Morning Report

February 8th, 2013

Case Presentation
HPI: 7Y boy with a history of Type I DM presents for difficulty breathing for past 2-3 days. Presented to urgent care the day prior to admission and was given Proventil (albuterol) inhaler to take 2 puffs q 2-4 hours as needed for symptoms. However, parents did not feel like it helped much, and the patient continued to have a hard time catching his breath. He developed cough and dyspnea, including trouble talking in complete sentences, along with fever to 104, and tachycardia later that night, and was brought to the ER for evaluation. Parents describe the cough as "wet" and "like an old man breathing". Both parents deny any barky sound to his cough. He has never had respiratory problems in the past. PAST MEDICAL HISTORY: Full term birth without complications, no hospitalizations or surgeries. Type1 DM diagnosed at age 5. MEDICATIONS: Insulin pump ALLERGIES: NKDA IMMS: Up to date FAMILY HISTORY: No history of diabetes, heart disease. Father, sibling ,and uncle with asthma.

SOCIAL HISTORY: Lives with parents, 2 brothers ,and 2 sisters visiting Utah on vacation from Europe.

More
He has not eaten in about 3 days and has had minimal fluid intake. Mother has noted his glucoses to be running high and so has been increasing his pump rate in accordance. She estimates an increase by approximately 30%. They have also been giving him boluses to correct for his glucose levels. His goal is 5.5-6.5 mmol/L, which is equivalent to 99-117mg/dL. He has been running as high as 10-15 (180-270mg/dL) since the onset of his illness. He is on an insulin pump with European settings.

Physical Examination
GENERAL: Awake, mild distress. Well developed, well nourished. HEENT: NCAT, PERRL, EOMI, gaze: conjugate. TMs clear bilaterally, with normal landmarks. Nares patent, no discharge. Oropharynx with dry mucous membranes, no exudates or petechiae.

NECK: Normal ROM, no LAD

CV: Tachycardic, regular rhythm. Murmur: none. Gallop: none. Pulses 2+, regular. Capillary refill ~2 seconds. LUNGS: Tachypneic. Wheezing heard best throughout bilateral middle and upper lung fields. Subcostal retractions noted and suprasternal tugging. Hoarse voice and catching breath while talking. ABDOMEN: Soft, non-tender, non-distended, active bowel sounds, no organomegaly, no masses. EXTREMITIES: No clubbing, no cyanosis, no edema. NEURO/PSYCH: Appropriate to situation, moving all extremities equally, no focal deficits.SKIN: no rashes. positive scars where insulin pump sites have been. No mottling. No jaundice. No unusual birthmarks.

Workup
LABORATORY: Complete Metabolic Panel: Na = 137, K = 4.7, Cl = 100, CO2 = 20, BUN = 15, Cr = 0.61, Glucose = 348, Ca = 8.8, Protein = 6.5, Albumin = 4.0, Bilirubin = 0.4, Alk. Phos. = 207, ALT = 30, AST = 34 . Urinalysis: Clean catch -- SG 1.025, pH 5.5, Glucose 3+, Ketones trace, Nitrite negative, Hemoglobin trace, Protein 1+, LCE negative, WBC negative, Bacteria negative. CBC: WBC = 6.8; differential 58% Neutrophils, 25% Band forms, 12% Lymphocytes, 5% Monocytes, Hgb = 12.8, Hct = 37.3, Platelet = 225. VRP and blood cultures pending.

Lets Think!
7Y boy with DM1 presenting with hoarseness, respiratory distress.

Differential Diagnosis
DKA
Viral URI Asthma Altitude

Diptheria
Epiglottitis Laryngomalacia Vocal cord paralysis Smoke inhalation Burns/Thermal injury Neoplasm Laryngeal fracture

Bacterial tracheitis
Foreign body Subglottic stenosis Peritonisillar abscess Retropharyngeal abscess

Hospital Admission
Given frequent albuterol with minimal effect on WOB, but improvement in wheezing.
Patient had marked respiratory distress with deep sternal retractions, no stridor.

CROUP
Laryngotracheobronchitis

Definition
Syndrome of characteristic events and clinical presentation caused by progressive airway edema
Viral Spasmodic Infectious laryngitis

Causes inflammation of:

Larynx Trachea Bronchi Bronchioles Lung parenchyma

Signs & Symptoms

Usually preceded by URI symptoms
Fever present in about 50% of children

Obstruction caused by swelling/inflammatory exudates is most pronounced in subglottic region

Barking spasmodic cough, hoarseness Increased WOB, tachypnea, retractions

Auscultation
Prolonged inspiration and stridor Rales may indicate lower airway involvement Breath sounds may be diminished due to atelectasis

Radiographs
Steeple sign indicates subglottic narrowing

http://www.merckmanuals.com/professional/pediatrics/respiratory_disorders_in_neonates_infants_and_young_children/croup.html

Etiology & Epidemiology

Typically affects children 6 mo. to 6 yrs.
Boys 1.5 times more likely than girls

Viral pathogens most common3

Parainfluenza (type 1 > type 3 > type 2); all ages Respiratory syncytial virus (RSV); < age 5 Influenza A/B; > 5 years old

Seasonal outbreaks (fall, winter, spring)

Treatment
Outpatient
Keep comfortable (hydrate, antipyretics) Cool, humidified air Oral corticosteroids
Dexamethasone 0.6 mg/kg PO/IM Benefit seen in the first 24 hours of illness

Inpatient
Humidified O2 (for sats < 92%)
PaCO2 > 45mmHg indicates fatigue

Oral corticosteroids (as above) Racemic epinephrine

Symptomatic relief, improves fatigue PaCO2 not altered by use

Take-home points
Hoarseness, barky cough, stridor
Children 6 mo. to 6 yrs. is classic presentation
Be on the lookout for OLDER KIDS WITH FLU!

Viral etiology is most common

No antibiotics

Hospitalization:
persistent distress hypoxemia

Questions?
References: 1. Behrman, RE, Kliegman, RM, Jenson, HB Nelson Textbook of Pediatrics, 16th Ed. W.B. Saunders Co. 2000. 2. Knutson, D, Aring, A. Viral Croup. American Family Physician 2004; 69:535-540. 3. Croup: An 11-Year Study in a Pediatric Practice. Denny, et al. Pediatrics 1983; 71:6 871-876. 4. http://www.merckmanuals.com/professional/pediatrics/respirat ory_disorders_in_neonates_infants_and_young_children/croup.h tml.

One for you

You are evaluating a 12-year-old boy who has asthma and has had increased coughing and difficulty catching his breath over the past 2 days despite using his albuterol inhaler "12 to 15 times."

On physical examination, his respiratory rate is 30 breaths/min and heart rate is 120 beats/min. He has labored breathing, with nasal flaring and sternal retractions. He has a markedly prolonged expiratory phase on lung auscultation, with decreased breath sounds bilaterally at the lung bases. His oxygen saturation on room air is 83%, but it increases to 90% on 3 L/min of oxygen administered by nasal cannula. An arterial blood gas shows a pH of 7.24, a PaCO2 of 55 mm Hg, and a PaO2 of 75 mm Hg.

What?
Of the following, the finding that is MOST consistent with a diagnosis of respiratory failure in this boy is: A. accessory muscle use

B. PaCO2 greater than 50 mm Hg

C. PaO2 less than 80 mm Hg D. tachycardia E. tachypnea

B. PaCO2 > 50 mmHg

Respiratory failure is defined as Inability to maintain adequate:
Oxygenation (hypoxemia, as defined by a PaO2 <60 mm Hg), and Ventilation (hypercarbia, as defined by a PaCO2 >50 mm Hg).

The patient described in the vignette has significant hypercarbia, with a PaCO2 of 55 mm Hg and, therefore, meets the definition of respiratory failure. Tachypnea, increased use of accessory muscles, or retractions may be signs of impending respiratory failure in pediatric patients, but they are not diagnostic. Tachycardia often is seen in patients who have respiratory failure, but it is not specific for respiratory illness.