First Aid for the Pediatrics Clerkship, 3 Ed.

Respiratory Disease

 

TABLE 12 - 1. Normal Respiratory Rates in Children

Image

RESPIRATORY DISTRESS

A common reason to visit emergency department (10% of ED visits).

Image Intercostal retractions.

Image Nasal flaring (indicates Image effort is needed to breathe).

Image Use of accessory muscles for breathing (eg, abdominals, sternocleidomastoids).

Image Restlessness, agitation.

Image Somnolence or lethargy may be due to severe hypoxia or hypercarbia.

Image Pallor, cyanosis.

Image Wheezing may or may not be present.

Image Stridor is an inspiratory sound that localizes respiratory distress to the upper airway

Image Grunting:

Image Due to exhalation against a partially closed glottis.

Image Occurs during expiration.

Image Indicates moderate to severe hypoxia.

Image See Table 12-1 for normal respiratory rates by age.

COMMON COLD (UPPER RESPIRATORY INFECTION, NASOPHARYNGITIS)

Image

A 7-year-old girl is well when she leaves for school, but arrives home afterwards with a sore throat and runny nose. She is also complaining of cough, sneezing, and facial heaviness. Think: Rhinovirus.Rhinovirus colds frequently start as a sore or “scratchy” throat with runny nose.

Image

A 17-year-old adolescent has acute onset of fever, cough, conjunctivitis, and pharyngitis. Think: Adenovirus. Characteristic presentation: Pharyngitis, rhinitis, and conjunctivitis. Conjunctivitis is typically follicular.

DEFINITION

Multi-etiology illness with a constellation of symptoms including cough, congestion, and rhinorrhea. Upper respiratory infections (URIs) are the most common pediatric ED presentation.

ETIOLOGY

Image > 200 viruses—especially rhinoviruses (one-third), parainfluenza, respiratory syncytial virus (RSV), adenovirus.

Image Risk factors: Child care facilities, smoking, passive exposure to smoke, low income, crowding, and psychological stress.

EPIDEMIOLOGY

Image Most frequent illness of childhood (three to eight episodes per year).

Image Most common medical reason to miss school.

Image Occurs in fall and winter especially.


Image

Mucopurulent rhinitis may accompany a common cold and doesn’t necessarily indicate sinusitis; it is not an indication for antibiotics.


SIGNS AND SYMPTOMS

Image Nasal and throat irritation.

Image Sneezing, nasal congestion, rhinorrhea.

Image Sore throat, postnasal drip.

Image Low-grade fever, headache, malaise, and myalgia.

Image Possible complications include otitis media, sinusitis, and trigger asthma.

Image Infants have a variable presentation—feeding and sleeping are difficult due to congestion, vomiting may occur after coughing, may have diarrhea.

TREATMENT

Image Supportive.

Image Avoid aspirin and over-the-counter cough suppressants or decongestants.

Image Direct therapy toward specific symptoms.


Image

The best treatment for the common cold is to Image oral fluids, not pharmacologic treatment.


INFLUENZA

DEFINITION

Viral respiratory illness.

ETIOLOGY

Image Influenza A and B—epidemic disease: H1N1 (influenza A).

Image Influenza C—sporadic.


Image

Aspirin is avoided in young children due to theoretical risk of Reye syndrome.


EPIDEMIOLOGY

Common over the winter months.

SIGNS AND SYMPTOMS

Image Incubation period: 1–3 days.

Image Sudden onset of fever, frequently with chills, headache, malaise, diffuse myalgia, and nonproductive cough.

Image Conjunctivitis, pharyngitis.

Image Typical duration of febrile illness is 2–4 days.

Image Complications include otitis media, pneumonia, myositis, and myocarditis.

Image Diarrhea and vomiting (H1N1).


Image

Influenza is an orthomyxovirus.


DIAGNOSIS

Image Nasal swab or nasal washing.

Image During epidemic, clinical signs can be used to save on test costs.


Image

Diagnosis of influenza depends on epidemiologic and clinical consideration.


TREATMENT

Image Symptomatic treatment is appropriate for healthy children—fluids, rest, acetaminophen.

Image For children at risk, see Table 12-2 for drug options.

Image Pregnant patients with H1N1 should receive a 5-day course of antiviral treatment.

Image Oseltamivir is preferred during pregnancy.

VACCINE


Image

Influenza can be severe in children with congenital heart disease, bronchopulmonary dysplasia (BPD), asthma, cystic fibrosis, and neuromuscular disease.


Intramuscular

Image Now recommended for all children over age 6 months, with priority given to high-risk groups.

Image High-risk groups include children with chronic diseases such as asthma, renal disease, diabetes, and any other form of immunosuppression.

Image Best administered mid-September to mid-November since the peak of the flu season is late December to early March.

Image Antibodies take up to 6 weeks to develop in children. Consider prophylaxis in high-risk children during this period.

Image Since composition of influenza virus changes, the flu vaccine needs to be administered every year.

Image Vaccine is a killed virus and therefore cannot cause the flu.

Image Not approved for children < 6 months of age.

Intranasal

Image Live, attenuated vaccine available for children > 5 years old.

Image Not licensed for children with reactive airway disease.

Image Contraindicated in immunosuppressed individuals.

TABLE 12 - 2. Drug Treatments for Influenza (All Pregnancy Category C)

Image

H1N1 VACCINE

Image Monovalent, inactivated influenza A virus vaccine.

Image 6–35 months: 0.25 mL IM. Two doses 4 weeks apart.

Image 3–9 years: 0.5 mL IM. Two doses 4 weeks apart.

Image Intranasal:

Image Monovalent live virus vaccine.

Image 2–9 years: 0.2 mL/dose (0.1 mL per nostril). Two doses 4 weeks apart.

PARAINFLUENZA

ETIOLOGY

Image Type 1 and 2—seasonal.

Image Type 3—endemic.

Image See Table 12-3.


Image

Parainfluenza is a paramyxovirus.


SIGNS AND SYMPTOMS

Image Incubation period: 2–6 days.

Image Causes:

Image Colds

Image Pharyngitis

Image Otitis media

Image Croup

Image Bronchiolitis

Image Can be severe in immunocompromised patients

TREATMENT

Specific antiviral therapy is not available.


Image

Parainfluenza types 1 and 2 cause croup; type 3 causes bronchiolitis and pneumonia; type 4 is a cause of the common cold.


TABLE 12 - 3. Respiratory Infections and Pathogens

Image

CROUP

Infectious Croup (Acute Laryngotracheobronchitis)

Image

An 18-month-old boy with inspiratory stridor and a barking cough and agitation when lying down is brought at night to the emergency department (ED) by parents. He has had a sore throat and cough for 2 days. On examination, he has hoarseness, high-pitched barking cough, and stridor. In addition, tachypnea, retractions, and nasal flaring was noted. Steeple sign is seen on x-ray. Think: Croup.


Image

Croup is the most common cause of stridor in a febrile child.


DEFINITION

Viral infection of upper respiratory tract.


Image

Croup is the most common infectious cause of acute upper airway obstruction.


ETIOLOGY

Parainfluenza virus types 1 and 2.


Image

Most common cause of stridor in children is croup.


EPIDEMIOLOGY

Occurs in children 3 months to 3 years of age in fall and winter months.


Image

Stridor and distress at home and calm and free of stridor in ED: Think croup.


SIGNS AND SYMPTOMS

Image Inspiratory stridor.

Image Seal-like, barking cough with retractions and nasal flaring.

Image May have coryza and fever.

Image Can progress to agitation, hypoxemia, hypercapnia, tachypnea, and tachycardia.

Image Most cases are mild and last 3–7 days.

Image Symptoms worse at night, and typically worse on second day of illness.


Image

Constant stridor and distress both at home and ED despite treatment: Think tracheitis.


DIAGNOSIS

Image X-ray usually not necessary. Consider only if diagnosis is in doubt.

Image Steeple sign—narrowing of tracheal air column just below the vocal cords (see Figure 12-1).

Image Ballooning—distention of hypopharynx during inspiration.

Image Differentiate croup from epiglottitis.


Image

Minimum observation of child brought in with croup is 3 hours.


TREATMENT

Image Position of comfort.

Image Mild—symptomatic care, cool air, nonsteroidal anti-inflammatories (NSAIDs), consider corticosteroids.

Image Moderate—racemic epinephrine (0.25 mL in 3–5 mL of normal saline [NS]), admit, early corticosteroids.

Image Severe—racemic epinephrine, intensive care unit (ICU), early use of corticosteroids.

Image Dexamethasone 0.6 mg/kg (lower dose [0.15 mg/kg] has also shown be effective).

Image Maximum: 10 mg/dose.

Image Admission criteria:

Image Persistent stridor (especially at rest).

Image Respiratory distress.


Image

Reconsider diagnosis of croup if child is hypoxic.


Image

FIGURE 12-1. Radiograph demonstrating steeple sign of croup.

Note narrowing of airway (arrow). (Courtesy of Dr. Gregory J. Schears.)


Image

Stridor at rest is an indication for hospital admission.


Image Multiple doses of racemic epinephrine.

Image Possibility of alternate diagnosis.

CORTICOSTEROIDS IN RESPIRATORY PROBLEMS

Image Dexamethasone (IM or PO 0.6 mg/kg).

Image Side effects associated with short-term steroid use are minimal.


Image

Give corticosteroids to febrile child with stridor for:

Image Croup

Image Epiglottitis

Image Retropharyngeal abscess

Image Bacterial tracheitis


Spasmodic Croup (Laryngismus Stridulus, Midnight Croup)

DEFINITION

Image Recurrent, sudden onset of barking cough and inspiratory stridor without preceding respiratory tract infection.

Image Well known to physicians but still defies definition of pathogenesis.

Image Familial predisposition: Family history of allergies.

ETIOLOGY

Image Probable viral etiology.

Image Other considerations—allergic, psychological, gastroesophageal (GE) reflux.


Image

Diagnosis of spasmodic croup can be made only on resolution of the symptoms.


EPIDEMIOLOGY

Image Usually at night.

Image Aggravated by excitement.

Image Winter months.

Image Occurs in children 1–3 years of age.

SIGNS AND SYMPTOMS

Image Recurrent episodes of acute-onset barking cough and inspiratory stridor.

Image No symptoms of infection.


Image

Steroids are not indicated in spasmodic croup.


DIAGNOSIS

Subglottic, noninflammatory edema.

TREATMENT

Image Reassurance and cool mist.

Image Spontaneous recovery.

EPIGLOTTITIS

Image

A 4-year-old boy brought to the ED is flushed, making high-pitched noises on forced inspiration, leaning forward in his mother’s lap, and drooling. His illness started with fever and sore throat and rapidly progressed to difficulty swallowing, drooling, restlessness, and stridor or air hunger. He appeared toxic and anxious. Lateral neck x-ray shows thumb sign. Think: Epiglottitis, and get him to an operating room (OR) to intubate and treat!

The classic presentation: “three Ds” (drooling, dysphagia, and distress).

See Figure 12-2.


Image

Minutes count in acute epiglottitis.


DEFINITION

Acute, life-threatening infection of supraglottic tissues.

ETIOLOGY

Image Haemophilus influenzae type B.

Image Other possible pathogens—Streptococcus pyogenes, Streptococcus pneumoniae, Staphylococcus aureus.

Image

FIGURE 12-2. Radiograph of lateral soft tissue of neck demonstrating epiglottitis.

Note the thickening of the epiglottic and ariepiglottic folds (arrows). (Reproduced, with permission, from Schwartz DT, Reisdorff BJ. Emergency Radiology. New York: McGraw-Hill, 2000: 608.)

PATHOPHYSIOLOGY

Acute inflammation and edema of epiglottis, aryepiglottic folds, and arytenoids.

EPIDEMIOLOGY

Image Image incidence due to H influenzae type B vaccine (HiB).

Image Usually 2–6 years of age, but can occur at any age.

Image Suspect in unvaccinated children.

Image H influenzae immunization has practically eliminated epiglottitis in young children.


Image

In doubtful cases, radiograph alone should not be used to diagnose epiglottitis.


SIGNS AND SYMPTOMS

Image Sudden onset of inspiratory stridor and respiratory distress.

Image Muffled voice (“hot potato” voice).

Image High fever (usually the first symptom).

Image Toxic appearing.

Image Tripod position—hyperextended neck, leaning forward, mouth open.

Image Three D’s: Dysphagia, drooling, and distress.

Image Cough (less frequent symptom)

Image Tachycardia is a constant feature.

Image Severe respiratory distress develops within minutes to hours.

Image May progress to restlessness, pallor/cyanosis, coma, death.

DIAGNOSIS

Image Laryngoscopy—swollen, cherry-red epiglottis.

Image Lateral neck x-ray to confirm (portable x-ray should be obtained).

Image Swollen epiglottis (thumbprint sign).

Image Thickened aryepiglottic fold.

Image Obliteration of vallecula.

TREATMENT

Image True medical emergency—potentially lethal airway obstruction.

Image Comfort.

Image Anticipate.

Image Secure airway (endotracheal intubation in OR).

Image Ceftriaxone (100 mg/kg/day) 7–10 days.

Image Rifampin prophylaxis for close contacts.


Image

Epiglottitis is a true medical emergency. If suspected, do not:

Image Examine the throat

Image Use narcotics or sedatives, including antihistamines

Image Attempt venipuncture or other tests

Image Place patient supine


TRACHEITIS/LARYNGITIS

DEFINITION

Rapidly progressive upper airway obstruction due to infection of the trachea and/or larynx.

ETIOLOGY

Image S aureus and H influenzae type b.

Image Also Moraxella catarrhalis.

Image High association with preceding influenza A infection.

SIGNS AND SYMPTOMS

Image Often present with croup symptoms. Differentiation can be made by the presence of:

Image High fever

Image Toxicity

Image Inspiratory stridor (constant)

Image Purulent sputum

Image A toxic-appearing child with croupy symptoms who responds poorly to croup management should be evaluated for tracheitis.

Image Tracheitis has features of both croup (stridor and croupy cough) and epiglottitis (high fever and toxic appearance).


Image

Bacterial tracheitis has a slower onset than epiglottitis.


DIAGNOSIS

Image X-ray—may be normal or identical to croup. Look for pseudomembrane on lateral view.

Image Epiglottis size normal

Image Tracheal narrowing

Image Pseudomembrane

Image Endoscopy.

Image Copious purulent secretion distal to glottis.

Image Secretions should be obtained for Gram stain and culture.

TREATMENT

Image Secure an adequate airway (endotracheal intubation):

Image Should be performed in an operating room under anesthesia.

Image Suction endotracheal tube of purulent material.

Image Specialty consultation: Ear, nose, and throat (ENT), and anesthesia.

Image Ceftriaxone 100 mg/kg/day.

Image Ampicillin-sulbactam 200 mg/kg/day.

Image ICU admission.

BRONCHIOLITIS

Image

A previously healthy 4-month-old who had rhinorrhea, cough, and a low-grade fever develops tachypnea, mild hypoxemia, and hyperinflation of lungs. Think: RSV bronchiolitis.

Classic presentation: Acute onset of cough, wheezing, and Image respiratory effort after an upper respiratory tract prodrome (fever and runny nose), during the winter season.

DEFINITION

Viral infection of upper and lower respiratory tract (medium and small airways).

ETIOLOGY

Image RSV—most common cause.

Image Adenovirus.

Image Parainfluenza 3.

Image Influenza.


Image

Bronchiolitis is the most common serious respiratory infection in children < 2 years.


Image Human metapneumovirus (hMPV): First recognized in 2001 and now increasingly implicated.

Image Mycoplasma pneumoniae (rare).

PATHOPHYSIOLOGY

Image Inflammatory obstruction (edema and mucus) of the bronchioles secondary to viral infection.

Image Alterations in gas exchange are most frequently the result of mismatching of pulmonary ventilation and perfusion.


Image

RSV causes more than 50% of cases of bronchiolitis.


EPIDEMIOLOGY

Image Occurs in first 2 years of life.

Image Reinfection is common.

Image Ninety percent are aged 1–9 months.

Image Occurs in winter and early spring.

Image Risks: Crowded conditions, not breast-fed, mothers who smoke, male gender.

Image High-risk infants:

Image Cardiac disease

Image Pulmonary disease

Image Neuromuscular disease

Image Premature infants

Image Immunocompromised


Image

Humans are the only source of RSV infection.


SIGNS AND SYMPTOMS

Image Starts with mild respiratory illness.

Image Respiratory distress gradually develops.

Image Paroxysmal wheezing—common but may be absent, cough, dyspnea.

Image Apneic spells—young infants should be monitored.

Image Frequent complications include bacteremia, pericarditis, cellulitis, empyema, meningitis, and suppurative arthritis.

Image Most common complication is hypoxia.

Image Dehydration is the most common secondary complication.


Image

Symptoms of asthma can be identical to bronchiolitis. Suspect asthma if:

Image Family history

Image Prior episodes

Image Response to bronchodilator


DIAGNOSIS

Image Viral detection in nasopharyngeal secretions via culture, polymerase chain reaction (PCR), or antigen detection.

Image Chest x-ray (rule out pneumonia or foreign body)—hyperinflation of lungs, Image anteroposterior (AP) diameter of rib cage.

Image Oxygen saturation is the single best objective predictor.

TREATMENT

Image Low threshold for hospitalization for high-risk infants.

Image Humidified oxygen.

Image Trial of nebulized albuterol (only 20–50% are responders, discontinue if no objective benefit).

Image Hypertonic saline—potential to reduce airway edema and mucous plugging.

Image Steroids not indicated.

Image Respiratory isolation.

Image Ribavirin (aerosol form) if high-risk patients such as immunocompromised, need for mechanical ventilation, or < 6 weeks old.

Image RSV intravenous immune globulin (RSV-IVIG) or palivizumab given prior to and during RSV season in high-risk infants < 2 years old.


Image

Indications for rapid antigen detection in suspected RSV bronchiolitis: cohorting RSV-positive patient or to confirm RSV in high-risk patient.


BRONCHIECTASIS

Image

A 7-year-old boy presents with an upper respiratory infection (URI) with productive cough (with purulent sputum). On examination, localized rales on the right side of his chest were noted. X-ray shows two discrete densities located in the right upper lobe of the lungs. Think: Bronchiectasis. Predisposition: Cystic fibrosis and ciliary dyskinesia.

DEFINITION

Abnormal and permanent dilatation of bronchi.

ETIOLOGY

Image Viruses: Adenovirus, influenza virus.

Image Bacteria: S aureus, Klebsiella, anaerobes.

Image Primary ciliary dyskinesia.

Image Kartagener syndrome.

Image Cystic fibrosis: Pseudomonas aeruginosa.

Image α1-antitrypsin deficiency.

PATHOPHYSIOLOGY

Consequence of inflammation and destruction of structural components of bronchial wall.

SIGNS AND SYMPTOMS

Image Physical exam quite variable.

Image Persistent or recurrent cough.

Image Purulent sputum.

Image Hemoptysis.

Image Dyspnea.

Image Wheezing.

Image Clubbing.

DIAGNOSIS

Image Chest x-ray.

Image Bronchography.

Image Computed tomographic (CT) scan.

Image Sputum culture.

TREATMENT

Image Elimination of underlying cause.

Image Clearance of secretion.

Image Chest physiotherapy.

Image Mucolytic agents.

Image Control of infection—antibiotics.

Image Reversal of airflow obstruction—bronchodilators.

BRONCHITIS

DEFINITION

Infection of conductive airways of lung.


Image

Cough is the most common symptom of chronic bronchitis.


ETIOLOGY

Image Viruses: Influenza A and B, adenovirus, parainfluenza, rhinovirus, RSV, coxsackievirus.

Image Bacteria: Bordetella pertussis, M pneumoniae, Chlamydia pneumoniae, S pneumoniae.

SIGNS AND SYMPTOMS

Image Acute productive cough (< 1 week).

Image Rhinitis.

Image Myalgia.

Image Fever.

Image No evidence of sinusitis, pneumonia, or chronic pulmonary disease.

Image Normal arterial oxygenation.

TREATMENT

Image Mostly self-limited.

Image Bronchodilators may help.

Image Antibiotics for high-risk patients.


Image

Pharyngitis is the second most common diagnosis in children aged 1–15 years in the pediatric clinic.


PHARYNGITIS

DEFINITION

Infection of the tonsils and/or the pharynx.


Image

Viruses (most common cause of pharyngitis): Rhinovirus, adenovirus, coxsackievirus.


ETIOLOGY

SIGNS AND SYMPTOMS

Image Viral pharyngitis:

Image Gradual onset.

Image Fever, malaise, throat pain.

Image Conjunctivitis, rhinitis, coryza, viral exanthem, diarrhea.

Image Streptococcal pharyngitis (> 2 years) (see Figure 12-3):

Image Headache, abdominal pain, and vomiting.

Image Fever (> 104°F [40°C]).

Image Tonsillar enlargement with exudates.

Image Fetid odor.

Image Cervical adenopathy.

Image Palatal petechiae and uvular edema.

Image It is not possible to distinguish clinically viral from bacterial pharyngitis, though high fever, cervical adenopathy, and absence of URI symptoms suggest bacterial etiology.


Image

Acute rheumatic fever occurs more after throat than skin infections and in children who have had acute rheumatic fever before.


Image

FIGURE 12-3. Streptococcal pharyngitis.

Note white exudates on top of erythematous swollen tonsils.

DIAGNOSIS

Rapid (DNase) antigen detection test (sensitivity 95–98%):

Image Culture if negative.

Image Treat if positive.

TREATMENT

Image Oral penicillin (25–50 mg/kg/day) for 10 days.

Image Alternatively, intramuscular (IM) benzathine and procaine penicillin can be used (single dose, weight based).

Image Macrolides or clindamycin for penicillin-allergic patients for 10 days.

Image Tetracycline and sulfonamides should not be used to treat group A beta-hemolytic streptococci (GABHS).

Image Antibiotics are not indicated for pharyngitis negative for GABHS.


Image

Penicillin remains the drug of choice for GABHS.


COMPLICATIONS

Image Suppurative:

Image Peritonsillar abscess

Image Retropharyngeal abscess

Image Cervical adenitis

Image Otitis media

Image Sinusitis

Image Nonsuppurative:

Image Acute glomerulonephritis

Image Acute rheumatic fever


Image

The more mucous membranes involved, the more likely an infection is viral.


PNEUMONIA

Image

A 2-month-old with fever, tachypnea, and mottled skin has a chest x-ray showing infiltrate of the right upper lung lobe, a pneumatocele, and a pleural effusion. Think: S aureus pneumonia.

Image

A previously healthy 9-year-old boy has a 7-day history of increasing cough, low-grade fever, and fatigue on exertion. Chest x-ray shows widespread diffuse perihilar infiltrates. Think: Mycoplasma pneumonia. Initially, nonproductive cough and no fever. Later, productive cough with fever, headache, coryza, otitis media, and malaise.

DEFINITION

Inflammation of lung parenchyma.


Image

Round pulmonary infiltrate on chest x-ray. Think: S pneumoniae pneumonia.


ETIOLOGY

Image Viruses: RSV, influenza, parainfluenza, adenovirus.

Image Bacteria: Less common, but more severe—S pneumoniae, S pyogenes, S aureus, H influenzae type B, M pneumoniae.


Image

Pneumonia with hilar adenopathy on chest x-ray. Think: Adenovirus. However, it is difficult to make an accurate etiologic diagnosis only on the basis of clinical presentation.


SIGNS AND SYMPTOMS

Image Tachypnea, dyspnea.

Image Fever and feeding difficulty (infant).

Image Productive cough, chest pain (children).

Image Chlamydia trachomatis (pneumonitis syndrome).

Image Occurs in children 1–3 months of age.

Image Staccato cough, tachypnea, progressive respiratory distress.

Image Lack of fever and other systemic signs.

Image Conjunctivitis.


Image

The most reliable sign of pneumonia is tachypnea.


DIAGNOSIS

Image Chest x-ray (Figure 12-4):

Image Viral (hyperinflation, perihilar infiltrate, hilar adenopathy, and atelectasis).

Image Bacterial (alveolar consolidation).

Image Mycoplasma (interstitial infiltrates).

Image Tuberculosis (hilar adenopathy).

Image Pneumocystis (reticulonodular infiltrates).

Image Blood culture (positive in 10–30% of bacterial cases).


Image

Consider pneumonia in children with neck stiffness or acute abdominal pain.


Image

FIGURE 12-4. Chest x-ray demonstrating diffuse bilateral pulmonary infiltrates.

Note tip of endotracheal tube (arrow) is in good position.


Image

In young children, auscultation may be normal with impressive x-ray findings.


TREATMENT

Image Inpatient:

Image 1–3 months old: Macrolide (pneumonitis syndrome) or third-generation cephalosporin.

Image ≥ 3 months and older: Third-generation cephalosporin.

Image Outpatient:

Image Patients should have normal O2 saturation and be able to take oral fluids in order to be outpatients.

Image Amoxicillin or erythromycin.

PERTUSSIS

DEFINITION

Image “Whooping cough.”

Image Highly infectious form of bronchitis.

ETIOLOGY

Image Bordetella pertussis gram-negative coccobacilli.

Image Humans are the only known host.

Image Whooping cough syndrome also may be caused by:

Image Bordetella parapertussis

Image M pneumoniae

Image C trachomatis

Image C pneumoniae

Image Adenoviruses


Image

Pertussis means “intense cough.”


PATHOPHYSIOLOGY

Image Pertussis toxin is a virulence protein that causes lymphocytosis and systemic manifestations.

Image Aerosol droplet transmission.


Image

Despite having “whooping cough,” most patients with pertussis do not whoop.


EPIDEMIOLOGY

Image Endemic, but epidemic every 3–4 years.

Image 60 million cases/year worldwide.

Image 500,000 deaths/year worldwide.

Image July to October.

Image Occurs in 1- to 5-year-olds worldwide, 50% < 1-year-olds in United States.


Image

With pertussis, fever may be absent or minimal; cough may be only complaint.


SIGNS AND SYMPTOMS

Image Incubation period 1–2 weeks.

Image Three stages: Catarrhal, paroxysmal, and convalescent.

Image Duration: 6 weeks.

Image Catarrhal stage: Congestion and rhinorrhea.

Image Paroxysmal stage (2–4 weeks):

Image Paroxysmal cough, with characteristic whoop following (chin forward, tongue out, watery, bulging eyes, purple face).

Image Fever is typically absent.

Image Post-tussive emesis and exhaustion.


Image

Apnea is common in infants with pertussis.


Image Convalescent stage: Number and severity of paroxysms plateaus.

Image Each stage lasts ∼ 2 weeks; shorter if immunized.

Image Complications include apnea, physical sequelae of forceful coughing, brain hypoxia/hemorrhage, secondary infections (bacterial pneumonia is the cause of death).


Image

Suspect pertussis if paroxysmal cough with color change.


DIAGNOSIS

Image Diagnosis is primarily clinical:

Image Inspiratory whoop

Image Post-tussive emesis

Image Lymphocytosis

Image Chest x-ray—perihilar infiltrate or edema (butterfly pattern).

Image Positive immunofluorescence test or PCR on nasopharyngeal secretions.


Image

No single serologic test is diagnostic for pertussis.


TREATMENT

Image Goal—to Image spread of organism. Antibiotics do not affect illness in paroxysmal stage, which is toxin mediated.

Image Macrolide antibiotic for patient and household contacts.

Image Isolation until 5 days of therapy.

Image Admit if:

Image Infant < 3 months.

Image Apnea.

Image Cyanosis.

Image Respiratory distress.

Image DTP (diphtheria, tetanus, pertussis)/DTaP (diphtheria, tetanus, acellular pertussis) vaccine.


Image

There is a risk of hypertrophic pyloric stenosis in infants younger than 6 weeks treated with oral erythromycin.


DIPHTHERIA

DEFINITION

Membranous nasopharyngitis or obstructive laryngotracheitis.

ETIOLOGY

Image Corynebacterium diphtheriae.

Image Humans are the only reservoir.

SIGNS AND SYMPTOMS

Image Incubation period: 2–7 days.

Image Erosive rhinitis with membrane formation.

Image Tonsillopharyngeal—sore throat, membranous exudate.

Image Cardiac symptoms.

Image Tachycardia out of proportion to fever.

DIAGNOSIS

Image Culture (nose, throat, mucosal, or cutaneous lesion).

Image Material should be obtained from beneath the membrane or a portion of membrane.

Image All C diphtheriae isolates should be sent to diphtheria laboratory.


Image

For treatment of diphtheria, antibiotics are not a substitute for antitoxin.


TREATMENT


Image

Most tuberculosis infections in children are asymptomatic with positive PPD.


Image Antitoxin—dose depends on:

Image Site of membrane

Image Degree of toxic effects

Image Duration of illness

Image Antibiotics:

Image Erythromycin or penicillin G for 14 days.

Image Elimination of organism should be documented by two consecutive cultures.


Image

A patient may develop TB despite prior bacillus Calmette-Guérin (BCG) vaccination.


TUBERCULOSIS (TB)

DEFINITION

Image Signs and symptoms and/or radiographic manifestations caused by M tuberculosis are apparent.

Image May be pulmonary, extrapulmonary, or both.

ETIOLOGY

Mycobacterium tuberculosis.


Image

A positive PPD skin test results from infection, not from exposure.


PATHOPHYSIOLOGY

Primary portal of entry into children is lung.


Image

Asymptomatic children with a positive PPD should be considered infected and get treatment.


EPIDEMIOLOGY

Image Children are never the primary source (look for adult contacts).

Image Risk factors:

Image Urban living

Image Low income

Image Recent immigrants

Image HIV


Image

All cases of active TB should be referred to public health department.


SIGNS AND SYMPTOMS

Image Chronic cough (nonproductive)

Image Hemoptysis

Image Fever

Image Night sweats

Image Weight loss

Image Anorexia

Image Lymphadenopathy

Image Present to ED with:

Image Primary pneumonia

Image Miliary TB (may mimic sepsis)

DIAGNOSIS

Image When to suspect TB:

Image Hilar adenopathy.

Image Pulmonary calcification.

Image Pneumonia with infiltrate and adenopathy.

Image Pneumonia with pleural effusion.

Image Painless unilateral cervical adenopathy (scrofula).

Image Meningitis of insidious onset.


Image

Persons with TB should be tested for HIV.


Image Bone or joint disease.

Image When any of the above are unresponsive to antibiotics.

Image PPD test (Mantoux test).

Image QuantiFERON®-TB Gold test.

Image Culture (gastric aspirates, sputum, pleural fluid, cerebrospinal fluid, urine, or other body fluids).

Image Look for the adult source.

Image Acid-fast stain or PCR.

TREATMENT

Image Two to four or more drugs (isoniazid, rifampin, pyrazinamide, ethambutol, streptomycin) for a minimum of 6 months for active disease.

Image Isoniazid for 9 months for latent disease.


Image

TB in children < 4 years of age is much more likely to disseminate; prompt and vigorous treatment should be started when the diagnosis is suspected.


CYSTIC FIBROSIS (CF)

Image

A 3-year-old child presents with constant cough with sputum. He has had six episodes of pneumonia, with Pseudomonas being isolated from sputum; loose stools; and is at the 20th percentile for growth. Think: CF.

CF is an inherited multisystem disorder resulting in chronic lung disease, exocrine pancreatic insufficiency, and failure to thrive.


Image

Cystic fibrosis is the most common lethal inherited disease of Caucasians.


DEFINITION

Disease of exocrine glands that causes viscous secretions:

Image Chronic respiratory infection

Image Pancreatic insufficiency

Image Image electrolytes in sweat

ETIOLOGY

Image Defect of cyclic adenosine monophosphate (cAMP)-activated chloride channel of epithelial cells in pancreas, sweat glands, salivary glands, intestines, respiratory tract, and reproductive system.

Image Autosomal recessive.


Image

The gene for cystic fibrosis is CFTR; the mutation is delta F508.


PATHOPHYSIOLOGY

Image Chloride does not exit from cells.

Image Image osmotic pressure inside cells attracts water and Image thick secretions.

EPIDEMIOLOGY

Image Most common cause of severe, chronic lung disease in children.

Image One in 2000–3000 live births (Caucasians).

SIGNS AND SYMPTOMS

Image Respiratory:

Image Cough—most common pulmonary symptom.

Image Wheezing, dyspnea, exercise intolerance.

Image Bronchiectasis, recurrent pneumonia.

Image Sinusitis, nasal polyps.

Image Reactive airway disease, hemoptysis.


Image

A patient with severe CF breathing room air can have an arterial blood gas (ABG) showing Image chloride and Image bicarbonate.


Image Image AP chest diameter.

Image Hyperresonant lungs.

Image Clubbing of nails.

Image Gastrointestinal (GI):

Image Failure to thrive.

Image Meconium ileus (10%).

Image Constipation, rectal prolapse.

Image Intestinal obstruction.

Image Pancreatic insufficiency:

Image Malabsorption.

Image Fat-soluble vitamin deficiencies.

Image Glucose intolerance.

Image Biliary cirrhosis (uncommon): Jaundice, ascites, hematemesis from esophageal varices

Image Reproductive tract: Image/absent fertility—female, thick cervical secretions; male, azoospermic.

Image Sweat glands:

Image Salty skin.

Image Hypochloremic alkalosis in severe cases.

Image Complications may include pneumothorax, chronic pulmonary hypertension, cor pulmonale, atelectasis, allergic bronchopulmonary aspergillosis, respiratory failure, gastroesophageal reflux.


Image

False-positive sweat test (not CF):

Image Nephrogenic diabetes insipidus

Image Myxedema

Image Mucopolysaccharidosis

Image Adrenal insufficiency

Image Ectodermal dysplasia


DIAGNOSIS

Image Sweat test—chloride concentration > 60 mEq/L (gold standard).

Image Genetic studies.

Image In utero screen available.

Image Pulmonary function tests (PFTs): Obstructive and restrictive abnormalities.

Image Prenatal diagnosis via gene proves CF mutations or linkage analysis.

TREATMENT

Image Multidisciplinary team approach—pediatrician, physiotherapist, dietitian, nursing staff, teacher, child, and parents.

Image Respiratory:

Image Chest physical therapy.

Image Exercise.

Image Coughing to move secretions and mucous plugs.

Image Bronchodilators.

Image Normal saline aerosol.

Image Anti-inflammatory medications.

Image Dornase-alpha nebulizer (breaks down DNA in mucus).

Image Pancreatic/digestive:

Image Enteric coated pancreatic enzyme supplements (add to all meals).

Image Fat-soluble vitamin supplements.

Image High-calorie, high-protein diet.

Image Antibiotics—sputum cultures used to guide antibiotic choice. Pseudomonal infections are especially common.

Image Lung transplant.

Image Gene therapy is being aggressively studied.


Image

Features of CF: CF PANCREAS

Chronic cough

Failure to thrive

Pancreatic insufficiency

Alkalosis

Nasal polyps

Clubbing

Rectal prolapse

Electrolytes Image in sweat

Absence of vas

Sputum mucoid


PROGNOSIS

Advances in therapy have Image life expectancy into adulthood.


Image

Ninety-nine percent of cases of meconium ileus are due to CF.


TONSILS/ADENOIDS

Tonsillitis/Adenoiditis

DEFINITION

Inflammation of:

Image Tonsils—two faucial tonsils.

Image Adenoids—nasopharyngeal tonsils.

SIGNS AND SYMPTOMS

Image Sore throat.

Image Pain with swallowing.

Image May have whitish exudate on tonsils.

Image Chronic tonsillitis:

Image Seven in past year.

Image Five in each of the past 2 years.

Image Three in each of the past 3 years.


Image

Fat-soluble vitamin deficiencies:

A—night blindness

D—Image bone density

E—neurologic dysfunction

K—bleeding


TREATMENT

Image < 2–3 years old: Tonsillectomy is performed for obstructive sleep symptoms.

Image Large size alone is not an indication to remove tonsils.

Enlarged Adenoids

DEFINITION

Nasopharyngeal lymphoid tissue.


Image

Tonsils and adenoids are part of Waldeyer’s ring that circles the pharynx.


SIGNS AND SYMPTOMS

Image Mouth breathing

Image Persistent rhinitis

Image Snoring


Image

It can be normal for tonsils to be relatively large during childhood.


DIAGNOSIS

Image Digital palpation

Image Indirect laryngoscopy

TREATMENT

Image Adenoidectomy:

Image Persistent mouth breathing.

Image Hyponasal speech.

Image Adenoid facies.

Image Recurrent otitis media or nasopharyngitis.

Image Tonsillectomy should not be performed routinely unless separate indication exists.

Peritonsillar Abscess

DEFINITION

Walled-off infection occurring in the space between the superior pharyngeal constrictor muscle and tonsils.

ETIOLOGY

Image GABHS

Image Anaerobes

EPIDEMIOLOGY

Usually preadolescent.


Image

Trismus is limited opening of the mouth.


SIGNS AND SYMPTOMS

Image Preceded by acute tonsillopharyngitis.

Image Severe throat pain.

Image Trismus.

Image Refusal to swallow or speak.

Image “Hot potato voice.”

Image Markedly swollen and inflamed tonsils.

Image Uvula displaced to opposite side.

TREATMENT

Image Antibiotics covering staph and strep. Typically, ampicillin—sulbactam.

Image Incision and drainage.

RETROPHARYNGEAL ABSCESS

DEFINITION

Potential space between the posterior pharyngeal wall and the prevertebral fascia. Commonly occurs in children < 5 years old.

ETIOLOGY

Usually a complication of pharyngitis:

Image GABHS

Image Oral anaerobes

Image S aureus

SIGNS AND SYMPTOMS

Image Sudden onset of high fever with difficulty in swallowing.

Image Refusal of feeding.

Image Throat pain.

Image Hyperextension of the head.

Image Toxicity is common.

Image May cause meningismus—extension of the neck causes pain.

DIAGNOSIS

Lateral neck x-ray: Normal retropharyngeal space should be less than one-half of width of adjacent vertebra (see Figure 12–5).

TREATMENT

Clindamycin or ampicillin-sulbactam.


Image

Lymph nodes in the retropharyngeal space usually disappear by the third to fourth year of life.


Image

FIGURE 12-5. Lateral radiograph of the soft tissue of the neck.

Note the large amount of prevertebral edema (solid arrow) and the collection of air (dashed arrow). Findings are consistent with retropharyngeal abscess. (Courtesy of Dr. Gregory J. Sc-hears.)

ASTHMA

Image

A 5-year-old boy with a history of sleeping problems presents with a non-productive nocturnal cough and shortness of breath and cough during exercise. Think: Asthma.

Start on a trial of a bronchodilator, which is helpful in confirming the diagnosis by the demonstration of reversible airways obstruction (Image in forced expiratory volume in 1 second [FEV1]). Asthma is an inflammatory disease. Diagnosis of asthma should be considered in the presence of recurrent wheezing in a child with a family history of asthma.

DEFINITION

Respiratory hypersensitivity, inflammation, and reversible airway obstruction.

ETIOLOGY

Hyperresponsiveness to a variety of stimuli:

Image Respiratory infection

Image Air pollutants

Image Allergens

Image Foods

Image Exercise

Image Emotions


Image

Asthma is the most common chronic lung disease in children.


PATHOPHYSIOLOGY

Image Bronchospasm (acute).

Image Mucus production (acute).


Image

Lack of wheezing does not exclude asthma.


Image Inflammation and edema of the airway mucosa (chronic).

Image Two types:

Image Extrinsic:

Image Immunologically mediated

Image Develop in childhood

Image Intrinsic:

Image No identifiable cause

Image Late onset

Image Worsen with age

Image Underlying abnormalities in asthma include Image pulmonary vascular pressure, diffuse narrowing of airways, Image residual volume and functional residual capacity, and Image total ventilation maintaining normal or reduced PCO2 despite Image dead space.


Image

Asthma is the most common cause of cough in school-age children.


SIGNS AND SYMPTOMS

Image Cough, wheezing, dyspnea.

Image Image work of breathing (retractions, use of accessory muscles, nasal flaring, abdominal breathing).

Image Image breath sounds.

Image Prolongation of expiratory phase.

Image Acidosis and hypoxia may result from airway obstruction.

Image See Table 12-4 for classification of severity.


Image

Classic trilogy of asthma:

Image Bronchospasm

Image Mucus production

Image Inflammation and edema of the airway mucosa


DIAGNOSIS

Image Clinical diagnosis, usually.

Image Peak expiratory flow rate (PEFR):

Image Maximal rate of airflow during forced exhalation after a maximal inhalation.

Image Normal values depend on age and height:

Image Mild (80% of predicted).

Image Moderate (50–80% of predicted).

Image Severe (< 50% of predicted).


Image

Respiratory drive is not inhibited in asthma.


TABLE 12 - 4. Asthma Severity Classification

CLASSIFYING SEVERITY OF ASTHMA EXACERBATIONS IN THE URGENT OR EMERGENCY CARE SETTING

Image

Image Chest x-ray will demonstrate hyperinflation and can be useful to look for pneumonia.

Image Pulse oximetry may demonstrate hypoxia.

Image Fever and focal lung exam—think pneumonia.

Image Unresponsive to usual URI therapy.

Image ABG—hypoxia in severe exacerbations; hypercapnia suggestive of impending respiratory failure.

Image Bloodwork should not be routinely ordered in the evaluation of asthma.


Image

All wheezing is not caused by asthma; all asthmatics do not wheeze.


TREATMENT

Goals: Improve bronchodilation, avoid allergens, Image inflammation, educate patient.


Image

Asthmatic patient in severe respiratory distress may not wheeze.


First-Line Agents

1. Oxygen.

2. Inhaled β2 agonist:

Image Albuterol (2.5 mg) (nebulized).

Image Short-acting/rescue medication—treats only symptoms, not underlying process.

Image Bronchial smooth-muscle relaxant.

Image Side effects: Tachycardia, tremors, hypokalemia.

3. Corticosteroids (sooner is better):

Image For treatment of chronic inflammation.

Image Oral prednisone (2 mg/kg, max 60 mg) or IV methylprednisolone 2 mg/kg max 125 mg).

Image Contraindication: Active varicella or herpes infection.

4. Anticholinergic agents:

Image Ipratropium bromide (nebulized).

Image Act synergistically with albuterol.

Image Bind to cholinergic receptors in the medium and large airways.

Second-Line Agents

1.     Magnesium sulfate—bronchodilation via direct effect on smooth muscle.

2.     Epinephrine or terbutaline.

3.     No role in acute asthma for theophylline; not recommended.

Others

1. Heliox—mixture of 60–70% helium and 30–40% oxygen:

Image Image work of breathing by improving laminar gas flow (nonintubated patient).

Image Improves oxygenation and Image peak airway pressure (intubated patients).

2. Mechanical ventilation indications:

Image Failure of maximal pharmacologic therapy.

Image Hypoxemia.

Image Hypercarbia.

Image Change in mental status.

Image Respiratory fatigue.

Image Respiratory failure.

3. Leukotriene modifiers:

Image Inflammatory mediators.

Image Improve lung function.

Image No role in acute asthma.

4. Cromolyn and nedocromil:

Image Effective in maintenance therapy.

Image Exercise-induced asthma.

Image May reduce dosage requirements of inhaled steroid.


Image

Spirometry is the most important study in asthma.



Image

O2 is indicated for all asthmatics to keep O2 saturation > 95%.



Image

Long-acting β2 agonist (salmeterol) should not be used for acute asthma exacerbation.


Admit if:

Image Respiratory failure requiring intubation.

Image Status asthmaticus.

Image Return ED visit in 24 hours.

Image Complete lobar atelectasis.

Image Pneumothorax/pneumomediastinum.

Image Underlying cardiopulmonary disease.


Image

Asthmatic child’s ability to use inhaler correctly should be regularly assessed.



Image

Inhaled corticosteroids are recommended as the first-line prophylactic therapy.


Status Asthmaticus

DEFINITION

Image Life-threatening form of asthma.

Image Condition in which a progressively worsening attack is unresponsive to usual therapy.

SIGNS AND SYMPTOMS


Image

Most important risk factor for morbidity is failure to diagnose asthma from recurrent wheezing.


Look for:

Image Pulsus paradoxus > 20 mm Hg.

Image Hypotension, tachycardia.

Image Cyanosis.

Image One- to two-word dyspnea.

Image Lethargy.

Image Agitation.

Image Retractions.

Image Silent chest (no wheezes—poor air exchange).


Image

Image white blood cell (WBC) count does not always signify infection in status asthmaticus.



Image

Dehydration may be present in status asthmaticus, but overhydration should be avoided (risk for syndrome of inappropriate antidiuretic hormone secretion [SIADH]).


FOREIGN BODY ASPIRATION

Image

A 2-year-old boy is brought to the ED with a history of a choking or gagging episode, followed by a coughing spell. In the ED, he was noted to have wheezing. His respiratory rate is 24, and he has mild intercostal retractions. His babysitter found him playing in his room. Think: Foreign body aspiration.

Image

A previously healthy 12-year-old boy presented with cough for almost a year. He had a persistent dry cough during the day and night that was occasionally productive. His parents reported a history of pneumonia with consolidation of the right lower lobe on three different occasions in 6 months. On physical examination, no nasal congestion is noted. Image air entry and wheezing is noted on the right side of his chest. Think: Foreign body aspiration.

However, this classic triad (sudden onset of paroxysmal coughing, wheezing, and diminished breath sounds on the ipsilateral side) may not be present in all children with foreign body aspiration.

PATHOPHYSIOLOGY

Cough reflex usually protects against aspiration.

EPIDEMIOLOGY

Image Twice as likely to occur in males, particularly 6-month-olds to 3-year-olds.

Image Most common age: 1–2 years.


Image

Prevention is key! Keep small food and objects away from young children.


SIGNS AND SYMPTOMS

Image Determined by nature of object, location, and degree of obstruction.

Image Narrowest portion of the pediatric airway is at the cricoid ring.

Image Foreign body in the upper airway: Respiratory distress with severe retractions and stridor.

Image Foreign body in the lower airway (most foreign bodies lodge in the lower airways [80%]). Symptoms may be subtle.

Image Initial respiratory symptoms may disappear for hours to weeks after incident.

Image Vegetal/arachidic bronchitis due to vegetable (usually peanut) aspiration causes cough, high fever, and dyspnea.

Image Most common aspirated foreign body: Peanut.

Image Most common foreign body aspirations resulting in death: Balloons.

Image Complications if object is not removed include pneumonitis/pneumonia, abscess, bronchiectasis, pulmonary hemorrhage, erosion, and perforation.


Image

Caution! Do not try to remove foreign bodies causing partial upper airway obstruction because these attempts may result in complete glottic obstruction.


DIAGNOSIS/TREATMENT


Image

Foreign Body Aspiration

Image Toddlers: R = L mainstem

Image Adults: R mainstem predominates


Larynx

Image Croupy cough; may have stridor, aphonia, hemoptysis, cyanosis.

Image Lateral x-ray.

Image Direct laryngoscopy—confirm diagnosis and remove object.

Trachea

Image Stridor, audible slap, and palpable thud due to expiratory impaction.

Image Chest x-ray (see Figure 12-6), bronchoscopy.

Bronchi

Image Initial choking, gagging, wheezing, coughing.

Image Latent period with some coughing, wheezing, possible hemoptysis, recurrent lobar pneumonia, or intractable asthma.


Percussion of Lung Fields

Image Hyperresonant = overinflation

Image Dull = atelectasis


Image

FIGURE 12-6. Radiograph of lateral soft tissue of the neck demonstrates a foreign body (nail) in the pharynx.

(Courtesy of Dr. Gregory J. Schears.)

Image

FIGURE 12-7. Foreign body (peanut) in the right mainstem bronchus visualized by bronchoscopy.

Foreign bodies tend to lodge most commonly in the right mainstem bronchus due to the larger anatomic angle that makes traveling down right mainstem easier. (Courtesy of Dr. Gregory J. Schears.)

Image Tracheal shift, Image breath sounds.

Image Midline obstruction can cause severe dyspnea or asphyxia.

Image Image chronic bronchopulmonary disease if not treated.

Image Direct bronchoscopic visualization (Figure 12-7).

Image Antibiotics for secondary infection if prolonged exposure.

Image Emergency treatment of local upper airway obstruction if necessary.

Image If the child can cough and verbalize:

Image Provide supplemental oxygen.

Image Maintain position of comfort.

Image Immediate consultation with ENT and anesthesia.

Image If the child cannot cough or verbalize, initiate basic life support.

TRACHEOESOPHAGEAL FISTULA (TEF)

DEFINITION

Connection between the trachea and esophagus (see Figure 12-8).

Image

FIGURE 12-8. Types of tracheoesophageal fistulas (TEFs).

Type A, esophageal atresia (EA) with distal TEF (87%). Type B, isolated EA. Type C, isolated TEF. Type D, EA with proximal TEF. Type E, EA with double TEF.

ETIOLOGY

Image Congenital

Image Acquired

SIGNS AND SYMPTOMS

Image Suspect esophageal atresia.

Image Maternal polyhydramnios.

Image Inability to pass catheter into stomach.

Image Image oral secretions—drooling.

Image Choking, cyanosis, or coughing with an attempt to feed.

Image Tachypnea.

DIAGNOSIS

Image X-ray: Radiopaque feeding tube passes no further than proximal esophagus.

Image Barium swallow: Aspiration of barium into the tracheobronchial tree.

TREATMENT

Esophageal atresia is a surgical emergency.

TRACHEOMALACIA/LARYNGOMALACIA

DEFINITION

Image Floppy epiglottis and supraglottic aperture.

Image Disproportionately small and soft larynx.

SIGNS AND SYMPTOMS

Image Usually begins within first month.

Image Noisy breathing.

Image Stridor—laryngomalacia is the most frequent cause of stridor in children.

Image Symptoms can be intermittent.

Image Hoarseness or aphonia (laryngeal crow).

Image Feeding difficulty.

Image Symptoms worse when crying or lying on back.

DIAGNOSIS

Image Direct laryngoscopy.

Image Collapse of laryngeal structures during inspiration especially arytenoid cartilages.

TREATMENT

Image Reassurance.

Image No specific therapy required.

Image Usually resolves spontaneously by 18 months.


Image

There is an association of tracheoesophageal fistulae with esophageal atresia.



Image

H-type tracheoesophageal fistula is the least common but the most likely to be seen in ED.


CONGENITAL LOBAR EMPHYSEMA (INFANTILE LOBAR EMPHYSEMA)

DEFINITION

Overexpansion of the airspaces of a segment or lobe of the lung.

EPIDEMIOLOGY

Most common congenital lung lesion.

PATHOPHYSIOLOGY

No significant parenchymal destruction.

SIGNS AND SYMPTOMS

Image Normal at birth.

Image Cough, wheezing, dyspnea, and cyanosis within a few days.

DIAGNOSIS

Image Chest x-ray.

Image Radiolucency.

Image Mediastinal shift to opposite side.

Image Flattened diaphragm.

TREATMENT

Image Remove bronchial obstruction (foreign bodies, mucous plug).

Image Lobectomy.

CYSTIC ADENOMATOID MALFORMATION

DEFINITION

Image Developmental anomaly of the lower respiratory tract.

Image Excessive overgrowth of bronchioles.

Image Image in terminal respiratory structure.

Image Hamartomatous lesions.

EPIDEMIOLOGY

Second most common congenital lung lesion.


Image

In patients with cystic adenomatoid malformation, avoid attempted aspiration or chest tube placement, as there is the risk of spreading infection.


SIGNS AND SYMPTOMS

Image Neonatal respiratory distress.

Image Recurrent pneumonia in same location.

Image Pneumothorax.

Image May be confused with diaphragmatic hernia in neonatal period.

DIAGNOSIS

Image Chest x-ray (posteroanterior [PA], lateral, and decubitus).

Image Cystic mass (multiple grapelike sacs) and mediastinal shift.

Image Air-fluid level.

Image CT scan.


Image

Cystic adenomatoid malformation Image the risk for pulmonary neoplasia.


TREATMENT

Surgical excision of affected lobe.



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