H I G H - YI E L D FAC TS I N

Respiratory Disease
Respiratory Disease in Children 210 Diphtheria 223

Respiratory Distress 210 Tuberculosis (TB) 224

Upper Respiratory Infection (the Common Cold) 210 Cystic Fibrosis (CF) 225

Influenza 211 Tonsils/Adenoids 227

Tonsillitis/Adenoiditis 227
Parainfluenza 213
Enlarged Adenoids 227
Croup 213
Peritonsillar Abscess (PTA) 227
Croup (Acute Laryngotracheobronchitis) 213
Retropharyngeal Abscess 228
Epiglottitis 215
Asthma 229
Bacterial Tracheitis 216
Status Asthmaticus 231
Bronchiolitis 217
Foreign Body Aspiration 232
Bronchiectasis 218
Tracheoesophageal Fistula (TEF) 233
Bronchitis 219
Laryngomalacia 234
Pharyngitis 220
Congenital Lobar Emphysema (Infantile
Pneumonia 221 Lobar Emphysema) 234

Pertussis 222 Cystic Adenomatoid Malformation 235

209

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 210 HIGH-YIELD FACTS IN RESPIRATORY DISEASE

Respiratory Disease in Children

■ Pediatric respiratory disorders are responsible for a number of acute and

EX AM TIP chronic health conditions and are a leading cause of pediatric emergency
room visits and hospitalizations.
Infants and young children have smaller ■ Anatomic and physiologic differences in the young child versus adults pre-
diameter airways, proportionally larger dispose the pediatric patient to more severe presentations.
tongues, a floppy epiglottis, a higher and
more anterior larynx leading to more
acute respiratory illnesses.
Respiratory Distress

■ Tachypnea (See Table 12-1 for normal respiratory rates by age).

WARD TIP ■ Intercostal retractions.
■ Nasal flaring (indicates ↑ effort is needed to breathe).
Respiratory arrest is the most common ■ Use of accessory muscles for breathing (e.g., abdominals, sternocleidomas-
cause of cardiac arrest in children. toids).
■ Restlessness, agitation.
■ Somnolence or lethargy may be due to severe hypoxia or hypercarbia.
■ Pallor, cyanosis.
EX AM TIP ■ Wheezing may or may not be present.
■ Stridor is an inspiratory sound that localizes respiratory distress to the
■ Stertor low-pitched, sounds like nasal upper airway.
congestion experienced with a cold, ■ Grunting:
■ Due to exhalation against a partially closed glottis.
or like the sound made with snoring.
■ Stridor is a higher-pitched noise that ■ Occurs during expiration.

■ Indicates moderate to severe hypoxia.

occurs with obstruction in or just
below the voice box.
■ Wheezing is a high-pitched noise

that occurs during expiration due to

narrowing, spasm, or obstruction of Upper Respiratory Infection
the smaller airways in the lungs.
(the Common Cold)

A 7-year-old girl is well when she leaves for school, but arrives home afterwards
EX AM TIP with a sore throat and runny nose. She is also complaining of cough, sneezing, and
facial heaviness. Think: Rhinovirus. Rhinovirus colds frequently start as a sore or “scratchy”
■ Inspiratory stridor suggests a laryn- throat with runny nose.
geal obstruction.
■ Expiratory stridor implies tracheo-

bronchial obstruction.
■ Biphasic stridor suggests a subglottic
A 17-year-old adolescent has acute onset of fever, cough, conjunctivitis,
and pharyngitis. Think: Adenovirus. Characteristic presentation: Pharyngitis, rhinitis,
or glottic anomaly.
and conjunctivitis.

WARD TIP
T A B L E 1 2 - 1 .   Normal Respiratory Rates in Children
Rhinovirus is an RNA virus while
adenovirus is a DNA virus. Age Birth–6 Weeks 6 Weeks–2 Years 2–6 Years 6–10 Years Over 10 Years

Respiratory 45–60/min 22–37/min 20–30/min 18–25/min 12–20/min

Rate

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 RESPIRATORY DISEASE HIGH-YIELD FACTS IN 211

Definition
WARD TIP
Multi-etiology illness with a constellation of symptoms including cough, con-
gestion, and rhinorrhea. Upper respiratory infections (URIs) are the most Mucopurulent rhinitis may accompany
common pediatric ED presentation. a common cold and doesn’t necessarily
indicate sinusitis; it is not an indication
Etiology
for antibiotics.
■ >200 viruses—especially rhinoviruses (one-third), parainfluenza, respira-
tory syncytial virus (RSV), adenovirus, influenza, metapneumovirus.
■ Risk factors: Child care facilities, smoking, passive exposure to smoke, low

income, crowding, and psychological stress. WARD TIP

Epidemiology The best treatment for the common cold
■ Most frequent illness of childhood (three to eight episodes per year). is to ↑ oral fluids, not pharmacologic
■ Most common medical reason to miss school. treatment.
■ Occurs in fall and winter especially.

Signs and Symptoms

■ Nasal and throat irritation. EX AM TIP
■ Sneezing, nasal congestion, rhinorrhea.
■ Sore throat, postnasal drip. Infants are obligate nasal breathers; the
■ Low-grade fever, headache, malaise, and myalgia. common cold can trigger respiratory
■ Possible complications include otitis media, sinusitis, and trigger asthma. distress in the young infant due to
■ Infants have a variable presentation—feeding and sleeping are difficult mucous obstruction of the nares. Nasal
due to congestion, vomiting may occur after coughing, may have diarrhea. saline drops and suctioning is important
to relieve the obstruction.
Treatment
■ Supportive including oral hydration, humidified air, topical saline drops to
nares.
■ Avoid aspirin and over-the-counter cough suppressants or decongestants. WARD TIP
■ Direct therapy toward specific symptoms.
Aspirin is avoided in young children due
to theoretical risk of Reye syndrome.

Influenza

Definition
EX AM TIP
Viral respiratory illness. Influenza is an orthomyxovirus.

Etiology
■ Influenza A and B—with varying epidemics associated with certain sub-
types (H1N1). WARD TIP
■ Influenza C—sporadic.

Diagnosis of influenza depends on

Epidemiology epidemiologic and clinical considerations.
Common over the winter months.

Signs and Symptoms

■ Incubation period: 1–3 days. WARD TIP
■ Sudden onset of fever, frequently with chills, headache, malaise, diffuse
myalgia, and nonproductive cough. Increased risk for bacterial superinfection;
■ Conjunctivitis, pharyngitis. most common organisms are
■ Typical duration of febrile illness is 2–4 days. Staphylococcus aureus and Streptococcus
■ Complications include otitis media, pneumonia, myositis, and myocarditis. pneumoniae.
■ Diarrhea and vomiting.

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 212 HIGH-YIELD FACTS IN RESPIRATORY DISEASE

Diagnosis
WARD TIP
■ Nasal swab or nasal washing.
Influenza can be severe in children
■ During epidemic, clinical signs can be used to save on test costs.
with congenital heart disease,
Treatment
bronchopulmonary dysplasia (BPD),
asthma, cystic fibrosis, and neuromuscular ■ Symptomatic treatment is appropriate for healthy children—fluids, rest,
disease, and these would be candidates acetaminophen, or ibuprofen.
for influenza prophylaxis. ■ For children at risk, see Table 12-2 for drug options.

■ Pregnant patients with H1N1 should receive a 5-day course of antiviral

treatment.
■ Oseltamivir is preferred during pregnancy.
EX AM TIP
Vaccine
Adamantane (M2 inhibitors) includes
amantadine and rimandatine. These
Intramuscular
■ Now recommended for all children over age 6 months, with priority given
medications are active against influenza A
viruses, but NOT influenza B viruses.
to high-risk groups.
■ High-risk groups include children with chronic diseases such as asthma,

renal disease, diabetes, and any other form of immunosuppression.

■ Best administered mid-September to mid-November since the peak of the
EX AM TIP flu season is late December to early March.
■ Antibodies take up to 6 weeks to develop in children. Consider prophy-

Amantadine is not routinely indicated but laxis in high-risk children during this period.
may have a role in oseltamivir resistance. ■ Since composition of influenza virus changes, the flu vaccine needs to be

administered every year.

■ Vaccine is a killed virus and therefore cannot cause the flu.

■ Not approved for children <6 months of age.

WARD TIP
Intranasal
Influenza can be severe in children ■ Live, attenuated vaccine available for children >5 years old.
with congenital heart disease, ■ No longer recommended as of 2016–2017 season due to concerns regard-
bronchopulmonary dysplasia (BPD), asthma, ing its effectiveness.
cystic fibrosis, and neuromuscular disease.

T A B L E 1 2 - 2 .   Drug Treatments for Influenza (All Pregnancy Category C)

Indications Age Groups Rx Dose Adverse Effects

Amantadine For type A only Age >1 year 200 mg PO bid × 7 days Central nervous system and
Both prophylaxis and treatment gastrointestinal effects

Rimantadine For type A only Px: Age >12 years 100 mg PO bid × 7 days Same as for amantadine, but less
frequent and less severe

Peramivir For Type A and B Tx: Age >18 years 600 mg IV × 1 dose Diarrhea
Treatment only

Zanamivir For types A and B Tx: >7years Tx: Two inhalations (10 mg) Wheezing in patients with asthma,
Treatment and prophylaxis Px: >5 years bid × 5 days sinusitis, nausea, diarrhea
Px: Two inhalations (10 mg)
once daily × 5 days

Oseltamivir For types A and B Treatment and Tx: >2weeks Weight-based dosing × Nausea, vomiting, diarrhea, abdominal
prophylaxis Px: >3 months 5 days pain, bronchitis, dizziness, headache

Tx, treatment; Px, prophylaxis.

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 RESPIRATORY DISEASE HIGH-YIELD FACTS IN 213

Parainfluenza

Etiology
■ Type 1 and 2—seasonal, less common.
EX AM TIP
■ Type 3—endemic, more prevalent.
■ See Table 12-3.
Parainfluenza is a paramyxovirus.
Pathogenesis
■ Infects epithelial cells of the nose and oropharynx first.
■ Moves distally to ciliated/alveolar cells of large and small airway epithelium.
WARD TIP
Signs and Symptoms
■ Incubation period: 2–6 days. Parainfluenza types 1 and 2 cause
■ Causes:
croup; type 3 causes bronchiolitis and
■ Colds.
pneumonia; type 4 is a cause of the
■ Pharyngitis.
common cold.
■ Otitis media.

■ Croup.

■ Bronchiolitis.

■ Can be severe in immunocompromised patients.

Treatment
Specific antiviral therapy is not available.

Croup

C r o u p ( A c u te L ar y n g o trac h e o b r o n c h iti s )
WARD TIP

Croup is the most common cause of

An 18-month-old boy awakes from his sleep at night with sudden onset of inspiratory
stridor in a febrile child.
stridor and a barking cough with difficulty breathing that calms down on route to the
emergency department. He has had a runny nose and cough for 2 days. On examination,
he has a barky cough, and inspiratory stridor only with agitation. Think: Croup.

T A B L E 1 2 - 3 .   Respiratory Infections and Pathogens

Respiratory Infection Most Common Pathogen Particular Signs and Symptoms

Croup Parainfluenza virus Barking cough, steeple sign

Epiglottitis H. influenzae type B Tripod position, thumb sign

Tracheitis S. aureus, H. influenzae type B Rapidly progressive

Bronchiolitis Respiratory syncytial virus Paroxysmal wheezing

Bronchitis Viral Productive cough

Pharyngitis Viral, group A strep Sore throat, tonsillar involvement

Bacterial pneumonia S. pneumoniae Productive cough, lobar consolidation

Pulmonary abscess S. aureus Cavity with air-fluid level

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 214 HIGH-YIELD FACTS IN RESPIRATORY DISEASE

Definition
WARD TIP
■ Viral infection of upper respiratory tract with inflammation and narrowing
Croup is the most common infectious
in the subglottic airway.
■ A subset of patient swill have non-infectious spasmodic croup which only
cause of acute upper airway obstruction.
occurs at night and is of sudden onset with very mild or no antecedent
URI symptoms.

Etiology
WARD TIP
Parainfluenza virus types 1 and 2.
Most common cause of stridor in children
is croup. Epidemiology
Occurs in children 3 months to 3 years of age in fall and winter months with
increased risk in males.

EX AM TIP Signs and Symptoms

Stridor and distress at home and calm and

■ Inspiratory stridor.
free of stridor in ED: Think croup.
■ Seal-like, barking cough with retractions and nasal flaring.
■ May have coryza, fever, and congestion.
■ Can progress to agitation, hypoxemia, hypercapnia, tachypnea, and tachy-
cardia.
■ Most cases are mild and last 3–7 days.

■ Symptoms worse at night, with sudden onset of symptoms.

WARD TIP
Diagnosis
Minimum observation of child brought in
with croup is 3 hours. ■ Diagnosis is made clinically.
■ X-ray usually not necessary. Consider only if diagnosis is in doubt.
■ Steeple sign—narrowing of tracheal air column just below the vocal cords

(see Figure 12-1).

■ Ballooning—distention of hypopharynx during inspiration.
WARD TIP
■ Differentiate croup from epiglottitis.

■ Severity can be measured by the Westley Croup Score (see Table 12-4).
Stridor at rest unresponsive to racemic
■ 0–2: mild croup.
epinephrine suggests hospital admission.
■ 3–7: moderate croup.

■ 8–11: severe croup.

■ 12–17: impending respiratory failure.

Treatment
■ Position of comfort. Cool mist humidification has limited role based on
evidence.
■ Mild—dexamethasone (PO, IV, IM), may discharge if no stridor at rest.

■ Moderate—dexamethasone, racemic epinephrine neb (0.25 mL in 3–5 mL

of normal saline [NS]), observe 3–4 hours, if improved may discharge,

if symptoms persist or worsen, repeat racemic epinephrine neb, and
admit.
■ Severe—racemic epinephrine, early use of corticosteroids, admit to inten-

sive care unit (ICU), consider heliox.

■ Dexamethasone 0.6 mg/kg (lower dose [0.15 mg/kg] has also shown to

be effective) is advantageous due to longer half-life that corresponds with

length of typical illness.
■ Admission criteria:

■ Persistent stridor (especially at rest).

F I G U R E 1 2 - 1 .   Radiograph dem-
■ Respiratory distress.
onstrating steeple sign of croup. Note
narrowing of airway (arrow). (Used with ■ Multiple doses of racemic epinephrine.

permission from Dr. Gregory J. Schears.) ■ Possibility of alternate diagnosis.

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 RESPIRATORY DISEASE HIGH-YIELD FACTS IN 215

T A B L E 1 2 - 4 .   Westley Croup Score: Classification of Croup Severity

Number of points assigned for this feature

Feature 0 1 2 3 4 5

Chest wall retractions None Mild Moderate Severe

Stridor None With agitation At rest

Cyanosis None With agitation At rest

Level of consciousness Normal Disoriented

Air entry Normal Decreased Markedly decreased

(Adapted with permission from National Asthma Education & Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis & Management of
Asthma NHLBI guidelines, Summary Report 2007: 54)

Corticosteroids in Respiratory Problems

■ Dexamethasone (IM, IV, or PO 0.6 mg/kg).
■ Side effects associated with short-term steroid use are minimal.

Epiglottitis

A 4-year-old unvaccinated boy brought to the ED is flushed, making high-pitched

noises on forced inspiration, leaning forward in his mother’s lap, and drooling. His
illness started with fever and sore throat and rapidly progressed to difficulty swallowing,
drooling, restlessness, and stridor or air hunger. He appeared toxic and anxious. Lateral
neck x-ray shows thumb sign. Think: Epiglottitis, and get him to an operating room (OR)
to intubate and treat!
The classic presentation: “three Ds” (drooling, dysphagia, and distress).

See Figure 12-2. F I G U R E 1 2 - 2 .   Radiograph of lateral

soft tissue of neck demonstrating epiglotti-
tis. Note the thickening of the epiglottic and
Definition aryepiglottic folds (arrows). (Reproduced,
Acute, life-threatening infection of epiglottic and supraglottic tissues due to with permission, from Schwartz DT,
Reisdorff BJ. Emergency Radiology. New
direct invasion of the epithelial layer by the organism. York: McGraw-Hill, 2000: 608.)

Etiology
■ Haemophilus influenzae type B.
■ Other possible pathogens—Streptococcus pyogenes, Streptococcus pneu- WARD TIP
moniae, Staphylococcus aureus.
Minutes count in acute epiglottitis.
Pathophysiology
Acute inflammation and edema of epiglottis, aryepiglottic folds, and aryte-
noids. WARD TIP

Epidemiology Primary source of pathogens in epiglottitis

■ ↓ incidence due to H. influenzae type B vaccine (HiB). is from the posterior nasopharynx.
■ Usually 6–12 years of age, but can occur at any age.

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 216 HIGH-YIELD FACTS IN RESPIRATORY DISEASE

■ Suspect in unvaccinated children and immunodeficient children.

WARD TIP ■ H. influenzae immunization has practically eliminated epiglottitis in young
children.
Epiglottitis is an acute airway emergency
and treatment should not be delayed in Signs and Symptoms
order to obtain confirmatory radiographs. ■ Sudden onset of inspiratory stridor and respiratory distress.
■ Three Ds: Dysphagia, drooling, and distress.
■ Tripod position—hyperextended neck, leaning forward, mouth open.
■ Muffled voice (“hot potato” voice).
■ High fever (usually the first symptom).
WARD TIP
■ Tachycardia is a constant feature.
■ Cough is typically absent.
Epiglottitis is a true medical emergency. If
■ Toxic appearing.
suspected, do not:
■ Severe respiratory distress develops within minutes to hours.
■ Examine the throat
■ May progress to restlessness, pallor/cyanosis, coma, death.
■ Use narcotics or sedatives, including

antihistamines
Diagnosis
■ Attempt venipuncture or other tests

■ Place patient supine ■ Laryngoscopy—swollen, cherry-red epiglottis.

■ Lateral neck x-ray to confirm (portable x-ray should be obtained).
■ Swollen epiglottis (thumbprint sign).
■ Thickened aryepiglottic fold.
■ Obliteration of vallecula.
EX AM TIP
Treatment
Third-generation cephalosporin in ■ True medical emergency—potentially lethal airway obstruction.
combination with anti-staphylococcal ■ Comfort.
agents (clindamycin, vancomycin) against ■ Anticipate.
MRSA for epiglottitis. ■ Secure airway (endotracheal intubation in OR).

■ Ceftriaxone (100 mg/kg/day) 7–10 days.

■ Rifampin prophylaxis for close contacts.

WARD TIP
Bacterial Tracheitis
Bacterial tracheitis generally occurs in the
setting of prior airway mucosal damage, Definition
as occurs with a preceding viral infection, ■ Rapidly progressive upper airway obstruction due to an invasive exudative
especially influenza A infection.
bacterial infection of the soft tissues of the trachea.
■ The larynx of healthy individuals is often colonized normally with bacte-

ria, some of which are potential pathogens. These pathogens can extend,
at least transiently, into the trachea.
EX AM TIP
Etiology
Croup symptoms for more than 2–3 days ■ S. aureus and H. influenzae type b.
with sudden worsening of symptoms ■ Also Moraxella catarrhalis.
■ High association with preceding viral infections, especially influenza A
with high fever and ill-appearance: Think
bacterial tracheitis. infection.
Signs and Symptoms
■ Often present with croup symptoms. Differentiation can be made by the
presence of:
EX AM TIP ■ High fever.

■ Toxicity.
Bacterial tracheitis has a slower onset ■ Inspiratory stridor (constant).
than epiglottitis but both appear toxic in ■ Purulent sputum.
appearance. ■ Tracheitis has features of both croup (stridor and croupy cough) and epi-

glottitis (high fever and toxic appearance).

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 RESPIRATORY DISEASE HIGH-YIELD FACTS IN 217

Diagnosis
EX AM TIP
■ X-ray—may be normal or identical to croup. Look for pseudomembrane
on lateral view. X-rays are not definitive, nor essential
■ Epiglottis size normal.
for the diagnosis of bacterial tracheitis.
■ Tracheal narrowing.
The only definitive way to diagnose is by
■ Pseudomembrane.
direct visualization by bronchoscopy.
■ Bronchoscopy showing inflamed and exudate covered trachea.

■ Copious purulent secretion distal to glottis.

■ Secretions should be obtained for Gram stain and culture.

Treatment
■ Secure an adequate airway (endotracheal intubation):
■ Should be performed in an operating room under anesthesia.

■ Suction endotracheal tube of purulent material to reduce obstruction.

■ Specialty consultation: Ear, nose, and throat (ENT), and anesthesia.

■ Ceftriaxone 100 mg/kg/day.

■ Ampicillin-sulbactam 200 mg/kg/day.

■ ICU admission even if intubation is not needed in order to monitor pro-

gression of disease.

Bronchiolitis

A previously healthy 4-month-old who had rhinorrhea, cough, and a low-grade

fever develops tachypnea, mild hypoxemia, and hyperinflation of lungs. Think: RSV
bronchiolitis.
Classic presentation: Acute onset of cough, wheezing, and ↑ respiratory effort after
an upper respiratory tract prodrome (fever and runny nose), during the winter season.

WARD TIP
Definition
Viral infection of the lower respiratory tract (medium and small airways) Bronchiolitis is the most common serious
which occurs after upper respiratory symptoms. respiratory infection in children <2 years.

Etiology
■ RSV—most common cause.
■ Rhinovirus. WARD TIP
■ Adenovirus.

■ Parainfluenza 3.
The virus infects terminal bronchiolar
■ Influenza.
epithelial cells.
■ Human metapneumovirus (hMPV): First recognized in 2001 and now

increasingly implicated.
■ Two or more viruses are found in one-third of children hospitalized with

bronchiolitis. EX AM TIP
Pathophysiology
RSV in fall and late winter; rhinovirus in
■ Inflammatory obstruction (edema and mucus) of the bronchioles second- spring and early fall typically.
ary to viral infection.
■ Alterations in gas exchange are most frequently the result of mismatching

of pulmonary ventilation and perfusion.

■ Can lead to atelectasis. EX AM TIP

Epidemiology RSV causes more than 50% of cases of

■ Occurs in first 2 years of life. bronchiolitis.
■ Reinfection is common.

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 218 HIGH-YIELD FACTS IN RESPIRATORY DISEASE

■ Occurs in winter and early spring.

EX AM TIP ■ Risks: Crowded conditions, not breast-fed, mothers who smoke, male gender.
■ High-risk infants:
Humans are the only source of RSV ■ Cardiac disease.
infection. ■ Pulmonary disease and bronchopulmonary dysplasia.

■ Neuromuscular disease.

■ Premature infants.

■ Immunocompromised.

WARD TIP Signs and Symptoms

■ Starts with mild upper respiratory symptoms: often profuse nasal discharge
RSV bronchiolitis symptoms tend to peak
and congestion with or without fever.
on days 3–5.
■ Respiratory distress gradually develops.

■ Paroxysmal wheezing—common but may be absent, cough, dyspnea.

■ Apneic spells—young infants should be monitored.

■ Frequent complications include bacteremia, pericarditis, cellulitis, empy-

WARD TIP ema, meningitis, and suppurative arthritis.

■ Most common complication is hypoxia.

■ Dehydration is the most common secondary complication.

Symptoms of asthma can be identical to
bronchiolitis. Suspect asthma if:
■ Family history Diagnosis
■ Prior episodes ■ Mostly clinical but if other DDx are suspected, then consider additional
■ Response to bronchodilator
testing.
■ Viral detection in nasopharyngeal secretions via culture, polymerase chain

reaction (PCR), or antigen detection.

■ Chest x-ray (rule out pneumonia or foreign body)—hyperinflation of

lungs, ↑ anteroposterior (AP) diameter of rib cage.

WARD TIP ■ Oxygen saturation is the single best objective predictor.

Indications for rapid antigen detection in Treatment

suspected RSV bronchiolitis: Cohorting
RSV-positive patient or to confirm RSV in
■ Low threshold for hospitalization for high-risk infants.
high-risk patient.
■ Humidified oxygen.
■ Nasal suctioning.
■ Trial of nebulized albuterol although no long-term benefit shown (only
20–50% are responders, discontinue if no objective benefit).
■ Hypertonic saline neb tx—potential to reduce airway edema and mucous
plugging.
■ Steroids not indicated in first episode of bronchiolitis.
■ Respiratory isolation.
■ Ribavirin (aerosol form) if high-risk patients such as immunocompro-
mised, need for mechanical ventilation, or <6 weeks old.
■ RSV intravenous immunoglobulin (RSV-IVIG) or palivizumab given prior
to and during RSV season in high-risk infants <2 years old.

Bronchiectasis

A 7-year-old boy presents with an upper respiratory infection (URI) with productive
EX AM TIP
cough (with purulent sputum). On examination, localized rales on the right side of
his chest were noted. X-ray shows two discrete densities located in the right upper lobe
Cystic fibrosis is the #1 cause of of the lungs. Think: Bronchiectasis. Predisposition: Cystic fibrosis (CF) and ciliary
bronchiectasis in children. dyskinesia.

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 RESPIRATORY DISEASE HIGH-YIELD FACTS IN 219

Definition
Abnormal and permanent dilatation of bronchi.

Etiology
■ Viruses: Adenovirus, influenza virus.
■ Bacteria: S. aureus, Klebsiella, anaerobes. EX AM TIP
■ Primary ciliary dyskinesia.

■ Kartagener syndrome. TNF alpha, IL-1B, and IL-8 are increased in

■ Cystic fibrosis: Pseudomonas aeruginosa. bronchiectasis, with or without CF.
■ α -antitrypsin deficiency.
1

Pathophysiology
Consequence of inflammation and destruction of structural components of
weak, easily collapsible bronchial walls and increased mucous plugs.

Signs and Symptoms

■ Physical exam quite variable.
■ Persistent or recurrent wet cough. WARD TIP
■ Purulent sputum.

■ Hemoptysis is not prevalent in children as it is in adults. Rhonchi are coarse, expiratory breath
■ Dyspnea. sounds; crackles are inspiratory popping
■ Crackles, rhonchi, less commonly wheezing. sounds.
■ Clubbing.

Diagnosis
WARD TIP
■ Chest x-ray.
■ Bronchography.
CXR shows dilated and thickened airways
■ Computed tomographic (CT) scan (most sensitive imaging method).
with linear atelectasis.
■ Sputum culture.

Treatment
■ Elimination of underlying cause. EX AM TIP
■ Clearance of secretions in airway with chest physiotherapy.
■ Mucolytic agents. Cough is the most common symptom of
■ Control of infection—antibiotics. chronic bronchitis.
■ Reversal of airflow obstruction—bronchodilators and anti-inflammatory meds.

Bronchitis

Definition
Infection of conductive airways of lung.

Etiology
■ Viruses: Influenza A and B, adenovirus, parainfluenza, rhinovirus, RSV,
coxsackievirus.
■ Bacteria: Bordetella pertussis, M. pneumoniae, Chlamydia pneumoniae,

S. pneumoniae.

Signs and Symptoms

■ Acute productive cough (<1 week).
■ Rhinitis.
■ Myalgia.

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 220 HIGH-YIELD FACTS IN RESPIRATORY DISEASE

■ Fever.
EX AM TIP ■ No evidence of sinusitis, pneumonia, or chronic pulmonary disease.
■ Normal arterial oxygenation.
Pharyngitis is the second most common
diagnosis in children aged 1–15 years in Treatment
the pediatric clinic. ■ Mostly self-limited.
■ Bronchodilators may help.
■ Antibiotics for high-risk patients.

EX AM TIP
Pharyngitis
Viruses (most common cause of
pharyngitis): Rhinovirus, adenovirus,
coxsackievirus. Definition
Infection of the tonsils and/or the pharynx.
Etiology
WARD TIP
■ Bacterial: Streptococcal pharyngitis
Strep pharyngitis tends to cause anterior
■ Viruses: Rhinovirus, adenovirus, coxsackievirus, mononucleosis
cervical lymphadenopathy vs. infectious Signs and Symptoms
mononucleosis which is more posterior.
■ Viral pharyngitis:
■ Gradual onset.

■ Fever, malaise, throat pain.

■ Conjunctivitis, rhinitis, coryza, viral exanthem, diarrhea.

■ Streptococcal pharyngitis (>2 years) (see Figure 12-3):

■ Headache, abdominal pain, and vomiting.

WARD TIP ■ Fever (>104°F [40°C]).

■ Tonsillar enlargement with exudates.

Acute rheumatic fever occurs more after ■ Fetid odor.
throat than skin infections and in children ■ Cervical adenopathy.
who have had acute rheumatic fever ■ Palatal petechiae and uvular edema.
before. ■ It is not possible to distinguish clinically viral from bacterial pharyngitis,

though high fever, cervical adenopathy, and absence of URI symptoms

suggest bacterial etiology.
WARD TIP Diagnosis
Rapid strep test: Rapid(DNase) antigen detection test (sensitivity 95–98%):
CENTOR CRITERIA for the presence ■ Culture if negative.
of strep throat: Presence of tonsillar ■ Treat if positive.
exudates, tender anterior cervical
lymphadenopathy, fever, absence of
cough.

F I G U R E 1 2 - 3 .   Streptococcal pharyngitis. Note white exudates on top of erythematous

swollen tonsils. (Reproduced, with permission, from Knoop KJ, Stack LB, Storrow AB, et al.
Atlas of Emergency Medicine, 3rd ed. New York: McGraw-Hill, 2010: 115.)

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 RESPIRATORY DISEASE HIGH-YIELD FACTS IN 221

Treatment
WARD TIP
■ Oral penicillin (25–50 mg/kg/day) for 10 days.
■ Alternatively, intramuscular (IM) benzathine and procaine penicillin can
Penicillin remains the drug of choice for
be used (single dose, weight based). GABHS.
■ Macrolides or clindamycin for penicillin-allergic patients for 10 days.

■ Tetracycline and sulfonamides should not be used to treat group A beta-

hemolytic streptococci (GABHS) due to high resistance.

■ Antibiotics are not indicated for pharyngitis negative for GABHS.

Complications
■ Suppurative:
■ Peritonsillar abscess. WARD TIP
■ Retropharyngeal abscess.

■ Cervical adenitis. The more mucous membranes involved,

■ Otitis media. the more likely an infection is viral.
■ Sinusitis.

■ Nonsuppurative:

■ Acute glomerulonephritis.

■ Acute rheumatic fever.

Pneumonia

A 2-month-old with fever, tachypnea, and mottled skin has a chest x-ray showing WARD TIP
infiltrate of the right upper lung lobe, a pneumatocele, and a pleural effusion.
Think: S. aureus pneumonia. Round lobar pulmonary infiltrate on chest
x-ray. Think: S. pneumoniae pneumonia.

A previously healthy 9-year-old boy has a 7-day history of increasing cough, low-
grade fever, and fatigue on exertion. Chest x-ray shows widespread diffuse perihilar
infiltrates. Think: Mycoplasma pneumonia.
Initially, nonproductive cough and no fever. Later, productive cough with fever,
headache, coryza, otitis media, and malaise. 

Definition
Lower respiratory tract infection resulting in inflammation of lung parenchyma.

Etiology
■ Viruses: RSV, influenza, parainfluenza, adenovirus.
■ Bacteria: Less common, but more severe—S. pneumoniae, S. pyogenes, WARD TIP
S. aureus, H. influenzae type B, M. pneumoniae.
The most reliable sign of pneumonia is
Signs and Symptoms tachypnea.
■ Respiratory distress including tachypnea, hypoxemia, increased work of
breathing.
■ Fever, productive cough, difficult feeding in infants.

■ Afebrile pneumonia seen with Chlamydia trachomatis (pneumonitis syn- WARD TIP
drome) in infants.
Consider pneumonia in children with
Diagnosis neck stiffness (upper lobe) or acute
■ Lung exam, can hear crackles, decreased breath sounds, and dullness to abdominal (lower lobe) pain.
percussion, egophany.

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 222 HIGH-YIELD FACTS IN RESPIRATORY DISEASE

■ Chest x-ray.
WARD TIP ■ Viral (hyperinflation, perihilar infiltrate, hilar adenopathy, and atelectasis).

■ Bacterial (alveolar consolidation).

In young children, auscultation may be ■ Mycoplasma (interstitial infiltrates).
normal with impressive x-ray findings ■ Tuberculosis (hilar adenopathy).
(occult pneumonia). ■ Pneumocystis (reticulonodular infiltrates).

■ CBC and blood culture (positive in 10–30% of bacterial cases).

Treatment
■ Inpatient:
■ IV ampicillin is first line, second- or third-generation cephalosporin

with or without vancomycin depending on degree of illness. Consider

macrolide (pneumonitis syndrome) in 1- to 3–month-olds if suspected.
■ Outpatient:

■ Patients should have normal O saturation and be able to take oral flu-
2
ids in order to be outpatients.
■ First line: High-dose amoxicillin. Alternative, second- or third-generation

cephalosporin or azithromycin.

Pertussis

Definition
EX AM TIP
■ “Whooping cough.”
■ Highly infectious acute respiratory illness.
Child coughs on expiration and “whoops”
on inspiration in pertussis.
Etiology
■ Bordetella pertussis gram-negative coccobacilli with exotoxin.
■ Humans are the only known host.
■ Whooping cough syndrome also may be caused by:
EX AM TIP
■ Bordetella parapertussis.
■ M. pneumoniae.
Pertussis means “intense cough.”
■ C. trachomatis.

■ C. pneumoniae.

■ Adenoviruses.

WARD TIP
Pathophysiology
Despite having “whooping cough,” most ■ Pertussis toxin is a virulence protein that causes lymphocytosis and
patients with pertussis do not whoop. systemic manifestations.
■ Aerosol droplet transmission.

Epidemiology
WARD TIP ■ Endemic, but epidemic every 3–4 years.
■ 60 million cases/year worldwide.
With pertussis, fever may be absent or ■ 500,000 deaths/year worldwide.
minimal; cough may be only complaint. ■ July to October.
■ Occurs in 1- to 5-year-olds worldwide, 50% <1-year-olds in the United
States.

WARD TIP Signs and Symptoms

■ Classic symptoms: Inspiratory whoop, paroxysmal cough, post-tussive emesis.
Apnea is common in infants with ■ Incubation period 1–2 weeks.
pertussis. ■ Three stages: Catarrhal, paroxysmal, and convalescent.
■ Duration: 6 weeks.

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 RESPIRATORY DISEASE HIGH-YIELD FACTS IN 223

■ Catarrhal stage: (1–2 weeks) Congestion, rhinorrhea, mild persistent cough.

■ Paroxysmal stage (2–4 weeks):
■ Paroxysmal cough, with characteristic whoop following (chin forward,

tongue out, watery, bulging eyes, purple face).

■ Fever is typically absent.

■ Post-tussive emesis and exhaustion.

■ Convalescent stage: Number and severity of paroxysms plateaus. WARD TIP

■ Each stage lasts ~2 weeks; shorter if immunized.

■ Complications include apnea, physical sequelae of forceful coughing, Suspect pertussis if paroxysmal cough
brain hypoxia/hemorrhage, secondary infections (bacterial pneumonia is with skin color change.
the cause of death).
Diagnosis
■ Diagnosis is primarily clinical:
■ Inspiratory whoop.

■ Post-tussive emesis.

■ Lymphocytosis.

■ Chest x-ray—perihilar infiltrate or edema (butterfly pattern).

■ Positive immunofluorescence test or PCR on nasopharyngeal secretions.

WARD TIP
Treatment
■ Goal—to ↓ spread of organism. Antibiotics do not affect illness in paroxys- No single serologic test is diagnostic for
mal stage, which is toxin mediated. pertussis.
■ Macrolide antibiotic for patient and household contacts.

■ Isolation until 5 days of therapy.

■ Admit if:

■ Infant <3 months. WARD TIP

■ Apnea.

■ Cyanosis. There is a risk of hypertrophic pyloric

■ Respiratory distress. stenosis in infants younger than 6 weeks
■ DTP (diphtheria, tetanus, pertussis)/DTaP (diphtheria, tetanus, acellu- treated with oral macrolide antibiotics.
lar pertussis) vaccine if not previously vaccinated.

Diphtheria

Definition
WARD TIP
Membranous nasopharyngitis or obstructive laryngotracheitis.

Etiology DTaP vaccine series is given between 6

weeks and 7 years with booster TDaP
■ Corynebacterium diphtheriae, gram-positive bacillus. given after age 11 years.
■ Humans are the only reservoir.

Signs and Symptoms

WARD TIP
■ Incubation period: 2–7 days.
■ Erosive rhinitis with membrane formation and low-grade fever.
■
For treatment of diphtheria, antibiotics are
Tonsillopharyngeal—sore throat, membranous exudate.
■
not a substitute for antitoxin.
Cardiac symptoms: Myocarditis, arrythmias.
■ Tachycardia out of proportion to fever.

Diagnosis WARD TIP

■ Culture (nose, throat, mucosal, or cutaneous lesion).
■ Material should be obtained from beneath the membrane or a portion of Most tuberculosis infections in children
membrane. are asymptomatic with positive PPD.
■ All C. diphtheriae isolates should be sent to diphtheria laboratory.

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 224 HIGH-YIELD FACTS IN RESPIRATORY DISEASE

Treatment
■ Antitoxin (obtained from CDC)—dose depends on:
■ Site of membrane.

■ Degree of toxic effects.

■ Duration of illness.

■ Antibiotics:

■ Erythromycin or penicillin G for 14 days.

■ Elimination of organism should be documented by two consecutive

cultures.

Tuberculosis (TB)

Definition
WARD TIP
■ Signs and symptoms and/or radiographic manifestations caused by
M. tuberculosis are apparent.
A patient may develop TB despite
■ May be pulmonary, extrapulmonary, or both.
prior bacillus Calmette-Guérin (BCG)
vaccination.
Etiology
Mycobacterium tuberculosis—acid fast bacilli.

Pathophysiology
Primary portal of entry into children is lung.
WARD TIP
Epidemiology
A positive PPD skin test results from
■ Children are never the primary source (look for adult contacts).
infection, not from exposure.
■ Risk factors:
■ Urban living.

■ Low income.

■ Recent immigrants.

■ HIV.

WARD TIP
Signs and Symptoms
Asymptomatic children with a positive ■ Chronic cough (nonproductive) for more than 3 weeks.
PPD should be considered infected and ■ Hemoptysis.
get treatment. ■ Fever.

■ Night sweats.

■ Weight loss or failure to thrive.

■ Anorexia.

■ Lymphadenopathy.

■ Present to ED with:

WARD TIP ■ Primary pneumonia.

■ Miliary TB (may mimic sepsis).

All cases of active TB should be referred to

public health department. Diagnosis
■ When to suspect TB:
■ Hilar adenopathy.

■ Pulmonary calcification or caseating granulomas.

■ Pneumonia with infiltrate and adenopathy.

■ Pneumonia with pleural effusion.

WARD TIP ■ Painless unilateral cervical adenopathy (scrofula).

■ Meningitis of insidious onset.

Persons with TB should be tested for HIV. ■ Bone or joint disease.

■ When any of the above are unresponsive to antibiotics.

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 RESPIRATORY DISEASE HIGH-YIELD FACTS IN 225

■ PPD test (Mantoux test).

■ QuantiFERON®-TB Gold test. WARD TIP
■ Culture (gastric aspirates, sputum, pleural fluid, cerebrospinal fluid, urine,

or other body fluids). Most common extra-pulmonary

■ Look for the adult source. manifestation of TB in children is
■ Acid-fast stain or PCR. involvement of superficial lymph nodes
and CNS involvement.
Treatment
■ Prompt treatment necessary as in very young, can disseminate quickly.
■ Two to four or more drugs (isoniazid, rifampin, pyrazinamide, ethambu-
tol, streptomycin) for a minimum of 6 months for active disease. WARD TIP
■ Isoniazid for 9 months for latent disease.
TB in children <4 years of age is much
more likely to disseminate; prompt and
vigorous treatment should be started
Cystic Fibrosis (CF) when the diagnosis is suspected.

A 3-year-old child presents with constant cough with sputum. He has had six
episodes of pneumonia, with Pseudomonas being isolated from sputum; loose
stools; and is at the 20th percentile for growth. Think: CF.
CF is an inherited multisystem disorder resulting in chronic lung disease, exocrine
pancreatic insufficiency, and failure to thrive.

Definition
EX AM TIP
Disease of exocrine glands that causes viscous secretions:
■ Chronic respiratory infection.
Cystic fibrosis is the most common lethal
■ Pancreatic insufficiency.
inherited disease of Caucasians.
■ ↑ electrolytes in sweat.

Etiology
■ Defect of cyclic adenosine monophosphate (cAMP)–activated chloride EX AM TIP
channel of epithelial cells in pancreas, sweat glands, salivary glands, intes-
tines, respiratory tract, and reproductive system. The gene for cystic fibrosis is CFTR; the
■ Autosomal recessive.
mutation is deletion of delta F508 on
chromosome 7.
Pathophysiology
■ Decreased chloride secretion from cells in lungs and GI tract.
■ ↑ osmotic pressure inside cells attracts water and → thick secretions.
WARD TIP
Epidemiology
■ Most common cause of severe, chronic lung disease in children. A patient with severe CF breathing room
■ One in 2000–3000 live births (Caucasians). air can have an arterial blood gas (ABG)
showing ↓ chloride and ↑ bicarbonate.
Signs and Symptoms
■ Respiratory:
■ Cough (persistent and productive)—most common pulmonary
symptom.
■ Wheezing, dyspnea, exercise intolerance.

■ Bronchiectasis, recurrent pneumonia.

■ Sinusitis, nasal polyps.

■ Reactive airway disease, hemoptysis which results in anemia.

■ ↑ AP chest diameter.

■ Hyperresonant lungs.

■ Clubbing of nails.

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 226 HIGH-YIELD FACTS IN RESPIRATORY DISEASE

■ Gastrointestinal (GI):
■ Failure to thrive.

■ Meconium ileus (10%).

■ Constipation, rectal prolapse.

■ Intestinal obstruction.
EX AM TIP
■ Pancreatic insufficiency:

■ Malabsorption with steatorrhea.

Fat-soluble vitamin deficiencies:
■ Fat-soluble vitamin deficiencies.
A—night blindness
■ Glucose intolerance.
D—↓ bone density
■ Biliary cirrhosis (uncommon): Jaundice, ascites, hematemesis from
E—neurologic dysfunction
K—bleeding
esophageal varices.
■ Reproductive tract: ↓/absent fertility—female, thick cervical secretions;

male, azoospermic.
■ Sweat glands:

■ Salty skin.
WARD TIP ■ Hypochloremic alkalosis in severe cases.

■ Complications may include pneumothorax, chronic pulmonary hyperten-

Pseudomonas aeruginosa is the MC sion, cor pulmonale, atelectasis, allergic bronchopulmonary aspergillosis,
bacteria to cause chronic infection in CF respiratory failure, gastroesophageal reflux.
lungs.

Diagnosis
■ Sweat test—chloride concentration >60 mEq/L (gold standard).
WARD TIP
■ Routine newborn screening done in all 50 states by IRT (immunoreactive
trypsinogen) assay (↑) and DNA analysis (CFTR mutations). A sweat test is
performed after 2 weeks old.
False-positive sweat test (not CF):
■ Genetic studies.
■ Nephrogenic diabetes insipidus
■ In utero screen available.
■ Myxedema
■ Pulmonary function tests (PFTs): Obstructive and restrictive abnormali-
■ Mucopolysaccharidosis

■ Adrenal insufficiency
ties.
■ Prenatal diagnosis via gene proves CF mutations or linkage analysis.
■ Ectodermal dysplasia

Treatment
■ Multidisciplinary team approach—pediatrician, physiotherapist, dietitian,
WARD TIP nursing staff, teacher, child, and parents.
■ Respiratory:

Features of CF: CF PANCREAS ■ Chest physical therapy to promote mucociliary clearance.

Chronic cough ■ Exercise.

Failure to thrive ■ Coughing to move secretions and mucous plugs.

Pancreatic insufficiency ■ Bronchodilators.

Alkalosis ■ Normal saline aerosol.

Nasal polyps ■ Anti-inflammatory medications.

Clubbing ■ Dornase-alpha nebulizer (breaks down DNA in mucus).

Rectal prolapse ■ Pancreatic/digestive:

Electrolytes ↑ in sweat ■ Enteric coated pancreatic enzyme supplements (add to all meals).

Absence of vas ■ Fat-soluble vitamin supplements.

Sputum mucoid ■ High-calorie, high-protein diet.

■ Antibiotics—sputum cultures used to guide antibiotic choice. Pseudo-

monal infections are especially common. Macrolide antibiotics are most

commonly used.
■ Lung transplant.
EX AM TIP
■ Gene therapy is being aggressively studied.

Ninety-nine percent of cases of

meconium ileus are due to CF. Prognosis
Advances in therapy have ↑ life expectancy into adulthood.

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 RESPIRATORY DISEASE HIGH-YIELD FACTS IN 227

Tonsils/Adenoids

T o n s illiti s / A de n o iditi s

Definition
Inflammation of:
■ Tonsils—two faucial/palatine tonsils.

■ Adenoids—nasopharyngeal tonsils.

Signs and Symptoms

■ Sore throat.
■ Pain with swallowing.
■ May have whitish exudate on tonsils.
■ Chronic tonsillitis:
■ Seven in past year.

■ Five in each of the past 2 years.

■ Three in each of the past 3 years.

EX AM TIP
Treatment
■ <2–3 years old: Tonsillectomy is performed for obstructive sleep apnea Tonsils and adenoids are part of
(OSA) and recurrent/chronic infections. Waldeyer’s ring that circles the pharynx.
■ Large size alone is not an indication to remove tonsils.

E n lar g ed A de n o id s

Definition
WARD TIP
Nasopharyngeal lymphoid tissue hypertrophy.
Signs and Symptoms It can be normal for tonsils to be relatively
large during childhood.
■ Mouth breathing.
■ Persistent rhinitis.
■ Snoring.

■ Mucopurulent nasal discharge.

WARD TIP
Diagnosis
■ Digital palpation and direct visualization. Enlarged adenoids is the MC nasal
■ Indirect laryngoscopy. obstruction in children.

Treatment
■ Adenoidectomy:
■ Persistent mouth breathing.

■ Hyponasal speech.

■ Adenoid facies—open mouth, flattened/elongated midface, retracted

upper lip, narrowed hard palate with crowded maxillary teeth.

■ Recurrent otitis media or nasopharyngitis.

■ Tonsillectomy should not be performed routinely unless separate indica-

tion exists.

P erit o n s illar A b s ce s s ( P TA )

Definition
Walled-off infection occurring in the space between the superior pharyngeal
constrictor muscle and the capsule of the palatine tonsils.

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 228 HIGH-YIELD FACTS IN RESPIRATORY DISEASE

Etiology
WARD TIP
■ GABHS.
Trismus is the limited ability to open the
■ Anaerobes.
mouth and distinguishes PTA from severe
Epidemiology
pharyngitis or tonsillitis.
Usually preadolescent.

Signs and Symptoms

■ Preceded by acute tonsillopharyngitis.
■ Severe throat pain, usually unilateral.
EX AM TIP ■ Trismus.

■ Refusal to swallow or speak.

Always look for presence of upper airway ■ “Hot potato voice.”
obstruction in PTA. ■ Markedly swollen and inflamed tonsils.

■ Uvula displaced to opposite side.

Treatment

WARD TIP
■ Antibiotics covering staph and strep. Typically, IV ampicillin—sulbactam
or IV clindamycin. If there is no response to these initial antibiotics, add
vancomycin.
Lymph nodes in the retropharyngeal
■ Needle aspiration or incision and drainage, followed by supportive care.
space usually disappear by the third to
fourth year of life.

Retropharyngeal Abscess

EX AM TIP Definition
Potential space between the posterior pharyngeal wall and the prevertebral
Retropharyngeal space is widened if fascia. Commonly occurs in children <5 years old.
>7mm at C2 level or >14mm at C6 level
of soft tissue lateral neck x-ray. Etiology
Usually a complication of pharyngitis:
■ GABHS.

■ Oral anaerobes.

■ S. aureus.

Signs and Symptoms

■ Associated with recent URI.
■ Sudden onset of high fever with difficulty in swallowing.
■ Refusal of feeding due to dysphagia and odynophagia.
■ Throat pain.
■ Unwilling to hyper-extend the head.
■ Toxicity is common.
■ May cause meningismus—extension of the neck causes pain.

Diagnosis
■ Lateral neck x-ray: Widened pre-vertebral/retropharyngeal space (see
Figure 12–4).
■ May also see reversal of lordosis, the normal curvature of the cervical
F I G U R E 1 2 - 4 .   Lateral radiograph
of the soft tissue of the neck. Note the spine.
large amount of prevertebral edema
(solid arrow) and the collection of air Treatment
(dashed arrow). Findings are consistent
with retropharyngeal abscess. (Used with ■ IV clindamycin or ampicillin-sulbactam.
permission from Dr. Gregory J. Schears.) ■ If airway compromised, immediate surgical drainage.

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 RESPIRATORY DISEASE HIGH-YIELD FACTS IN 229

Asthma

A 5-year-old boy with a history of sleeping problems presents with a nonproductive WARD TIP
nocturnal cough and shortness of breath and cough during exercise. Think: Asthma.
Start on a trial of a bronchodilator, which is helpful in confirming the diagnosis by Asthma is the most common chronic lung
the demonstration of reversible airways obstruction (↑ in forced expiratory volume in disease in children.
1 second [FEV1]). Asthma is an inflammatory disease. Diagnosis of asthma should be
considered in the presence of recurrent wheezing in a child with a family history of
asthma.

EX AM TIP
Definition
Respiratory hypersensitivity, inflammation, and reversible airway obstruction. It is important to ask for allergy history
and family history of asthma.
Etiology
Hyper-responsiveness to a variety of stimuli:
■ Respiratory infection.

■ Air pollutants.

■ Allergens: Seasonal, dust, mold, animal dander.

WARD TIP
■ Foods.

■ Exercise.
Lack of wheezing does not exclude
■ Emotions.
asthma.

Pathophysiology
■ Bronchospasm (acute).
■ Mucus production (acute). WARD TIP
■ Inflammation and edema of the airway mucosa (chronic).
■ Two types: In asthma there is cellular infiltration of
■ Extrinsic: mucosa by eosinophils, activated helper T
■ Immunologically mediated due to allergies. cells, and mast cells.
■ Develop in childhood.

■ Intrinsic:

■ No identifiable cause, most likely stress, anxiety, exercise, quality of

air, irritants.
■ Late onset. WARD TIP
■ Worsen with age.

■ Underlying abnormalities in asthma include ↑ pulmonary vascular pres- Asthma is the most common cause of
sure, diffuse narrowing of airways, ↑ residual volume and functional resid- cough in school-age children.
ual capacity, and ↑ total ventilation maintaining normal or reduced PCO2
despite ↑ dead space.

Signs and Symptoms

EX AM TIP
■ Cough, wheezing, dyspnea, and tachypnea.
■ ↑ work of breathing (retractions, use of accessory muscles, nasal flaring,
Before puberty, boys have a higher
abdominal breathing). prevalence of asthma.
■ ↓ breath sounds.

■ Prolongation of expiratory phase.

■ Acidosis and hypoxia may result from airway obstruction.

■ See Table 12-5 for classification of severity.

WARD TIP
Diagnosis
■ Mostly a clinical diagnosis. URI is the most important triggering
■ Peak expiratory flow rate (PEFR): Is used to assess severity of an acute factor for patients with asthma of all ages.
exacerbation.

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 230 HIGH-YIELD FACTS IN RESPIRATORY DISEASE

T A B L E 1 2 - 5 .   Asthma Severity Classification

Classifying severity of asthma exacerbations in the urgent or emergency care setting

Mild Dyspnea only with activity

PEFR >70% predicted personal best

Moderate Dyspnea interferes with or limits usual activity

PEFR 40–69% predicted personal best

Severe Dyspnea at rest, interferes with conversation

WARD TIP PEFR <40% predicted personal best

Life threatening Too dyspneic to speak

Classic trilogy of asthma:
■ Bronchospasm PEFR <25% predicted personal best
■ Mucus production

■ Inflammation and edema of the PEFR, peak expiratory flow rate.

airway mucosa (Adapted with permission from National Asthma Education & Prevention Program Expert Panel Report
3: Guidelines for the Diagnosis & Management of Asthma NHLBI guidelines, Summary Report 2007: 54.)

EX AM TIP ■ Maximal rate of airflow during forced exhalation after a maximal

inhalation.
Respiratory drive is not inhibited in ■ Normal values depend on age and height:

asthma. ■ Mild (80% of predicted).

■ Moderate (50–80% of predicted).

■ Severe (<50% of predicted).

■ Spirometry—the preferred method of diagnosis of airflow obstruction.

■ Recommended >5 years old if asthma is suspected.
WARD TIP
■ Measure forced vital capacity (FVC) and forced expiratory volume in

All wheezing is not caused by asthma; all 1 second (FEV1).

■ Airway obstruction present if FEV  < 80%; FEV /FVC < 85%.
asthmatics do not wheeze. 1 1
■ Chest x-ray will demonstrate hyperinflation and can be useful to look for
pneumonia.
■ Pulse oximetry may demonstrate hypoxia.
■ ABG—hypoxia in severe exacerbations; hypercapnia suggestive of impend-
WARD TIP ing respiratory failure.
■ Bloodwork should not be routinely ordered in the evaluation of asthma.
Asthmatic patient in severe respiratory
distress may not wheeze.
Treatment
Goals: Improve bronchodilation, avoid allergens, ↓ inflammation, educate patient.

WARD TIP First-Line Agents for Acute Exacerbations

1. Oxygen if O2 saturation <92% on room air.
O2 is indicated for all asthmatics to keep 2. Inhaled β2 agonist:
O2 saturation >95%. ■ Albuterol (2.5 mg) (nebulized).

■ Short-acting/rescue medication—treats only symptoms, not underlying

process.
■ Bronchial smooth-muscle relaxant in increase airflow.
WARD TIP ■ Side effects: Tachycardia, tremors, hypokalemia.

3. Corticosteroids (sooner is better):

Low-dose daily inhaled corticosteroids are ■ For treatment of chronic inflammation.
the first-line controller therapy for mild, ■ Oral prednisone (2 mg/kg, maximum 60 mg) or IV methylpredniso-
persistent asthma. lone 2 mg/kg (maximum 125 mg).
■ Contraindication: Active varicella or herpes infection.

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 RESPIRATORY DISEASE HIGH-YIELD FACTS IN 231

4. Anticholinergic agents:
■ Ipratropium bromide (nebulized).
EX AM TIP
■ Act synergistically with albuterol.

■ Bind to cholinergic receptors in the medium and large airways. Spirometry is the most important study
in asthma.
Second-Line Agents
1. Magnesium sulfate—bronchodilation via direct effect on smooth muscle.
2. Epinephrine or terbutaline.
3. No role in acute asthma for theophylline; not recommended. WARD TIP
Others
Long-acting β2 agonist (salmeterol)
1. Heliox—mixture of 60–70% helium and 30–40% oxygen:
should not be used for acute asthma
■ ↓ work of breathing by improving laminar gas flow (nonintubated
exacerbation.
patient).
■ Improves oxygenation and ↓ peak airway pressure (intubated patients).

2. Mechanical ventilation indications:

■ Failure of maximal pharmacologic therapy.

■ Hypoxemia.
WARD TIP
■ Hypercarbia.

■ Change in mental status.

Asthmatic child’s ability to use inhaler
■ Respiratory fatigue.
correctly should be regularly assessed and
■ Respiratory failure.
should be used with a spacer to ensure
3. Leukotriene modifiers: Used in long-term treatment of asthma. most effective administration of dose.
■ Inflammatory mediators.

■ Improve lung function.

■ No role in acute asthma.

4. Cromolyn and nedocromil:

■ Effective in maintenance therapy. EX AM TIP
■ Exercise-induced asthma.

■ May reduce dosage requirements of inhaled steroid. Most important risk factor for morbidity is
failure to diagnose asthma from recurrent
Admit if:
wheezing.
■ Respiratory failure requiring intubation.
■ Status asthmaticus.
■ Return ED visit in 24 hours.

■ Complete lobar atelectasis.

■ Pneumothorax/pneumomediastinum.
WARD TIP
■ Underlying cardiopulmonary disease.

↑ white blood cell (WBC) count does

Stat u s A s t h matic u s not always signify infection in status
asthmaticus.
Definition
■ Life-threatening form of asthma.
■ Condition in which a progressively worsening attack is unresponsive to
usual therapy. WARD TIP
Signs and Symptoms Ketamine is used for sedation/
Look for: analgesia before intubating a child with
■ Pulsus paradoxus >20 mm Hg. asthma in respiratory failure due to its
■ Hypotension, tachycardia. bronchodilatory properties.
■ Cyanosis.

■ One- to two-word dyspnea.

■ Lethargy.

■ Agitation.

■ Retractions.

■ Silent chest (no wheezes—poor air exchange).

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 232 HIGH-YIELD FACTS IN RESPIRATORY DISEASE

Foreign Body Aspiration

WARD TIP A 2-year-old boy is brought to the ED with a history of a choking or gagging
episode, followed by a coughing spell. In the ED, he was noted to have wheezing.
Dehydration may be present in status His respiratory rate is 24, and he has mild intercostal retractions. His babysitter found
asthmaticus, but over hydration him playing in his room. Think: Foreign body aspiration.
should be avoided (risk for syndrome
of inappropriate antidiuretic hormone
secretion [SIADH]).
A previously healthy 12-year-old boy presented with cough for almost a year. He
had a persistent dry cough during the day and night that was occasionally
productive. His parents reported a history of pneumonia with consolidation of the right
lower lobe on three different occasions in 6 months. On physical examination, no nasal
congestion is noted. ↓ air entry and wheezing is noted on the right side of his chest.
Think: Foreign body aspiration.
However, this classic triad (sudden onset of paroxysmal coughing, wheezing, and
diminished breath sounds on the ipsilateral side) may not be present in all children with
foreign body aspiration.

Pathophysiology
WARD TIP
Cough reflex usually protects against aspiration.
Prevention is key! Keep small food and
objects away from young children. E pidemiology
■ Twice as likely to occur in males, particularly 6-month-olds to 3-year-olds.
■ Most common age: 1–2 years.

S igns and Symptoms

WARD TIP ■ Determined by nature of object, location, and degree of obstruction.
■ Narrowest portion of the pediatric airway is at the cricoid ring.
Caution! Do not try to remove foreign ■ Foreign body in the upper airway: Respiratory distress with severe retrac-
bodies causing partial upper airway tions and stridor.
obstruction because these attempts may ■ Foreign body in the lower airway (most foreign bodies lodge in the lower
result in complete glottic obstruction. airways [80%]). Symptoms may be subtle.
■ Initial respiratory symptoms may disappear for hours to weeks after

incident.
■ Vegetal/arachidic bronchitis due to vegetable (usually peanut) aspiration

causes cough, high fever, and dyspnea.

■ Most common aspirated foreign body: Peanut.

■ Most common foreign body aspirations resulting in death: Balloons.

■ Complications if object is not removed include pneumonitis/pneumonia,

abscess, bronchiectasis, pulmonary hemorrhage, erosion, and perforation.

Diagnosis/Treatment
Larynx
WARD TIP ■ Croupy cough; may have stridor, aphonia, hemoptysis, cyanosis.

■ Lateral x-ray.
Foreign Body Aspiration ■ Direct laryngoscopy—confirm diagnosis and remove object.
■ Most are located in the bronchi.

■ Toddlers: R = L mainstem Trachea

■ Adults: R mainstem predominates ■ Stridor, audible slap, and palpable thud due to expiratory impaction.
■ Chest x-ray (see Figure 12-5), bronchoscopy.

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 RESPIRATORY DISEASE HIGH-YIELD FACTS IN 233

WARD TIP

Percussion of Lung Fields

■ Hyperresonant = overinflation

■ Dull = atelectasis

WARD TIP
F I G U R E 1 2 - 5 .   Radiograph of lateral soft tissue of the neck demonstrates a foreign body
Rigid bronchoscopy is the procedure of
(nail) in the pharynx. (Used with permission from Dr. Gregory J. Schears.)
choice to identify and remove object.

Bronchi
■ Initial choking, gagging, wheezing, coughing.

■ Latent period with some coughing, wheezing, possible hemoptysis, recur-

rent lobar pneumonia, or intractable asthma.

■ Tracheal shift, ↓ breath sounds.

■ Midline obstruction can cause severe dyspnea or asphyxia.

■ → chronic bronchopulmonary disease if not treated.

■ Direct bronchoscopic visualization (Figure 12-6).

■ Antibiotics for secondary infection if prolonged exposure.

■ Emergency treatment of local upper airway obstruction if necessary.

■ If the child can cough and verbalize:

■ Provide supplemental oxygen. F I G U R E 1 2 - 6 .   Foreign body (pea-

■ Maintain position of comfort. nut) in the right mainstem bronchus
visualized by bronchoscopy. Foreign
■ Immediate consultation with ENT and anesthesia.
bodies tend to lodge most commonly
■ If the child cannot cough or verbalize, initiate basic life support.
in the right mainstem bronchus due to
the larger anatomic angle that makes
traveling down right mainstem easier.
(Used with permission from Dr. Gregory
Tracheoesophageal Fistula (TEF) J. Schears.)

Definition
Connection between the trachea and esophagus (see Figure 12-7).
Etiology EX AM TIP
■ Congenital.
■ Acquired. There is an association of
tracheoesophageal fistulae with
Signs and Symptoms esophageal atresia.
■ Suspect esophageal atresia.
■ Maternal polyhydramnios.
■ Inability to pass catheter into stomach.

■ ↑ oral secretions—drooling.

■ Choking, cyanosis, or coughing with an attempt to feed. WARD TIP

■ Tachypnea.

TEF and EA are caused by a defect in

Diagnosis the lateral septation of foregut into the
■ X-ray: Radiopaque feeding tube passes no further than proximal esophagus. esophagus and trachea.
■ Barium swallow: Aspiration of barium into the tracheobronchial tree.

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 234 HIGH-YIELD FACTS IN RESPIRATORY DISEASE

C E
A D
B

F I G U R E 1 2 - 7 .   Types of tracheoesophageal fistulas (TEFs). Type A, esophageal atresia (EA)

with distal TEF (87%). Type B, isolated EA. Type C, isolated TEF. Type D, EA with proximal
TEF. Type E, EA with double TEF.

Treatment
WARD TIP
Esophageal atresia is a surgical emergency—ligation of the fistula is performed.
H-type tracheoesophageal fistula is the
least common but the most likely to be
seen in ED. Laryngomalacia

Definition
■ Collapse of supraglottic structures during inspiration.
■ Disproportionately small and soft larynx.

WARD TIP Signs and Symptoms

■ Usually begins within first month.
Tracheomalacia is the collapse of the ■ Noisy breathing, snoring.
trachea during EXPIRATION causing ■ “Wet” inspiratory stridor most frequent cause of stridor in children.
airway obstruction; the presentation ■ Symptoms can be intermittent.
and management are similar to ■ Hoarseness or aphonia (laryngeal crow).
laryngomalacia. ■ Feeding difficulty; gastroesophageal reflux, laryngoesophageal reflux.
■ Symptoms worse when crying or lying on back.

Diagnosis
■ Flexible fiberoptic laryngoscopy.
■ Collapse of laryngeal structures during inspiration especially arytenoid
cartilages.

Treatment
■ Reassurance.
■ No specific therapy required.
■ Usually resolves spontaneously by 18 months.

■ Surgery is rare and only done if severe.

Congenital Lobar Emphysema (Infantile Lobar

Emphysema)

Definition
Developmental anomaly of the lower respiratory tract that is characterized by
hyperinflation of one or more of the pulmonary lobes.

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 RESPIRATORY DISEASE HIGH-YIELD FACTS IN 235

Epidemiology
■ Most common congenital lung lesion.
■ More common in males (3:1)

Pathophysiology
No significant parenchymal destruction.

Signs and Symptoms

■ Normal at birth.
■ Cough, wheezing, dyspnea, and cyanosis within a few days.
■ Decreased breath sounds and hyper-resonant to percussion over involved lobe.

Diagnosis
■ Chest x-ray:
■ Distention of the affected lobe.

■ Can see compressive atelectasis of contralateral lung.

■ Radiolucency.

■ Mediastinal shift to opposite side. WARD TIP

■ Flattened diaphragm.

Both CLE and CAM can be diagnosed

Treatment prenatally by ultrasound.
Lobectomy.

Cystic Adenomatoid Malformation

Definition
WARD TIP
■ Also called congenital pulmonary airway malformation (CPAM).
■ Developmental anomaly of the lower respiratory tract.
Disorders of HOXB5 gene have been
■ Excessive overgrowth of bronchioles.
noted with CAM.
■ ↑ in terminal respiratory structure.
■ Hamartomatous lesions in tracheal, bronchial, bronchiolar, and alveolar
tissues.

Epidemiology
Second most common congenital lung lesion.
WARD TIP
Signs and Symptoms
■ Neonatal respiratory distress. In patients with cystic adenomatoid
■ Recurrent pneumonia in same location. malformation, avoid attempted aspiration
■ Pneumothorax. or chest tube placement, as there is the
■ May be confused with diaphragmatic hernia in neonatal period. risk of spreading infection.
■ Can be asymptomatic.

Diagnosis
■ Chest x-ray (posteroanterior [PA], lateral, and decubitus).
■ Cystic mass (multiple grapelike sacs) and mediastinal shift.
■ Air-fluid level. EX AM TIP
■ CT scan shows small and large air- or fluid-filled cysts.
Cystic adenomatoid malformation ↑ the
Treatment risk for pulmonary neoplasia.
Surgical excision of affected lobe.

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