Pediatric Pulmonary Pearls

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1 Pediatric Pulmonary Pearls Terrence W. Carver, Jr., M.D. Children s Mercy Hospitals and Clinics Medical Director of Respiratory Care and Pulmonary Medicine Associate Professor of Pediatrics University of Missouri-Kansas City The Children's Mercy Hospital, 2016

2 Disclosures Many medications used in pediatric patients are not specifically approved by the FDA. Many medications used in cystic fibrosis (CF) patients are not specifically approved by the FDA.

3 Educational Objectives Review management of (some) pulmonary concerns encountered in primary care practice. Recognize a typical clinical scenario for foreign body aspiration. Review evaluation for hemoptysis in a noncystic fibrosis patient. Evaluation of a pediatric patient with chronic cough.

4 Selfish Goal My goal is to get invited back!

5 Foreign Body Aspiration Typical presentation (acute) Toddler Cough/choke episode Unilateral wheeze

6 Foreign Body Aspiration O 2 saturation and respiratory rate Retractions/distress CXR Lateral decubitus views Air trapping

7 What s wrong with this picture?

8

9 Foreign Body Aspiration Witnessed Suspected Possible

10 Foreign Body Aspiration Solid/particulate ENT or Surgery for rigid bronchoscopy NPO Write checks that I don't cash. Oils/Volatiles Supportive care and oxygen (likely admission) Not bronchoscopic removal

11 New Hemoptysis non CF Amount and color Bright red blood, clots, blood streaked mucus Source Lung, nose, GI Bronchitis/pneumonia Epistaxsis Liver disease, GERD

12 New Hemoptysis non CF Urine output/blood Pulmonary/Renal Syndrome Rash, abnormal joints, chronic/recurrent fever Rheumatologic

13 New Hemoptysis non CF CXR findings and oxygen saturation CBC and reticulocyte count PT/PTT/LFTs/platelet count Guaiac stool Urinalysis/BUN/creatinine Blood and casts

14 Umm Dr. Segeleon

15 New Hemoptysis non CF CT Chest with contrast or CT angiogram Bronchoscopy/BAL P and C-ANCA, RF, ANA, ESR, CRP, type and cross, brain natriuretice peptide, D- dimer, sputum culture/afb/tb evaluation? Echocardiogram

16

17 New Hemoptysis non CF Consults; "Who you gonna call?" Rheumatology, Renal, ID, Surgery, ENT, GI Positive pressure ventilation Lung biopsy Lung resection Blood transfusion

18 Stridor Think airway (ENT) Laryngomalacia Recurrent croup Vocal Cord Dysfunction (VCD)

19 Infant Laryngomalacia Growing well and no distress Some chest wall retractions esp. supine If more severe consider subglottic stenosis, laryngeal papillomatosis, others Scope (ENT) if suspicious for others or severe

20 Recurrent Croup Rule out anatomic abnormality (ENT) Occasionally responds to "reactive airway disease" medications (Pulmonary) Trial of inhaled corticosteroids

21 Vocal Cord Dysfunction Adolescent Type A personality Stress related (games vs. practice) Confused with exercise induced asthma Dysphonia, throat/neck vs. chest, choking sensation Video on cell phone Speech Therapy for breathing exercises

22 Chronic/Recurrent Cough History How long When AM/PM While asleep Associated feeding Good growth or failure to thrive

23 Chronic/Recurrent Cough Triggers Upper respiratory tract infections, allergies, exercise,cold air, etc. Seasonal Previous steroids

24 Chronic/Recurrent Cough Symptoms of GERD/aspiration Family history of cystic fibrosis, asthma, or allergic rhinitis Vocal Cord Dysfunction with wheeze but normal oxygen saturation

25 Chronic/Recurrent Cough Asthma Early morning around GERD Feeding/chest rattle Family often says "wheeze"

26 Chronic/Recurrent Cough Allergic Rhinitis/Sinusitis On awakening Aspiration CF Cough/choke with po feeds vs. silent aspiration Loose Difficulties gaining weight

27 Chronic/Recurrent Cough Vascular ring Stridor, dysphagia Immune dysfunction Other sites of infection, failure to thrive Habit Loud, honking, resolves with sleep

28 TB Chronic/Recurrent Cough Weight loss, night sweats Large tonsils/upper airway obstruction Hard to judge Primary cilia dyskinesia recurrent sinusitis and otitis media, situs inversus, respiratory difficulties as term newborn

29 Chronic/Recurrent Cough Vitals and oxygen saturation Exam of nose and lungs, etc. Type of cough Any stridor

30 Chronic/Recurrent Cough Labs CXR UGI Sweat test Newborn screening began: MO 7/1/07 SD 6/1/05 KS 7/1/08 NE 1/1/06

31 What s wrong with this picture?

32

33 Chronic/Recurrent Cough TST Immune evaluation Swallow study ph probe CT Chest with contrast

34

35 Chronic/Recurrent Cough Bronchoscopy/BAL Anatomy Lipid laden macrophages

36 Chronic/Recurrent Cough Cilia biopsy by ENT Structure typically but not function

37 Pneumothorax First or recurrent Same side Connective tissue disease CT Chest (with contrast) Blebs Surgery consult

38 What s wrong with this picture?

39 Tracheostomy & Cough Color, amount of sputum Increased suctioning Fever Acts sick Increased oxygen need

40 Tracheostomy & Cough Previous organisms and sensitivities Previous antibiotics that helped or didn t Ever Pseudomonas or MRSA

41 Tracheostomy & Cough Vitals and oxygen saturation Type and size of tracheostomy Breath sounds CXR compared to previous

42 Home Ventilator Similar to tracheostomy Ventilator settings and times of day used Cuffed vs. uncuffed tubes Blood gas evaluation and bicarbonate level from basic metabolic panel

43 Tracheostomy Concerns ENT generally Too big Too small Can t get back in Critical vs. inconvenient Cuff problems

44 Snoring/Obstructive Sleep ENT Apnea Large tonsils/adenoids Needs Polysomnogram (PSG aka Sleep Study) Sleep or Pulmonary Clinic Consider admit

45 Pectus Excavatum Pulmonary Fuction Testing Surgery Clinic Cardiology Clinic Exercise study

46

47 CF with Cough Color and amount of sputum Change in taste--anaerobes Fever--not typically noted Associated symptoms Fatigue Weight loss URI

48 CF with Cough History of ABPA (Allergic Bronchopulmonary Aspergillosis) Other pertinent history Home medications Last antibiotic course/dosing Last admit therapy--especially if admitting

49 CF with Cough Oxygen saturation Fever--atypical for standard exacerbation Respiratory rate/distress Breath sounds Crackles Reduced air movement Wheeze uncommon

50 CF with Cough Previous culture results CXR results compared to previous Other labs WBC, RSV, Influenza Pulmonary function tests with reduced FEV 1

51 Pseudomonas aeruginosa Frequent pathogen Resistance pattern important Consider ciprofloxan (Cipro) Often admit for IV antibiotics Ceftazidime and tobramycin unless resistant

52 MRSA Increased incidence in CF not unlike overall community Decreased survival Consider linezolid (Zyvox) or Bactrim Medication interactions

53 CF with Cough What does family want? Home antibiotics Admit Repeat sputum or throat culture

54 CF with Hemoptysis Amount, color < 5 ml vs. more Bright red blood vs. streaks in mucus New or many times Can patient tell where the bleeding is coming from?

55 CF with Hemoptysis Home medications ADEK Other recent history Pulmonary exacerbation Other pertinent history Liver disease/portal HTN

56 CF with Hemoptysis Oxygen saturation Respiratory rate/distress Breath sounds Crackles Reduced air movement Wheeze

57 CF with Hemoptysis PT PTT CBC Liver function testing Type and cross for PRBC transfusion

58 CF with Hemoptysis CXR compared to previous Bronchiectasis

59 CF with Hemoptysis Positive pressure ventilation Bronchial artery embolization Lung resection Stop NSAIDS FFP and/or vitamin K

60 CF with Hemoptysis Hold airway clearance Antibiotics PRBC transfusion

61 CF with Hemoptysis What does family want? Home antibiotics Admit Repeat sputum or throat culture

62 CF with Abdominal Pain Location and duration Lack of stooling With eating (constipation, DIOS) Spitting up (GERD) Hematemesis (liver disease)

63 CF with Abdominal Pain Home medications Previous history Meconium ileus (adhesions/bowel obstruction) Previous KUB/abdominal ultrasound Previous liver enzymes

64 CF with Abdominal Pain Considering (more likely) DIOS (Distal Intestional Obstructive Syndrome) Constipation Missing enzymes GERD

65 CF with Abdominal Pain Considering (less likely) Gall stones Portal hypertension Liver disease Pancreatitis Pancreatic sufficient

66 Exam CF with Abdominal Pain Tenderness Mass Palpable stool Rebound

67 CF with Abdominal Pain KUB Abdominal ultrasound Liver enzymes Lipase/amylase PT

68 CF with Abdominal Pain GI or Surgery services Cautious with narcotics Enema GoLYTELY po or NG Increase constipation medications MiraLax Fluids

69 CF with Abdominal Pain What does the family want? Trial of therapy at home Admit

70 Suggested Reading Kendig s and Chernick's Disorders of the Respiratory Tract in Children, 8 th ed., Respiratory Disease in Children: Diagnosis and Management, ed. Loughlin and Eigen, Care of the Child with a Chronic Tracheostomy; Am J Respir Crit Care Med. 2000;161: Management of Spontaneous Pneumothorax; Chest. 2001;119:

71 Suggested Reading Cystic Fibrosis Pulmonary Guidelines Chronic Medications for Maintenance of Lung Health; Am J Respir Crit Care Med. 2007;176: Cystic Fibrosis Pulmonary Guidelines Pulmonary Complications: Hemoptysis and Pneumothorax; Am J Respir Crit Care Med. 2010;182:

72 Suggested Reading Association Between Respiratory Tract Methicillin-Resistant Staphylococcus aureus and Survival in Cystic Fibrosis; JAMA. 2010;303(23): Update on treatment of pulmonary exacerbations in cystic fibrosis; Current Opinion in Pulmonary Medicine. 2006;12:

73 Suggested Reading Guidelines for Evaluating Chronic Cough in Pediatrics: ACCP Evidenced-Based Clinical Practice Guidelines; Chest. 2006;129:260S- 283S Recommendations for the assessment and management of cough in children; Thorax. 2008;63:1-15

74 Suggested Reading UpToDate, April Clinical Practice Guidelines From the Cystic Fibrosis Foundation for Preschoolers With Cystic Fibrosis, Pediatrics. 2016;137(4):e nscreening/screeningforcf/

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