pearls 1

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=90 BGCOLOR="#006699" TEXT="#080000" bgproperties="fixed" background="02c285a1erlcgo.png"> <div> <FONT SIZE="5" COLOR="#FFCC66" FACE="Arial" ><B>usmle med 6</B></FONT><B>     |     </B><A HREF="index.htm" TARGET="_top" TITLE="usmle med 6"><U><B>home</B></U></A></div> <div> <B>pearls 1</B>   |   <A HREF="id20.htm" TARGET="_top" TITLE="pearls 2"><U>pearls 2</U></A>   |   <A HREF="id21.htm" TARGET="_top" TITLE="pearls 3"><U>pearls 3</U></A>   |   <A HREF="id22.htm" TARGET="_top" TITLE="pearls 4"><U>pearls 4</U></A>   |   <A HREF="id24.htm" TARGET="_top" TITLE="pearls 5"><U>pearls 5</U></A>   |   <A HREF="id18.htm" TARGET="_top" TITLE="qcm"><U>qcm</U></A>   |   <A HREF="id19.htm" TARGET="_top" TITLE="answers"><U>answers</U></A>   |   <A HREF="id17.htm" TARGET="_top" TITLE="Contact Me"><U>Contact Me</U></A></div> <div> </div> </td> </tr><tr> <td valign="top" width=210 BGCOLOR="#FFCC66" TEXT="#080000" background="02ad2c00dkelyh.png"> <div> pearls 1</div> <div> <A HREF="id20.htm" TARGET="_top" TITLE="pearls 2"><U>pearls 2</U></A></div> <div> <A HREF="id21.htm" TARGET="_top" TITLE="pearls 3"><U>pearls 3</U></A></div> <div> <A HREF="id22.htm" TARGET="_top" TITLE="pearls 4"><U>pearls 4</U></A></div> <div> <A HREF="id24.htm" TARGET="_top" TITLE="pearls 5"><U>pearls 5</U></A></div> <div> <A HREF="id18.htm" TARGET="_top" TITLE="qcm"><U>qcm</U></A></div> <div> <A HREF="id19.htm" TARGET="_top" TITLE="answers"><U>answers</U></A></div> <div> <A HREF="id17.htm" TARGET="_top" TITLE="Contact Me"><U>Contact Me</U></A></div> <div> d</div> <bR> <bR> <div> <IMG SRC="09a9e780.png" border=0 width="158" height="120" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <IMG SRC="09da0780.png" border=0 width="160" height="120" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> epiglottitis movie</div> <div> <IMG SRC="09f7b2a0.png" border=0 width="379" height="298" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> laryngomalacia</div> </td> <td valign="top" height=390 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <I>pearls 1</I></div> <div> a urine sodium greater than 40 meq/L suggests acute tubular necrosis </div> <div> urine sediment that shows renal tubular epithelial cells and muddy brown casts is diagnostic for acute tubular necrosis [see my renal failure lecture under renal physiology ] .</div> <bR> <div> =======================================================================================================</div> <div> Transient tachypnea of the newborn [<FONT SIZE="3" COLOR="#000000" FACE="Arial" >Wet Lung Disease (Transient Tachypnea of the Newborn) (TTN) (Retained Fetal Lung Liquid)<IMG SRC="096d8cf0.jpg" border=0 width="472" height="207" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></FONT></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> </B>Transient tachypnea of the newborn (TTN) is a disease common in infants throughout the world and has been encountered by all physicians who care for newborn infants</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">. Infants with TNN present within the first few hours of birth with</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> tachypnea, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">increased oxygen requirement,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> and occasional hypoxia noted on arterial blood gases without concomitant carbon dioxide retention. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">When managing an infant with TTN, it is important to observe for signs of clinical deterioration that may suggest other diagnoses and to observe closely for the development of fatigue</div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">occurs due to latent fluid remaining in the lungs post-partum.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">  it usually follows normal delivery. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Look for tachypnea, retractions of the chest expiratory grunting and cyanosis.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">  It is do to slow absorption of fetal lung fluid with</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> decreased pulmonary compliance, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">increased dead space and low tidal volume.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A newborn with transient tachypnea (TTN) has extra fluid in his lungs which causes him to: </div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="669" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="40"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="40" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="622"><div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">breathe rapidly (more than 60 times a minute) </div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="40"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="40" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="622"><div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">pull in his chest wall with each breath (retractions) </div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 38 WIDTH="40"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="38" ALIGN="bottom" WIDTH="40" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="622"><div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">occasionally have a bluish tinge around his lips (cyanosis), which indicates a need for extra oxygen. </div> </tD> </tR> </TABLE></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This rapid breathing begins shortly after birth and the baby's breathing rate usually becomes normal within 24 to 48 hours</div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Transient tachypnea is fast breathing that gradually gets better. </div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">It is thought to be due to slow reabsorption of fetal lung fluid.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Before birth the lungs continuously make fluid. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Some of this fluid is squeezed out as the baby comes down the birth canal. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The rest must be absorbed by the baby during the first minutes to hours of life.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> In babies with TTNB this process may last hours to days. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">TTNB is more <B>common in babies delivered by cesarean section because they did not have fluid squeezed out with delivery.</B></div> <bR> <div> The baby will have some difficulty with breathing. S/he may</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">breathe rapidly [TACHYPNEA]</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">make the "ugh" sound with each breath, called grunting. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">have a widening of the nostrils with each breath, called flaring. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">need extra oxygen. Room air is 21% oxygen. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The baby needs higher oxygen to stay pink. </div> <bR> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The roentgenographic findings are mild to moderate overaeration, symmetric parahilar patches or streaks, and occasionally mild cardiomegaly or pleural effusions .</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The right lung may be more opacified than the left.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The chest film returns to normal by 48-72 hours of age. </div> <DIV ALIGN="LEFT"></DIV> <div> ..<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> <B>Pathophysiology: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Noninfectious acute respiratory disease develops in approximately 1% of all newborn infants and results in admission to a critical care unit.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> TTN is the result of a delay in clearance of fetal lung liquid.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Respiratory distress typically was thought to be a problem of relative surfactant deficiency, but it is now characterized by an airspace-fluid burden secondary to the inability to absorb fetal lung liquid. </div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In vivo experiments have demonstrated that lung epithelium secretes Cl<FONT SIZE="1" COLOR="#000000" FACE="Arial" >-</FONT> and fluid throughout gestation but only develops the ability to actively reabsorb Na<FONT SIZE="1" COLOR="#000000" FACE="Arial" >+</FONT> during late gestation. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A<B>t birth, the mature lung switches from active Cl</B><FONT SIZE="1" COLOR="#000000" FACE="Arial" ><B>-</B></FONT><B> (fluid) secretion to active Na</B><FONT SIZE="1" COLOR="#000000" FACE="Arial" ><B>+</B></FONT><B> (fluid) absorption in response to circulating catecholamines. </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Changes in oxygen tension augment the Na<FONT SIZE="1" COLOR="#000000" FACE="Arial" >+</FONT>-transporting capacity of the epithelium and increase gene expression for the epithelial Na<FONT SIZE="1" COLOR="#000000" FACE="Arial" >+</FONT> channel (ENaC). </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The inability of the immature fetal lung to switch from fluid secretion to fluid absorption results, at least in large part, from an immaturity in the expression of ENaC, which can be upregulated by glucocorticoids. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Both pharmacologic blockade of the lung's EnaC channel and genetic knockout experiments using mice deficient in the ENaC pore-forming subunit have demonstrated the critical physiologic importance of lung Na<FONT SIZE="1" COLOR="#000000" FACE="Arial" >+</FONT> transport at birth.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> When Na<FONT SIZE="1" COLOR="#000000" FACE="Arial" >+</FONT> transport is ineffective, newborn animals develop respiratory distress; hypoxemia; fetal lung liquid retention; and, in the case of the ENaC knockout mice, death. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Bioelectrical studies of human infants' nasal epithelia demonstrate that both TTN and respiratory distress syndrome (RDS) have defective amiloride-sensitive Na<FONT SIZE="1" COLOR="#000000" FACE="Arial" >+</FONT> transport. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">These results suggest that infants with neonatal RDS have, in addition to a relative deficiency of surfactant, defective Na<FONT SIZE="1" COLOR="#000000" FACE="Arial" >+</FONT> transport, which plays a mechanistic role in the development of the disease.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> An infant born by cesarean delivery is at risk of having excessive pulmonary fluid as a result of having not experienced all of the stages of labor and subsequent low release of counter-regulatory hormones at the time of delivery. </div> <bR> <div> <B>Frequency: </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In the US: </B>Frequency is equivalent universally. Approximately 1% of infants have some form of respiratory distress that is not associated with infection. Respiratory distress includes both RDS (ie, hyaline membrane disease) and TTN. Of this 1%, approximately 33-50% is TTN. </div> <bR> <bR> <div> <B>Mortality/Morbidity: </B>TTN is generally a self-limited disorder without significant morbidity. TNN resolves over a 24- to 72-hour period. </div> <bR> <bR> <div> <B>Race: </B>No racial predilection exists. </div> <bR> <bR> <div> <B>Sex: </B>Risk is equal in both males and females. </div> <bR> <bR> <div> <B>Age: </B>Clinically, TTN presents as respiratory distress in full-term or near-term infants</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Signs of respiratory distress (eg, tachypnea, nasal flaring, grunting, retractions, cyanosis in extreme cases) become evident shortly after birth. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The disorder is indeed transient, with resolution occurring usually by age 72 hours. </div> <bR> <div> <B>Physical: </B>Physical findings include tachypnea, with variable grunting, flaring, and retracting. Extreme cases also may exhibit cyanosis. </div> <bR> <bR> <div> <B>Causes: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The disorder results from delayed absorption of fetal lung fluid following delivery. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">TNN commonly is observed following birth by cesarean delivery because infants do not receive the thoracic compression that accompanies vaginal delivery. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cesarean delivery</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Studies utilizing lung mechanic measurements were performed on infants born by either cesarean or vaginal delivery. Milner et al noted that the mean thoracic gas volume was 32.7 mL/kg for infants born vaginally and 19.7 mL/kg for infants born via cesarean delivery. Importantly, chest circumferences were the same. Milner et al noted that the infants born via cesarean delivery had higher volumes of interstitial and alveolar fluid compared to those born vaginally, even though the overall thoracic volumes were within the normal range.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Epinephrine release during labor has an effect on fetal lung fluid. In the face of elevated epinephrine levels, the chloride pump responsible for lung liquid secretion is inhibited, and the sodium channels that absorb liquid are stimulated. As a result, net movement of fluid from the lung into the interstitium occurs. Therefore, in the lack of this normal surge in counter-regulatory hormones in the infant, excursion of pulmonary fluid is limited.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Maternal asthma and smoking</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In a recent study, Demissie et al performed a historical cohort analysis on singleton live deliveries in New Jersey hospitals during 1989-1992. After controlling for confounding effects of important variables, infants of mothers with asthma were more likely to exhibit TTN than infants of mothers in the control group.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Schatz et al studied a group of 294 pregnant women with asthma and a group of 294 pregnant women without asthma with normal pulmonary function test results. The groups of women were matched for age and smoking status. TTN was found in 11 infants (3.7%) of the women with asthma and in 1 infant (0.3%) of the women from the control group. No significant differences between asthmatic and matched control subjects in other TTN risk factors were observed.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Prolonged labor</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Other recent studies have found that obstetric histories of mothers of newborns with TTN were characterized by longer labor intervals and a higher incidence of failure to progress in labor leading to cesarean delivery.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Excessive maternal sedation, perinatal asphyxia, and elective cesarean delivery without preceding labor are not frequently associated with TTN.</div> <div> DIFFERENTIALS DIAG:</div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pneumomediastinum </U></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pneumonia </U></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pneumothorax </U></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Respiratory Distress Syndrome </U></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Respiratory Failure </U></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Other Problems to be Considered: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cerebral hyperventilation</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Metabolic acidosis</div> <div> <B>Lab Studies: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Arterial blood gas</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">An ABG is important to ascertain the degree of gas exchange and acid-base balance.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Consider an intraarterial catheter if the infant's inspired fraction of oxygen exceeds 40%.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hypoventilation is very uncommon, and partial carbon dioxide tensions are usually low because of the tachypnea. However, a rising carbon dioxide tension in an infant with tachypnea may be a sign of fatigue and impending respiratory failure.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pulse oximetry</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Continuously monitor infants by pulse oximetry for assessment of oxygenation.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pulse oximetry allows the clinician to adjust the level of oxygen support needed to maintain appropriate saturation.</div> <div> <B>Imaging Studies: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Chest x-ray</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The chest x-ray (CXR) is the diagnostic standard for TTN.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The characteristic findings are prominent perihilar streaking, which correlates with the engorgement of the lymphatic system with retained lung fluid, and fluid in the fissures. Patchy infiltrates also have been described.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A follow-up CXR may be necessary if the clinical history suggests meconium aspiration syndrome or neonatal pneumonia. In these cases, the CXR shows persistent infiltrates. Abnormalities resolve by 72 hours of life in cases of TTN.</div> <bR> <div> How is transient tachypnea treated?</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">have his/ her respirations, heart rate, and blood oxygenation monitored.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> In addition your baby may need one of the following:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Oxygen. This can be given through a plastic hood placed over the baby's head or by oxgen into the isolette. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">CPAP (Continuous Positive Airway Pressure). </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This is oxygen delivered under a small amount of pressure usually through little tubes that fit into the nostrils of the nose. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Delivering oxygen under pressure helps keep the fluid out of the air sacs and speeds up its reabsorption. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Medical care is supportive. As the retained lung fluid is absorbed by the infant's lymphatic system, the pulmonary status improves.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Supportive care includes intravenous fluids and gavage feedings (until the respiratory rate has decreased enough to allow oral feedings). Supplemental oxygen to maintain adequate arterial oxygen saturation, maintenance of thermoneutrality, and an environment of minimal stimulation are the therapies necessary for these infants.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">As TTN resolves, the infant's tachypnea improves, oxygen requirement decreases, and the CXR shows resolution of the perihilar streaking.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Infants with TTN may have signs that last from a few hours to several days. Rarely, an infant may develop a worsening picture of respiratory distress after several days. This may require more aggressive support including the use of continuous positive airway pressure (CPAP) by nasal prongs or endotracheal tube, or mechanical ventilation.</div> <div> <B>Consultations: </B>Infants with TTN occasionally may require consultation by a neonatologist. Consider this consultation if the fraction of inspired oxygen exceeds 40%, if metabolic or respiratory acidosis is present, if CPAP or mechanical ventilation is required, if the infant begins to display fatigue (periodic breathing or apnea), or if the infant fails to improve by age 48-72 hours. </div> <div> <B>Diet: </B>Infants with TTN generally are supported by intravenous fluids or gavage feedings. Oral feedings are withheld until the respiratory rate is consistently normal (<60 bpm).</div> <bR> <div> The use of medications for TTN is minimal. Aside from the use of antibiotics for a period of 36-48 hours after birth until sepsis has been ruled out, no further pharmacotherapy generally is prescribed. Diuretics have not been shown to be beneficial.</div> <div> Drug Category: <I>Antibiotics</I> <FONT SIZE="3" COLOR="#000000" FACE="Arial" >- Used when sepsis is clinically suggested. Antibiotics generally consist of a penicillin (usually ampicillin) and an aminoglycoside (usually gentamicin) or a cephalosporin (usually cefotaxime). Choices are based on local flora and antibiotic sensitivities. </FONT></div> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="959" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 38 WIDTH="149"><div> <B>Drug Name</B></div> <bR> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="795"><div> Ampicillin- A penicillin antibiotic with activity against gram-positive and some gram-negative bacteria. Ampicillin binds to penicillin-binding proteins (PBPs), inhibiting bacterial cell wall growth. </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 38 ><NOBR><div> <B>Pediatric Dose</B></div> </NOBR></tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="795"><div> <2000 g: 50 mg/kg/d IV/IM divided q12h</div> <div> >2000 g: 75 mg/kg/d IV/IM divided q8h </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 ><NOBR><div> <B>Contraindications</B></div> </NOBR></tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="795"><div> Documented hypersensitivity </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 WIDTH="149"><div> <B>Interactions</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="795"><div> Probenecid increases the serum concentration of ampicillin </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 WIDTH="149"><div> <B>Pregnancy</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="795"><div> B - Usually safe but benefits must outweigh the risks. </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 WIDTH="149"><div> <B>Precautions</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="795"><div> Dose adjustments may be necessary in patients diagnosed with renal failure</div> </tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="952" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 57 WIDTH="149"><div> <B>Drug Name</B></div> <bR> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="788"><div> Gentamicin- Provides gram-negative aerobic coverage. Gentamicin also provides synergistic activity with penicillins against gram-positive bacteria including enterococcus. Gentamicin inhibits protein synthesis by irreversibly binding to bacterial 30S and 50S ribosomes. </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 56 ><NOBR><div> <B>Pediatric Dose</B></div> </NOBR></tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="788"><div> <29 weeks GA: 2.5 mg/kg/dose IV/IM q24h</div> <div> 30-36 weeks GA: 3 mg/kg/dose IV/IM q24h</div> <div> >37 weeks GA: 2.5 mg/kg/dose IV/IM q12h </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 ><NOBR><div> <B>Contraindications</B></div> </NOBR></tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="788"><div> Documented hypersensitivity to gentamicin or any other aminoglycosides </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 WIDTH="149"><div> <B>Interactions</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF><NOBR><div> Amphotericin B, cyclosporine, cephalosporins, and furosemide may increase the risk of renal toxicity </div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 WIDTH="149"><div> <B>Pregnancy</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="788"><div> D - Unsafe in pregnancy </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 38 WIDTH="149"><div> <B>Precautions</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="788"><div> Nephrotoxicity and ototoxicity may be associated with prolonged elevated trough concentrations; monitor levels to minimize the risk of toxicity and to optimize therapy</div> </tD> </tR> </TABLE></div> <bR> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The time course is variable. It may last hours or days. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Gradually the baby's need for oxygen will decrease.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Then, his/her respiratory rate will slowly come down to normal.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Some babies have fast respirations for several days.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">, once it resolves, it does not come back.</div> <div> <B>Further Inpatient Care: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">After resolution of TNN, focus further inpatient care on routine newborn management.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">No further medical therapy concerning the infant's pulmonary function is required.</div> <div> <B>Transfer: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">When managing an infant with TTN, it is important to have appropriately trained support staff. Infants with TTN and pneumonia or meconium aspiration may have similar clinical presentations. Therefore, staff members must be competent in recognizing worsening respiratory distress or impending failure and must be able to appropriately resuscitate the infant.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Transfer generally is indicated by the need for a higher level of observation and/or care.</div> <div> <B>Complications: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Few potential complications exist.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Gross et al noted a population of 55 pregnancies after which newborns developed TTN compared to 355 pregnancies after which respiratory distress did not occur. Neonatal complications and procedures often associated with prematurity were found to be significantly increased in the infants who developed TTN. Therefore, potential complications can occur in these patients. Carefully monitor infants for signs of worsening respiratory distress.</div> <div> <B>Prognosis: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Prognosis is excellent.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Asthma: Schaubel et al looked at neonatal characteristics as risk factors for preschool asthma. The study demonstrated that infants with TTN are at an increased risk for hospitalization from asthma during the preschool years.</div> <div> <B>Patient Education: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Inform parents that TTN is usually a self-limited disorder and is not life threatening</div> <DIV ALIGN="LEFT"></DIV> <div> <IMG SRC="097ebc00.jpg" border=0 width="235" height="192" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="09895410.jpg" border=0 width="661" height="577" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> Note streak densities in the parahilar regions and patchy </div> <div> infiltrates in the right lung</div> <div> ===================================================================================================</div> <div> Epiglottitis is an infection of the epiglottis and supraglottic structures. </div> <div> MEDICAL EMERGENCY</div> <div> It more precisely should be called acute supraglottitis, because inflammation of the supraglottic structures can cause this constellation of symptoms without actually involving the epiglottis itself</div> <bR> <div> It characteristically occurs in children ages 2-7 years old and is caused by Haemophilus influenzae type b also known as H. influenzae </div> <div> <IMG SRC="099a0120.jpg" border=0 width="416" height="274" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><FONT SIZE="3" COLOR="#000000" FACE="Arial" >Haemophilus influenza a gram negative pleomorphic rod appears pink of gram stain.</FONT></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Epiglottitis has an abrupt onset of high fever, sore throat and dysphagia, moderate to severe respiratory distress, stridor, and lethargy .</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> These children appear very toxic with flushed skin and often sits leaning forward with mouth open and chin extended in an effort to maintain their airways. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The dysphagia does not allow them to clear their oral secretions, and they are often drooling on presentation. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The voice is also muffled, called a "hot potato" voice, because it sounds as if the child is talking with a hot potato in his or her mouth. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The child may also show intercostal retractions and perioral cyanosis and sounds stridorous </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> These children may be so tired from their work of breathing that they may present with lethargy, fatigue, or even frank respiratory failure </div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Diagnosis is often presumptively based on history and observation of the child at a distance! </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Physical examination should be done expediently and with careful attention so as not to increase the child's anxiety. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This is imperative!!! Increased anxiety in the child may lead to reflex laryngospasm, acute airway obstruction, and respiratory arrest. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Even minor annoyances to the child such as placement of electrocardiogram or ECG leads, or placement of mist by his or her face may cause the child to cry and possibly obstruct the airway. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The child should remain with a trusted caretaker at all times, often in their arms.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Close monitoring should be done by observation with emergency equipment readily available </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">. Do not attempt direct visualization of the epiglottis in the emergency room or office by depressing the tongue as this may also cause reflex laryngospasm and obstruction, which may lead to respiratory arrest</div> <bR> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b701400000ff00.png" HEIGHT="21" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Toxic Appearance </div> <div> <IMG BORDER="0" SRC="Symb075c00b701400000ff00.png" HEIGHT="21" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hot Potato Voice</div> <div> <IMG BORDER="0" SRC="Symb075c00b701400000ff00.png" HEIGHT="21" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Dysphagia </div> <div> <IMG BORDER="0" SRC="Symb075c00b701400000ff00.png" HEIGHT="21" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and Sore Throat</div> <div> <IMG BORDER="0" SRC="Symb075c00b701400000ff00.png" HEIGHT="21" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Fever </div> <div> <IMG BORDER="0" SRC="Symb075c00b701400000ff00.png" HEIGHT="21" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Stridor</div> <div> <IMG BORDER="0" SRC="Symb075c00b701400000ff00.png" HEIGHT="21" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Lethargy </div> <div> <IMG SRC="09ce3100.png" border=0 width="483" height="272" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> Endolateral neck x-rays show classic swelling of the epiglottis on the lateral film. </div> <div> This is also known as the "thumb" sign as it resembles the size and shape of the human thumb .</div> <div>  The anteroposterior film is usually unremarkable.</div> <div> <IMG SRC="09e5e140.png" border=0 width="350" height="532" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">If the child shows classic signs and symptoms, direct visualization of the supralaryngeal area is carried out promptly using a laryngoscope or bronchoscope.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The patient is anesthetized with an inhalation anesthetic, an intravenous line is started with blood sent to the laboratory for culture and CBC, and the larynx and supraglottic tissues are inspected. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The diagnosis is based on the finding of swollen cherry-red supraglottic structures usually including the epiglottis . </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">There is thickening of the aryepiglottic folds and arytenoid cartilages, which form the lateral and posterior aspects of the laryngeal vestibule and actually cause the marked upper airway obstruction in acute epiglottitis</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">. These thickened aryepiglottic folds and arytenoid cartilages cause the "thumb sign" on the x-ray - the swollen epiglottis itself does not. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">An appropriately sized, uncuffed endotracheal tube is inserted with direct visualization and mechanical ventilation initiated </div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cultures of the epiglottis and throat should also be taken in the operating room.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The child is taken to the intensive care unit where mechanical ventilation is continued . </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Systemic antibiotics directed against H. influenzae such as ampicillin and chloramphenicol combined or single agents such as ceftriaxone or cefotaxime, should be started as soon as possible.</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Ventilation is continued and direct visualization of the epiglottis is done on a daily basis until the edema resolves, generally within 24-48 hours. Systemic antibiotics are administered for approximately 2 weeks.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Note that respiratory isolation of the patient for the first 24 hours of antibiotic treatment is necessary. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The CBC is remarkable for a leukocytosis with a marked left shift but this is not specific.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Rapid latex particle agglutination of urine or serum for H. influenzae may confirm the diagnosis before blood or direct epiglottis cultures grow. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The physician should also consider doing a lumbar puncture for possible meningitis as this organism is highly invasive.</div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Racemic epinephrine and corticosteroids are not helpful in the treatment of epiglottitis. </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Control measures for invasive H. influenzae type b are very important since asymptomatic carriage in the nasopharynx of household contacts and possibly day care centers is quite high. </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Chemoprophylaxis with rifampin given once daily for 4 days eradicates H. influenzae in approximately 95% of carriers</B>.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> <B>Rifampin prophylaxis should be given to all household contacts regardless of age where at least one household contact is less than 48 months of age.</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A nasopharyngeal culture should be done before treatment. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Chemoprophylaxis should be instituted as soon as possible after diagnosis of H. influenzae type b is made. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Guidelines for the treatment of day care contacts but not definitive recommendations have been set forth by the American Academy of Pediatrics.</div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Vaccination to prevent H. influenzae disease was originally begun in 1985 in the United States for children 24 months or older, but in October 1990 H. influenzae type b conjugate vaccines were approved for children 2 months of age and older. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Any children less than 24 months experiencing invasive H. influenzae disease such as epiglottitis should be vaccinated with the standard regimen for age as they might not acquire natural immunity from the infection. If the child is older than 24 months, then the disease itself most likely will cause natural immunity, and immunization is not needed</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> In the future, physicians should expect to see less invasive H. influenzae disease as more children receive adequate immunization.</div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Complications associated with epiglottitis include </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">otitis media, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">adenitis, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">meningitis, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">pericarditis,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> and pneumonia. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mortality may be as high as 5-10% owing to difficulties in maintaining the airway early in the illness </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The differential diagnosis includes the various members of the croup syndromes especially viral croup and also foreign bodies </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">. Note that the epiglottis may be enlarged for other reasons, but these causes do not show the life-threatening clinical syndrome of acute epiglottitis </div> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="637" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" BGCOLOR=#000033 > <tR> <tD VALIGN=CENTER HEIGHT= 20 WIDTH="212"><div> <B>Characteristic</B> </div> </tD> <tD VALIGN=CENTER WIDTH="193"><div> <B>Viral Croup</B> </div> </tD> <tD VALIGN=CENTER WIDTH="212"><div> <B>Acute Epiglottis</B> </div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="212"><div> Age </div> </tD> <tD VALIGN=CENTER WIDTH="193"><div> 3 mo.-5 years </div> </tD> <tD VALIGN=CENTER WIDTH="212"><div> 2-7 years </div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="212"><div> Organism </div> </tD> <tD VALIGN=CENTER WIDTH="193"><div> Viral </div> </tD> <tD VALIGN=CENTER WIDTH="212"><div> H. Influenza: type b </div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="212"><div> Incidence </div> </tD> <tD VALIGN=CENTER WIDTH="193"><div> Common </div> </tD> <tD VALIGN=CENTER WIDTH="212"><div> Rare </div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 75 ><NOBR><div> Clinical Presentation </div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="193"><div> Gradual onset</div> <div> Mild URI symptoms</div> <div> Barky cough</div> <div> Low fever </div> </tD> <tD VALIGN=CENTER WIDTH="212"><div> Sudden onset</div> <div> Drooling</div> <div> Sitting forward</div> <div> High fever </div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 38 WIDTH="212"><div> Physical Exam </div> </tD> <tD VALIGN=CENTER><NOBR><div> Respiratory distress</div> <div> Inspiratory stridor </div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="212"><div> Toxic appearance</div> <div> "Hot potato voice" </div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 38 WIDTH="212"><div> X-ray and Projection </div> </tD> <tD VALIGN=CENTER WIDTH="193"><div> Steeple sign</div> <div> A/P view </div> </tD> <tD VALIGN=CENTER WIDTH="212"><div> Thumb sign</div> <div> Lateral view </div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 38 WIDTH="212"><div> Treatment </div> </tD> <tD VALIGN=CENTER><NOBR><div> Humidification</div> <div> Racemic epinephrine </div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="212"><div> Epiglottitis protocol </div> </tD> </tR> </TABLE></div> <div> Causes of an Enlarged Epiglottis on X-ray</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Prominent Normal Epiglottis </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Omega-Shaped Epiglottis </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Angioneurotic Edema </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Stevens-Johnson Syndrome </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hemophilia </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Aryepiglottic Cyst </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Epiglottic Cyst </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Foreign Body </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Trauma including Caustic, Thermal, Irradiation, or Chemical </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Chronic Epiglottitis </div> <bR> <div> ======================================================================================</div> <div> <B>High risk pregnancies</B> </div> <div> Maternal status: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Teenage (< 16) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Elderly (> 40) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Low socioeconomic status </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Maternal illness: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Diabetes </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hypertension </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Rh sensitization </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Severe anaemia </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Previous pregnancies: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Previous abortions </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Previous stillbirths </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Previous early neonatal deaths </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Previous preterm infants </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Present pregnancy: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">No antenatal care </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hypertension </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Multiple pregnancy </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Polyhydramnios </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Abnormal presentation or position </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Certain drugs - alcohol, smoking </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Preterm labour </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Severe fetal growth retardation </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">High risk pregnancies should be delivered in hospitals where appropriate facilities are available. </div> <div>  <A NAME="7"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Fetal distress</B> </div> <div> If the fetus becomes hypoxaemic it develops bradycardia with shunting of blood away from less vital organs to the brain. This is an appropriate physiological response to stress. Meconium may also be passed and the fetus may make gasping respiratory movements, aspirating amniotic fluid and meconium into the upper airways. </div> <div> Fetal hypoxaemia is usually transient, intermittent and occurs towards the end of a uterine contraction (a late deceleration). If the placental blood flow from the mother is able to recover between contractions a metabolic acidosis does not develop and the fetus is said to be stressed. When this ability to compensate fails, tissue hypoxia results in a metabolic acidosis. Only now can the fetus be regarded as distressed. </div> <div> Fetal heart rate monitoring and the assessment of scalp pH (normally above pH 7,25) are used to detect fetal distress. Unfortunately these methods cannot always differentiate the stressed from the distressed fetus</div> <bR> </td> </tr></table></body>