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Pediatrics 2 Respiratory distress 4th/December 15, 2008 *may*pau*kix*ces*

Prevalence: 50% acute 66% chronic Etiology of childhood respiratory distress: Genetic (cystic fibrosis) Anatomic (laryngomalacia) Iatrogenic (oxygen toxicity) Immunologic (immune deficiency) Infectious (viral croup) Extrapulmonary (congenital heart disease) *A child is not a miniaturized adult Unique pedia features: Small airway size Airways lack cartilaginous stability airway smooth muscle > mucous gland density channels of collateral ventilation more compliant chest wall diaphragm structure different with decrease number of fatigue-resistant fiber Etiology in neonatal period: Abnormal growth and development

Incomplete maturation Incomplete adaptation to extrauterine life Perinatal insults including infection; asphyxia Apnea of maturity Meconium aspiration TTNB Pneumonia (croup B strep) Spontaneous pneumothorax Age Premature 0-3 months 3-6 months 6-12 months 1-3 yrs 3-6 yrs 6-12 yrs 12 yrs old Respiratory rate 40-70 35-55 30-45 25-40 20-30 20-25 14-22 12-18

Family history PE: Inspection: Pattern of breathing Obstructive pattern: slower, deeper Extrathoracic I>E (+) inspiratory stridor Intrathoracic E>I (use of accessory expiratory muscles) Restrictive pattern: shallow, rapid Tachypnea 24-26/min Schamroths sign clubbing of fingers, cyanosis due to chronic hypoxemia - Iatrogenic (environment, habitat) - Chronic heart problems Palpation: Symmetry- consolidation effusion collapse Vocal and tactile fremiti - consolidation effusion - collapse Perscussion limited value in small infants 2 types: Direct Indirect Pleximeter finger touches the skin Plexor tapping fingers *pressure should come from the wrist Auscultation breath sounds Normal breath sounds: Bronchial Vesicular Bronchovesicular common in the chest Discontinuous crackles Continuous - wheezes, ronchi Stridor inspiratory; signifies upper airway obstruction Rales/crackles inspiratory; rarely expiratory Wheezes caused by development of turbulent flow in narrow airways Grunting expiratory in nature; an attempt to raise FRC by closing glottis at end of expiration Ronchi low pitched

Respiratory rate:

Blood gas analysis Single most useful test of pulmonary function

Clinical Diagnostic approach to respiratory diseases: History Questions on the ff: Respiratory sx Chronicity Timing Associated with other activities

Evaluated by direct measurement of pO2, pCO2, & pH Best collected anaerobically in heparinized syringe containing only enough heparin 7.35-7.45 35-50 83-105 22-28 mmol/L 10-16 mmol/L 98-107 mmol/L pH paCO2 N HCO3 N N

Chronic cough: TB or asthma PMH With repeat pneumonias GI reflux Immune status Wiscot Aldrich, agammaglobulinemia (Bruttons)

Normal values: pH: paCO2: paO2: std HCO3: anion gap: chloride:

Resp. acidosis Resp. alkalosis Metabolic acidosis

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:
Page 2 of 2 Metabolic alkalosis N Allergic rhinitis: prominent sneezing and itching; nasal eosinophilia Foreign body: unilateral foul smelling discharge; bloody nasal secretions Sinusitis: headache, facial pain, periorbital edema Streptococaal nasopharyngitis: excoriations Pertussis: paroxysmal cough Congenital syphilis: consistent rhinorrhea (snuffles); onset on first 3 mos of life Laboratory findings: - Lab studies generally not indicated - Based on clinical sx Treatment: RSV ribavirin Influenza oseltamivir & zanamivir Rhinovirus n/a pleconaril still being developed antibacterial therapy is of no benefit systemic treatment: fever, nasal obstruction, rhinorrhea, sore throat, cough Complications: Otitis media most common, 5-30% children with colds Sinusitis Asthma exacerbation Inappropriate use of antibiotics antibiotic resistance

Transillumination of chest Can diagnose pneumothorax in infants <6 mos (light probe)

Free air in the pleura results in unusually large halo of light in the skin surrounding the probe

Radiographic/chest x-ray AP/L or PA/L should be obtained If fluid is suspected, decubitus films are indicated Lateral view indicators: upper airway obst.,glottic Upper airway films: lateral view of the neck *epiglotitis: thumb sign sinutsitis: CT scan fluoroscopy is useful for evaluating stridor Pulmonary function testing: Spirometry FEV1 Upper Respiratory Tract diseases: Common colds 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: