RT Review in Pediatrics PDF

RT Review in Pediatrics Cesar M Ong, MD, MHPEd Pediatric Pulmonologist Outline ARDS, SIDS & apnea syndromes head injuries, neuromuscular diseases congenital airway & pulmonary malformations sepsis, meningitis ARDS  first described in 1967 11 adults & 1 child with acute o...

RT Review in Pediatrics Cesar M Ong, MD, MHPEd Pediatric Pulmonologist Outline ARDS, SIDS & apnea syndromes head injuries, neuromuscular diseases congenital airway & pulmonary malformations sepsis, meningitis ARDS  first described in 1967 11 adults & 1 child with acute onset of tachypnea & hypoxemia refractory to supplemental oxygen adult respiratory distress syndrome acute respiratory distress syndrome Definition an acute, diffuse, inflammatory lung injury caused by many pulmonary & non-pulmonary etiologies Etiology Pulmonary Non-pulmonary pneumonia sepsis pancreatitis bronchiolitis major trauma fat embolism aspiration burns envenomation pulmonary contusion massive transfusions drug reactions inhalation injury submersion injuries malignancy lung transplantation Pathophysiology insult damaged type II cells release of mediators ↓ surfactant production ↑ permeability of AC vascular narrowing membrane atelectasis bronchoconstriction pulmonary edema ↓ lung compliance impaired gas exchange pulmonary hypertension ARDS  3 phases  exudative  proliferative  fibrotic Clinical Presentation 50% would develop ARDS within 24 hours of insult 85% with clinically apparent ARDS at 72 hours tachypnea – usual initial finding progressive respiratory distress, agitation crackles Diagnosis Berlin consensus (2012 – 14): differences  acute lung injury (ALI) – eliminated  3 exclusive subgroups  PAWP to exclude cardiac cause of pulmonary edema – removed (echocardiography suggested)  minimum PEEP level  included: SpO2, OI & OSI age exclude patients with perinatal lung disease timing within 7 days of known clinical insult origin of edema RF not fully explained by cardiac failure or fluid overload chest imaging new infiltrates consistent with acute pulmonary parenchymal disease oxygenation Non-Invasive MV Invasive MV mild moderate severe Full face mask bi-level OI 4 – < 8 OI 8 – < 16 OI > 16 ventilation or CPAP > OSI 5 – < 7.5 OSI 7.5 – < 12.3 OSI > 12.3 5 cm H2O PF ratio < 300 SF ratio < 264 PF ratio: PaO2 / FiO2 SF ratio: SpO2 / FiO2 oxygenation index (OI): (FiO2 x MAP x 100) / PaO2 oxygen saturation index (OSI): (FiO2 x MAP x 100) / SpO2 Which pulmonary-specific ancillary treatment is recommended routinely in PARDS? A. inhaled nitric oxide B. prone position C. suctioning D. chest physiotherapy answer – C Management ventilation surfactant therapy vasodilators: inhaled NO, epoprostenol corticosteroids – not recommended ECMO supportive care APNEA SYNDROMES & SIDS Apnea Syndromes periodic breathing  regular respirations as long as 20 sec followed by apneic episodes < 10 sec occurring > 3 in succession  occurrence directly proportional to degree of prematurity  apnea – cessation of breathing  > 20 seconds  < 20 seconds with  bradycardia – resting HR < 30  cyanosis  more common in preterm infants (apnea of prematurity)  underlying pathology in term infants (apnea of infancy)  ALTE  bradycardia, cyanosis & hypotonia Pathophysiology 3 types  central  due to inadequate medullary responsiveness or poor response of respiratory muscles  no respiratory effort  immaturity (preterm), head trauma  obstructive  results from attempts to breathe through an occluded airway obstruction in airways  with respiratory effort but no airflow  OSA  mixed – combination Diagnosis all infants < 35 weeks AOG should be monitored (HR & respiratory movements) for apnea investigation of underlying cause  History Physical Examination Maternal Lethargy or irritability Labor & delivery Cyanosis or pallor Neonatal Peripheral perfusion Abnormal movements / tone Respiratory distress  Laboratory Evaluation of Apnea Potential Cause Evaluation Infection CBC, cultures Impaired oxygenation ABG, oximeter Respiratory distress Chest x-ray Metabolic disorders Electrolytes, glucose Drugs Serum levels Intracranial pathology Cranial ultrasound, CT scan Seizures EEG GERD Barium swallow Management specific therapy for underlying cause prematurity  tactile stimulation  methylxanthines: caffeine, theophylline, aminophylline  CPAP infancy  home monitoring of respiration & HR Obstructive Sleep Apnea (OSA) episodic upper airway obstruction that occurs during sleeps complete or partial obstruction Pathophysiology partial closure of upper airways during inspiration -> snoring & hypoventilation complete closure -> no airflow & snoring -> obstructive apnea  first 6 months: almost always associated with anatomic abnormalities (micrognathia, macroglossia, choanal stenosis) toddlers & school-aged: large tonsils & adenoids, continual symptoms of nasal stuffiness & mouth breathing older school-aged & adolescents: obese Clinical Presentation abnormal breathing during sleep frequent awakenings or restlessness frequent nightmares enuresis unusual sleeping positions  difficulty awakening excessive daytime sleepiness daytime fatigue morning headaches irritability / behavioral problems poor growth & weight gain What is the only available tool for the definitive diagnosis of OSA in children? A. serial ABG B. polysomnography C. nasopharyngoscopy / bronchoscopy D. spirometry answer – B Diagnosis careful history PE: upper airway narrowing, nasal congestion, sinus disease laboratory tests  sleep study  ABG – assess gas exchange  ECG – RVH  spirometry – to rule out coexisting lower airway disease Management medical, surgical or both weight loss for obese patients antihistamines, mast cell stabilizers, corticosteroids TNA nasal CPAP or tracheostomy  HEAD INJURIES & NEUROMUSCULAR DISEASES Traumatic Head Injuries causes  unintentional: falls, motor vehicle collisions  intentional: child abuse age-dependent etiology  infants & young children: abusive  toddlers: falls  school-aged: bicycle-related  adolescents: motor vehicle, sports-related, assaults  clinical presentation  scalp injury  skull fracture  concussion – mild TBI  contusion – more serious TBI  hematoma  hemorrhage  evaluation  secure airway, cervical spine, breathing & circulation  danger signs: loss of consciousness, vomiting, level of sensorium  CT scan, MRI  monitor ICP, drain fluid / hematoma  Glasgow Coma Scale EYE OPENING (TOTAL POINTS 4) Spontaneous 4 To voice 3 To pain 2 None 1 VERBAL RESPONSE (TOTAL POINTS 5) Older Children Infants & Young Children Oriented 5 Appropriate words; smiles, 5 fixes & follows Confused 4 Consolable crying 4 Inappropriate 3 Persistently irritable 3 Incomprehensible 2 Restless, agitated 2 None 1 None 1 MOTOR RESPONSE (TOTAL POINTS 6) Obeys 6 Flexion 3 Localizes pain 5 Extension 2 Withdraws 4 None 1  interpretation: brain injury is classified as  severe < 8 – 9  moderate 8 – 12  minor > 13 An 18-month old male had cough & fever of 3 days. He was given carbocisteine TID & aspirin q 4H. A day PTA, he had several episodes of vomiting & diarrhea. Thirty minutes PTA, he was noted to be lethargic & had seizures. You should consider: A. meningitis B. Guillain-Barre syndrome C. Reye syndrome D. epilepsy answer – C Reye’s Syndrome potentially fatal disease affects many organs especially the liver & brain exact cause unknown associated with viral infection & aspirin consumption  classic features: rash, vomiting & liver damage usual presenting complaints: vomiting & changes in mental status blood sugar drops, serum ammonia & acidity rises clinical suspicion  no absolutely effective treatment  monitor metabolic & neurologic condition  some cases: hemodialysis to remove toxins causing brain swelling prognosis  mild disease – recovers  permanent brain dysfunction  death Guillain-Barre Syndrome most common cause of acute flaccid paralysis in children abnormal immune response to an antecedent event  infection: respiratory or GIT  vaccines  pathophysiology  antibodies formed from previous infection  attacks peripheral nerves & damages myelin sheath signs & symptoms  numbness, tingling & pain  weakness of legs -> ascending  diagnostic evaluation  clinical  CSF analysis  electromyography (EMG) management  pain management, nutrition, psychosocial support  IVIG  mechanical ventilation Duchenne’s Muscular Dystrophy x-linked recessive disorder clinical features  manifests before 5 years ~ infancy  main symptom: muscle weakness with muscle wasting  progressive difficulty in walking  Gowers’ sign  clinical features  frequent falls, difficulty with motor skills  lumbar lordosis, enlarged calves  wheelchair-bound by 12 years  progressive decline in respiratory function  rapid & shallow breathing pattern  death by 20 years Cerebral Palsy insult to immature brain before birth disorder of movement, muscle tone or posture -> impaired movement with:  exaggerated reflexes  floppiness or rigidity of limbs & trunk  abnormal posture  involuntary movements  unsteadiness of gait  may have dysphagia varied motor abilities often with developmental brain abnormalities evaluation  cranial ultrasound, CT scan or MRI  EEG to determine epilepsy  additional tests  management  multi-disciplinary approach  botulinum toxin – isolated spasticity  muscle relaxants – generalized spasticity  PT, OT, SLT  orthopedic surgery Management of Respiratory Muscle Weakness oxygen support mechanical ventilation tracheostomy mucoregulators, mucokinetic drugs treat co-morbid conditions others CONGENITAL AIRWAY & PULMONARY DISEASES Congenital Cystic Lung Diseases aberrant differentiation of bronchi, bronchioles, alveoli & vasculature cause neonatal dyspnea chest x-ray, CT scan prenatal diagnosis surgery A 2-hour old male was tachypneic & cyanotic at birth. The prenatal history was unremarkable. Which of the following PE findings would suggest congenital diaphragmatic hernia? A. diffuse crackles B. pectus excavatum C. absence of breath sounds D. scaphoid abdomen answer – D Pulmonary Sequestration cystic or solid mass composed of nonfunctioning tissues no communication with TBT blood supply from systemic circulation rather than pulmonary circulation – feeding vessels Bronchogenic Cyst originate from abnormal sacs of lung bud located adherent to left bronchus cyst may be filled with air, fluid or both Congenital Cystic Adenomatoid Malformation congenital pulmonary airway malformation arrested alveolar development with proliferation of terminal bronchioles Congenital Lobar Emphysema hyperinflation of >1 lobes 25% due to obstruction of developing airways usually symptomatic in neonatal period Congenital Diaphragmatic Hernia developmental defect in diaphragm allows abdominal viscera to herniate into the chest compression -> hypoplasia types  Bochdalek – postero-lateral  Morgagni – anterior barrel chest, scaphoid abdomen INFECTIONS Sepsis spectrum of disorders resulting from infection by bacteria, viruses, fungi, or parasites or their toxic products early signs of circulatory compromise to full blown circulatory collapse with multiple organ dysfunction syndrome  evaluation  history & PE – diverse presentations  look for foci of infection antibiotics Meningitis inflammation of the membranes surrounding the brain or the spinal cord normally occurs as complication from infection in the bloodstream (blood-brain barrier leaks) spread of a nearby infection direct trauma  etiology  neonate: group B Streptococcus, E coli, Listeria  > 1 month: Hemophilus influenzae, Streptococcus pneumoniae, Neisseria meningitidis  Mycobacterium tuberculosis  viruses  common signs & symptoms  poor feeding, vomiting  irritability, sensorial changes  seizures  temperature changes  jaundice  bulging fontanelle  neck rigidity  hypotonia A 6-month old female was admitted because of poor feeding & activity. On examination, she had tensed bulging fontanels & neck rigidity. Which of the following tests should be done to establish the diagnosis of meningitis? A. cranial ultrasonography B. lumbar puncture C. blood culture D. CBC answer – A  evaluation  history & PE  CBC  CSF analysis  blood culture  cranial ultrasound / CT scan antibiotics TESTWISENESS IN MCQ Testwiseness skill where a student chooses the correct answer on an item without knowing the correct answer  look for mistakes in test construction  make guesses based on teacher tendencies  search for unintentional clues The non-pharmacologic management of pulmonary tuberculosis includes: A. personal hygiene B. good nutrition C. search for index case D. all of the above All or none of the above is usually the correct answer. Palpable cervical lymphadenopathies in children are usually due to infections. A. true B. false Always & never are false statements; often & usually are true statements. Which of the following PE findings is expected in massive pneumothorax? A. dull percussion note B. symmetrical chest expansion C. asymmetrical chest expansion D. egophony B & C are exactly opposite choices. Children with bronchiectasis typically present with recurrent pneumonia, __________ & _________________________. A. fever & cough B. hemoptysis & copious sputum production C. progressive weight loss & wheezing D. chest retractions & cyanosis B approximates the length of the blanks. Which of the following mechanisms will result to accumulation of pleural fluid? A. decreased lung compliance B. increased rate of reabsorption C. increased rate of filtration D. decreased rate of filtration C & D are exactly opposite choices. B & C are also exactly opposite choices. A is clearly a different choice. A child with recurrent attacks of asthma is best managed with: A. montelukast B. salbutamol C. ipratropium bromide D. inhaled steroids at the lowest dose possible to control symptoms D is the longest choice. A chest radiograph is done in a child with community acquired pneumonia to: A. determine response to treatment B. confirm the presence of complications C. should be correlated with the history & PE D. may be omitted if the diagnosis is certain C & D do not connect grammatically with the stem. The second booster of the DPT / IPV vaccine is given at what age? A. 4 – 6 years B. 7 – 9 years C. 7 – 10 years D. 8 – 9 years B, C & D overlap with each other. Which of the following diseases does NOT present with stridor? A. epiglottitis B. croup C. acute laryngotracheobronchitis D. bronchiolitis B & C are synonyms – both are incorrect choices. Additional Pointers Check the completeness of the exam. Read the instructions carefully. Be aware of the time allotted. Do not spend more than 1 minute for an item. Check for related questions. Transfer your answers carefully.