiration • Airway deformity

16. Bronchitis • Physical Findings • Brassy cough • Coarse breath • May have tracheal tenderness • Diagnostic Tests/Findings • Based on history and physical • Radiograph of chest may be normal • Pulmonary function tests may be normal

17. Bronchitis • Management/Treatment • Avoidance of irritants • Expectorants, increase fluid intake • Bronchodilators • Inhaled steroids

18. Bronchiolitis • An acute viral infection of the smaller airway • Etiology/Incidence • RSV • Parainfluenza • Almost all children have it at least once before age 3 • Gerd

19. Bronchiolitis • If <6 months must be hospitalized or if they have cardio-respiratory disease • mid-winter to early spring (usually) • Signs and symptoms • Congestions, cough, and low-grade fever • Work of breathing • May present as apnea

20. Bronchiolitis • Differential diagnosis • Bacterial or chlamydia pnuemonia • Aspiration pneumonia • Asthma • Foreign body aspiration • Retropharyngeal abscess • Salicylate poisoning

21. Bronchiolitis • Physical Findings • Symptoms of rhinorrhea • Often low grade fever • Nasal flaring • Wheezing • Hypoxia

22. Bronchiolitis • Diagnostic Tests/Findings • Based on history and physical • Chest radiograph • Pulse oximetry • White blood cell count • Viral culture with rapid diagnostic techniques

23. Bronchiolitis • Management/Treatment • Oxygen therapy • Fluid and nutritional support • Brochodilators • Corticosteroids • Ribavirin may be used with caution • RSV IV

24. Pneumonia • Infectious- infection which involves small airways in children • Aspiration- caused by ingestion of food, saliva, or gastric content into air passages • Etiology/ Incidence • Common viral agents- RSV

25. Pneumonia • Newborns- most common bacterial causes group B strep, gram-negative enteric bacilli • Infant and young children < 6 years- streptococcus pneumoniae is primary cause • Older children and adolescents- streptococcus pneumoniae most likely • Aspiration pneumonia occurs in specific settings • 4% preschool children

26. Pneumonia • Signs and Symptoms • Cough • Fever • Chest pain • May have change in level of activity • May have nasal flaring

27. Pneumonia • Differential Diagnosis • Athelctasis • Foreign body aspiration • Asthma • Cystic fibrosis • Tuberculosis

28. Pneumonia • Physical Findings • Fever • May have tachypnea • May have wheezing • Localized dullness to percussion

29. Pneumonia • Diagnostic Tests/Findings • Chest radiograph • Atelectasis • Viral usually begins with scattered perihilar and peribronchial infiltrations • Bacterial- patchy infiltrates in infants • Acute aspiration usually develops in portion of lung that is dependent at time of aspiration

30. Pneumonia • White blood cell count may or may not elevate • Viral cultures of nasopharyngeal secretions • Blood cultures • Sputum cultures • Positive cold agglutinin screen or titer > 1:32 suggestive of Mycoplasma Pneumonia • Pulse oximetry- decreased O2 saturations

31. Pneumonia • Management/Treatment • Antimicrobial treatment based on etiology • Bronchodilators and chest physiotherpy may improve airway clearance • Flu vaccine for those with chronic illness • Other supportive therapy may include additional fluids and/or oxygen • Can progress rapidly and should be monitored

32. Pleurisy, Pleural Effusion and Empyema • Pleurisy- inflammation of the pleural lining • Pleural Effusion- accumulation of fluid in pleural space • Empyema- inflammation and purulent exudate

33. Pleurisy, Pleural Effusion and Empyema • Etiology/Incidence • Often caused by disease process else where in the body • Parapneumoic effusions • Signs and Symptoms • Chest pain • High fever • effusions

34. Pleurisy, Pleural Effusion and Empyema • Differential diagnosis • Tuberculosis • Neoplasm • Connective tissue disorder • Sarcoidosis • Physical Findings • Unilateral decrease in chest expansion during inspiration

35. Pleurisy, Pleural Effusion and Empyema • Splinting toward the affected side • Dullness to percussion • Diagnostic Tests • Chest radiograph • Thracentersis for evaluation of the pleural liquid • Mantoux test- PPD • Blood cultures • Pulse oximetry

36. Pleurisy, Pleural Effusion and Empyema • Management/Treatment • May involve treatment of an underlying systemic illness

37. Cystic Fibrosis • Defective epithelial chloride transport results in dehydrated viscous secretion which obstruct the exocrine ducts • Signs and Symptoms • Extremely viscid meconium • Weight loss despite voracious appetite • Recurrent respiratory infections • Liquid, large, foul smelling stools

38. Cystic Fibrosis- signs con’t • Frequent flatulence • Recurrent wheezing • Salty-tasting skin • Heat prostration • Differential Diagnosis • Asthma • Immunologic deficiencies • Antitrypsin deficiency (rare)

39. Cystic Fibrosis-differentials con’t • Airway abnormalities • Gastroesophageal reflux • Physical Findings • Respiratory • Chronic cough • Altered lung exam • Increased work of breathing • Increased anteroposterior diameter of chest

40. Cystic Fibrosis-respiratory SX con’t • Dyspnea on exertion • Recurrent otitis media • Chronic rhinorrhea • Nasal polyps • Gastrointestional • Meconium ileus • FTT • Abdominal distention • Abdominal pain

41. Cystic Fibrosis-GI SX con’t • Enlarged liver and spleen • Rectal prolapse • Evidence of vitamins A,E, and/or K deficiences • Other-digital clubbing • Diagnostic Tests • Pilocarpine iontophoresis sweat test • Genetic testing from buccal mucosa • Chest radiograph

42. Cystic Fibrosis-tests con’t • Pulmonary function tests • Sputum culture • Oximetry • Hyponatremia, hypochloremic alkalosis • Treatment will be managed by Pulmonary and GI MD’s through CF clinic- meds are very expensive and not all are covered by ins.

43. Asthma • Chronic lung disease characterized by: • Airway inflammation • Airway hyper-responsiveness to variety of stimuli • Variable airway obstruction • Etiology • Triggers • Indoor allergens

44. Asthma-etiology con’t • Outdoor allergens • Respiratory infection • Weather • Exercise • Gastroesophageal reflux • Irritants • Food allergies • Medications • Approximately 10% of children affected

45. Asthma • Signs and Symptoms • Recurrent episode of cough • Symptoms often worse at night • A subset of patients present with chronic cough without wheezing or exercise intolerance

46. Asthma • Differentials • aspiration • Cystic fibrosis • Cardiac defects • Lower respiratory tract infections • Physical Findings • Cough • Diffuse wheezes • Respiratory distress • Allergic appearance • Concurrent respiratory infection • Barrel chest

47. Asthma • Diagnostic Tests • Spirometry • Chest radiograph • Allergy testing • Nasal and sinus evaluation • Pulse oximetry

48. Asthma • Management/Treatment • Diagnose asthma and initiate partnership with family • Classify severity • Medication classification • Identify and reduce child-specific triggers • Provide clear written instructions • Educate child/family

49. Asthma-management-con’t • Long term care • Provide smoking cessation counseling as needed Review medications-use rescue meds as little as possible!!! Albuteral Xopenex Pulmicort Advair Flovent Allergy medications