[03.02] CM - Approach to Pediatric Patients with Pulmonary Disease V2.pdf

Not all patients presenting with respiratory distress have a pulmonary disease

What critical general observation is highlighted by comparing the three cases?

Comfortable seating for all

What kind of seating arrangement should be present during the pediatric pulmonary interview?

Assured

What level of privacy is required during the clinical interview?

Primary caregiver who knows the child well

Who should begin the narrative history of a pediatric patient?

Househelp, caregiver, or yaya

Who is the most commonly missed reliable source of history for a pediatric patient?

Include the child

What should you do if the pediatric patient is already able to converse during history taking?

Chronicity, timing, and associations with activities

What three characteristics must you ask about when evaluating pediatric pulmonary symptoms?

Day or night

What options for timing of symptoms should you inquire about?

Exercise or food intake

What are two examples of activities that symptoms may be associated with?

Cough, dyspnea, snoring, apnea, wheezing, cyanosis, pain, exercise intolerance

What are the eight chief complaints associated with pediatric pulmonary disease?

Sudden onset, days, or months

What are the three categories of onset described in the HPI components table?

Less than 3 weeks

What is the duration of acute symptoms according to Kendig's reference?

3 weeks to 3 months

What is the duration of subacute symptoms according to Kendig's reference?

More than 3 months

What is the duration of chronic symptoms according to Kendig's reference?

2 weeks

What is the duration of acute symptoms according to the alternative duration intervals from the doctor's lecture?

2 to 4 weeks

What is the duration of subacute symptoms according to the alternative duration intervals from the doctor's lecture?

More than 4 weeks

What is the duration of chronic symptoms according to the alternative duration intervals from the doctor's lecture?

Kendig's Respiratory Diseases in Children

From which reference text are the HPI duration intervals in Table 1 taken?

Recurrent

What term describes symptoms that are clearly discontinuous, with documented intervals of well-being?

Persistent

What term describes symptoms that do not resolve over time?

Wet, dry, barking, or worse at night

What are four characters or qualities of cough to ask about in the HPI?

Inspiration, exhalation, heard at rest, or worse when crying

What are the patterns of noisy breathing to check in the HPI?

More comfortable after nebulization

What is an example of an alleviating factor to document in the HPI?

Winter or -ber months

What seasons or months are associated with worsening of symptoms as aggravating factors?

Play or exercise

What physical triggers can act as aggravating factors for respiratory symptoms?

Chemicals, trauma, or foreign body

What are three exposures that must be asked about in the HPI?

Immunization

What pediatric preventative history component is listed under HPI exposures and protections in the table?

Past month or past year

Over what two timeframes should you ask about the number of previous pulmonary episodes?

Review antibiotic intake

What history-taking action should be performed to evaluate previous antibiotic treatments?

Chest X-ray CXR

Which previous imaging result should be reviewed if available?

Any member in the household with similar symptoms

What household exposure question should be asked regarding current illness?

History of atopy in the family

What family genetic history should be screened in pediatric respiratory cases?

History of PTB exposure

What infectious disease exposure is critical to screen for in our society?

Household member with chronic cough or taking vitamins para sa baga

What are two smart, non-stigmatizing ways to ask about TB exposure in the household?

Secure the airway

What must be done for a patient requiring an emergent airway before proceeding with the rest of history and PE?

Cyanotic

What skin and mucous membrane color change indicates an emergent airway is needed in Figure 2?

Tripod position

What sitting posture indicates severe respiratory distress and the need for an emergent airway?

Lethargic

What level of consciousness combined with respiratory distress signifies a critical need for an airway?

Hyperextended

How does the neck appear in a child with severe air hunger?

Air hunger

What does hyperextension of the neck in a distressed child signify?

Alert versus altered sensorium

What are the two opposite states of consciousness to assess in the general appearance?

Irritable, anxious, or lethargic

What are three behavioral descriptors of a child in respiratory distress?

Ability to feed, drink, speak, or cry

What four functional abilities of the child should be assessed during general observation?

Work of breathing

What term refers to how hard a child is working to breathe?

Describe how the child is breathing

What is essential to do during the respiratory exam in addition to counting the respiratory rate?

Tachypnea, retractions, nasal flaring, grunting, head bobbing, and use of accessory muscles

What are six signs of increased work of breathing in children?

Head bobbing

What specific sign of increased work of breathing is seen in infants?

Cyanosis and SpO2

What are two parameters used to assess a child's oxygenation?

Mental status, air entry, and fatigue

What three parameters are checked to evaluate a child's ventilation?

Auscultation

How is air entry assessed as good, fair, or poor during physical examination?

PALS and WHO

What are the two acceptable reference frameworks for pediatric respiratory rates?

30 to 53 per minute

What is the normal respiratory rate range for an infant aged 1 to 12 months according to PALS?

22 to 37 per minute

What is the normal respiratory rate range for a toddler aged 1 to 2 years according to PALS?

20 to 28 per minute

What is the normal respiratory rate range for a preschooler aged 3 to 5 years according to PALS?

18 to 25 per minute

What is the normal respiratory rate range for a school-aged child aged 6 to 9 years according to PALS?

12 to 20 per minute

What is the normal respiratory rate range for an adolescent aged 10 years and older according to PALS?

60 per minute or more

What is the WHO tachypnea cut-off for an infant up to 30 days of age?

50 per minute or more

What is the WHO tachypnea cut-off for an infant aged 2 to 12 months?

40 per minute or more

What is the WHO tachypnea cut-off for a child aged 1 to 5 years?

30 per minute or more

What is the WHO tachypnea cut-off for a child aged over 5 years?

20 per minute or more

What is the WHO tachypnea cut-off for a child aged over 10 years?

Listen underneath their clothes

What is the correct technique for auscultating a pediatric patient?

Auscultating on top of the patient's clothing

What common but incorrect physical examination technique is depicted in Figure 3?

Adventitious sounds

What type of respiratory sounds can only be properly appreciated when listening underneath clothing?

High-pitched expiratory sound

What is the auditory quality of expiratory wheezing?

Bronchial asthma, bronchiolitis, viral-induced wheezing, viral pneumonia, or foreign body aspiration

What are five clinical conditions where expiratory wheezing can be appreciated?

Low-pitched bubbling sound

What is the auditory character of coarse crackles?

Blowing air through a straw in a drink or cup

What physical action is coarse crackles compared to?

Pneumonia or congestion

What are two clinical conditions where coarse crackles can be appreciated?

Low-pitched hair rubbing sound

What is the auditory character of fine crackles?

Hair rubbing against each other

What physical contact sounds like fine crackles?

Bronchovesicular breath sounds

What normal breath sound indicates proper air entry and a normal physical exam?

Inspiratory and expiratory phases

Which phases of respiration are clearly heard in normal bronchovesicular breath sounds?

Is there a pulmonary problem, Where is the problem, and What is the problem

What are the three questions that must be asked when approaching a pediatric patient with respiratory distress?

To determine if a chief complaint that seems respiratory actually originates elsewhere

Why is it important to ask the three approach questions?

Does the clinical problem originate from the respiratory system

What does the question 'Is there a pulmonary problem' seek to determine?

Cough, adventitious sounds, dyspnea, chest pain, and hypoxemia

What are the five category clues that point to a primary pulmonary problem?

Wheezing, stridor, and crackles

What are three adventitious sounds that act as pulmonary clues?

Tachypnea and increased work of breathing

What are two signs of dyspnea that act as pulmonary clues?

Heart failure and congenital heart disease

What are two cardiac causes of non-pulmonary respiratory distress?

DKA and metabolic acidosis

What are two metabolic causes of non-pulmonary respiratory distress?

Severe anemia

What is a hematologic cause of non-pulmonary respiratory distress?

CNS depression and increased intracranial pressure

What are two neurologic causes of non-pulmonary respiratory distress?

Myasthenia and Guillain-Barre

What are two neuromuscular causes of non-pulmonary respiratory distress?

Localize the problem anatomically

What is the objective of the second question, 'Where is the problem?'

Glottic inlet

What anatomical structure separates the upper respiratory tract from the lower respiratory tract?

Stridor, stertor, hoarseness, barking cough, drooling, difficulty swallowing, and sudden onset of distress after playing/eating

What are seven clues indicating upper airway involvement?

Inspiratory versus biphasic

What two characters of stridor should be evaluated during physical exam?

Hoarseness

What voice or cry quality indicates upper airway involvement?

Listen before touching the child

What is the key clinical instruction during physical exam of a child with suspected upper airway obstruction?

Touching can aggravate any obstructions

Why must you listen to a child with potential upper airway obstruction before touching them?

Croup, foreign body, laryngomalacia, epiglottitis, and vocal cord paralysis

What are five examples of upper airway disorders?

Cough, tachypnea, hypoxemia, wheezing, crackles, asymmetry upon auscultation, and changes in vocal or tactile fremitus

What are seven clues of lung parenchyma involvement?

Good, fair, or poor

How is air entry characterized on physical exam of lung parenchyma?

Decrease or increase

What changes in vocal or tactile fremitus are checked during percussion and palpation for parenchymal disease?

Asthma, bronchiolitis, pneumonia, and foreign body aspiration

What are four examples of lung parenchyma involvement?

Outside the lung but still within the thoracic cavity

Where is the pleura located in relation to the lung parenchyma?

Something is preventing the lung from expanding

What is the mechanical problem in pleural diseases if the lungs themselves are okay?

Cough, chest pain, sudden respiratory distress, asymmetric chest findings, decreased breath sounds, dullness, and hyperresonance

What are seven clues of lung pleura involvement?

Pleural effusion

Which pleural pathology presents with dullness to percussion?