Differentiating Bronchoconstriction Out of a Sea of Wheezes

Transcription

1 Differentiating Bronchoconstriction Out of a Sea of Wheezes

2 Disclosure Statement I have no affiliation with any drug company medical equipment provider or whatever Cardinal Glennon Children s Medical Center transport therapist I married a nurse I have really cute kids you will see them in the presentation!

3 Wheezing -What, When and Where Musical - whistle Monophonic - single Polyphonic - general Expiratory - small Inspiratory - large Full Cycle - the works All lung fields Scattered Localized Throat

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6 Not everything you hear is Wheezing Wheezes Crackles (or rales) fine vrs loud or coarse Rhonchi - generally associated with mucus Stridor - typically upper airway Diminished BS or absent (vrs shallow) Pleural Rub

7 Crackles vrs Wheezing Fine Velcro Atelectasis Fluid filled alveoli Coarse - Often confused with wheezing Low pitched Fluid in alveoli

8 Rhonchi vrs Wheezing Large low toned intermittent breath sounds Rattling, Rumbling, Bubbling, Gurgling Throughout the respiratory cycle Wet May clear with cough

9 Stridor vrs Wheezing Stridor Latin for hiss grating creaking whistle or shriek Monotonic wheezing Typically heard at maximal airflow Inspiratory Stridor - emergency? Expiratory Stridor - Lower airway obstruction FB

10 All that wheezes is not asthma Can be heard with Bronchospasm Bronchial constriction Pulmonary edema Tumors RSV (Bronchiolitis) Excessive mucus

11 And now on with the show!!!!

12 Treating Little Wheezers Differential Diagnosis Asthma - Reversible bronchoconstriction Congenital anomalies - Modified breath sounds Laryngotracheobronchitis - Croup Bronchopulmonary Dysplagia Epiglottitis Bronchiolitis (RSV) Foreign body aspiration PNS

13 Other wheezing we wont touch Pulmonary embolism Cardiac failure Tumors Aspiration Carcinoid Loeffler's Syndrome Tropical Eosinophilia Vascular rings Hyperventilation Syndrome Sarcoid Laryngeal Edema Factitious Wheezing Alpha-1-Antitrypsin Immotile cilia syndrome Kartagener's syndrome

14 Asthma - Presentation Wheezing Distressed Tachypnea Prolonged expiratory phase Labored Breathing Unable to eat

15 Pediatric Asthma - How to treat it Typical wheezer Pre and post peak flows (if capable) Bronchodilators - Albuterol vs. Xopenex MDI instruct or review (get them a spacer) Steroids IV vs. Oral vs. Inhaled Atrovent - PDR vs. Practice

16 Asthma Severe acute attack Albuterol continuous treatment mg/hr Corticosteroids Prednisone Dexamethasone Magnesium sulfate Oxygen Heliox severe cases

17 Continuous better than intermittent Continuous vs intermittent beta agonists in the treatment of acute asthma. Multiple hours available Mask modification for high oxygen needs Pediatric study 15mg/Hr Carmargo CA Jr, Spooner CH, Rowe BH. Cochrane Database Syst Rev. 2003: (4): CD001115

18 Timing of Oral Steroid Admission status is associated with timing of oral steroid Oral Steroid given in 1 st hour decreased admission rate Wait >2 hours after steroid to determine admission status Aim to give steroid with first beta 2 agonist Inhaled Steroids??

19 Magnesium in Asthma Intravenous magnesium sulphate for acute asthma: meta analysis For moderate to severe asthma, IV Mg reduces admissions to hospital by 30% Avoid PICU??? S Mohammed and S Goodacre Emerg.Med J. 2007;24;

20 Keep them happy (or sleeping) Screaming I:E ratio Percent particle deposition is reduced Breath holders They will breath eventually NO BLOW BY Proper Toddler Wrestling

21 Avoid Waking a Sleeping Toddler!!

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23 Status Asthmaticus Medical gases - O 2, Heliox 80/20 blend in O 2 up to 60% Epinephrine Subcutaneous injection Subcutaneous Solution (1:1,000) : 0.01 ml/kg or 0.3 ml/m 2 (0.01 mg/kg or 0.3 mg/m 2 ); repeat every 20 minutes to 4 h. Do not exceed 0.5 ml (0.5 mg) in single dose. IV caution Intubation - RARE!

24 Asthma - Resolution Nearly always controllable - exceptions Improves to clear (or not) Peak flows improve to >75% predicted Decreased WOB Pt comfort increased Able to eat or hold down fluids

25 Congenital Anomalies

26 Congenital Anomalies - Modified breath Larygeal malacia Tracheal malacia Vocal Chord Paralysis Airway stenosis Fistula sounds

27 Congenital Anomalies ER presentation Patient history - given in report Tracheal assessment Typically localized or unilateral wheezing Tracheostomy scar Deviated trachea

28 Congenital Anomalies of Upper Airways - How do I treat it? Bronchoscopy refferal Discriminate use of bronchodilators - may make things worse Airway protection Tracheostomy Artificial Airway

29 Epiglottitis Acute onset 66% are 2-4 years of age No hoarseness Drooling, dysphasia High Fever (>103) without cough Type B Haemophilus Influenza

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31 Epiglottitis ER treatment Keep pt calm Get your best intubator - consider fiberoptics? Protect your airway Sedate X-rays play no role at this point

32 Epiglottitis

33 Laryngotracheobronchitis - Croup Barking Cough Typically Viral Low grade fever Swelling below the chords Difficulty breathing - retractions 3 months - 5 years - Worse in pre 3 yr/olds Typically not an emergency

34 Croup X-ray may demonstrate the narrowing of trachea.

35 Croup - How do I treat it Cool mist mask - lap them Glucocorticoids - Decadron, Hexadrol Epinephrine nebs - always Prn! Oxygen as needed Keep them calm Intubation - rare Home treatment - Keep it cool, 2-5 days

36 RSV-Bronchiolitis

37 What Is Bronchiolitis? Bronchiolitis is acute inflammation of the airways, characterized by wheeze May or may not involve bronchoconstriction Bronchiolitis most often results from a viral infection Respiratory Syncytial Virus (RSV) may be responsible for up to 90% of bronchiolitis cases in young children

38 Bronchiolitis - RSV Extremely contagious - once introduced to a day care setting it has 98% transferal rate Secretion production both upper and lower airways Low Grade Fever - increased O 2 demand Labored breathing - retractions Coarse bilateral breath sounds Typically unresponsive to bronchodilation

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40 RSV Bronchiolitis - How do you treat it? Suction, Suction, Suction CPT O 2 Hydration Bronchodilator trial indicated but rarely useful. RSV - antibody injection Palivizumab

41 History of RSV and Nebs Cool Mist Bronchodilators possibly helpful Steroids some patients seem to benefit Ribavirin life and death

42 Bronchopulmonary Dysplagia

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44 Bronchopulmonary Dysplasia Inflammatory Mediators ~Asthma Cystic Lesions Fibrotic Lesions around Bronchi (oles) Squamous Metaplasia of Bronchi(oles) Acute Lung Injury with chronic repair Restrictive Lung Disease in first months Obstructive Lung disease later on

45 BPD - BronchoPumonary Dysplagia - What they are doing at home Supplemental Oxygen Aggressive Pulmonary Hygiene Prophylactic pharmacology Bronchodilators caution here Aggressive Nutritional Support Systemic Steroids Nebulized Corticosteroids

46 BPD - Bronchopumonary Dysplagia Scarred lung tissue Floppy airways Challenging pulmonary hygiene Reduced air movement Crackles and Coarse

47 BPD - How do I treat it 20 times more likely to require artificial ventilation upon ER visit Oxygenation Airway concerns Review Pulmonary Hygiene Hydration Alveolar eugenesis till age 8

48 Bronchopulmonary Dysplagia - Outcomes Mortality rate (10-50%) Related to Gestational Maturity and Complications 10% May die Suddenly (Unexpectedly) Mid-Severe Chronic Lung Disease Reversible Pulmonary Arterial Hypertension Treatment is Supportive eg. Home O 2

49 Foreign Bodies can be an EMERGENCY!

50 Foreign body aspiration 60% are below the age of 2 45% present to the ER on same day <5% of Foreign Bodies are radio-opaque Typically involves coughing but not always Undiagnosed leads to chronic problems

51 Foreign Body Aspiration - Coughing 50% presentation Wheezing 56% - (more likely to wheeze than cough!) Respiratory Distress 42% Fever 22% Choking 2%

52 Foreign Body Aspiration Large Airway blockages - far more obvious Beware legos Onset questions - remove the sooner the better

53 Check out the highlights of this case: Direct laryngoscopy in the OR of cap to highlighter marker below vocal cords.

54 The Foreign Body Blue Plate Special!

55 Right mainstem bronchus aspiration is more common but children can aspirate into the left side. Chest radiograph of 2 year old who aspirated a peanut into the left mainstem bronchus with resultant hyperinflation of hemithorax. The child presented with wheezing and cough.

56 Child abuse Autopsy photo of 5 month old infant boy who was suffocated by mother with black pepper to break his thumb sucking habit Photo courtesy of James Monteleone, MD, Child Maltreatment, Second Edition, GW Medical Publishing, 1998

57 Hydrocarbons like these can be aspirated and behave like a foreign body substance in the lungs. Even heavier mineral oil has been aspirated and acts like an obstructive foreign body in the smaller airways.

58 Aspiration of hydrocarbon oil into lungs. This patient required oscillator ventilation, ECMO and a trial of partial liquid ventilation.

59 FBA - How to treat it Radiology Scope and scoop Thoracotomy Tracheotomy Do Not Administer CPT Do not try to suction out

60 Upper airway congestion Upper airways often reverberate Noses and nasopharyx whistling Treat with Suctioning - Neosucker Saline nasal Spray Prescription stuff

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