Pediatric Diseases

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Pediatric Diseases

• Croup
• Epiglottitis
• Bronchiolitis
• Pneumonia

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I. CROUP
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The Clinical Picture---Predisposing Factors

• Viral Croup occurs between 3 months and 3
  years.
• H. influenza epiglottitis occurs between 3 and 7
  years.
• Typically seen in males.
• Time of year---cold season.
• Strong familial history (15).
• Past history in the same child.

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Critical Point 1

• a. Croup is not a disease. It is a description of
  those symptoms that involve a barking cough and
  hoarseness associated with upper airway
  inflammation.

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Critical Point 2

• b. When upper airway swelling is above the
  larynx, involving the laryngopharynx and
  epiglottis, this is known as Supraglottitis or
  more commonly Epiglottitis.

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Critical Point 3

• c. When the disease process is below the larynx,
  the inflammation causes laryngitis,
  laryngotracheitis, or laryngo-tracheobronchitis
  (or L-T bronchitis).

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Critical Point 4

• d. 85 of croup is of viral origin 15 of croup
  is of bacterial origin

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TYPICALLY

• Epiglottitis is caused by bacteria, i.e., H.
  influenza bacteria
• laryngitis, laryngotracheitis, and L-T bronchitis
  are caused by viruses, i.e.,Influenza,Parainfluenz
  a, Respiratory Syncytial Virus (RSV). These are
  typically treated with Ribaviran.

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II. ACUTE EPIGLOTTITIS
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The Clinical Picture

• 1. Abrupt onset.
• 2. Preceding minor upper respiratory illness in
  25 of all cases.
• 3. Sudden onset of high fever and increased WOB
• 4. Hyperextension of the neck, open mouth,
  protruding tongue and drooling.
• 5. Inspiratory Stridor, hoarseness, brassy cough,
  dysphagia, irritability, and restlessness.
• 6. Shock-like state w/pallor, cyanosis, and
  impaired consciousness in some.
• Nasal flaring inspiratory retractions large
  cherry-red epiglottis mild to moderate cervical
  adenitis

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Clinical Picture Continued

• Elevated WBC's (15,000 to 25,000)
• Positive blood cultures (H. Influenza B or
  pneumococci)
• lateral neck X-ray shows soft tissue swelling

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TREATMENT AND MANAGEMENT OF CROUP AND EPIGLOTTITIS

• 1. Supportive, intensive care w/monitoring.
• 2. Hydration and nutrition.
• 3. Croup tent with high humidity air or O2.
• 4. Racemic epinephrine typically via nebulizer.
• 5. Possibly endotracheal intubation, emergency
  cricothyrotomy if needed...tracheostomy...
• 6. Transtracheal ventilation.

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III. BRONCHIOLITIS
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The Clinical Picture

• 1. Hx of exposure to others w/minor respiratory
  illness.
• 2. Mild respiratory symptoms lasting several
  days.
• 3. Mild fever (101F - 102F)---may be normo or
  hypothermic.
• 4. Gradual development of respiratory distress.
• 5. Paroxysmal, wheezy cough, dyspnea and
  progressive irritability.

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A Full Blown Bronchiolitis...

• Tachypnea (RR 60-80/min)
• severe air hunger and cyanosis nasal flaring
• intercostal and substernal retractions
• palpable liver and spleen secondary to emphysema
  
• widespread, fine rales end-inspiratory phase
• prolonged expiratory phase w/wheezing diminshed
  BS
• Increased AP diameter.

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Pathophysiology of Bronchiolitis

• 1. Bronchiolar obstruction secondary to edema,
  secretions, and cellular debris
• 2. Increased Airway resistance
• 3. Ball-valve obstruction w/air trapping
  emphysema
• 4. Atelectatic changes
• 5. V/Q abnormalities decreased alveolar
  ventilation with intra-pulmonary R-L shunting (up
  to 17 of cardiac output) hypoxemia

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Pathophysiology of Bronchiolitis

• 6. Increased Vd/Vt ratios (normal in infants is
  0.3)
• 7. Increased RR, tidal volume and minute
  ventilation (NML or decreasedPaCO2's)
• 8. Increased WOB
• 9. Fatigue, increased minute ventilation
  increasing PaCO2's and then, respiratory failure

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Criteria of Acute Respiratory Failure in
Bronchiolitis

• 1. Diminished breath sounds
• 2. Severe thoracic retractions on inspiration.
• 3. Maximal hyperinflation of the thorax.
• 4. Cyanosis of the mucus membranes w/FIO2 of
  0.40.
• 5. Decreased or abssent response to painful
  stimuli.
• 6. PaCO2 gt65 torr
• RULE I. Acute Respiratory Failure (Three of
  the above clinical criteria) (PaCO2 gt 65
  torr)RULE 2. Impending Respiratory Failure
  (lt Three of the above clinical criteria)
  (PaCO2 gt65 torr)

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Management and Treatment of Bronchiolitis

• 1. Supportive, intensive care w/monitoring.
• 2. Hydration and nutrition.
• 3. Humidified oxygen to maintain PaO2.
• 4. Antibiotics therapy.
• 5. Chest PT.
• 6. Direct laryngoscopy and tracheal aspiration.
• 7. Tracheostomy and tracheobronchial hygiene, if
  necessary.
• 8. Bronchoscopy, if necessary.
• 9. Mechanical ventilation, if necessary.

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IV. THE PNEUMONIAS IN INFANTS AND CHILDREN
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The Clinical Picture

• 1. History
• 2. General Systemic manifestations.
• 3. Fever, restlessness, apprehension dyspnea.
• 4. Acutely ill infant w/air hunger.
• 5. Cyanosis (typically peripheral)
• 6. Nasal flaring.
• 7. Expiratory grunting w/retractions
• 8. Tachypnea and tachycardia
• 9. Cough (may be absent in infants)

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The Clinical Picture

• Diminished BS rales tubular breathing findings
  consistent w/pleural effusion or emphysema
  abdominal distention w/displaced liver and
  spleen typical X-ray findings associated with
  pneumonias elevated WBC and sedimentation rate
  isolation of organisms.

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Management and Treatment of Pneumonia

• 1. Prevention against aspiration pneumonitis.
• 2. Supportive intensive care, w/ monitoring.
• 3. Empty stomach.
• 4. IV fluids, nutrition and Rx of shock.
• 5. Humidified O2 to provide normal PaO2.
• 6. Antibiotics.
• 7. Antipyretics and/or physical cooling.
• 8. Chest PT and postural drainage.
• 9. Sedation?
• 10. Digitalis?? Mast trousers?? Diuretics??
• 11. Mechanical ventilation?