RESPIRATORY SYSTEM 2

Normal Newborn Nose

• newborn infants are obligate nasal breathers and significant nasal obstruction
presenting at birth, such as choanal atresia, may be life-threatening
• Nasal congestion with obstruction is common in the 1st yr of life
• internal nasal airway doubles in size in the 1st 6 mo of life, leading to resolution of
symptoms in many infants.
• Nasal passages contribute as much as 50% of thE total resistance of normal breathing

CHOANAL ATRESIA
• the most common congenital anomaly of the nose
• most cases are a combination of bony and membranous atresia between the nose and
pharynx
• Unilateral more common
• female: male ratio is approximately 2:1

Approximately 50-70% of affected infants have other congenital anomalies

• CHARGE syndrome (coloboma, heart disease, atresia choanae, retarded growth and
development Or central nervous system anomalies or both, genital anomalies or
hypogonadism or both, and ear anomalies or deafness or both) is one of the more
common anomalies associated with choanal atresia- approximately 10-20% of
patients with choanal atresia have it. Most patients with CHARGE syndrome have
mutations in the CHD7 gene, which is involved in chromatin organization.

CHOANAL ATRESIA: Clinical Manifestations

• obstruction is unilateral:
• infant may be asymptomatic for a prolonged period,
• often until the first respiratory infection, when unilateral nasal discharge or
persistent nasal obstruction can suggest the diagnosis
•
• If bilateral choanal atresia:
• have difficulty with mouth breathing and make vigorous attempts to inspire,
often suck in their lips, and develop cyanosis
• Distressed children then cry (which relieves the cyanosis) , and become calmer,
with normal skin color, only to repeat the cycle after closing their mouths.
• experience difficulty when sucking and swallowing, becoming, cyanotic when
they attempt to feed

CHOANAL ATRESIA: DIAGNOSIS

 • established by the inability to pass a firm catheter through each nostril 3-4 cm
into the nasopharynx
• The atretic plate may be seen directly with fiberoptic rhinoscopy
• The anatomy is best evaluated by using high- resolution CT

CHOANAL ATRESIA: Treatment

• Initial treatment consists of prompt placement of an oral airway, maintaining the mouth
in an open position, or intubation
• transnasal repair is the treatment of choice

Nasal Foreign Body

• Foreign bodies (food, beads, crayons, small toys, erasers, paper wads, buttons,
batteries, beans, stones, pieces of sponge, and other small objects) are often Placed in
the nose by small children and developmentally delayed children and constitute $1% of
pediatric emergency department visits

Foreign Body
• First symptoms include unilateral obstruction, sneezing, relatively mild discomfort, and,
rarely, pain.
• Presenting clinical symptoms include
• history of insertion of foreign bodies (86%)
• patient might also present with a generalized body odor known as bromhidrosis.

Foreign Body: DIAGNOSIS

• Unilateral nasal discharge and obstruction should suggest the presence of a foreign
body
• long-standing foreign body can become embedded in granulation tissue or mucosa and
appear as a nasal mass
• lateral skull radiograph assists in diagnosis if the foreign body is metallic or radiopaque.

Foreign Body: Treatment

• "mother kiss" approach in acute situations
• person occludes the unaffected nostril and then, with a complete seal over the child's
mouth attempts to dislodge the foreign body by blowing into the mouth
• A similar approach uses an Ambu bag over the mouth with the unaffected nostril
occluded
Foreign Body: COMPLICATIONS
• posterior dislodgement and aspiration
• trauma caused by the object itself or removal attempts
• infection- common and gives rise to a purulent, malodorous, or bloody discharge
• Local tissue damage from long-standing foreign body, or alkaline injury from a disk
battery, can lead to local tissue loss and cartilage destruction
• Tetanus is a rare complication of long-standing nasal foreign bodies in nonimmunized
children
• Toxic shock syndrome is also rare and most commonly occurs from nasal surgical
packing oral antibiotics should be administered when nasal surgical packing is placed

Epistaxis
• Rare in infancy, nosebleeds are common in children between the ages of 3 and 8, then
decline in incidence after puberty
• most common site of bleeding is the Kiesselbach Plexus Kiesselbach's area

Epistaxis: ETIOLOGY
• Common causes of nosebleeds from the anterior septum include
•digital trauma
• foreign bodies
• dry air
• inflammation, including upper respiratory tract infections, sinusitis, and allergic rhinitis
• Chronic nasal steroid sprays may be associated with nasal mucosal bleeding.
• family history may be positive for abnormal bleeding (epistaxis or other sites); specific
testing for von Willebrand disease is indicated because the prothrombin time or partial
thromboplastin time may be normal despite having a bleeding disorder.

Epistaxis: TREATMENT
• Most nosebleeds stop spontaneously
• nares should be compressed and the child kept as quiet as possible, in upright position
with the head tilted forward to avoid blood trickling back into the throat.
• oxymetazoline or phenylephrine(0.25-1%) may be useful
• If bleeding persists, an anterior nasal pack may need to be inserted; if bleeding
originates in the posterior nasal cavity, combined anterior and posterior packing is
necessary
• After bleeding is under control, and if a bleeding site is identified, its obliteration by
cautery with silver nitrate may prevent further difficulties
• dry environment, a room humidifier, saline drops, and petrolatum (Vaseline) applied to
the septum can help to prevent epistaxis
Epistaxis: TREATMENT
• Antiseptic cream (e.g., mupirocin) has been used for epistaxis because it has been found
that many patients with idiopathic epistaxis have nasal bacterial colonization with
subsequent inflammation, new vessel formation, and irritation, likely leading to
epistaxis
• Severe despite conservative medical measures should be considered for surgical ligation
techniques or embolization
• Otolaryngologic evaluation is indicated for these children and for those with bilateral
bleeding or with hemorrhage that does not arise from the Kiesselbach plexus.

Epistaxis: PREVENTION
• discouragement of nose picking
• attention to proper humidification of the bedroom during dry winter months
• Prompt attention to nasal infections and allergies
• Prompt cessation of nasal steroid sprays prevents ongoing bleeding.

The Common Cold

• rhinorrhea and nasal obstruction are prominent
• There is self-limited involvement of the sinus mucosa and is more correctly termed
rhinosinusitis.
• Most common pathogens associated with the common cold are the more than 200
types of human rhinoviruses ( in 50% of cases)

The Common Cold: EPIDEMIOLOGY

• occur year-round
• Young children have an average of 6-8 colds per yr, but 10-15% of children have at least
12 infections per yr.
• incidence of illness decreases with increasing age, with 2- 3 illnesses per yr by
adulthood.
• Mannose-binding lectin deficiency with impaired innate immunity_may be associated
with an increased incidence of colds in children.

The Common Cold: PATHOGENESIS

spread by three mechanisms:
• HRV and RSV
• direct hand contact (self-inoculation of one's own nasal mucosa or conjunctivae after
touching a contaminated person or object)
• inhalation of small-particle aerosols that are airborne from coughing influenza viruses
and coronaviruses
 • deposition of large-particle_aerosols that are expelled during a sneeze and land on nasal
or conjunctival mucosa.

The Common Cold: PATHOGENESIS

• Viral infection of the nasal epithelium can be associated with destruction of the
epithelial lining, as with influenza viruses and adenoviruses, or there can be no apparent
histologic damage, as with HRV, coronaviruses, and RSV
• infection of the nasal epithelium is associated with an acute inflammatory response
characterized by release of interleukin-8 and infiltration of the mucosa by inflammatory
cells
• HRV also increases vascular permeability in the nasal submucosa, releasing albumin and
bradykinin, which may contribute to symptoms.
• Viral shedding of most respiratory viruses peaks 3-5 days after

The Common Cold:

CLINICAL MANIFESTATIONS
• In infants, fever and nasal discharge may predominate.
• Fever is uncommon in older children and adults.
• onset of common cold symptoms typically occurs 1-3 days after viral infection
• first symptom noted is often sore or scratchy throat, followed closely by nasal
obstruction and rhinorrhea
• sore throat usually resolves quickly, and, by the 2nd and 3rd day of illness, nasal
symptoms predominate.
• Cough is associated with two-thirds of colds in children and usually begins after
the onset of nasal symptoms
• Influenza viruses, RSV, MPV, and adenoviruses are more likely than HRV or
coronaviruses to be associated with fever and other constitutional symptoms
• headache, hoarseness, irritability, difficulty sleeping, or decreased appetite. usual cold
persists for approximately 1 wk, although 10% last for 2 wk.
• PE: a change in the color or consistency of the secretions is common during the course
of the illness and does not indicate sinusitis or bacterial superinfection but may indicate
accumulation of polymorphonuclear cells

The Common Cold:

DIAGNOSIS
• most important task of the physician caring for a patient with a cold is to exclude other
conditions that are potentially more serious or treatable.
The Common Cold: Treatment
Antiviral treatment
• oseltamivir and zanamivir have a modest effect on the duration of symptoms associated
with influenza
• Oseltamivir also reduces the frequency of influenza-associated otitis media
• therapy be started early in the illness (within 48 hr of onset of symptoms) to be
beneficial
Supportive
• hydration
• AAP recommends nonprescription products not to be used for infants and children
younger than 6 years of age
• Zinc reduces duration not severity if begun within 24 hours of symptoms
• Topical or oral adrenergic agents
• First generation antihistamines preferred for anticholinergic effect

Prolonged use of the topical adrenergic agents should be avoided to prevent

the development of rhinitis medicamentosa, an apparent rebound effect that
causes the sensation of nasal obstruction when the drug is discontinued.

The Common Cold: Complication

• most common complication of a cold is acute otitis media (AOM)
• may be indicated by new-onset fever and earache after the 1st few days of cold
symptoms. AOM is reported in 5-30% of children who have a cold

• Sinusitis: considered if rhinorrhea or daytime cough persists without Improvement for at

least 10-14 days, if acute symptoms worsen over time, or if acute signs of more severe
sinus involvement such as fever, facial pain, or facial swelling develop.

• Asthma exacerbation

• inappropriate use of antibiotics for these illnesses and the associated contribution to
the problem of increasing antibiotic resistance of pathogenic respiratory bacteria, as
well as adverse effects from antibiotics
 • .

Sinusitis: Etiology
• Bacterial pathogens in children and adolescents include Streptococcus pneumoniae
(~30%) nontypeable Haemophilus influenzae (~30%), and Moraxella catarrhalis (~10%)
• 50% of H. influenzae and 100% of M. catarrhalis are B-lactamase positive.
Approximately 25% of S. pneumoniae may be penicillin resistant
• Staphylococcus aureus, other streptococci, and anaerobes are uncommon cause chronic
sinus disease H. influenzae, a- and 6-hemolytic streptococci, M. catarrhalis, S.
pneumoniae, and coagulase- negative staphylococci are commonly recovered from
children

Sinusitis: Epidemiology
• occur at any age
• Predisposing conditions include: viral URTI, allergic rhinitis and tobacco smoke exposure
• Children with immune deficiencies, particularly of antibody production (immunoglobulin
(Ig)G, IgG subclasses, IgA), cystic fibrosis, ciliary dysfunction, abnormalities of phagocyte
function, gastroesophageal reflux, anatomic defects (cleft palate), nasal polyps, cocaine
abuse, and nasal foreign bodies (including nasogastric tubes), can develop chronic or
recurrent sinus disease
 • Immunosuppression for bone marrow Transplantation or malignancy with profound
neutropenia and lymphopenia predisposes to severe fungal (aspergillus, mucor)
sinusitis, often

Sinusitis: Definition
• Acute is defined by a duration of <30 days,
• Subacute by a duration of 1-3 months
• Chronic by a duration of longer than 3 mo.

Sinusitis: Pathogenesis
• typically follows a viral rhinosinusitis
• Nose blowing has been demonstrated to generate sufficient force to propel nasal
secretions into the sinus cavities
• Bacteria from the nasopharynx that enter the sinuses are normally cleared readily, but
during viral rhinosinusitis, inflammation and edema can block sinus drainage and impair
mucociliary clearance of bacteria.
• The growth conditions are favorable, and high titers of bacteria are produced

Sinusitis: Clinical Manifestation

• Nasal congestion, purulent nasal discharge (unilateral or bilateral), fever, and cough.
• Less-common symptoms include bad breath (halitosis), a decreased sense of smell
(hyposmia), and periorbital edema
• headache and facial pain are rare in children.
• Additional symptoms include maxillary tooth discomfort and pain or pressure
exacerbated by bending forward

Sinusitis: PE
• Erythema and swelling of the nasal mucosa with purulent nasal discharge
• Sinus tenderness may be detectable in adolescents and adults
• Transillumination reveals an opaque Sinus that transmits light poorly

Sinusitis: Differentiating from colds

• patterns suggestive of sinusitis:
• persistence of nasal congestion, rhinorrhea (of any quality), and daytime cough
210 days without improvement
• severe symptoms of temperature 239°C (102°F) with purulent nasal discharge for
3 days or longer
• worsening symptoms either by recurrence of symptoms after an initial
improvement or new symptoms of fever, nasal discharge, and daytime cough
Sinusitis: Diagnosis
• based on History: Bacteria are recovered from maxillary sinus aspirates in 70% of
children with such persistent or severe symptoms studied.
• Children with chronic sinusitis have a history of persistent respiratory symptoms,
including cough, nasal discharge, or nasal congestion, lasting longer than 90 days.
• Sinus aspirate culture is the only accurate method of diagnosis but only done for
suspected fungal sinusitis
• Findings on radiographic studies (sinus plain films, CT scans) including
opacification, mucosal thickening, or presence of an air-fluid level are not diagnostic and
are not recommended in otherwise healthy children

Sinusitis: Treatment
• Major guidelines recommend antimicrobial treatment for acute bacterial sinusitis with
severe onset or a worsening course to promote resolution of symptoms and prevent
suppurative complications, although 50-60% of children with acute bacterial sinusitis
may recover without antimicrobial therapy
• Initial therapy: Amoxicillin 45 mkd BID
• If allergic to penicillin: Cefnidir, Cefuroxime, Cefpodoxime, Cefixime
• In older children: Levofloxacin is an alternative
• Azithromycin and trimethoprim-sulfamethoxazole are no longer indicated because of a
high prevalence of antibiotic resistance.
• for children with risk factors (antibiotic treatment in the preceding 1-3 mo, daycare
attendance, or age younger than 2 yr) for the presence of resistant bacterial species,
and for children who fail to respond to initial therapy with amoxicillin within 72 hr, or
with severe sinusitis, give high dose Amoxicillin-Clavulanate ( 80-90 mkd based on
amoxicillin)
• Ceftriaxone (50 mg/kg, IV or IM) may be given to children who are vomiting or who are
at risk for poor compliance

Sinusitis: Complications
• periorbital cellulitis and more often orbital cellulitis as an infection can spread directly
through the lamina papyracea, the thin bone that forms the lateral wall of the
ethmoidal sinus
• Intracranial complications can include epidural abscess, meningitis, cavernous sinus
thrombosis, subdural empyema, and brain abscess children with altered mental status,
nuchal rigidity, severe headache, focal neurologic findings, or signs of increased
intracranial pressure (headache, vomiting) require immediate CT scan of the brain,
orbits, and sinuses to evaluate for the presence of intracranial complications of acute
bacterial sinusitis.
 • osteomyelitis of the frontal bone ( Pott puffy tumor and mucoceles which resultant
diplopia

Acute Pharyngitis
• Pharyngitis refers to inflammation of the pharynx, including erythema, edema,
exudates, or an enanthem (ulcers, vesicles)
• Pharyngeal inflammation can Be related to environmental exposures, such as tobacco
smoke, air pollutants, and allergens; from contact with caustic substances, hot food, and
liquids; and from infectious agents.
• Usual clinical task is to distinguish important, potentially serious, and treatable causes of
acute pharyngitis from those that are self-limited and require no specific treatment or
follow-up
• Specifically, identifying patients who have group A streptococcus (GAS;
Streptococcus pyogenes pharyngitis and treating them with antibiotics forms
the core of the management paradigm.
• Viruses predominate as acute infection cause.
•
Acute Pharyngitis: Group A Streptococcus
• Produce Streptococcal pyrogenic exotoxin A, B, C demonstrate the fine red, papular
(sandpaper) rash of scarlet fever (encoded by the gene spe A)
• Virulence factor: M protein
• Diagnostics:
• Clinical scoring systems: Mclsaac score 24 is associated with a positive laboratory
test for GAS in less than 70% of children with pharyngitis
• throat culture remains the gold standard for diagnosing streptococcal pharyngitis
• Streptococcal RATs highly specific > 95%, NO need for culture; If negative, throat
culture is recommended
• High sp and sen GAS molecular tests amplify the DNA of a specific GAS gene from
a throat swab in less than 1 hr
• nonspecific, symptomatic therapy can be an important part of the overall treatment
plan.
• Antipyretic, anesthetic sprays, lozenges
• Corticosteroids NOT recommended for children
• Antibiotic therapy of bacterial pharyngitis depends on the organism identified
 • Primary benefit is to prevent acute rheumatic fever effective when started
within 9 days of onset of illness)
• DOES NOT prevent acute glomerulonephritis
• The lymph nodes in these deep neck spaces communicate with each other,
allowing bacteria from either cellulitis or node abscess to spread to other nodes.
• Infection of the nodes usually occurs as a result of extension from a localized
infection of the oropharynx.

Retropharyngeal Abscess
• most commonly in children younger than 3-4 yr of age; as the retropharyngeal nodes
involute after 5 yr of age
• Boys affected more than girls; usually with history of recent ear, nose, throat infection

Retropharyngeal Abscess: Clinical Manifestations

• nonspecific include fever, irritability, decreased oral intake, and drooling, neck stiffness,
torticollis, and refusal to move the neck may also be present
• muffled voice, stridor, respiratory distress, or even obstructive sleep apnea
• Physical examination can reveal bulging of the posterior pharyngeal wall, cervical
lymphadenopathy may also be present.
• DDx: acute epiglottitis and foreign body aspiration. In the young child with limited neck
mobility, meningitis must also be considered. Other possibilities include lymphoma,
hematoma, and vertebral osteomyelitis.

Lateral Pharyngeal Abscess: Clinical Manifestations

• fever, dysphagia
• A prominent bulge of The lateral pharyngeal wall, sometimes with medial displacement
of the tonsil.

Retropharyngeal and Lateral Pharyngeal Abscess: Diagnosis

• Incision and drainage and culture of an abscessed node provides the definitive diagnosis
• But CT can Be useful in identifying the presence of a retropharyngeal, lateral pharyngeal,
or parapharyngeal abscess

Retropharyngeal and Lateral Pharyngeal Abscess:

Treatment
• most often polymicrobial; the usual pathogens include group A streptococcus,
oropharyngeal anaerobic bacteria, and Staphylococcus aureus Other pathogens include
Haemophilus influenza, Klebsiella, and Mycobacterium avium-intracellulare
• third-generation cephalosporin combined with ampicillin- sulbactam or clindamycin to
provide anaerobic coverage is effective
• Drainage necessary if patient in respiratory distress or fails to respond to IV antibiotics
Lemierre Disease
• uncommon but characteristic infection of the parapharyngeal space
• infection from the oropharynx extends to cause septic thrombophlebitis of the internal
jugular vein and embolic abscesses in the lungs
• causative pathogen is Fusobacterium necrophorum. constituent of the oropharyngeal
flora
• typical presentation is that of a previously healthy adolescent or young adult with a
history of recent pharyngitis who becomes acutely ill with fever, hypoxia, tachypnea,
and respiratory distress
• CXR shows multiple cavitary nodules, often bilateral and often accompanied by pleural
effusion.
• Blood culture may be positive
• Treatment involves prolonged intravenous antibiotic therapy with penicillin or cefoxitin;
surgical drainage of extrapulmonary metastatic abscesses may be necessary

Peritonsillar Cellulitis / Abscess

• Relatively common compared to the deep neck infections
• caused by bacterial invasion through the capsule of the tonsil, leading to cellulitis
and/or abscess formation in the surrounding tissues
• The typical patient with a peritonsillar abscess is an adolescent with a recent
history of acute pharyngotonsillitis.
• Clinical manifestations include sore throat, fever, trismus and dysphagia
• Physical examination reveals an asymmetric tonsillar bulge with displacement of
the uvula. asymmetric tonsillar bulge is diagnostic
• Group A streptococci and mixed oropharyngeal anaerobes are the most common
pathogens
 •

Remember
• Airway resistance is inversely proportional to the 4th power of the radius

• Because the lumen of an infant's or child's airway is narrow, minor reductions in cross-
sectional area as a result of mucosal edema or other inflammatory processes cause an
exponential increase in airway resistance and a significant increase in the work of
breathing

Acquired Disorders of the Upper Airways

• term croup refers to a heterogeneous group of mainly acute and infectious processes
affecting the larynx, trachea, and bronchi.
• are characterized by a barklike or brassy cough and may be associated with
hoarseness, inspiratory stridor, and respiratory distress
• Stridor is a harsh, high-pitched respiratory sound, which is usually inspiratory but can be
biphasic and is produced by turbulent airflow; it is not a diagnosis but a sign of upper
airway obstruction
Acute Epiglottitis (Supraglottitis):
Rifampin Prophylaxis
• Indications for rifampin prophylaxis (20 mg/kg orally once a day for 4 days; maximum
dose: 600 mg) for all household members include:
1. A child within the home who is younger than 4 yr of age and incompletely immunized
2. Younger than 12 mo Of age and has not completed the primary vaccination series,
3. immunocompromised

Differential Diagnosis
• Acute Infectious Laryngitis: Hoarseness and loss of voice
• Spasmodic Croup: similar to LTB except without hx of viral prodrome; ore of an allergic
reaction to viral antigens
• Bacterial Tracheitis: most important differential diagnostic consideration and has a high
risk of airway obstruction
• Foreign Body Aspiration: sudden onset of respiratory obstruction, sudden choking and
coughing occur suddenly, usually without prodromal signs
• retropharyngeal or peritonsillar abscess
• Angioedema
REMEMBER
• location of the obstruction produces characteristic changes in the sound of inspiration
and/or expiration.
• Inspiratory stridor : EXTRATHORACIC
• expiratory wheezing: INTRATHORACIC
• The timing of noisy breathing in relation to the sleep- wake cycle is important.
• Obstruction of the pharyngeal airway (by enlarged tonsils, adenoids, tongue, or
syndromes with midface hypoplasia) typically produces worse obstruction during sleep
• Obstruction that is worse when awake is typically laryngeal, tracheal, or
bronchial and is exacerbated by exertion

Laryngomalacia
• Accounts for 45-75% Of congenital laryngeal anomalies in children with stridor
• Stridor is inspiratory, low-pitched, and exacerbated by any exertion: crying, agitation, or
feeding
• caused, in part, by decreased laryngeal tone leading to supraglottic collapse
during inspiration
• Symptoms usually appear within the 1st 2 wk of life and increase in severity for up to 6
mo, although gradual improvement can begin at any time.

Diagnosis: made primarily based on symptoms; confirmed by outpatient flexible laryngoscopy

• 15-60% of infants with laryngomalacia have synchronous airway anomalies, Complete
bronchoscopyis undertaken for patients with moderate to severe obstruction.
• Expectant observation is suitable for most infants because most symptoms resolve
spontaneously as the child and airway grow

Laryngotracheal Stenosis and Subglottic Stenosis

• Laryngotracheal stenosis
• the second most common cause of stridor in neonates
• the most common cause of airway obstruction requiring tracheostomy in infants
• Congenital or acquired

Laryngotracheal Stenosis and Subglottic Stenosis

• Ninety percent of acquired stenoses are a result of endotracheal intubation.
• The narrowest portion of the pediatric larynx is the subglottic region due to the narrow
cricoid cartilage.
 • When the pressure of the endotracheal tube against the cricoid mucosa is greater
than the capillary pressure, ischemia occurs, followed by necrosis and ulceration.
• Secondary infection and perichondritis develop with exposure of cartilage
• Granulation tissue forms around the ulcerations and these changes and edema
throughout the larynx usually resolve spontaneously after extubation
• gold standard to confirm the diagnosis is via direct laryngoscopy and bronchoscopy in
the operating room

Foreign Bodies in the Airway

• most common objects on which children choke are food items (59.5-81% of all choking
cases).
• Nuts, seeds, hot dogs, hard candy, gum, bones, and raw fruits and vegetables are
the most frequently aspirated food
• recommended that children younger than 5 yr of age should avoid hard candy and
chewing gum and that raw fruits and vegetables be cut into small pieces.
• most serious complication: complete obstruction of the airway, which may be
recognized in the conscious child as sudden respiratory distress followed by an inability to
speak or cough.
• History is the most important factor in determining the need for bronchoscopy
• Choking or coughing episodes accompanied by new-onset wheezing and asymmetric
breath sounds are highly suggestive of foreign body in the airway

• plain films are typically recommended first, although many foreign bodies are
radiolucent (80-96%), and therefore providers often must rely on secondary findings
(such as air trapping, asymmetric hyperinflation, obstructive emphysema, atelectasis,
mediastinal shift, and consolidation) to indicate suspicion of a foreign body

• Treatment: treatment of choice for airway foreign bodies is prompt endoscopic removal
with rigid instruments by a specialist

• Airway foreign bodies are usually removed the same day the diagnosis is first
considered.

Bronchial Foreign Bodies

• Most airway foreign bodies lodge in a bronchus (80-90%)
• Some asymptomatic, whereas others have asymmetric breath sounds, coughing, and
wheezing
• Posteroanterior and lateral chest radiographs (including the abdomen) are standard;
EXPIRATORY most helpful
• During expiration, the bronchial foreign body obstructs the exit of air from the
obstructed lung, producing obstructive emphysema and air trapping.
 • persistent inflation of the obstructed lung causes shift of the mediastinum
toward the opposite side

General Pathophysiology of Wheezing in Infants

• A musical and continuous sound that originates from oscillations in narrowed airways
• Infants >>> older children, as a result of differing lung mehanics.
• Obstruction of airflow is affected by both airway size and compliance of the infant lung
• In children younger than 5 yr, small-caliber peripheral airways can contribute up
to 50% of the total airway resistance.

Wheezing
• Infant chest wall compliance is also quite high, thus the inward pressure produced In
normal expiration subjects the intrathoracic airways to collapse.
• Differences in tracheal cartilage and airway smooth muscle tone increase the
collapsibility of the infant airways in comparison with older children.
• These mechanisms combine to make the infant more susceptible to airway obstruction,
creased resistance, and subsequent wheezing.

Acute Bronchiolitis
• respiratory findings observed in bronchiolitis include tachypnea, wheezing, crackles, and
rhonchi which result from inflammation of the small airways
• Respiratory syncytial virus (RSV) is responsible for more than 50% of cases
• more common in males, those exposed to second-hand tobacco smoke, those who have
not been breastfed, and those living in crowded conditions.
• Risk is also higher for infants with mothers who smoked during pregnancy.
• Resistance in the small air passages is increased during
• both inspiration and exhalation but because the radius of an airway is smaller
during expiration, the resultant respiratory obstruction leads to early air trapping
and overinflation
• If obstruction becomes complete, trapped distal air will be resorbed and the child will
develop atelectasis

Acute Bronchiolitis and Asthma: cohort study

• 3 patterns of infant wheezing were proposed:
• transient early wheezing, (20%) characterized by lower lung function at birth which
improves with growth resulting in resolution of wheezing by age 3
• persistent wheezing, (14%) characterized by declining lung function and wheezing
before and after age 3
 • late-onset wheezing, (15%) characterized by relatively stable lung function and
wheezing that does not begin until after age 3.
• remaining 50% of the population did not suffer a wheezing illness.
• Following the cohort into adulthood revealed continued declines in the rates of
persistent symptoms

Acute Bronchiolitis
• describe the recent event including onset, duration, and associated factors
• Birth Hx (AOG, 02 req, intubation, prenatal smoke exposure)
• Past Medical Hx
• Family Hx (CF, Asthma 1° relative)
• Social Hx ( second-hand tobacco or other smoke exposure, daycare exposure, number of
siblings, pets, and concerns regarding home environment (e.g., dust mites, construction
dust, heating and cooling techniques, mold, cockroaches). second-hand tobacco or
other smoke exposure, daycare exposure, number of siblings, pets, and concerns
regarding home environment (e.g., dust mites, construction dust, heating and cooling
techniques, mold, cockroaches).
• usually preceded by exposure to an older contact with a minor respiratory syndrome
within the previous week.
• first develops a mild upper respiratory tract infection with sneezing and clear rhinorrhea
accompanied by diminished appetite and fever of 38.5-39°C (101-102°F)
• Tachypneic; if less than two months old or premature, may present with apnea instead
• evaluation of the patient's vital signs with special attention to the respiratory rate and
oxygen saturation is an important initial step
• PE: wheezing, crackles, prolonged expiratory time, markedly increased work of
breathing nasal flaring and retractions
• Complete obstruction to airflow can eliminate the turbulence that causes wheezing;
thus the lack of audible wheezing is not reassuring if the infant shows other signs of
respiratory distress.
• Poorly audible breath sounds suggest severe disease with nearly complete
bronchiolar obstruction.

Acute Bronchiolitis: Diagnostic Evaluation

• Diagnosis is CLINICAL: previously healthy infant presenting with a first episode of
wheezing following a period of upper respiratory symptoms
• Chest radiography is not routinely indicated in children with suspected bronchiolitis;
Atelectasis difficult to distinguish from bacterial pneumonia and may encourage
unnecessary antibiotic use
• white blood cell and differential counts are usually normal and are not predictive of
bacterial superinfection
• Concurrent serious bacterial infection (sepsis, pneumonia, meningitis) is unlikely
Acute Bronchiolitis: Treatment
• Supportive
• If with respiratory distress (hypoxia, inability to feed, apnea, extreme tachypnea) should
be hospitalized
• Risk factors for severe disease include
• younger age
• preterm birth
• underlying comorbidity such as cardiovascular, pulmonary, neurologic, or
immunologic disease.
• Oxygen: high flow nasal cannula provides PEEP and can avoid intubation
• Supplemental hydration: ISOTONIC fluids to avoid hyponatremia
• Frequent suctioning
• No benefit: chest physiotherapy
• Pharmacologic agents have largely proven ineffective: albuterol, corticosteroids,
racemic epinephrine, Ribavirin

Acute Bronchiolitis: Prevention

• Meticulous hand hygiene is the best measure to prevent transmission of the viruses
responsible for bronchiolitis
• For high-risk populations, palivizumab an intramuscular monoclonal antibody to the RSV
F protein, may be given as a prophylactic agent

Community Acquired Pneumonia

• an inflammation of the parenchyma of the lungs leading infectious cause of death
globally among children younger than 5 yr
• Most cases of pneumonia are caused by microorganisms, but there are several
noninfectious causes, which include but are not limited to:
• aspiration of food or gastric acid, foreign bodies, hydrocarbons, and lipoid
substances; hypersensitivity reactions; and drug- or radiation-induced
pneumonitis

Community Acquired Pneumonia:

Etiology
• Streptococcus pneumonia: most common 3wk to 4 years old
• Mycoplasma and Chlamydia pneumoniae: 5 years and older
Community Acquired Pneumonia:
Pathogenesis
• The lower respiratory tract possesses physiologic defense mechanisms, including the
mucociliary clearance, macrophages, secretory lgA, and clearing of the airway by
coughing
• recent conceptual models postulate that pneumonia results from disruption of a
complex lower respiratory ecosystem that is the site of dynamic interactions between
potential pneumonia pathogens, resident microbial communities, and host immune
defenses.

Community Acquired Pneumonia:

Clinical Manifestations
• Viral and bacterial pneumonias are most often preceded by several days of symptoms of
an upper respiratory tract infection, typically rhinitis and cough
• In viral pneumonia, fever usually is present; however, temperatures are generally lower
than in bacterial pneumonia.
• Tachypnea is the most consistent clinical manifestation of pneumonia.
• Increased work of breathing accompanied by intercostal, subcostal, and suprasternal
retractions, nasal flaring, and use of accessory muscles is common;
• Severe infection may be accompanied by cyanosis and respiratory fatigue, especially in
infants
• in adults and older children typically begins suddenly with high fever, cough, and chest
pain
• In many children, splinting on the affected side to minimize pleuritic pain and improve
ventilation is noted; such children may lie on one side with the knees drawn up to the
chest.

Community Acquired Pneumonia:

PE findings
• depend on the stage of pneumonia
• Early in the course of illness, diminished breath sounds, scattered crackles, and rhonchi
are commonly heard over the affected lung field
• With the development of increasing consolidation or complications of pneumonia such
as effusion, empyema, or pyopneumothorax, dullness on percussion is noted and breath
sounds are markedly diminished
• A lag in respiratory excursion often occurs on the affected side
Community Acquired Pneumonia:
Diagnosis
• infiltrate on chest radiograph (posteroanterior and lateral views) supports the diagnosis
of pneumonia and may indicate a complication pleural effusion, empyema)
• Viral: hyperinflation with bilateral interstitial infiltrates and peribronchial cuffing
• pneumococcal pneumonia: Confluent lobar consolidation
• radiographic appearance alone does not accurately identify pneumonia etiology,
and other clinical features of the illness must be considered
• Portable ultrasonography is highly sensitive and specific
• WBC count
• large pleural effusion, lobar consolidation, and a high fever at the onset of the
illness are also suggestive of a bacterial etiology.
• The definitive diagnosis of a viral infection rests on the isolation virus or
detection of viral antigens in respiratory tract secretions
• The definitive diagnosis of a bacterial infection requires isolation a organism
from the blood, pleural fluid, or lung

Community Acquired Pneumonia:

Treatment
• based on the presumptive cause and the age and clinical appearance of the child
• OPD: amoxicillin 90mkd BID or cefuroxime or co-amoxiclav
• School aged kids: macrolides- Azithromycin is preferred with Clarithromycin or
Doxycycline (8 y/o) as alernatives
• Adolescents: levofloxacin, moxifloxacin) may also be considered as an alternative
• Admitted: ampicillin or penicillin G ; vancomycin if staphylococcus is suspected
• If viral pneumonia: withhold antibiotic; watch out for bacterial superinfection

Community Acquired Pneumonia:

Complications
• usually the result of direct spread of bacterial infection within the thoracic cavity
(pleural effusion, empyema, and pericarditis) or bacteremia and hematologic spread
• Meningitis, endocarditis, suppurative arthritis, and osteomyelitis are rare complications
of hematologic spread of pneumococcal or H. influenza type b infection
• S. aureus, S. pneumoniae, and S. pyogenes are the most common causes of
parapneumonic effusions and empyema

Community Acquired Pneumonia:

Complications
• Analysis of pleural fluid parameters, including pH, glucose, protein, and lactate
dehydrogenase, can differentiate transudative from exudative effusions
Community Acquired Pneumonia:
Complications
• Small (<1 cm on lateral decubitus radiograph), free- flowing parapneumonic effusions
often do not require drainage but respond to appropriate antibiotic therapy.
• Larger effusions should typically be drained, particularly if the effusion is purulent
(empyema) or associated with respiratory distress.
• Chest ultrasound, or alternatively CT, may be helpful in determining whether loculations
are present.
• mainstays of therapy include
• antibiotic therapy
• drainage by tube thoracostomy with the instillation of fibrinolytic agents
(urokinase, streptokinase, tissue plasminogen activator).
• Video-assisted thoracoscopy is a less often employed alternative that enables
debridement or lysis of adhesions and drainage of loculated areas of pus

Community Acquired Pneumonia:

Prevention
• PCV
• Influenza vaccine
• should be administered to all children >6 mo of age
 • For infants <6 mo of age, household contacts and other primary caregivers should
be immunized.
• Maintaining high rates Of vaccination for H. influenzae type b, pertussis, and
measles remains important for the prevention of pneumonia from these causes

Pleurisy, Pleural Effusions, and Empyema

• Pleurisy is the inflammation of the pleura; it may be accompanied by an effusion.
• The most common cause of pleural effusion in children is bacterial pneumonia
• heart failure, rheumatologic causes, and metastatic intrathoracic malignancy are also
common causes
• A variety of other diseases account for the remaining cases, including tuberculosis, lupus
erythematosus, aspiration pneumonitis, uremia, pancreatitis, subdiaphragmatic abscess,
and rheumatoid arthritis.
• Inflammatory processes in the pleura are usually divided into 3 types:
• dry pleurisy
• serofibrinous or serosanguineous
• purulent pleurisy or empyema

Dry Pleurisy
• associated with acute bacterial or viral pulmonary infections or also associated with
tuberculosis and autoimmune diseases such as systemic lupus erythematosus.
• Pathogenesis: usually limited to the visceral pleura with small amounts of yellow serous
fluid and adhesions between the pleural surfaces
• In TB, adhesions develop rapidly, and the pleura are often thickened, with fibrin
deposition and adhesions severe enough to produce a fibrothorax that markedly
inhibits the excursions of the lung.

Dry Pleurisy: Clinical Manifestations

• Pain, the principal symptom, is exaggerated by deep breathing, coughing, and straining
• often localized over the chest wall and is referred to the shoulder or the back.
• Pain with breathing is responsible for grunting and guarding of respirations, and the
child often lies on the affected side in an attempt to decrease respiratory excursions.
• Early: leathery, rough, inspiratory and expiratory friction rub may be audible, but it
usually disappears rapidly.
• If the layer of exudate is thick, increased dullness to percussion and decreased breath
sounds
• Chronic pleurisy _is occasionally encountered with conditions such as atelectasis,
pulmonary abscess, connective tissue diseases, and tuberculosis.
Serofibrinous or Serosanguineous Pleurisy With Pleural Effusion
• Serofibrinous pleurisy is defined by a fibrinous exudate on the pleural surface and an
exudative effusion of serous fluid into the pleural cavity
• In general, it is associated with infections of the lung or with inflammatory conditions of
the abdomen or mediastinum, SLE, periarteritis, and Rheumatoid arthritis, primary or
metastatic neoplasms of the lung, pleura, or mediastinum
• Pathogenesis: Pleural inflammation increases the permeability of the pleural surface,
with increased proteinaceous fluid formation;
• there may also be some obstruction to lymphatic absorption

Serofibrinous or Serosanguineous Pleurisy With Pleural Effusion: Clinical Manifestations

• Preceded by dry pleurisy SO there may be pain but as fluid accumulates, it may
disappear
• asymptomatic if the effusion remains small
• Large fluid collections can produce cough, dyspnea, retractions, tachypnea, orthopnea,
or cyanosis
• PE: Dullness to flatness may be found on percussion. Breath sounds are decreased or
absent, and there is a diminution in tactile fremitus, a shift of the mediastinum away
from the affected side, and, occasionally, fullness of the intercostal spaces.
• If the fluid is not loculated, these signs may shift with changes in position
• If extensive pneumonia is present, crackles and rhonchi may also be audible.
• shows a generally homogeneous density obliterating the normal markings of the
underlying lung
• Small effusions may cause obliteration of only the costophrenic or cardiophrenic angles
or a widening of the interlobar septa
• Examinations should be performed with the patient both supine and upright, to
demonstrate a shift of the effusion with A change in position; the decubitus position
may be helpful.
• Ultrasonographic examinations are useful and may guide thoracentesis if the effusion is
loculated.

Serofibrinous or Serosanguineous Pleurisy With Pleural Effusion: Dxtics

• Examination of the fluid is essential to differentiate exudates from transudates
• Depending on the clinical scenario, pleural fluid is sent for
• culture for bacterial, fungal, and mycobacterial cultures; antigen testing;
• Gram staining;
• chemical evaluation of content, including protein, lactic dehydrogenase and
glucose, amylase, specific gravity, total cell count and differential, cytologic
examination, and pH
• Exudates usually have at least 1 of the following features:
• protein level >3.0 g/dL,
• with pleural fluid:serum protein ratio >0.5;
 • pleural fluid lactic dehydrogenase values >200 IU/L;
• or fluid:serum lactic dehydrogenase ratio >0.6
• pH ‹ 7.20 suggests an exudate
• Glucose is usually <60 mg/dL in malignancy, rheumatoid disease, and tuberculosis
• the finding of many small lymphocytes and a pH < 7.20 suggest tuberculosis
• The fluid of serofibrinous pleurisy is clear or slightly cloudy and contains relatively few
leukocytes and, occasionally, some erythrocytes
• Gram staining may occasionally show bacteria; however, acid-fast staining rarely
demonstrates tubercle bacilli.
• Thoracentesis should be performed when pleural fluid is present or is suggested, unless
the effusion is small, and the patient has a classic-appearing lobar pneumococcal
pneumonia.
• Can differentiate serofibrinous pleurisy, empyema,
• hydrothorax, hemothorax, and chylothorax.
• Hydrothorax: the fluid has a specific gravity <1.015, and evaluation reveals only a few
mesothelial cells
• Chylothorax and hemothorax usually have fluid with a distinctive appearance
• Cytologic examination may reveal malignant cells.

Serofibrinous or Serosanguineous Pleurisy With Pleural Effusion: Complications

• Unless the fluid becomes purulent, it usually disappears relatively rapidly, particularly
with appropriate treatment of bacterial pneumonia.
• persists somewhat longer if a result of tuberculosis or a connective tissue disease and
may recur or remain for a long time if caused by a neoplasm
• adhesions often develop between the 2 layers of the pleura, but usually little or no
functional impairment results
• Pleural thickening may develop and is occasionally mistaken for small quantities of fluid
or for persistent pulmonary infiltrates.
• may persist for months, but the process usually disappears, leaving no residual.

Serofibrinous or Serosanguineous Pleurisy With Pleural Effusion: Treatment

• address the underlying disease.
• effusion is less than 10 mm in size on a chest x-ray, then there is no need for drainage.
• When a diagnostic thoracentesis is performed, as much fluid as possible should be
removed for therapeutic purposes
• Rapid removal of 21 L of pleural fluid may be associated with the development of
reexpansion pulmonary edema
• If sufficient fluid reaccumulates to cause Respiratory embarrassment, chest tube
drainage should be performed
 • In older children with suspected parapneumonic effusion, tube thoracostomy is
considered necessary if the pleural fluid pH is <7.20 or the pleural fluid glucose level is
<50 mg/dL.
• If the fluid is thick, loculated, or clearly purulent, tube drainage with fibrinolytic therapy
or less often video-assisted thoracoscopic surgery (VATS) is indicated

Empyema
• accumulation of pus in the pleural space
• most often associated with pneumonia caused by Streptococcus pneumonia although
Staphylococcus aureus is most common in developing nations and Asia, as well as in
posttraumatic empyema.
• Hib, Group A streptococcus, Gram-negative organisms, tuberculosis, fungi, viruses, and
malignancy are less common causes.
• also be produced by rupture of a lung abscess into the pleural space, by contamination
introduced from trauma or thoracic surgery, or, rarely, by mediastinitis or the extension
of intraabdominal abscesses.

Empyema: Pathology
• 3 stages: exudative, fibrinopurulent, and organizational.
• exudative stage: fibrinous exudate forms on the pleural surfaces. fibrinopurulent
stage, fibrinous septa form, causing loculation of the fluid and thickening of the
parietal pleura.
• If the pus is not drained, it may dissect through the pleura into lung
parenchyma, producing bronchopleural fistulas and pyopneumothorax, or
into the abdominal cavity.
• Rarely, the pus dissects through the chest wall (i.e., empyema necessitatis).
• During the organizational stage, there is fibroblast proliferation; pockets of
loculated pus may develop into thick-walled abscess cavities or the lung may
collapse and become surrounded by a thick, inelastic envelope (peel)

Empyema: Clinical Manifestations

• Most patients are febrile, develop increased work of breathing or respiratory distress,
and often appear more ill.
• Physical findings are identical to those described for serofibrinous pleurisy, and the 2
conditions are differentiated only by thoracentesis, which should always be performed
when empyema is suspected.

Empyema: Lab Findings

• Radiographically, all pleural effusions appear similar, but the absence of a shift of the
fluid with a change of position indicates a loculated empyema
 • The effusion is an empyema if bacteria are present on Gram staining, the pH is <7.20,
and there are >100,000 neutrophils/uL
• Cultures of the fluid must always be performed to help identify the causal organism.
• Using standard culture methods, the organism can be identified in up to 60%

Empyema: Complications
• With staphylococcal infections, bronchopleural fistulas and pyopneumothorax
commonly develop
• purulent pericarditis, pulmonary abscesses, peritonitis from extension through the
diaphragm, and osteomyelitis of the ribs.
• Septic complications such as meningitis, arthritis, and osteomyelitis
• Septicemia is often encountered in H. influenzae and pneumococcal infections.
• effusion may organize into a thick "peel," which may restrict lung expansion and may be
associated with persistent fever and temporary scoliosis

Empyema: Treatment
• aim of empyema treatment is to sterilize pleural fluid and restore normal lung function
• Treatment includes systemic antibiotics and thoracentesis and chest tube drainage
initially with a fibrinolytic agent;
• promotes drainage, decreases the length of time a chest tube is in place,
decreases fever, lessens need for surgical intervention, and shortens hospitalization
• Streptokinase 15,000 units/kg in 50 mL of 0.9% saline, urokinase 40,000 units in
40 mL saline, and alteplase (tPA) 4 mg in 40 mL of saline
• risk of anaphylaxis with streptokinase, and all 3 drugs can be associated with
hemorrhage and other complications.
• if no improvement occurs, VATS is indicated.
• Open decortication is indicated if fibrinolysis and VATS are ineffective
• If empyema is diagnosed early, antibiotic treatment plus thoracentesis achieves
a complete cure.
• Clinical response in empyema is slow, and systemic antibiotics may be needed
for up to 4 wk
• In the child who remains febrile and dyspneic for more than 72 hr after initiation
of therapy with intravenous antibiotics and thoracostomy tube drainage, surgical
decortication via VATS or, less often, open thoracotomy may speed recovery.
• If pneumatoceles form, no attempt should be made to treat them surgically or
by aspiration, unless they reach sufficient size To cause respiratory compromise or
become secondarily infected
• Pneumatoceles usually resolve spontaneously with time

Bronchiectasis
• irreversible abnormal dilation and anatomic distortion of the bronchial tree
 • In industrialized nations, cystic fibrosis is the most common cause of clinically significant
bronchiectasis
• Other conditions associated with bronchiectasis include primary ciliary dyskinesia,
foreign body aspiration, aspiration of gastric contents, immune deficiency syndromes
(especially humoral immunity), and infection, especially pertussis, measles, and
tuberculosis

3 Mechanisms in Pathogenesis of Bronchiectasis

1. Obstruction can occur because of tumor, foreign body, impacted mucus because of poor
mucociliary clearance, external compression, bronchial webs, and atresia
2. Infections caused by Bordetella pertussis measles, rubella, togavirus, respiratory
syncytial virus, adenovirus, and Mycobacterium tuberculosis induce chronic inflammation,
progressive bronchial wall damage, and dilation
3. Chronic inflammation similarly contributes to the mechanism by which obstruction leads
to bronchiectasis

Pathogenesis of Bronchiectasis
• Both inadequate and exaggerated/dysregulated immune responses may play a role in
the development of bronchiectasis
• Activation of Toll-like receptors results in the activation of nuclear factor KB and
the release of proinflammatory cytokines interleukin (IL)-1ß, IL-8, and tumor necrosis
factor- a.
• IL-8 is a chemoattractant for neutrophils, which are the main inflammatory cell
involved in the pathogenesis of bronchiectasis.
• Once activated, neutrophils produce neutrophil elastase and matrix
metalloproteinases, MMP-8 and MMP-9.
• IL-6, IL-8, and tumor necrosis factor-a are elevated in the airways of patients
with bronchiectasis.
• Eosinophils are also elevated which promote neutrophil recruitment, goblet cell
hyperplasia, and airway destruction
• increase in proinflammatory cytotoxic T lymphocytes in peripheral blood of children
with bronchiectasis.
• The mechanism by which bronchiectasis occurs in congenital forms is likely related to
abnormal cartilage formation.
• The common thread in the pathogenesis of bronchiectasis consists of difficulty clearing
secretions and recurrent infections with a "vicious cycle" of infection and inflammation
resulting in airway injury and remodeling
• early stages, bronchiectasis consists primarily of bronchiolar wall thickening and
destruction of elastin resulting in bronchial dilatation.
• In later stages, the bronchial walls develop cartilage destruction with associated
pulmonary artery/arteriole vascular remodeling, resulting in pulmonary hypertension.
Bronchiectasis
• 3 pathologic forms: cylindrical, varicose, saccular (most severe)
• Most common complaints in patients with bronchiectasis are cough and production of
copious purulent sputum
• PE: reveals crackles localized to the affected area but wheezing as well as digital
clubbing may also occur.; In severe cases, dyspnea and hypoxemia can occur

Bronchiectasis: Diagnosis
• Rule out conditions associated with bronchiectasis
• CXR nonspecific;
• increase in size and loss of definition of bronchovascular markings, crowding of
bronchi, and loss of lung volume.
• In more severe forms, cystic spaces, occasionally with air- fluid levels and
honeycombing, Compensatory overinflation of unaffected lung may be seen.
• Thin-section HRCT scanning is the gold standard because it has excellent sensitivity and
specificity
• Cylindrical ("tram lines,' "signet ring appearance"), varicose (bronchi with
"beaded contour"), cystic (cysts in "strings and clusters"), or mixed forms

Bronchiectasis: Treatment
• initial therapy is medical and aims at decreasing airway obstruction and controlling
infection
• Airway clearance techniques (e.g., gravity-assisted drainage, active cycle of
breathing, positive expiratory pressure [PEP], acapella, high-frequency chest wall
oscillation),
• Antibiotics
• most common organisms found in children with bronchiectasis include S.
pneumoniae H. influenzae non-type b, M. catarrhalis and Mycoplasma pneumoniae.
• Amoxicillin/clavulanic acid (22.5 mg/kg/dose twice daily) successful at
treating most pulmonary exacerbations bronchodilators
• Long-term prophylactic macrolide antibiotics or nebulized antibiotics (e.g., tobramycin,
colistin, aztreonam) may be beneficial (reduced exacerbations and hospitalizations,
improved lung function) but may also increase antibiotic resistance.
• Airway hydration (inhaled hypertonic saline or mannitol
• Address any underlying disorder (immunodeficiency, aspiration)
• When localized bronchiectasis becomes more severe or resistant to medical
management, segmental or lobar resection may be warranted.
• Lung transplantation
Pulmonary Abscess
• Lung infection that destroys the lung parenchyma, resulting in cavitations and central
necrosis, can result in localized areas composed of thick-walled purulent material, called
lung abscesses
• In children, aspiration of infected materials or a foreign body is the predominant source
of the organisms causing abscesses.
• Recumbent: the right and left upper lobes and apical segment of the right lower lobes
are the dependent areas most likely to be affected.
• Upright: the posterior segments of the upper lobes were dependent and therefore are
most likely to be affected.
• Primary abscesses are found most often on the right side, whereas secondary lung
abscesses, particularly in immunocompromised patients, have a predilection for the left
side.
• Common anaerobic bacteria that can cause a pulmonary abscess include Bacteroides
spp., Fusobacterium spp., and Peptostreptococcus spp.
• Abscesses can be caused by aerobic organisms such as Streptococcus spp.,
Staphylococcus aureus, Escherichia coli, Klebsiella pneumonia, Pseudomonas
aeruginosa, and very rarely Mycoplasma pneumoniae.
• Aerobic and anaerobic cultures should be part of the workup for all patients with lung
abscess.
• Occasionally, concomitant viral-bacterial infection can be detected.
• Fungi can also cause lung abscesses, particularly in immunocompromised patients.

Pulmonary Abscess: Clinical Manifestations

• The most common symptoms of pulmonary abscess in the pediatric population are
fever, cough, and emesis.
• Other common symptoms include tachypnea, dyspnea, chest pain, sputum production,
weight loss, and hemoptysis.
• Physical examination typically reveals tachypnea, dyspnea, retractions with accessory
muscle use, decreased breath sounds, and dullness to percussion in the affected area.
• Crackles and occasionally prolonged expiratory phase may be heard on lung
examination.

Pulmonary Abscess: Diagnosis

• chest radiograph shows a parenchymal inflammation with a cavity containing an air-fluid
level ( Fig. 431.1 )
• A chest CT scan can provide better anatomic definition of an abscess, including location
and size.
Pulmonary Abscess vs.pneumatoceles
• Abscesses should be distinguished from pneumatoceles, which often complicate severe
bacterial pneumonias
• characterized by thin- and smooth-walled, localized air collections with or without air-
fluid level ( Fig. 431.3 ).
• Pneumatoceles often resolve spontaneously with the treatment of the specific cause of
the pneumonia

Pulmonary Abscess: Treatment

• Conservative management is recommended for pulmonary abscess.
• Most experts advocate a 2- to 3-wk course of parenteral antibiotics for uncomplicated
cases, followed by a course of oral antibiotics to complete a total of 4-6 wk.
• initially should include agents with aerobic and anaerobic coverage.
• Treatment regimens should include a penicillinase-resistant agent active against S.
aureus and anaerobic coverage, typically with clindamycin or ticarcillin/clavulanic acid
• If gram-negative bacteria are suspected or isolated, an aminoglycoside should be added
• Early CT-guided percutaneous aspiration or drainage has been advocated because it can
hasten the recovery and shorten the course of parenteral antibiotic therapy needed.
• For severely ill patients, patients with larger abscess, or those whose status fails to
improve after 7-10 days of appropriate antimicrobial therapy, surgical intervention
should be considered.
• Minimally invasive percutaneous aspiration techniques, often with CT guidance, are the
initial and, often, only intervention required
• Thorascopic drainage has also been successfully used with
• minimal complications.
• In rare complicated cases, thoracotomy with surgical drainage or lobectomy and/or
decortication may be necessary.
• Abscess drainage is reportedly required in ~20% of cases

Pulmonary Abscess: Prognosis

• Overall, prognosis for children with primary pulmonary abscesses is excellent.
• The presence of aerobic organisms may be a negative prognostic indicator, particularly
in those with secondary lung abscesses.
• Most children become asymptomatic within 7-10 days, although the fever can persist
for as long as 3 wk.
• Radiologic abnormalities usually resolve in 1-3 mo but can persist for years.

Pulmonary Edema
 • abnormal fluid collection in the interstitium and air spaces of the lung resulting in
oxygen desaturation, decreased lung compliance, and respiratory distress
• common in the acutely ill child
• traditionally separated into two categories according to cause ( cardiogenic and
noncardiogenic) but the end result of both processes is a net fluid accumulation within
the interstitial and alveolar spaces.
• Noncardiogenic pulmonary edema, in its most severe state, is also known as acute
respiratory distress syndrome

Pulmonary Edema: Pathogenesis

• forces and physical factors that determine fluid movement through the vessel:
1. hydrostatic pressure
2. colloid osmotic (oncotic) pressure on either side of pulmonary vascular wall
3. vascular permeability
• Baseline conditions lead to a net filtration of fluid from the intravascular space into the
interstitium
• "extra" interstitial fluid is usually rapidly reabsorbed by pulmonary lymphatics
• Conditions that lead to
Altered-vascular permeability
Increased- pulmonary vascular pressure
Decreased - Intravascular oncotic pressure
• lead to increase in the net flow of fluid out of the vessel
• Once the capacity of the lymphatics for fluid removal is exceeded, water accumulates in
the lung.

Pulmonary Edema: Clinical Manifestations

• clinical features depend on the mechanism of edema formation.
• In general, interstitial edema and alveolar edema prevent the inflation of alveoli,
leading to atelectasis and decreased surfactant production
• This results in diminished pulmonary compliance and tidal volume.
• patient must increase respiratory effort and/or the respiratory rate so as to
maintain minute ventilation.
• Earliest clinical signs of increased work of breathing, tachypnea, and dyspnea.
• As fluid accumulates in the alveolar space, auscultation reveals fine crackles and
wheezing, especially in dependent lung fields
• In cardiogenic pulmonary edema, a gallop may be present as well as peripheral
edema and jugular venous distention.
Pulmonary Edema: Diagnostics
•CXR
• Normal
• Early: peribronchial and perivascular cuffing
• Late; Diffuse, patchy densities, the so-called butterfly pattern, represent bilateral
interstitial or alveolar infiltrates
• Cardiomegaly is often seen with cardiogenic causes
• Chest tomography demonstrates edema accumulation in the dependent areas of the lung.

Pulmonary Edema: Treatment

• Noncardiogenic pulmonary edema
• largely supportive, with the primary goal to ensure adequate ventilation and
oxygenation.
• Patients should receive supplemental oxygen to increase alveolar oxygen
tension and pulmonary vasodilation
• Additional therapy is directed toward the underlying cause.
• Cardiogenic
• diuretics, inotropic agents and systemic vasodilators to reduce left ventricular
afterload
• Positive airway pressure improves gas exchange in patients with pulmonary edema
• prevents complete closure of alveoli at the low lung volumes present at the end of
expiration.
• also recruit already collapsed alveolar units leads to increased functional residual
capacity and improved pulmonary compliance, improved surfactant function, and
decreased pulmonary vascular resistance
• net effect is to decrease the work of breathing, improve oxygenation, and decrease
cardiac afterload.
• Lung protective strategies for mechanically ventilated patients include:
• setting low tidal volumes
• relatively high positive end-expiratory pressure
• allowing for permissive hypercapnia
SAMPLEX PEDIATRICS 2

SOURCE: BRS PULMO SAMPLEX

1. A 2-year-old toddler presents with a 3-day history of increasing inspiratory stridor, cough, and increased work of breathing. On examination,
you confirm the inspiratory stridor and also note intercostal retractions and tachypnea with a respiratory rate of 44 breaths/min. Which of the
following is correct regarding the cause and management of the probable diagnosis?
(A) Parainfluenza virus is the most likely cause.
(B) Foreign body aspiration is unlikely because of the absence of a history of choking. (C) Albuterol nebulization should be administered.
(D) A “thumbprint sign” will be found on a lateral radiograph of the neck.
(E) Antibiotics against Staphylococcus aureus are indicated.

Croup is the most common cause of acute stridor and cough in toddlers, and parainfluenza virus causes the majority of these infections. Foreign
body aspiration may cause stridor or cough and should be considered as a cause because in as many as 50% of foreign body aspirations, choking
is not witnessed. Albuterol plays no role in management of croup unless associated asthma or wheezing is present. An anterior-posterior
radiograph of the neck will show a “steeple sign” characteristic of subglottic narrowing; however, a “thumbprint sign” is associated with
epiglottitis. Antibiotics are not indicated for croup.

2. A 5-month-old female infant in a day care facility develops a low-grade fever to 100.8 F (38.2 C), rhinorrhea, and cough. A few days later, she
is brought to the emergency department with tachypnea, chest retractions, diffuse expiratory wheezing, and fine inspiratory crackles bilaterally.
Which of the following is correct regarding her likely diagnosis?
(A) Chest radiography will demonstrate decreased lung volumes with bilateral lobar consolidation.
(B) Chlamydia trachom atis should be considered as a possible etiologic agent.
(C) Supportive care is the most important management.
(D) Intravenous erythromycin should be started.
(E) Ribavirin should be administered.

This patient’s clinical features are consistent with bronchiolitis, a lower respiratory tract infection. Supportive care is the most effective
management, although inhaled albuterol and racemic epinephrine may have some benefit for some patients. Respiratory syncytial virus (RSV) is
the most common cause of bronchiolitis. Chest radiography usually demonstrates hyperinflation and atelectasis. Chlamydia trachom atis
pneumonia generally occurs in a young infant, 1–3 months of age, and would be very unlikely in a 5-month-old infant. Erythromycin is not effective
for bronchiolitis. Evidence for the benefit of ribavirin in the treatment of bronchiolitis is lacking, and ribavirin should only be considered for
severely ill infants.

3. A previously healthy 13-year-old boy presents with a 2-week history of nonproductive cough and low-grade fever. On examination, you note a
normal respiratory rate and no evidence of respiratory distress, but are surprised to also hear inspiratory rales at the bilateral lung bases. Which
of the following is the most likely cause of pneumonia in this adolescent?
(A) Pneumocystis carinii
(B) Staphylococcus aureus
(C) Group B streptococcus
(D) Haemophilus influenzae type b
(E) Chlamydia pneumoniae

The most common cause of pneumonia in older children and adolescents is infection with Mycoplasma pneum oniae and Chlamydia pneum
oniae. Pneumonia in immunocompromised patients may be caused by Pneum ocystis carinii. Although pneumonia as a result of Staphylococcus
aureus may occur in adolescents, it is less common than Mycoplasma and Chlamydia infection. Group B streptococcus is an organism unique to
the neonatal period. Haem ophilus influenzae type b (HIB) typically causes pneumonia in infants and toddlers, although the incidence has declined
markedly as a result of effective vaccination against HIB.

4. A 7-month-old male infant presents with failure to thrive, and he has had two previous episodes of pneumonia. Past medical history is also
significant for meconium ileus during the neonatal period. Which of the following is correct regarding his likely diagnosis?
(A) Electrolytes demonstrate hypernatremic, hyperchloremic metabolic alkalosis.
(B) His lungs are likely colonized with Staphylococcus aureus.
(C) Pulmonary function studies show increased lung volume consistent with restrictive lung disease.
(D) There is a 50% chance that a subsequent sibling will have the same illness.
(E) Pathophysiology involves abnormal calcium transport.

The likely diagnosis is cystic fibrosis (CF). Lung disease eventually develops in all individuals with CF; the lungs are initially colonized with
Staphylococcus aureus and subsequently with Pseudomonas aeruginosa. Twenty percent of neonates with CF present with meconium ileus, an
impaction of inspissated meconium that causes congenital intestinal obstruction. Classic electrolytes reveal a hyponatremic, hypochloremic,
hypokalemic metabolic alkalosis. Pulmonary function studies demonstrate decreased respiratory flow rates consistent with obstructive lung
disease early in the disease process. Later, restrictive lung disease patterns are present. The autosomal recessive inheritance of CF means that
each subsequent sibling has a 25% chance of having the disease. Pathophysiology involves an altered ion-channel regulator (CFTR) protein,
resulting in abnormal sodium and chloride transport in epithelial cells.
5. A 5-year-old girl presents with failure to thrive. Workup reveals a sweat chloride level of 90 mmol/L, which is consistent with cystic fibrosis.
Which of the following is true regarding this patient’s management?
(A) True malabsorption is uncommon and if it occurs, the malabsorption responds well to good nutrition.
(B) Antibiotic therapy should be avoided to prevent development of resistant organisms.
(C) Bronchodilators are ineffective in this condition.
(D) Replacement of vitamin K is necessary.
(E) Chest physical therapy provides little added benefit.

Pancreatic insufficiency and malabsorption are very common and require pancreatic enzyme replacement and the administration of fat-soluble
vitamins (vitamins A, D, E, and K). Nutritional support is very important as patients commonly have failure to thrive with difficulty gaining weight,
and high-calorie diets are therefore prescribed. Broad-spectrum antibiotics should be used for treatment of pulmonary exacerbations. Other
effective modalities in CF are bronchodilators for wheezing and aggressive pulmonary toilet, including chest physical therapy

6. A male infant born at 29 weeks gestation was diagnosed with surfactant deficiency syndrome. He required 3 months of mechanical ventilatory
support and oxygen therapy. Now he is ready for discharge from the neonatal intensive care unit and will go home on 0.25 L/min of oxygen.
Which of the following is likely to be correct regarding his lung function?
(A) He will probably develop obstructive lung disease.
(B) Because of the difficulties breathing and swallowing in young premature infants, his caloric intake should be minimized.
(C) His lung function will continue to deteriorate with time and further growth.
(D) His chest radiograph will be normal because he has clinically improved. (E) His lung disease should not affect his development.

Prematurity and barotrauma from prolonged mechanical ventilation are significant risk factors for the development of bronchopulmonary
dysplasia or chronic lung disease. Lung injury typically causes a combination of obstructive (from dysplastic and narrowed airways) and restrictive
(from lung tissue fibrosis) lung disease. To meet their metabolic demands and facilitate growth, patients require very high caloric intakes.
Pulmonary disease improves with time and lung growth, although chest radiographs may remain abnormal for years. Development is often
delayed in children with chronic lung disease.

7. A 3-month-old female infant required mouth-to-mouth resuscitation by her mother when she became blue and limp after feeding. In the
emergency department, the physical examination is completely normal. Which of the following is correct regarding her presentation?
(A) A home apnea monitor should be ordered and will prevent sudden infant death syndrome in this high-risk infant.
(B) Her presentation likely represents periodic breathing, and reassurance should be given.
(C) Sweat chloride test should be performed to rule out cystic fibrosis.
(D) Even though no seizure activity was witnessed, an electroencephalogram should be considered as part of the evaluation.
(E) Given a normal examination in the emergency department, the patient may be discharged home with close follow-up.

This patient had an apparent life-threatening event (ALTE). The evaluation of an ALTE should include attempts to identify an underlying cause,
and workup may include an electroencephalogram to rule out a seizure disorder, an electrocardiogram to rule out a dysrhythmia such as long QT
syndrome, electrolytes, a barium esophagogram or pH probe study to rule out gastroesophageal reflux disease, and a sleep study. An ALTE is not
a presentation of cystic fibrosis (CF), and therefore a sweat chloride test is not indicated. Patients with CF generally present with failure to thrive,
repeated pulmonary infections, or evidence of pancreatic insufficiency. After an ALTE, many experts recommend observation and monitoring of
the infant in the hospital and, sometimes, discharge home on an apnea monitor. However, the effectiveness of an apnea monitor in preventing
sudden infant death syndrome has not been established. The patient’s presentation is not consistent with periodic breathing, which is defined as
a breathing pattern with three or more respiratory pauses lasting 3 seconds each, with less than 20 seconds of normal respirations in between.

8. A 3-year-old boy presents with acute onset of fever to 103.5 F (39.7 C), diminished appetite, and drooling. He has been previously well, and
inspection of his immunization records reveals that all are up-to-date for his age. On examination, you note that he appears very ill and prefers
to sit leaning forward on his hands with his neck hyperextended. His voice is muffled. Which of the following is correct regarding his likely
diagnosis?
(A) This patient likely has bacterial tracheitis and should be started on antistaphylococcal antibiotics.
(B) Racemic epinephrine should be immediately administered.
(C) Anesthesiology should be consulted and should visualize his airway and intubate him in a controlled environment (e.g., operating room).
(D) An anterior-posterior radiograph of the neck will show a “steeple sign.”
(E) The throat should be examined with a tongue depressor to rule out retropharyngeal abscess.

This patient’s presentation with fever, toxic appearance, muffled speech, tripod positioning when seated, drooling, and neck hyperextension all
point to epiglottitis as a possible diagnosis. Epiglottitis is now a very uncommon infection as a result of the successful immunization of children
against Haem ophilus influenzae type b (HIB); however, epiglottitis may still occur secondary to infection with streptococcal and staphylococcal
species. Management includes avoidance of excessive stimulation, including examination of the pharynx with a tongue depressor, because this
may induce respiratory distress. Evaluation of the airway and intubation by experienced personnel in a controlled setting is necessary. Racemic
epinephrine is not effective in epiglottitis. A “steeple sign” on a radiograph of the neck is consistent with the diagnosis of croup, not epiglottitis
(which demonstrates a “thumbprint sign” on lateral radiograph of the neck). Bacterial tracheitis presents with fever and stridor (rather than a
muffled voice), and drooling and neck hyperextension are unlikely to be present.
9. A 6-week-old female infant presents with increased work of breathing and a staccato type cough for 3 days. On physical examination you note
a temperature of 98.8 F (37.1 C), a respiratory rate of 60 breaths/min, and bilateral conjunctival erythema. The lungs are clear except for mild
wheezing at the bilateral lung bases. Which of the following is correct regarding her likely diagnosis?
(A) Pneumonia is unlikely given the absence of fever, and therefore a noninfectious cause of the patient’s symptoms should be sought.
(B) Eosinophilia will be found on complete blood count.
(C) Blood culture will be positive in 25% of cases.
(D) Corticosteroids are indicated and will improve the patient’s clinical course.
(E) Ribavirin should be considered.

This patient’s clinical features point to a likely diagnosis of pneumonia secondary to infection with Chlamydia trachom atis, which is a common
cause of pneumonia in patients 1–3 months of age. Patients are afebrile, have a characteristic staccato-type cough, and may have a history of
conjunctivitis (in 50% of cases). Diagnosis is suggested by the presence of elevated eosinophils on complete blood count. Blood cultures are not
positive in this infection. Management includes oral erythromycin or azithromycin. Neither corticosteroids nor ribavirin are effective treatments
for C. trachom atis pneumonia.

10. A 9-year-old girl with asthma is brought to the office for the first time. On average, she uses her albuterol inhaler three times per week, but
for the past 10 days, she has been wheezing both day and night and is using the inhaler three to four times per day. On examination, you note
diffuse wheezing and moderate subcostal retractions. Which of the following is the next step in management?
(A) Order a chest radiograph to assess pneumonia.
(B) Refer her to an allergist for allergen immunotherapy.
(C) Start an oral leukotriene modifier.
(D) Start a low-dose inhaled corticosteroid.
(E) Start a 5-day course of systemic corticosteroids.

This patient presents with a moderate exacerbation of her chronic asthma and therefore would benefit from a 5- to 10-day course of systemic
corticosteroids. Both inhaled corticosteroids and leukotriene inhibitors are effective management options for the prevention and long-term
management of asthma, and these agents should be considered for this patient after the systemic corticosteroids. Allergen immunotherapy may
also be beneficial but would not be the initial step in management. Pneumonia is unlikely, and therefore a chest radiograph is not indicated.

The response options for statements 11 and 12 are the same . You will be required to select one and sw e r for each statement in the set.
(A) Short-acting inhaled 2-agonist for symptom relief plus medium-dose inhaled corticosteroid
(B) Short-acting inhaled 2-agonist for symptom relief
(C) Short-acting inhaled 2-agonist for symptom relief plus long-acting 2-agonist and high-dose inhaled corticosteroid
(D) Short-acting inhaled 2-agonist for symptom relief plus low-dose inhaled corticosteroid
(E) Inhaled cromolyn sodium for symptom relief For each description of a patient with asthma, select the most appropriate pharmacologic
therapy.

11. A 12-year-old girl with daily wheezing and nighttime symptoms two times per week. A

12. A 10-year-old boy with wheezing every other month associated with cold symptoms. B

Asthma is graded on a severity scale on the basis of the frequency of asthma symptoms during the day and night and also on pulmonary function
testing. The 12-year-old girl’s asthma would be characterized as moderate persistent asthma because of the presence of daily symptoms and
nighttime wheezing more often than once per week. The best treatment for moderate persistent asthma is mediumdose inhaled corticosteroids
added to as needed inhaled 2-agonists. The 10-year-old boy’s asthma would be characterized as intermittent asthma because his asthma
symptoms occur twice weekly or less, and nighttime symptoms twice monthly or less. The best treatment for intermittent asthma is short-acting
inhaled 2-agonist medication.

SOURCE: NELSON

CLINICAL APPROACH TO COMMON PULMONOLOGIC COMPLAINTS

1. A 5-year-old developed intermittent wheezing and coughing with activities after his first trip to the park in the wintertime. However, his
symptoms are present on a daily basis now. He was born full term and had some episodes of wheezing in the past. He has never been started on
controller medication. His symptoms improve with albuterol when needed. What would be the best first-line approach to management in
preventing exacerbations in patients with chronic asthma?
a. Emergency room visit and as-needed albuterol treatments
b. Leukotriene inhibitors
c. Anti-immunoglobulin (Ig) E
d. Inhaled corticosteroids
e. Cromolyn sodium (Intal)

2. A 3-year-old girl presents with a temperature of 100.2°F, generalized malaise, and good oral intake. "She gets these all the time," the parents
tell you, "and her primary doctor always gives us the pink medicine and sometimes the white fruity one." The child is alert, with some discomfort,
nasal congestion, and slight cough. Her tympanic membranes are red with positive movement on insulation. Her chest examination notes no
increased work of breathing and good aeration with some mild wheezing. What would be the most appropriate treatment?
a. Myringotomy for positive identification and treatment
b. Antihistamines and decongestants
c. Acetaminophen
d. Azithromycin
e. Amoxicillin/potassium clavulanate

3. A 16-week-old afebrile infant presents with a runny nose and cough for the past 2 to 3 days. Physical examination shows that the infant has
intercostal retractions and bilateral rales, with a respiratory rate of 65 breaths/min and a heart rate of 130 beats/min. A chest x-ray shows diffuse
infiltrates. He was born full term without delivery complications with Apgars
9 and 9 at and 5 minutes. How did the infant most likely acquire this infection?
a. In your office during the routine 2-week visit
b. Fomites at the hospital
c. During the birth process
d. Droplet infection transmission
e. Airborne infection

4. A 6-month-old child is brought to your office by his parents. They report he has always been a noisy breather.They describe the sound as
inspiratory and loud. He was diagnosed with laryngomalacia at 4 weeks of age, but parents were told he was going to get better with time. Now
the baby appears tired and has peripheral and central cyanosis. His oxyhemoglobin saturation is 85%. What is the most important next step in
the diagnosis of this patient?
a. Screen for pneumonia
b. Follow-up and reassurance
C. Monitor for pulmonary hypertension
d. Chest radiograph and follow-up the following day
e. Albuterol treatment

5. A 20-month-old girl is brought to the emergency department by her parents. She developed upper respiratory symptoms 2 days ago but now
has "noisier breathing." Upon examination she has a cough and a loud stridor. A radiograph shows a tapered narrowing of the immediate
subglottic airway (see Fig. 74.2). Which of the following organisms is the most likely cause of this patient's symptoms?
a. S. Pneumoniae
b. Rhinovirus
c. Parainfluenza virus
d. Adenovirus
e. Haemophilus influenzae type b

6. A 15-month-old boy born at 35 weeks of gestation is brought to your primary care office with respiratory distress, coughing, and wheezing. His
5-year-old brother had coughing 5 days ago. The baby is in mild respiratory distress and has mild intercostal flaring, bilateral polyphonic wheezing,
and intermittent cough. His pulse oximetry is 95%. He is moderately dehydrated. While in the office, you give him an albuterol treatment. and
his respiratory status improves. His parents appear overwhelmed by the situation. What would be your next step in management?
a. Reassurance and follow-up the following day
b. Admit to the hospital for close monitoring and rehydration
C. Systemic steroids for 7 days
d. Start a combination therapy
e. Start albuterol every 4 hours and discharge home

7. You are evaluating a 5-year-old boy for the first time in your practice. He presents for regular checkups. You notice that the patient has digital
clubbing. On further questioning. you find out that he has had recurrent pneumonias (five to six episodes every year) and that his weight has
always been in the 10th percentile. Which of the following laboratory tests is most appropriate to order during additional evaluation of this
patient?
a. Serum transaminase level
b. Sweat test
c. Chest radiography
d. Serum protein levels
e. Fecal elastase

8. A 14-year-old male with upper respiratory symptoms and cough has been taking benzocaine candy to alleviate oropharyngeal pain. This
morning he noted that his hands and feet were blue and came to your office for evaluation. He appears tired and is coughing, his oxy-
hemoglobin saturation by pulse oximeter is 50%. And the Pa0, on arterial blood gas is 98 mm Hg. Which of the following is the most likely cause
of this patient's clinical and laboratory findings?
a. Pulmonary hypertension
b. Spontaneous pneumothorax
c. Methemoglobinemia
d. CO intoxication
e. Congenital heart disease
9. During a well checkup, the mother of a 4-month-old baby informs you that her child "is always wheezing." He has periods of quiet breathing,
but after feeding he has wet regurgitation and cough, followed by wheezing. He was born full term, was discharged home with his mother, and
has been gaining weight adequately. During the office visit, you notice an emetic event followed by transient intermittent costal retractions and
wheezing. He remained happy
and without discomfort during the episode and was ready to continue feeding immediately after. Of the following, which would be the most
adequate next
step in management?
a. Admit to the hospital for pH probe testing
b. Reassurance followed by providing simple initial reflux control strategies (limit overfeeding, elevate the head after feeds, etc.)
c. Chest radiograph
d. Chest tomography
e. Referral to surgery for a Nissen fundoplication

10. A 4-year-old girl is brought to the office by her parents for a new well-child visit. Height is in the 3rd percentile, and weight is in the 1st
percentile. During the inter- view, the parents say that the patient has been treated multiple times since infancy because of sinus infections and
pneumonia. They also note that her stools are generally loose. greasy, and resembling mucus. During physical examination, the patient coughs
frequently. Your examination is remarkable for diffuse polyphonic wheezing. No other abnormalities are noted. Which of the following studies is
most effective to determine the diagnosis in this patient?
a. Bronchoscopy
b. CT scan of the chest
C. Culture of aspirate from the trachea
d. Measurement of serum immunoglobulin levels
e. Sweat chloride test

NEONATAL LUNG DISORDER

1. You are called to the newborn nursery to assess a full-term infant noted to have frothing at the mouth and coughing. The nurse attempted to
feed the infant a bottle, and the baby began to choke. Upon review of the infant's chart. you note that the prenatal course and delivery were
unremarkable. Maternal prenatal laboratory results were negative. The infant has not passed meconium. On examination. You also note that the
infant has malformed thumbs and a holosystolic murmur. What is the best next step in your diagnostic evaluation of this infant?
a. Place a nasogastric tube and obtain a chest x-ray.
b. Perform an echocardiogram.
c. Continue to observe the infant.
d. Obtain a blood culture and administer IV antibiotics.
e. Proceed with endotracheal intubation to secure the airway.

2. You attend the delivery of a full-term infant noted to have meconium-stained fluid upon rupture of membranes. The prenatal course was
otherwise unremarkable. When the infant is delivered, he has nasal flaring, is tachypneic, and has subcostal and intercostal retractions. He is
hypoxemic. The infant ultimately requires endotracheal intubation and umbilical line placement. He is started on broad-spectrum IV antibiotics
upon transfer to the neonatal intensive care unit. What complication is this infant most at risk for developing?
a. Surfactant deficiency
b. Pneumothorax
c. Subglottic stenosis
d. Gastroesophageal reflux
e. Intracranial hemorrhage

3. Risk factors for the development of transient tachypnea of the newborn include:
a. Female sex
b. Shoulder dystocia
C. Cesarean section without labor
d. Preeclampsia
e. Prolonged rupture of membranes.

4. You are called to the delivery of an infant whose mother had no prenatal care. The infant is born precipitously via vaginal delivery. On
examination, she is tachypneic and hypoxemic. You note that her abdomen is sunken in. Upon auscultation, you do not appreciate breath sounds
on the left side of her chest. You place an endotracheal tube and stabilize the infant. You obtain chest and abdominal radiographs. What is the
most likely finding on imaging?
a. A large pneumothorax
b. Congenital pulmonary airway malformation
c. Congenital diaphragmatic hernia
d. Tracheoesophageal fistula
e. Duodenal atresia
5. An infant born at 29 weeks' gestation for premature rupture of membranes has nasal flaring. retractions, and tachypnea. The disease process
that this infant is most likely to be exhibiting is:
a. Meconium aspiration syndrome
b. Neonatal respiratory distress syndrome
c. Persistent pulmonary hypertension of the newborn
d. Transient tachypnea of the newborn
e. Congenital diaphragmatic hernia

DISORDER OF THE UPPER AND LOWER AIRWAYS

1. An 18-month-old male with no past medical history presents to your emergency room with days of rhinorrhea, cough. and fever. Since
yesterday he developed shortness of breath and has refused all oral intake. Denies history of choking or aspiration. He has not had a wet diaper
for almost 24 hours, He is currently febrile, and pulse oximetry shows saturation of 94%. On examination he is tachycardia and tachypneic, with
subcostal retractions and occasional
nasal flaring. He is irritable yet consolable. Oral membranes are dry, tacky, and without erythema. Pulmonary auscultation reveals fair aeration
with rhonchi and expiratory wheezes scattered bilaterally. What is the next step?
a. Administer three back-to-back bronchodilator treatments and reassess.
b. Obtain a chest radiograph.
C. Administer an IV fluid bolus and admit for hydration and respiratory monitoring.
d. Prepare for rapid-sequence endotracheal intubation and mechanical ventilation.
e. Administer IV antibiotics.

2. An 18-month-old male with a history of bronchiolitis presents to your emergency room with less than an hour of coughing and trouble
breathing. A week ago he had rhinorrhea and a fever of 106°F. The fever resolved after 2 days, with onset of a worsening rash. Today his mother
was feeding him when she turned her back for a minute to grab more grapes from the refrigerator. He suddenly started coughing and became
agitated. They were brought in via ambulance. Abdominal thrusts were attempted while in transit, without any change in status. He is currently
awake, stridulous, and exhibiting suprasternal and intercostal retractions and head bobbing. He has a maculopapular rash on his trunk and limbs
that is beginning to fade. He is tachycardic and tachypneic with normal heart sounds and noisy breath sounds with transmitted stridor throughout.
What is the next step?
a. CT scan of chest
b. Admission to the hospital for initiation of CPAP therapy
C. Education of the mother regarding safe toddler foods
d. Lateral neck radiograph
e. Advanced airway management: call otolaryngology for emergent rigid bronchoscopy

3. A 12-year-old female with a history of static encephalopathy. spastic cerebral palsy, severe Intellectual disability, and tracheostomy presents
to clinic for a well-child visit. The tracheostomy was placed almost a year ago after development of obstructive
sleep apnea and a hospitalization with prolonged endotracheal intubation for complicated influenza pneumonia. Since then she has developed
worsening wheezing and coughing episodes, often occurring during oral feeds of pureed foods. These symptoms have
persisted despite initiation of a proton pump inhibitor for treatment of gastroesophageal reflux. In the last few months she has had three
pneumonias. You review her chest radiographs and determine that all of them demonstrate an area of patchy opacity in the right lower lobe. On
examination she has scattered rhonchi bilaterally but decreased breath sounds at the right base. She is febrile, well-appearing, and not in acute
distress, Pediatric pulmonology services are not immediately available in your geographic area of practice. Which of the following is the next best
step to evaluate this patient's underlying condition?
A. Modified barium swallow study with speech pathology
b. Addition of home mechanical ventilation
C. Initiation of nebulized bronchodilators
d Repeat a sleep study to reevaluate obstructive sleep apnea
e, CT scan of the chest

4. A 4-year-old former full-term-gestation. Typically developing male has a history of chronic wet cough since 6 months of age, multiple sinus
infections and pneumonias, and weight loss. Which list of diagnostic tests would represent all of the most concerning diseases in the differential
diagnosis?
A. Swallow study, sweat chloride test. ciliary brush biopsy, ANA. serum immunoglobulins
b. Swallow study, sweat chloride test, exercise stress test, blood count, serum immunoglobulins
C. Chest CT. sweat chloride test, ciliary brush biopsy, blood count, serum immunoglobulins
d. Chest CT. Epstein-Barr serologies, ciliary brush biopsy, blood count. serum immunoglobulins
e. Chest CT. sweat chloride test, exercise stress test, blood count. echocardiography

5. A 10-month-old female presents with 4 days of rhinorrhea, cough, and fever and is found to have bilateral wheeze. Which of the following
increases the child's risk of developing chronic asthma?
a. Prior wheezing episodes, especially in the absence of respiratory viral infection
b. Physician-made diagnosis of eczema in a parent
c. Physician-made diagnosis of asthma in a parent
d. A and B
e. A and C

6. A 7-year-old male who was lost to long-term follow-up for a few years now returns to the clinic with a long history of wheezing episodes,
frequent bronchodilator use, and multiple hospitalizations for status asthmaticus. He has not had intensive care admissions. He has a dry cough
that bothers him every day and wakes him up at night twice a week. When he is playing and running around lot. he gets short of breath and
sometimes has to catch his breath. He has a history of mild eczema and seasonal allergic rhinitis. His growth and development are otherwise
normal. Spirometry reveals a PEV1 of 70% and is otherwise normal. How would you categorize his disease?
A. exercise-induced asthma
b. intermittent asthma
c. mild persistent asthma
d. moderate persistent asthma
e. severe persistent asthma

7. An 18-month-old male with multiple prior wheezing episodes responding to albuterol presents to your emergency room with 4 days of
rhinorrhea, cough, and fever. Since yesterday he developed shortness of breath and has refused all oral intake. His parents deny a history of
choking or aspiration. He has not had a wet diaper for almost 12 hours. Albuterol given at home today did not improve his work of breathing. His
blood pressure is normal, rectal temperature is 39°C. and pulse oximetry shows saturation of 94%. On examination he is tachycardic and
tachypneic, with subcostal retractions and nasal flaring. He is irritable. Oral membranes
are moist and without erythema. Pulmonary auscultation reveals fair aeration with rhonchi and expiratory wheezes scattered bilaterally. What is
the next step?
a. Administer three back-to-back bronchodilator treatments and reassess.
b. Obtain a chest radiograph.
C. Administer an IV fluid bolus and admit for hydration and respiratory monitoring.
d. Prepare for rapid-sequence endotracheal intubation and mechanical ventilation.
E. Administer IV antibiotics.

8. The above patient was admitted to the hospital on continuous nebulized albuterol: however, his father refused for his son to receive systemic
steroid treatment after he noticed the child becoming tremulous and unable to sleep. Which of the following statements regarding systemic
steroids are false?
a. They are indicated for asthma exacerbations not fully responding to bronchodilators,
b. They are typically administered intramuscularly, intravenously. or via inhalation.
C. They can prevent/treat late-phase response of asthma.
d. Prolonged or frequent use may cause adrenal sup- pression.
e. They are not indicated for maintenance therapy of mild or moderate persistent asthma.

9. The above patient improves and is eventually dis- charged from the hospital. At outpatient follow-up a couple of days later, he is well-appearing
and you initiate a low-dose inhaled corticosteroid. Six weeks later he returns to the clinic for another asthma evaluation. His mother reports that
he has been "doing well," without any hospital or ER visits. On further questioning. she reveals that he has a recurring dry cough *about every
other day." He has woken up coughing once a week. This cough responds well to "the medication." All of the following actions are appropriate
except for which?
a. Ask about triggers and environmental exposures.
b. Review schedule and indications for each medication.
C. Review medication technique.
d. Add on LTRA.
e. Increase inhaled steroid to medium dose.

10. Which of the following increases a child's risk of hospitalization for asthma?
a. Poor perception of symptoms
b. Daily asthma symptoms or decreased pulmonary function
C. Daily use of oral steroids
d. Excessive use of bronchodilators
e. All of the above

PARENCHYMAL AND EXTRAPULMONARY DISORDERS

1. A previously healthy and fully immunized 20-month-old girl presents to the clinic with fever and a productive cough that started abruptly 2
days ago. On examination, her temperature is 102°F, heart rate is 134 beats/ min. respiratory rate is 38 breaths/min. and oxyhemoglobin
saturation is 99% in room air. She has scattered crackles at the right lung base. She is fussy but fights vigorously and appropriately on examination.
She appears well hydrated and parents note that she Is playful after ibuprofen. What is the next step in her management?
a. Admit to the hospital for IV antibiotics.
b. Order CBC. blood culture, and chest x-ray.
c. Start amoxicillin.
d. Start azithromycin.
e, No antibiotics are needed.
2. A previously healthy and fully immunized 20-month-old girl presents to the clinic with fever and a productive cough that started abruptly 2
days ago. She had a few crackles at the right base and was sent home on ibuprofen and amoxicillin. Two days later, parents report that she
continues to have fevers to 104°F. She is having several episodes of post-tussive emesis per day and seems more tired and fussy than usual. On
examination, she is febrile to 103°F, has a respiratory rate of 42 breaths/min. and has an oxyhemoglobin saturation of 88% in room air.
She has intermittent grunting and mild subcostal retractions. She has decreased breath sounds with dullness to percussion three-quarters of the
way up the right chest. A CXR with lateral decubitus view is obtained, which shows a layering effusion. CBC shows a WBC of 29,000 with 82%
PMN, and blood culture is pending. Select the most appropriate next step in this child's care.
a. Plan for immediate VATS.
b. Place a chest tube.
c. Change antibiotics from amoxicillin to IV vancomycin.
d. Discharge on linezolid and cefdinir.
C. Change antibiotics from amoxicillin to ampicillin.

Systemic disease with pulmonary involvement

1. A new baby has an elevated IRT level newborn screening, The sample is sent automatically for genetic analysis, One mutation that causes CF
and one mutation of unknown clinical significance are identified. The sweat test was 35 mmol/L. Choose the
best answer:
a. The baby has cystic fibrosis.
b. The parents should be tested for cystic fibrosis.
c. The IRT should be resent.
d. The patient should be monitored over time for the development of cystic fibrosis,

2. The most common gastrointestinal manifestation of cystic fibrosis is:

a. Rectal prolapse
b. Pancreatic insufficiency
c. Failure to thrive
d. Gallstones

3. Which of the following is the most accurate statement regarding the protein CFTR?
a. CFTR is a transmembrane protein chloride channel that upregulates ENaC.
b. CFTR dysfunction leads to increased chloride secretion into the airway lumen and decreased sodium absorption from the airway lumen.
C. CFTR dysfunction leads to decreased chloride secretion into the airway lumen and increased sodium absorption from the airway lumen.
d. CFTR downregulates ENaC, leading to decreased chloride secretion into the airway lumen.

4, Which of the following is the most accurate statement regarding mutations in CFTR?
a. Patients with a class 2 and class mutation are predicted to have milder disease.
b. Patients with a class 3 and class mutation are predicted to have severe disease.
c. Patients with two class 2 mutations are predicted to have milder disease.
d. Patients with class 2 and class 3 mutation are predicted to have milder disease.

5. Which of the following is the most accurate statement regarding Cystic Fibrosis?
a. Cystic fibrosis is the most common lethal genetic disease in the Caucasian population.
b. Bronchiectasis is an uncommon complication of cystic fibrosis.
C. Newborns with a positive IRT and two CFTR mutations identified have cystic fibrosis.
d. Male infertility is a rare complication of cystic fibrosis,

6. Choose the best answer regarding noninvasive ventilation for patients with neuromuscular weakness:
a. CPAP is effective in patients with nocturnal hypoventilation.
b. Patients often need bilevel with high inspiratory and expiratory pressures,
c. The use of noninvasive ventilation improves symptoms of nocturnal hypoventilation but does not increase longevity.
d. The use of narcotics after surgical procedures can exacerbate hypoventilation in neuromuscular patients.

7. Which of the following statements is true about diagnosing primary ciliary dyskinesia?
a. Clinical history is not helpful toward confirming a diagnosis.
b. Defects in microtubule structure are always visible when electron microscopy is performed on ciliary biopsy samples from positive PC cases.
C. Standard light microscopy is the gold standard for detecting normal ciliary movement.
d. Nasal nitric oxide testing is a noninvasive method to diagnose PCD in younger children.
e. Genetic testing may diagnose up to 70% of PCD cases.

8. Which of the following respiratory complications is associated with CVID?

a. Recurrent pneumonia and rhinosinusitis
b. Bronchiolitis obliterans organizing pneumonia
C. Granulomatous lymphocytic interstitial lung disease
d. Bronchiectasis
e. All of the above

9. Which of the following is the most accurate statement regarding the pulmonary manifestations of connective tissue disorders?
a. Hilar adenopathy is a common finding in young patients (under age 4 years) with sarcoidosis.
b, Pleuritis is the most frequent respiratory symptom in systemic lupus erythematosus.
C. Respiratory complications are rare with mixed connective tissue disease.
d. Chest x-ray is useful to diagnose connective-tissue disease related interstitial lung disease.
e. Pulmonary function testing is performed only at baseline diagnosis.

10. A 9-year-old boy underwent allogeneic stem cell transplant for acute lymphoblastic leukemia 20 days ago, His absolute neutrophil count is
120. He now has fever, dyspnea, and new oxygen requirements. Which of the following diagnostic tests should be performed first?
a. Spirometry
b. Bronchoalveolar lavage
c. Chest CT
d. A and C
E. Band C

PEDIA PULMO 2 QNA ACTIVITY

Pedia 2

1. The following statements about choanal atresia are correct, except?

a. Most common congenital anomaly of the nose

b. Babies born with it are always symptomatic

c. Associated with CHARGE syndrome

d. Suggested by inability to pass a catheter into the nasopharynx

e. Trans nasal repair is the treatment of choice

2. The ff statement is true regarding nasal foreign body:

a. Unilateral nasal discharge and sneezing are symptoms

b. Lateral skull radiograph Is done for all patients

c. Anterior dislodgement and aspiration are common complications

i. Posterior dislodgement

d. Mother’s blow approach can be done

i. Mother’s kiss

3. The most common site of bleeding in epistaxis

a. Kiesselbach plexus
4.

5. The frontal sinus is present at birth. Is this statement true or false?

a. False

6. How is sinusitis diagnosed in children?

a. Clinical diagnosis

7. A ten year old male is seen for moderate to high grade fever, vomiting and sore throat. On PE he is found to
have an erythematous rash on his palms, soles, neck and trunk. He has a bright red throat and a petechial rash on
his posterior palate. There are no exudates on the tonsils. The most probable infecting agent is? - bacterial

a. Coxsackie virus

b. Group A strep

c. MRS

d. Respiratory Syncytial virus

8.

9. A 2 year old presented at the ER with a sudden onset of cough, high fever, dysphagia and drooling. On PE, you
noted a stridor and the child in a tripod position. This is most likely:

a. Laryngotracheobronchitis

b. Epiglottitis
 c. Bacterial Tracheitis

d. Spasmodic Croup

10. Patient presenting with recurrent stridor since the first month of life. The most probable diagnosis is:

a. Laryngomalacia

11. The organism responsible for >50% of bronchiolitis

a. RSV

12.

13. This is the most consistent finding in pneumonia

a. Tachypnea

14. Pulmonary edema in drowning and near-drowning is characterized by:

a. Increase capillary permeability

b. Increase hydrostatic pressure

c. Increase oncotic pressure

d. Increase negative thoracic pressure