Pediatrics 2

Respiratory distress

4th/December 15, 2008

*may*pau*kix*ces*

Prevalence: 50% acute  Family history

66% chronic  PE:
Etiology of childhood respiratory distress: • Inspection: Pattern of breathing
• Genetic (cystic fibrosis) Obstructive pattern: slower, deeper
• Anatomic (laryngomalacia) Extrathoracic – I>E (+) inspiratory stridor
• Iatrogenic (oxygen toxicity) Intrathoracic – E>I (use of accessory expiratory muscles)
• Immunologic (immune deficiency) Restrictive pattern: shallow, rapid
• Infectious (viral croup) Tachypnea – 24-26/min
• Extrapulmonary (congenital heart disease) Schamroth’s sign – clubbing of fingers, cyanosis due to
chronic hypoxemia
- Iatrogenic (environment, habitat)
*A child is not a miniaturized adult
- Chronic heart problems
Unique pedia features:
• Palpation:
• Small airway size
Symmetry- consolidation
• Airways lack cartilaginous stability
- effusion
• ↓ airway smooth muscle - collapse
• > mucous gland density Vocal and tactile fremiti - consolidation
• ↓ channels of collateral ventilation - effusion
• more compliant chest wall - collapse
• diaphragm structure different with decrease number of • Perscussion – limited value in small infants
fatigue-resistant fiber 2 types:
 Direct
Etiology in neonatal period:  Indirect
• Abnormal growth and development Pleximeter finger – touches the skin
• Incomplete maturation
Plexor – tapping fingers
*pressure should come from the wrist
• Incomplete adaptation to extrauterine life • Auscultation – breath sounds
• Perinatal insults including infection; asphyxia Normal breath sounds: Bronchial
• Apnea of maturity Vesicular
• Meconium aspiration Bronchovesicular – common in the
- TTNB chest
- Pneumonia (croup B strep) Discontinuous – crackles
- Spontaneous pneumothorax Continuous - ↑ wheezes, ↓ ronchi

Respiratory rate:  Stridor – inspiratory; signifies upper airway

Age Respiratory rate obstruction
Premature 40-70  Rales/crackles – inspiratory; rarely expiratory
0-3 months 35-55  Wheezes – caused by development of turbulent flow
3-6 months 30-45 in narrow airways
6-12 months 25-40
1-3 yrs 20-30
 Grunting – expiratory in nature; an attempt to raise
FRC by closing glottis at end of expiration
3-6 yrs 20-25
 Ronchi – low pitched
6-12 yrs 14-22
12 yrs old 12-18 Blood gas analysis
- Single most useful test of pulmonary function
Clinical - Evaluated by direct measurement of pO2, pCO2, & pH
Diagnostic approach to respiratory diseases: History - Best collected anaerobically in heparinized syringe
containing only enough heparin
 Questions on the ff:
- Respiratory sx Normal values:
- Chronicity pH: 7.35-7.45
- Timing paCO2: 35-50
- Associated with other activities paO2: 83-105
std HCO3: 22-28 mmol/L
Chronic cough: TB or asthma anion gap: 10-16 mmol/L
chloride: 98-107 mmol/L
 PMH
 With repeat pneumonias pH paCO2 HCO3
GI reflux Resp. acidosis ↓ ↑ N
Immune status – Wiscot Aldrich, agammaglobulinemia Resp. alkalosis ↑ ↓ N
(Brutton’s) Metabolic acidosis ↓ N ↓

MARY YVETTE ALLAIN TINA RALPH SHERYL BART HEINRICH PIPOY TLE JAM CECILLE DENESE VINCE HOOPS CES XTIAN LAINEY RIZ KIX EZRA GOLDIE BUFF MONA AM MAAN ADI KC
PENG KARLA ALPHE AARON KYTH ANNE EISA KRING CANDY ISAY MARCO JOSHUA FARS RAIN JASSIE MIKA SHAR ERIKA MACKY VIKI JOAN PREI KATE BAM AMS HANNAH MEMAY PAU
RACHE ESTHER JOEL GLENN TONI
 Subject:
Topic:
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Metabolic alkalosis ↑ N ↑ Allergic rhinitis: prominent sneezing and itching; nasal
eosinophilia
Foreign body: unilateral foul smelling discharge; bloody nasal
Transillumination of chest secretions
- Can diagnose pneumothorax in infants <6 mos (light Sinusitis: headache, facial pain, periorbital edema
probe) Streptococaal nasopharyngitis: excoriations
- Free air in the pleura results in unusually large halo of Pertussis: paroxysmal cough
light in the skin surrounding the probe Congenital syphilis: consistent rhinorrhea (snuffles); onset on
first 3 mos of life
Radiographic/chest x-ray
- AP/L or PA/L should be obtained Laboratory findings:
- If fluid is suspected, decubitus films are indicated - Lab studies generally not indicated
- Based on clinical sx
Lateral view indicators: upper airway obst.,glottic
Treatment:
Upper airway films: lateral view of the neck RSV – ribavirin
Influenza – oseltamivir & zanamivir
*epiglotitis: thumb sign Rhinovirus – n/a
- pleconaril – still being developed
sinutsitis: CT scan - antibacterial therapy is of no benefit
fluoroscopy is useful for evaluating stridor systemic treatment: fever, nasal obstruction, rhinorrhea, sore
throat, cough
Pulmonary function testing:
Spirometry Complications:
FEV1  Otitis media – most common, 5-30% children with colds
 Sinusitis
Upper Respiratory Tract diseases:  Asthma exacerbation
Common colds  Inappropriate use of antibiotics – antibiotic resistance
Influenza
Otitis media
Sinusitis
Pharyngitis
Retropharyngeal & lateral pharyngeal abscess*
Peritonsillar cellulitis*
(*life threatening)

Common cold
- Viral, rhinorrhea, nasal obstruction, systemic SSx may be
absent or mild

Influenza
- Etiology: rhinovirus – most common pathogen
- Early fall (aug-oct) and late spring (apr-may)
- Seasonal: rainy season

RSV and influenza – December to April

 Young children average: 6-7 colds/yr

10-15%: 12 infxns/yr
2-3/yr by adulthood
 manner of spread:
small particle
large aerosol particle
direct contact: RSV and rhinovirus
 manifestations:
onset of symptoms: 1-3 days
sore/scratchy throat
nasal obstruction
rhinorrhea
cough – persists about 1 wk, 10% lasts 2 wks
 PE findings:
Limited to upper respiratory tract
Increased nasal secretion
Nasal cavity – swollen, erythematous, non-specific finding

Allergic rhinitis
- Pale, boggy, grayish turbinates
- Nasal salute
- Rabbit nose

Differential diagnosis: