Medical Archive

N433-440 Epiglottis to Bronchiole

C412 Acute Inflammatory Upper Airway Obstruction (Croup, Epiglottitis, Laryngitis, and Bacterial Tracheitis)

Etiology and epidemiology

  • ?? ???? virus? m/c. (?? ?????)
  • ?? UTI ?, ??? ?, ?? X, ??? X, ??? ?? ??? ??
  • Microbiology
    • Viral: ??? ??? ????, ?? ????? ???? ??? ???? URI ???? ??? ??. ??? ????
    • Bacterial: S.pneumoniae, H.influenzae, Mycoplasma (m/c)
    • ???, immunocompromised: S.aureus, E.coli, P.aerusinosa
  • ?? O: ??, ???, ??? ??
  • ?? X: ???, ????, ?????

Clinical manifestations

Croup (Laryngotracheobronchitis)

  • Parainfluenza virus (75%) > Hib, etc. 3m~3yr ??
  • Symptom
    • ??? ?? ??? ?? ? 1-3?? URI symptom ??.
    • ?? ?? Barking cough, ??? ????? ?. ????
    • Inspiratory stridor
    • Hoarseness
    • # Spasmodic croup
  • Diagnosis
    • XR PA: ? ???? ??. ????? ??! Subglottic narrowing
  • Differential
    • Spasmodic croup
      • Non-infectious! ?? ??? WBC ?? ??, +/- ??? ???
      • ?? ???? ??? ?? ????? ?? ??? ?? ??? ??.
      • ??? ?? ?? ?? ?? ??. ? ??????, steroid
    • Bacterial tracheitis: croup ? ?? ?? ?? ? ??. S.aureus ? ?? ???! Epinephrine ?? ??x
  • Treatment
    • Goal: to correct the underlying subglottic edema.
    • Mild cases (no stridor at rest)
      • Humidified air ? PO corticosteroids
    • Moderate/severe (stridor at rest)
      • PO corticosteroids + nebulized epinephrine
      • After administration, patients are observed for 4 hrs b/c symptoms can recur. If do, typically require hospital admission.
    • Refractory and/or have signs of impending respiratory failure
      • Intubation with mechanical ventilation
  • Prevention
    • Handwashing
    • Decontamination of surfaces
    • Proper ventilation

Acute Epiglottitis (Supraglottitis)

  • Epidemiology
    • 2-7? ??
    • H.influenzae type B
    • Other strains of H.influenzae, Streptococcus spp., S.aureus
  • Symptom
    • High fever, drooling with dysphagia, stridor, ??? ?????? ??
  • Diagnosis
    • XR lateral: ???? ??? (thumb sign)
    • ???: ?? ?? ?? ?? ???? ??
  • Treatment
    • Antibiotics
      • Ceftriaxone – targeting H.influenzae & streptococcus spp.
      • Vancomycin – targeting S.aureus, including MRSA
    • ??? ??, ??? ?????.

Acute Infectious Laryngitis

Spasmodic Croup

Differential Diagnosis

Complications

Treatment

Antibiotic ?? ?? (eg, ceftriaxone, cefotaxime, meropenem)
??? ??? ???? ????? ??? rifampin ????.

Endotracheal/Nasotracheal Intubation and Tracheotomy

Prognosis

C413 Congenital Anomalies of the Larynx, Trachea, and Bronchi

C413.1 Laryngomalacia

Supraglottic tissues appear floppy and collapse on inspiration to partially block the airway.

Clinical manifestations

  • Stridor
    • Begins in the neonatal period and is loudest at age 4-8 months.
    • Increases with exertion (eg, crying, feeding) and improves with prone positioning.
    • Usually resolves spontaneously by age 18 months.
  • Gastroesophageal reflux (GER)

Diagnosis

Treatment

No need for specific treatment

C413.2 Congenital subglottic stenosis

Clinical manifestations

Diagnosis

C413.3 Vocal cord paralysis

Diagnosis

Treatment

C413.4 Congenital laryngeal webs and atresia

C413.5 Congenital subglottic hemangioma

C413.6 Laryngocelesand saccular cysts

C413.7 Posterior Laryngeal Cleft and Laryngotracheoesophageal Cleft

C413.8 Vascular and Cardiac Anomalies

Vascular ring

<Harrison>
Great vessels encircle & compress trachea
Biphasic stridor that improves with neck extension.

Noisy breathing shortly after birth.

C413.9 Tracheal Stenoses, Webs, and Atresia

C413.10 Foregut Cysts

C413.11 Tracheomalacia and Bronchomalacia

C414 Foreign Bodies in the Airway

6m~3yr, ??? m/c.
Supine?? RUL / Upright?? RML, RLL
Bypass valve (wheezing) < Check valve (hyperinflation) < Stop valve (atelectasis)
??? ??? ???? ??? ?? ??? ??? ??? ?? ??.
24hr ?? ??? ???? ?????? ?? ???? ??? ???? ??.

  • CXR
    • ??, ??? ?? ? ??. Check valve? ?? ??? ???? ???? ??.
    • Secondary change ??
  • Brohchoscopy
    • Flexible? ???, rigid? ?? ??+??

????? ?? ?? ? ????
1? ??: 5 back blow + 5 chest thrust
1? ??: Heimlich maneuver

C415 Laryngotracheal Stenosis and Subglottic Stenosis

C415.1 Congenital subglottic stenosis

See chapter 413.2

C415.2 Acquired laryngotracheal stenosis

Clinical manifestations

Diagnosis

Treatment

C416 Bronchomalacia and Tracheomalacia

C417 Neoplasms of the Larynx, Trachea, and Bronchi

C417.1 Vocal nodules

C417.2 Recurrent respiratory papillomatosis

  • Etiology
    • HPV subtypes 6 and 11
    • Most likely acquired via vertical transmission prior to delivery
  • Clinical features
    • Voice problems, airway obstruction, repeated operative interventions
    • In rare instances, it can spread beyond the vocal cords to involve the LRT.
  • Treatment
    • Surgical debridement

C418 Wheezing, Bronchiolitis, and Bronchitis

Bronchiolitis

Etiology and pathophysiology

  • Epidemiology
    • RSV (>50%) > parainfluenza, influenza, metapneumovirus, and other viruses.
    • 2? ?? ?? 6??? m/c ??, peaks in winter
  • Pathophysiology
    • ??, ??, ??? ? ? ???? ?? (check valve) ? ?? ???
  • Risk factors for severe RSV infection
    • <6 months of age
    • Prematurity
    • Heart or lung disease
    • Neuromuscular disease
    • Immunodeficiency

Clinical manifestations and diagnosis

  • Symptoms
    • Days 1-3: low-grade fever, rhinorrhea, cough. Young infants might have apnea
    • Day 4-6: respiratory distress, tachypnea, hypoxia
    • ?? ?? 48~72hr ?? ?? ??. ????? ??.
  • Physical exam
    • Tachypnea, hypoxia, intercostal retractions, nasal flaring
    • RR is the earliest and most sensitive vital sign change.
    • Wheezing ? crackles and respiratory distress
  • Chest XR
    • Hyperinflation with flattened diaphragms, interstitial infiltrates, and atelectasis
    • Consolidation (30%) – noisy chest
  • Nasopharyngeal aspirate
    • To test for RSV and other viruses
    • Highly sensitive and specific but has little effect on management
  • Differential diagnosis
    • Asthma
      • FHx / ?? / ????x / ???? / ?2 agonist? ??
      • ?? ?? ??? : FHx / ????? ?? ??? / ?????
    • Pneumonia
      • Chest XR – absence of a focal consolidation

Treatment

  • Supportive
    • Hydration (5DS + Half Saline)
    • Suctioning, and supplemental humidified O2
    • 30-40? ??, ? ??
  • If strong family history of asthma
    • Bronchodilators
  • Hospitalize
    • Those who are premature or young (age <2 months)
    • if intant’s tachypnea interferes with feeding or signs of severe illness are present
  • Ribavirin(virazole)
    • ??? ???/BPD ?? ???? ???? ??.
  • ???(????)
  • Steroid(??????)

Complications

  • Apnea (especially age <2 months)
  • Recurrent wheezing throughout childhood
  • Respiratory failure
  • Acute otitis media (~10%)
  • Bacterial pneumonia and sepsis are rare (<1%)

Prevention

  • Indication
    • Children age <2 yrs who are at exceptionally high risk of complications
    • <29 weeks gestation
    • Chronic lung disease of prematurity
    • Hemodynamically significant congenital heart disease
  • Contraindications
    • ?? ?? ???? ?? ????
  • RSV-IVIG or IM monoclonal antibody to RSV
    • RSV immune globulin is a polyclonal immune globulin formerly used in the prophylaxis of RSV infection. As a blood product prepared from donor serum, it had the potential to be contaminated. Its use was also associated with increased morbidity and mortality in patients with congenital heart disease. For these reasons, it was replaced by a safer alternative and is no longer available.
  • Nirsevunab (preferred)
    • Long-acting, single IM injection
  • Palivizumab (alternative)
    • Short-acting, monthly IM injection
IndicationsAgens and administration
Routine prophylaxis in 1st RSV seasonAll infants < 8 months of age if a maternal RSV vaccine was: Not given during pregnancy or cannot be verified
Administered within 14 days of birth		Give nirsevimab once.
A second dose is not required for healthy infants without indications for additional RSV prophylaxis even if they are < 8 months of age when entering their second RSV season.
Additional RSV prophylaxis in 2nd RSV season<Infants < 12 months of age>
Preterm birth at < 29 weeks’ gestation [11]
Chronic lung disease of prematurity
Hemodynamically significant congenital heart disease
Consider prophylaxis in infants with conditions that impair mucous clearance.
<Children 12–24 months of age>
Chronic lung disease of prematurity requiring treatment
Severely immunocompromised state
Cystic fibrosis with severe lung disease or poor weight gain [12][25][27]
Nirsevimab only: American Indian or Alaska Native descent
[26]		Preferred: Give nirsevimab once before the RSV season.
Alternative: Give palivizumab monthly DOSAGE
just before and during the RSV season. [12]
Infants and children given palivizumab can transition to nirsevimab if they have received:
[25] < 5 doses of palivizumab in the current RSV season
Palivizumab during the prior RSV season
If nirsevimab has been given in the current RSV season, do not administer palivizumab.




C419 Plastic Bronchitis