asthma and other respiratory disorders

croup

epiglottitis

bacterial tracheitis

laryngomalacia

vocal cord paralysis

foreign body aspiration

differential diagnosis for stridor

- Asthma-

Bronchiolitis (RSV)

- Viral-induced wheeze

- Allergic reaction/anaphylaxis

- Foreign body aspiration

- Tracheomalacia

differential diagnosis for wheezing

Choanal stenosis/atresia

-congenital problem in the neonatal period, relatively rare

-obstruction off nasal passages----> resp distress esp when feeding

Inability to easily pass a small catheter through the nostrils should raise the suspicion of choanal atresia.

The diagnosis is confirmed by CT scan and by inspecting the area directly with a flexible nasopharyngoscope. An oral airway may be useful in the short term, but the definitive treatment is surgery

how do you diagnose choanal atresia?

Croup (laryngotracheobronchitis)

Inspiratory stridor is a harsh high pitched respiratory sound produced by turbulent flow

Barking or brassy harsh cough

Hoarseness

Low grade fever

steeple sign due to subglottic narrowing on CXR

diagnostic finding of croup

dexamethasone and rest

treatment of croup

GAS or S. aureus, Hib

most common agents of epiglottitis

epiglottitis

Prefer sitting head held forward, mouth open, jaw thrust forward (sniffing position)

Muffled voice, sore throat, fever, drooling/secretions, dyspnea or stridor

thickened and bulging epiglottis (thumb print sign)

CXR findinng of epilottitis

Antibiotics and endotracheal intubation, can be extubated 48-72 hours

management of epiglottitis

Laryngomalacia

soft tissues of larynx fall over the airway opening and partially block it---> inspiratory stridor

resolve on own usually by 20 months

management of laryngomalacia

bacterial tracheitis

Superinfection of the trachea that may follow viral croup and most commonly caused by S. aureus

Toxic appearing

Spasmodic croup usually at night

inspiratory stridor

signs and symptoms of bacterial tracheitis

subglottic stenosis

Narrowing of the space below the glottis and above the first tracheal ring; involves narrowing of the cricoid, the only complete cartilage ringg in the airway

often occurs after long periods of intubation and ventilation for respiratory problems

cause of acquired subglottic stenosis

Recurring croup

Respiratory distress

Noisy breathing

Inability to breathe without tracheostomy

signs and symptoms of subglottic stenosis

Associated with birth trauma, neuro conditions, infections or recent cardiac surgery or idiopathic

conditions associated with vocal cord paralysis

low dose ICS

treatment of step 2 persistent asthma

Low dose ICS + LABA

or

medium dose ICS

treatment of step 3 persistent asthma

medium dose ICS + LABA

treatment of step 4 persistent asthma

high dose ICS + LABA

treatment of stepp 5 persistent asthma

high dose IC + LABA + oral corticosteroid

treatment of step 6 persistent asthma

intermittent asthma

Symptoms less than 2 times/week and <2 nighttime symptoms/month

Tx with SABA

mild persistent asthma

Symptoms: >2x/wk but <1x/d

Night Sxs: >2x/mo

FEV: >80% prediction

Tx: Low-dose ICS > Cromolyn, leukotriene (S/E: ↑ mucous production)

moderate persistent asthma

FEV1/PEF 60-80%, daily symptoms. SABA, daily moderate dose ICS, or low dose ICS and LABA

severe persistent asthma

FEV1/PEF <60%, symptoms most of day. SABA, high dose ICS, LABA, oral steroid daily

-nightly wakenings

Ongoing self-management, detecting early decline before symptoms

indication to measure peak expiratory flow

peak expiratory flow meter

Device measuring maximum airflow during exhalation.

spirometry

-gold standard for diagnosis of asthma and assessing severity

normal ~0.75-0.80 in adults, ≥0.85 in children

what is a normal FEV1/FVC ratio

↑ FEV₁ ≥ 12% and ≥ 200 mL = significant reversibility

post bronchodilator response FEV1 value supporting asthma diagnosis

FVC

total air exhaled after full inspiration

Asthma episode not controlled in 30-60 min with standard treatment

Hypoxemia, hypercarbia, secondary respiratory failure

define status astmaticus

O2

SABA

anticholinergic

systemic corticosteroidsd

management of status asthmaticus

tracheomalacia

congenital Floppy tracheal cartilage → airway collapse during expiration

Sweat chloride test (>60 mmol/L), CFTR genetic testing, newborn screening (IRT)

diagnostic approach to cystic fibrosis

Bronchiectasis, chronic lung infection, infertility (absent vas deferens), malnutrition

sequelae of cystic fibrosis

Expiratory stridor, barking cough, worse with crying/URI, recurrent respiratory infections

signs and symptoms of tracheomalacia

Mild: observation (improves by 18-24 mo); Severe: CPAP, surgical aortopexy/tracheal stenting

management of tracheomalacia

bronchopulmonary dysplasia

Chronic lung disease in preterm infants (<32 wks) with prolonged oxygen/mechanical ventilation → alveolar simplification & fibrosis

tracheoesophageal fistula

Failed separation of trachea & esophagus (most often esophageal atresia + distal TEF)

Polyhydramnios prenatally; newborn with choking, coughing, cyanosis, drooling during feeds; inability to pass NG tube

signs and symptoms of tracheoesophageal fistula

AR defect in dynein arms → impaired ciliary motility → defective mucociliary clearance

etiologgy of primary ciliary dyskinesia

Neonatal respiratory distress, chronic sinusitis/otitis, recurrent pneumonia, situs inversus (Kartagener: PCD + situs inversus + chronic sinusitis), infertility

signs of primary ciliary dyskinesia

Primary Ciliary Dyskinesia

-Inherited abnormality of ultrastructure of the cilia

-Caused by dynein arm defect

-Pt's present w/ recurrent infections, bronchiectasis, Kartagener syndrome

Dx: Electron microscopy of respiratory cilia

Tx: Preventative abx, surveillance cultures, sinus surgeries

pectus excavatum

Posterior depression of sternum & costal cartilages

pectus carinatum

Anterior protrusion of sternum & costal cartilages

-often asymptomatic