Clinical_Medicine_III_Lecture_05_Pediatrics_I_Eye_ENT_Resp

1. Clinical Medicine III
Pediatrics I: Review of Eye, Ears, Nose, Throat, Respiratory
Sean Kramer MSHS, PA-C
6/6/16

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Pre-test
© Sean Kramer MSHS, PA-C 45

3. •Categories of
disease in system
Overview of
Section
© Sean Kramer MSHS, PA-C

4. • Categories of disease in system
– Eye
– Ears
– Nose
– Throat/ Respiratory
– Respiratory
Overview of section
© Sean Kramer MSHS, PA-C

5. • Categories of disease in system
– Eye
• Blepharitis
• Chalazion
• Hordeolum
• Conjunctivitis
– Bacterial
– Viral
– Allergic
• Periorbital cellulitis
– Orbital cellulitis
• Amblyopia
• Strabismus
• Retinoblastoma
Overview of section
© Sean Kramer MSHS, PA-C

6. • Categories of disease in system
– Ear
• Otitis Media
• Otitis externa
• Mastoiditis
– Nose
• Epistaxis
• Foreign Body
• Rhinitis
• Sinusitis
• Upper respiratory infection
Overview of section
© Sean Kramer MSHS, PA-C

7. • Categories of disease in system
– Throat/ Respiratory
• Strep pharyngitis
• Mononucleosis
• Croup
• Epiglottitis
• Pertussis
• Laryngomalacia
• Bacterial tracheitis
Overview of section
© Sean Kramer MSHS, PA-C

8. • Categories of disease in system
– Respiratory
• Asthma
• Bronchiolitis
• Bronchopulmonary Dysplasia
• Cystic Fibrosis
• Foreign Body
• Pneumonia
• Hyaline membrane disease
Overview of section
© Sean Kramer MSHS, PA-C

9. •Blepharitis
•Chalazion
•Hordeolum
•Conjunctivitis
•Bacterial
•Viral
•Allergic
•Periorbital cellulitis
•Orbital cellulitis
•Amblyopia
•Strabismus
•Retinoblastoma
Eye
© Sean Kramer MSHS, PA-C

10. © Sean Kramer MSHS, PA-C
Blepharitis

11. • Diagnosis
– History and physical
• Eye lid margin inflammation
– Often with crusting
– Blepharoconjunctivitis– with conjunctivitis
Blepharitis
© Sean Kramer MSHS, PA-C

12. • Plan
– Typical patient
1. Lid scrubs
2. Warm compresses
3. Ophthalmic antibiotic ointment
– Erythromycin OR
– Bacitracin
Blepharitis
© Sean Kramer MSHS, PA-C

13. © Sean Kramer MSHS, PA-C
Hordeolum

14. • Diagnosis
– History and physical
• Tender nodule on eyelid
Hordeolum
© Sean Kramer MSHS, PA-C

15. • Plan
– Typical patient
• <see blepharitis>
• Consider referral if severe or no improvement
– Incision and drainage
Hordeolum
© Sean Kramer MSHS, PA-C

16. © Sean Kramer MSHS, PA-C
Chalazion

17. • Diagnosis
– History and Physical
• Nontender nodule on eyelid
Chalazion
© Sean Kramer MSHS, PA-C

18. • Plan
– Typical patient
• <same as blepharitis>
• If no resolution
– Refer to ophthalmology
» Incision and curettage
Chalazion
© Sean Kramer MSHS, PA-C

19. © Sean Kramer MSHS, PA-C
Conjunctivitis

20. • Types
– Allergic
– Viral
– Bacterial
• Diagnosis
– History and Physical
• All types
– Injected (erythematous) conjunctiva
Conjunctivitis
© Sean Kramer MSHS, PA-C

21. • Common etiologies
– Pollen
– Animals
– Detergents
• Diagnosis
– History and Physical
• Lacrimation
• Sneezing
• Cobblestoning
• Stringy discharge
• Pruritus
• Rhinorrhea
Allergic conjunctivitis
© Sean Kramer MSHS, PA-C

22. • Plan
– Typical patient
1. Remove source
• Consider
– Ophthalmic antihistamines (olaptadine)
– Ophthalmic mast cell stabilizers (ketotifen)
– Ophthalmic NSAID (ketorolac)
• *Careful
– corticosteroids (prednisolone)
Allergic conjunctivitis
© Sean Kramer MSHS, PA-C

23. • Pathogen
– Mostly adenovirus
– Occasional herpes simplex
• Diagnosis
– History and Physical
• Watery discharge
• Preauricular lymphadenopathy
• URI symptoms
• Herpes
– Vesicular rash
– Keratitis– corneal involvement
» Visual disturbance
Viral conjunctivitis
© Sean Kramer MSHS, PA-C

24. • Plan
– Typical patient
• Supportive
• Hand washing!
• Herpes etiology (uncommon)
– Ophthalmic trifluridine OR
– Oral acyclovir
Viral conjunctivitis
© Sean Kramer MSHS, PA-C

25. • Pathogens most common
1. Haemophilus species
2. Strep pneumonia
3. Moraxella catarrhalis
• Diagnosis
– History and Physical
• Purulent discharge
• Lid crusting
• Eye lids “glued together”
Bacterial conjunctivitis
© Sean Kramer MSHS, PA-C

26. • Plan
– Typical patient
• Ophthalmic antibiotics
– Choice of:
» Macrolide (erythromycin)
» Aminoglycoside (gentamicin)
» Sulfacetamide
» Polymixin-bacitracin
– If possible pseudomonas
» Fluoroquinolone (ofloxacin)
Bacterial conjunctivitis
© Sean Kramer MSHS, PA-C

27. © Sean Kramer MSHS, PA-C
Periorbital cellulitis / Orbital
cellulitis

28. • Most common cause
– Periorbital– anterior eye infection (i.e. blepharitis)
– Orbital cellulitis– sinusitis
• Diagnosis
– History and physical
• Periorbital
– Edematous eyelids
– Pain
– Fever +/-
• Orbital
– Painful eye movements
– Restricted eye movements
– Proptosis
– Afferent pupillary defect
– High fever
Periorbital (Preseptal) cellulitis /
Orbital cellulitis
© Sean Kramer MSHS, PA-C

29. • Diagnosis
– Diagnostic Studies
• Typical patient
– CT orbits with contrast
Periorbital cellulitis /
Orbital cellulitis
© Sean Kramer MSHS, PA-C

30. • Diagnosis
– Diagnostic Studies
• CT orbits with contrast
– Periorbital
» Inflammation before septum
– Orbital
» Inflammation after septum
» Possible abscess
Periorbital cellulitis /
Orbital cellulitis
© Sean Kramer MSHS, PA-C

31. • Plan
– Typical patient
• Periorbital
– Warm compresses
– Oral antibiotics
• Orbital
– IV antibiotics
– Ophthalmology STAT referral
Periorbital cellulitis /
Orbital cellulitis
© Sean Kramer MSHS, PA-C

32. • Plan
– Pharmacology
• Periorbital abx (oral)
– PCNase resistant PCN
» Amoxicillin-clavulanate
• Orbital abx (IV)
– PCNase resistant PCN
» Ampicillin-sulbactam
– Consider adding
» Clindamycin
» Metronidazole
Periorbital cellulitis /
Orbital cellulitis
© Sean Kramer MSHS, PA-C

33. © Sean Kramer MSHS, PA-C
Amblyopia

34. • Definition
– unilateral or bilateral reduction in vision
• Causes
– Strabismus <covered next>
– Refractive error
• Hyperopia– farsightedness
• Myopia– nearsightedness (begins >8y)
– Deprivation– usually cataracts
Amblyopia
© Sean Kramer MSHS, PA-C

35. • Plan
– Typical patient
• Treat cause
– earlier treatment improves outcome
– Refractive– glasses
– Cataracts– early removal
– Strabismus– <covered next>
– If unilateral
» Make correction early
» Patch dominant eye
Amblyopia
© Sean Kramer MSHS, PA-C

36. © Sean Kramer MSHS, PA-C
Strabismus

37. • Diagnosis
– History and physical
• Misalignment of the eyes
• Penlight reflection displacement
• May be constant or intermittent
• Usually unilateral
• Types
– Esotropia– medial deviation
– Exotropia– lateral deviation
– Hypertropia– superior deviation
– Hypotropia– inferior deviation
Strabismus
© Sean Kramer MSHS, PA-C

38. • Plan
– Typical patient
• Congenital– surgery
• Accommodative– glasses
• Unilateral
– Patch dominant eye
Strabismus
© Sean Kramer MSHS, PA-C

39. © Sean Kramer MSHS, PA-C
Retinoblastoma

40. • Diagnosis
– History and Physical
• Leukocoria
Retinoblastoma
© Sean Kramer MSHS, PA-C

41. • Plan
– Typical patient
1. Chemoreduction
• Then local options
– laser photocoagulation
– Cryotherapy
– plaque radiotherapy
– thermotherapy
Retinoblastoma
© Sean Kramer MSHS, PA-C

42. •Ear
•Otitis externa
•Mastoiditis
•Otitis Media
•Nose
•Epistaxis
•Foreign Body
•Rhinitis
•Sinusitis
•Upper respiratory
infection
Ears &
Nose
© Sean Kramer MSHS, PA-C

43. © Sean Kramer MSHS, PA-C
Otitis externa

44. • Diagnosis
– Most common pathogens
• Staph aureus
• Pseudomonas aeruginosa
– History and physical
• External canal edema
• Drainage minimal, thick
• Pain with movement of auricle/tragus
Otitis externa
© Sean Kramer MSHS, PA-C

45. • Plan
– Typical patient
• Remove debris if present
• Otic antibiotics
1. Fluoroquinolones (ciprofloxacin, ofloxacin)
» With or without hydrocortisone
– Consider
» Neomycin, bacitracin, polymyxin B and hydrocortisone
(Cortisporin)
• If complicated (perichondritis/ fever)
– Oral quinolone (ciprofloxacin)
Otitis externa
© Sean Kramer MSHS, PA-C

46. © Sean Kramer MSHS, PA-C
Otitis media

47. • Most common pathogens
– Strep pneumoniae
– Haemophilus influenzae
• Diagnosis
– History and Physical
• Ear pain (otalgia)
• Bulging of TM
• Middle ear effusion
• Ear holding, tugging
Otitis media
© Sean Kramer MSHS, PA-C

48. • Diagnosis
– Diagnostic Studies
• Typical patient
1. Pneumatic otoscopy
2. Tympanometry
Otitis media
© Sean Kramer MSHS, PA-C

49. • Diagnosis
– Diagnostic Studies
• Pneumatic otoscopy
– Absent mobility OR
– Fluid wave
• Tympanometry
– Diminished compliance
Otitis media
© Sean Kramer MSHS, PA-C

50. • Plan
– Typical patient
• Oral antibiotics
1. Amoxicillin
– If failure in 48-72 hrs
» Amoxicillin-clavulanate OR
» Cephalosporins (cefuroxime, cefdinir)
• Observation option
– Watch 48-72 hours for improvement
• If recurrent
– Tympanostomy tubes
Otitis media
© Sean Kramer MSHS, PA-C

51. © Sean Kramer MSHS, PA-C
Mastoiditis

52. • Diagnosis
– History and physical
• AOM otitis media is
almost always present
• Postauricular pain and
erythema
• Ear protrusion (late
finding)
Mastoiditis
© Sean Kramer MSHS, PA-C

53. • Diagnosis
– Diagnostic Studies
• Typical patient
– CT head
» Opacification of
mastoid air cells
Mastoiditis
© Sean Kramer MSHS, PA-C

54. • Plan
– Typical patient
1. Admission
2. IV antibiotics
• Consider
– surgical debridement
Mastoiditis
© Sean Kramer MSHS, PA-C

55. • Plan
– Pharmacology
• IV antibiotics
– Broad spectrum (i.e. piperacillin/tazobactam)
– Surgery or procedures
• Surgical debridement if
– Abscess
– No improvement within 48 hours
Mastoiditis
© Sean Kramer MSHS, PA-C

56. © Sean Kramer MSHS, PA-C
Epistaxis

57. • Diagnosis
– History and Physical
• Common causes
– Dryness
– vigorous nose rubbing
– nose blowing
– nose picking
• anterior septum
– red, raw surface
– with fresh clots or old crusts
Epistaxis
© Sean Kramer MSHS, PA-C

58. • Diagnosis
– Diagnostic Studies
• Typical patient
– None
– If concern for bleeding disorder (5%) such as von
Willebrand
» CBC
» PT/PTT
» Bleeding time
» Platelet function analysis
Epistaxis
© Sean Kramer MSHS, PA-C

59. • Diagnosis
– Diagnostic Studies
• CBC– normal unless severe
• PT/PTT– only abnormal for hemophilia
• Bleeding time– abnormal for von Willebrand
• Platelet function analysis– abnormal for von
Willebrand
Epistaxis
© Sean Kramer MSHS, PA-C

60. • Plan
– Typical patient
• Lean forward and hold nose 5 min
• Consider
– Vasoconstrictors (oxymetazoline)
– Nasal saline twice daily
– Gelatin sponge (Gelfoam)
Epistaxis
© Sean Kramer MSHS, PA-C

61. © Sean Kramer MSHS, PA-C
Nasal foreign body

62. • Diagnosis
– History and physical
• Object identified
• Late
– unilateral foul-smelling rhinorrhea
– Halitosis
– Bleeding
– nasal obstruction
Nasal foreign body
© Sean Kramer MSHS, PA-C

63. • Plan
– Typical patient
• Nose blowing
• Forceps removal
Nasal foreign body
© Sean Kramer MSHS, PA-C

64. © Sean Kramer MSHS, PA-C
Allergic rhinitis

65. • Diagnosis
– History and Physical
• nasal congestion, sneezing, rhinorrhea, and itchy
nose, palate, throat, and eyes
• nasal turbinates are swollen
– red or pale pink-purple
Allergic rhinitis
© Sean Kramer MSHS, PA-C

66. • Plan
– Typical patient
1. intranasal corticosteroids
Consider
• oral and intranasal antihistamines
• leukotriene antagonists
• decongestants
Allergic rhinitis
© Sean Kramer MSHS, PA-C

67. • Plan
– Patient Education
• Remove source
• Saline spray may irrigate
– Pharmacology
• intranasal corticosteroids
– Fluticasone
• oral and intranasal antihistamines
– Loratadine (Claritin) oral
– Olopatadine (Patanase) nasal
• leukotriene antagonists
– Montelukast (Singulair)
• Decongestants
– Guaifenesin
Allergic rhinitis
© Sean Kramer MSHS, PA-C

68. © Sean Kramer MSHS, PA-C
Viral upper respiratory infection

69. • Diagnosis
– Most common pathogen
• Rhinovirus
– History and Physical
• Clear or mucoid rhinorrhea, nasal congestion, sore
throat
• Possible fever, particularly in younger children
(under 5–6 years)
• Symptoms resolve by 7–10 days
Viral upper respiratory infection
© Sean Kramer MSHS, PA-C

70. • Plan
– Typical patient
• Pain medication
• Humidified air
• Nasal saline
• Consider
– Cough suppressants
Viral upper respiratory infection
© Sean Kramer MSHS, PA-C

71. • Plan
– Pathway
Viral upper respiratory infection
© Sean Kramer MSHS, PA-C

72. © Sean Kramer MSHS, PA-C
Bacterial sinusitis

73. • Most common pathogens
– S pneumoniae
– H influenzae
– M catarrhalis
• Diagnosis
– History and physical
• URI symptoms >10 days
• nasal congestion
• nasal drainage
• postnasal drainage
• facial pain
• Headache
• fever
Bacterial sinusitis
© Sean Kramer MSHS, PA-C

74. • Diagnosis
– Diagnostic Studies
• Typical patient
– CT only if concerned about abscess or orbital cellulitis
Bacterial sinusitis
© Sean Kramer MSHS, PA-C

75. • Plan
– Typical patient
1. First line
– Amoxicillin high dose OR
– Amoxicillin-clavulanate
• Second line
– Cephalosporin (cefuroxime, cefdinir)
– Clindamycin
– Levofloxacin
Bacterial sinusitis
© Sean Kramer MSHS, PA-C

76. • Plan
– Decision path
Bacterial sinusitis
© Sean Kramer MSHS, PA-C

77. •Strep pharyngitis
•Mononucleosis
•Croup
•Epiglottitis
•Pertussis
•Laryngomalacia
•Bacterial tracheitis
Throat/
Respiratory
© Sean Kramer MSHS, PA-C

78. © Sean Kramer MSHS, PA-C
Strep pharyngitis

79. • Diagnosis
– History and physical
• Sudden onset of sore throat
• Fever
• tender cervical adenopathy
• palatal petechiae
• beefy-red uvula
• tonsillar exudate
Strep pharyngitis
© Sean Kramer MSHS, PA-C

80. • Diagnosis
– Diagnostic Studies
• Typical patient
– Rapid antigen
– Culture
Strep pharyngitis
© Sean Kramer MSHS, PA-C

81. • Diagnosis
– Diagnostic Studies
• Rapid antigen- 85-95% sensitive
• Culture– often initiated at same time as rapid test
Strep pharyngitis
© Sean Kramer MSHS, PA-C

82. • Diagnosis
– Centor criteria
• 3 or 4 suggest treating without testing
– Fever
– Tonsillar exudates
– Tender anterior cervical lymphadenopathy
– Absence of cough
Strep pharyngitis
© Sean Kramer MSHS, PA-C

83. • Plan
– Typical patient
• First line (penicillins)
– Penicillin VK oral OR
– Benzathine penicillin IM 600,000 units OR
– Amoxicillin oral OR
• If PCN allergy
– Clindamycin
– Cephalexin
– Azithromycin
Strep pharyngitis
© Sean Kramer MSHS, PA-C

84. © Sean Kramer MSHS, PA-C
Mononucleosis

85. • Diagnosis
– History and Physical
• patients >5 years
• Prodrome
– Fatigue
– Malaise
– myalgia
• exudative tonsillitis
• Posterior cervical lymphadenopathy primarily
• Fever
• palpable spleen
• axillary adenopathy
Mononucleosis
© Sean Kramer MSHS, PA-C

86. • Diagnosis
– Diagnostic Studies
• Typical patient
– Testing limited, consider
» CBC
» Heterophile antibody (Monospot)
Mononucleosis
© Sean Kramer MSHS, PA-C

87. • Diagnosis
– Diagnostic Studies
• CBC
– Lymphocytosis
– >10% Atypical lymphocytes
• Heterophile antibody (Monospot)
– positive in 40% during the first
week
– 80–90% during the third week
– remain positive for 3 months after
the onset, can persist for up to 1
year
– Usually not detectable in children
<5y
Mononucleosis
© Sean Kramer MSHS, PA-C

88. • Plan
– Typical patient
• Supportive care
• Avoid contact sports
Mononucleosis
© Sean Kramer MSHS, PA-C

89. • Pearl
– If given penicillin will develop diffuse
maculopapular rash
Mononucleosis
© Sean Kramer MSHS, PA-C

90. © Sean Kramer MSHS, PA-C
Croup (laryngotracheobronchitis)

91. • Pathogen
– Parainfluenza virus
• Diagnosis
– History and physical
• URI symptoms before
• Barking cough
• Low grade fever
• Stridor
Croup
© Sean Kramer MSHS, PA-C

92. • Diagnosis
– Diagnostic Studies
• Typical patient
– Consider AP/ lateral neck XR
Croup
© Sean Kramer MSHS, PA-C

93. • Diagnosis
– Diagnostic Studies
• AP/ lateral neck
– Steeple sign– subglottic
narrowing
Croup
© Sean Kramer MSHS, PA-C

94. • Plan
– Typical patient
• Home
– Steaming bathroom
– Cold weather exposure
– Oral hydration
• Mild
– Humidified oxygen
Croup
© Sean Kramer MSHS, PA-C

95. • Plan
– Typical patient
• More significant
– Racemic epinephrine nebulized
– Dexamethasone IM/ oral
• Severe or persistent symptoms
– Consider heliox
– Consider intubation
– Admit to hospital
Croup
© Sean Kramer MSHS, PA-C

96. © Sean Kramer MSHS, PA-C
Epiglottitis

97. • Pathogen
1. Haemophilus influenza
• Unimmunized children
– Neisseria meningitides
– Streptococcus
• Diagnosis
– History and Physical
• high fever
• Dysphagia
• Drooling
• muffled voice
• inspiratory retractions
• Cyanosis
• soft stridor
Epiglottitis
© Sean Kramer MSHS, PA-C

98. • Diagnosis
– Diagnostic Studies
• Typical patient
– Consider
» Direct inspection of epiglottis
» Lateral neck XR
» Blood culture
Epiglottitis
© Sean Kramer MSHS, PA-C

99. • Diagnosis
– Diagnostic Studies
• Direct inspection of epiglottis
– cherry-red and swollen
epiglottis and swollen
arytenoids
• Lateral neck XR
– "thumbprint" sign
Epiglottitis
© Sean Kramer MSHS, PA-C

100. • Plan
– Typical patient
1. AIRWAY FIRST!
– Consider intubation
» Do not delay for testing
2. Antibiotics
– 3rd generation cephalosporin (Ceftriaxone)
Epiglottitis
© Sean Kramer MSHS, PA-C

101. © Sean Kramer MSHS, PA-C
Bacterial tracheitis
(pseudomembranous croup)

102. • Most common pathogen
– Staphylococcus aureus
• Diagnosis
– History and physical
• <see croup>, +
• Higher fever
• Toxicity
• progressive or intermittent severe upper airway
obstruction
– unresponsive to standard croup therapy
Bacterial tracheitis
© Sean Kramer MSHS, PA-C

103. • Diagnosis
– Diagnostic Studies
• Typical patient
– CBC
– Lateral neck XR
– Bronchoscopy
Bacterial tracheitis
© Sean Kramer MSHS, PA-C

104. • Diagnosis
– Diagnostic Studies
• CBC
– Leukocytosis with left shift
• Lateral neck XR
– normal epiglottis but severe
subglottic and tracheal
narrowing
– Irregular contour of proximal
trachea
Bacterial tracheitis
© Sean Kramer MSHS, PA-C

105. • Diagnosis
– Diagnostic Studies
• Bronchoscopy
– normal epiglottis and the presence of copious purulent
tracheal secretions
Bacterial tracheitis
© Sean Kramer MSHS, PA-C

106. • Plan
– Typical patient
• Intubation
• Debridement of airway
– With Suctioning
• IV antibiotics
Bacterial tracheitis
© Sean Kramer MSHS, PA-C

107. • Plan
– Pharmacology
• IV antibiotics
– Need staph and h flu coverage
– 3rd generation cephalosporins (Ceftriaxone)
Bacterial tracheitis
© Sean Kramer MSHS, PA-C

108. © Sean Kramer MSHS, PA-C
Pertussis

109. • Pathogen
– Bordatella pertussis
• Diagnosis
– History and physical
• Prodromal catarrhal stage (1–3 weeks)
– mild cough
– Coryza
– No fever
• Paroxysmal stage (2-4 weeks)
– paroxysmal cough– Persistent staccato, ending with a high-pitched
inspiratory "whoop.”
– Post-tussive vomiting
– Sweating
– Cyanosis
Pertussis
© Sean Kramer MSHS, PA-C

110. • Diagnosis
– Diagnostic Studies
• Typical patient
– CBC
– PCR nasopharyngeal
– Consider
» CXR
Pertussis
© Sean Kramer MSHS, PA-C

111. • Diagnosis
– Diagnostic Studies
• CBC
– WBC 20,000-30,000
– Significant lymphocytes
• PCR nasopharyngeal
– Diagnostic for B pertussis
• CXR
– Nonspecific, may show
» thickened bronchi
» "shaggy" heart border
Pertussis
© Sean Kramer MSHS, PA-C

112. • Plan
– Typical patient
• Prevention
– DTaP immunizations
• Treatment
– Macrolide antibiotics (azithromycin)
» Best in initial stage
– Consider
» Corticosteroids
» Albuterol nebulized
Pertussis
© Sean Kramer MSHS, PA-C

113. © Sean Kramer MSHS, PA-C
Laryngomalacia

114. • Diagnosis
– History and Physical
• birth or within the first few months of life.
• Intermittent, high-pitched, inspiratory stridor.
– Worse supine and with activity
Laryngomalacia
© Sean Kramer MSHS, PA-C

115. • Diagnosis
– Diagnostic Studies
• Typical patient
– Pulse oximetry
– ENT referral
» Direct laryngoscopy
Laryngomalacia
© Sean Kramer MSHS, PA-C

116. • Diagnosis
– Diagnostic Studies
• Pulse oximetry
– May desaturate at night
• Direct laryngoscopy
– inspiratory collapse of an omega-shaped epiglottis
» with or without long, redundant arytenoids
Laryngomalacia
© Sean Kramer MSHS, PA-C

117. • Plan
– Typical patient
• Mild
– Observation
• Moderate-Severe
– surgical epiglottoplasty
Laryngomalacia
© Sean Kramer MSHS, PA-C

118. •Hyaline membrane
disease
•Bronchopulmonary
Dysplasia
•Asthma
•Bronchiolitis
•Cystic Fibrosis
•Foreign Body
•Pneumonia
Respiratory
© Sean Kramer MSHS, PA-C

119. © Sean Kramer MSHS, PA-C
Hyaline membrane disease (Fetal
respiratory distress syndrome)

120. • Diagnosis
– History and physical
• Preterm infant
• Respiratory distress
• Tachypnea
• Hypoxia
• Cyanosis
Hyaline membrane disease
© Sean Kramer MSHS, PA-C

121. • Diagnosis
– Diagnostic Studies
• Typical patient
– CXR
Hyaline membrane disease
© Sean Kramer MSHS, PA-C

122. • Diagnosis
– Diagnostic Studies
• CXR
– Air bronchograms
– Diffuse atelectasis
– Ground glass opacities
– Doming of diaphragm
Hyaline membrane disease
© Sean Kramer MSHS, PA-C

123. • Plan
– Typical patient
1. Prevention
– Maternal glucocorticoids
2. Exogenous surfactant
– Can initiate in delivery room
3. Synchronized mandatory
ventilation
Hyaline membrane disease
© Sean Kramer MSHS, PA-C

124. © Sean Kramer MSHS, PA-C
Bronchopulmonary dysplasia

125. • Diagnosis
– History and physical
• Acute respiratory distress in the first week of life.
• Required oxygen therapy or mechanical ventilation,
with persistent oxygen requirement at 36 weeks'
gestational age or 28 days of life.
Bronchopulmonary dysplasia
© Sean Kramer MSHS, PA-C

126. • Plan
– Typical patient
• Ventilation
• Surfactant
Bronchopulmonary dysplasia
© Sean Kramer MSHS, PA-C

127. © Sean Kramer MSHS, PA-C
Asthma

128. • Diagnosis
– History and physical
• Common
– Wheezing
» Expiratory
» Higher pitch if worse
– recurrent cough
– shortness of breath
– "chest congestion,"
– prolonged cough
– exercise intolerance
– Dyspnea
• Severe
– No lung sounds
– Nasal flaring
– Accessory muscle use
Asthma
© Sean Kramer MSHS, PA-C

129. • Diagnosis
– Severity
Asthma
© Sean Kramer MSHS, PA-C

130. • Diagnosis
– Diagnostic Studies
• Typical patient
– Spirometry
– Consider
» CBC
» CXR
Asthma
© Sean Kramer MSHS, PA-C

131. • Diagnosis
– Diagnostic Studies
• Spirometry
– Lower FEV1 and FEV1/FVC
– Improvement with bronchodilator
• CBC
– Nonspecific
– May show eosinophilia or >WBC
• CXR
– Nonspecific, unless additional pneumonia
– hyperinflation (flattening of the diaphragms),
peribronchial thickening
Asthma
© Sean Kramer MSHS, PA-C

132. • Plan
– Typical
patient
Asthma
© Sean Kramer MSHS, PA-C

133. © Sean Kramer MSHS, PA-C
Bronchiolitis

134. • Most common pathogen
– Respiratory syncytial virus (RSV)
• Diagnosis
– History and Physical
• Coughing
• Tachypnea
• labored breathing
• hypoxia
• Irritability
• poor feeding
• vomiting
• Wheezing and crackles
Bronchiolitis
© Sean Kramer MSHS, PA-C

135. • Diagnosis
– Diagnostic Studies
• Typical patient
1. RSV nasal swab
– Consider
» CBC
» CXR
Bronchiolitis
© Sean Kramer MSHS, PA-C

136. • Diagnosis
– Diagnostic Studies
• RSV nasal swab
– May be positive
• CBC
– May show lymphocytosis
• CXR
– Nonspecific
– hyperinflation, peribronchial cuffing, increased interstitial
markings, and subsegmental atelectasis.
Bronchiolitis
© Sean Kramer MSHS, PA-C

137. • Plan
– Typical patient
1. Suction
2. Supplemental oxygen
3. Hydration
• If severe
– Ribavarin
• Prevention premature infant
– palivizumab
Bronchiolitis
© Sean Kramer MSHS, PA-C

138. © Sean Kramer MSHS, PA-C
Cystic fibrosis

139. • Diagnosis
– History and Physical
• Recurrent lung problems
• Cough
– With sputum
• Infertility
• Pancreatitis hx
• Steatorrhea
• Abd pain
• Finger clubbing
• Increased AP chest
• Percussion hyperresonance
• Nasal polyps
Cystic fibrosis
© Sean Kramer MSHS, PA-C

140. • Diagnosis
– Diagnostic Studies
• Typical patient
– Sweat chloride test– diagnostic
– Consider
» CXR
» CT Chest
» Pulmonary function test
Cystic fibrosis
© Sean Kramer MSHS, PA-C

141. • Diagnosis
– Diagnostic Studies
• Sweat chloride test
– Diagnostic (should be done in x2)
» >60mEq/L
• Genotyping
– Limited, screening
– Only checks for a fraction of CF mutations
• CT scan chest
– Confirms bronchiectasis
Cystic fibrosis
© Sean Kramer MSHS, PA-C

142. • Diagnosis
– Diagnostic Studies
• Chest x-ray
– Hyperinflation
– Peribronchial cuffing
– Bronchiectasis
– Blebs
• Options
– ABG
– Hypoxemia
• PFT– mixed obstructive
restrictive pattern
Cystic fibrosis
© Sean Kramer MSHS, PA-C

143. • Plan
– Typical patient
1. Clear secretions
2. Bronchodilators
3. Pancreatic enzymes replace
• Consider as needed
– Treat infections
– Screen yearly for acid fast bacilli sputum
– Lung transplant
Cystic fibrosis
© Sean Kramer MSHS, PA-C

144. © Sean Kramer MSHS, PA-C
Foreign body (Trachea, bronchi)

145. • Diagnosis
– History
• Choking
• Coughing
• Unexplained wheezing
• Hemoptysis
– Physical
• Wheezing
Foreign body of trachea or bronchi
© Sean Kramer MSHS, PA-C

146. • Diagnosis
– Diagnostic Studies
• Typical patient
– Screening
» CXR with expiratory view
– Definitive
» Bronchoscopy
– Consider
» Sputum culture
Foreign body of trachea or bronchi
© Sean Kramer MSHS, PA-C

147. • Diagnosis
– Diagnostic Studies
• CXR
– Add post-expiratory view
– Findings
» Possible foreign body
» Regional
hyperinflation
(check-valve effect)
» Infiltrates with toxic
material and gastric
aspiration– lower lung
fields (right> left)
Foreign body aspiration
© Sean Kramer MSHS, PA-C

148. • Diagnosis
– Diagnostic Studies
• Bronchoscopy
– Used for definitive
diagnosis or retrieval
• Sputum culture
– If post-obstructive
pneumonia considered
Foreign body aspiration
© Sean Kramer MSHS, PA-C

149. • Plan
– Typical patient
• Prevention
– Avoid small toys with children
• Acutely
– Heimlich maneuver
– Bronchoscopy
• If pneumonia
– IV antibiotics
Foreign body of trachea or bronchi
© Sean Kramer MSHS, PA-C

150. • Plan
– Patient Education
• Carefully watch children
• Avoid small toys with children
– Acutely
• Heimlich maneuver
Foreign body aspiration
© Sean Kramer MSHS, PA-C

151. • Plan
– If unable to remove
• Bronchoscopy
– Gastric aspiration
• Only give abx if evidence of
pneumonia (only 1/4th of cases)
• Controversial on benefit of
steroids
Foreign body aspiration
© Sean Kramer MSHS, PA-C

152. © Sean Kramer MSHS, PA-C
Pneumonia

153. • Pathogens
Pneumonia
© Sean Kramer MSHS, PA-C

154. • Diagnosis
– History and Physical
• Fever
• Cough
• Wheezing
• Crackles
Pneumonia
© Sean Kramer MSHS, PA-C

155. • Diagnosis
– Diagnostic Studies
• Typical patient
– CXR
– Consider
» Sputum culture
» Blood culture
Pneumonia
© Sean Kramer MSHS, PA-C

156. • Diagnosis
– Diagnostic Studies
• CXR
– Typical
» Lobar infiltrate (step pneumo)
– Atypical
» Diffuse bilateral (mycoplasma)
Pneumonia
© Sean Kramer MSHS, PA-C

157. • Plan
– Typical patient
• Typical
– Amoxicillin OR
– Ceftriaxone
• Atypical
– Mycoplasma
» Macrolide antibiotics (azithromycin)
– RSV
» Ribavarin
Pneumonia
© Sean Kramer MSHS, PA-C

158. • Plan
Pneumonia
© Sean Kramer MSHS, PA-C

159. Enter question text...
A. Enter answer text...
B. Enter answer text...
C. Enter answer text...
D. Enter answer text...
Post-test
© Sean Kramer MSHS, PA-C

160. Questions?
© Sean Kramer MSHS, PA-C