PART 19. RESPIRATORY SYSTEM
section 1. development and function
#
respiratory system의 development.
1. morphogenesis or formation
of all necessary structures.
2. adaptation to postnatal
atmospheric breathing.
3. dimensional growth.
Chapter 319. Development Of Respiratory System
Prenatal Development : Morphogenesis
1)
embryogenic period
; begin *4wk of gestation
; peribronchial mesenchyme or
splanchnopleura가 이 기간에 lung형성에 필수적인 역할.
2)
*pseudoglandular period
; 6-16wks
; *TEF, CDH(Bochdale)의
congental malformation 이 시기에
생김
3)
canalicular period
; 16-28wks
; accessory structure(cart,.gl,m.)완성typeⅠⅡpneumocytes.
4)
saccular period
; 28-36wks
; terminal sac 완성
5)
alveolar period
; *after 36주
; at birth 50 million alveoli→adult
300 million.
; acinus형성에
fetal lung내의 liguid에 의한
stretch와 respiratory muscle의
period distension이 필수적.
; lung or chest compress(diaphragmatic
hernia or oligohydramnios)or fetal breathing abolished(spinal
cord lesion)시 pulmonary hypoplasia.
Adaptation To Air Breathing.
#
Pulmonary Surfactant
; *hetergenous mixture of phospholipid and
protein
; synthesis by typeⅡ
pneumocyte
-
first recognized *as early as 24wks
-
*not detectable in amniotic fluid
until 30wks : chronologic gap
; apoprotein:3가지
type (SP-A, SP-B, SP-C)
; glucocorticoid
-
apoprotein &lipid 합성↑
-
parenteral administration to prevent RDS
;
thyroid H
-
phospholipid 합성↑
; β-adrenergic
agonists & other agent
-
apoprotein &phosphatidylcholine secretion↑
; ★insulin,
hyperglycemia, ketosis, androgen
-
*surfactant 합성에 negative effect
- DM mother의 infant or male infant에서
respiratory distress syndrome high incidence.
#
pu.l resistance
; high→low
resistance
; 원인
①
lung tissue expanding에 의해 pulmonary vascular
wall에 mechanical forces.
②
alveola의 oxygen 농도에 의해
pul arterial smooth muscle의relaxation, vasodilator의
endogenous release.
; foramen ovale &
ductus arteriosus가 closure되므로
pulmonary와 system circulation 완전히 분리
Postnatal Development
first
phase:① 출생후∼18개월
② gas exchange에 관여하는
compartment의 surface &
volume↑
③ air space vol보다
capillary vol이 더 많이↑
second
phase:① alveolar &
capillary surface↑.
Chap 320. ★Regulation Of Respiration
The Respiratory Control System Is Negative Feedback
System With A Central Controller
· Co2↑시
ventilation 증가시켜 Co2 ↓.
· feedback system
afferent
limb : airway, carotid 같은 receptor ending을 가지는
tissue
efferent
limb : respiratory muscle and their innervation
ex) intercostal m, diaphragm, airway m.
The Central Controller Integrates Incoming Afferent
Information And Generates And Maintains Respiration
1)
respiratory controller는 아마 neuron group이
emergent network를 형성하
든지, endogenous or conditional
burster일 것이다.
2) medullary neuron.
two group : nucleus tractus solitarius
nucleus ambiguus
⇒
respiration initiation의 potential site
3) medulla (pre-B tzinger) : respiration 조정에 중요
Afferent Information In Not Necessary For Initiating
Respiration But Plays An Important Role In Modulating Breathing
1)peripheral
nerve sys
(1)larynx
& upper airway의
chemoreceptor & mechanoreceptor
:mucosa에 stretch, air temp, chemical change
→superior
laryngeal nerve & 10th cranial nerve.
(2)Carotid
& aortic bodies:o2
or co2 tension
(3)Skin
or mucosal receptor hypothalamic neuron:thermal or metabolic
change
2)high
brain center
(1)medulla
oblongata의 ventral surface:co2
sense
(2)limbic
system
:emotion &
changes in mood
Centeral Integration And Processing In The Brain Stem
Hierachical
·다양한 요구에 의한
neurophysiologic signals이 있을때,
central controller는
stimuli에 따라 반응을 향상시키기로 하고 감쇄시키기
도 한다.
ex)trigeminal
afferent impulse는 REM sleep or 깨어 있을때 보다
quiet sleep시에 cortical influence을 덜 받아 더
respiration에
trigeminal stimulation이 저명해 진다.
Respiratory Muscles And Chest Wall Properties(E.G.
Efferent Organ) Undergo Postnatal Maturation And Can Fatigue
·respiratory
muscle innervation의 maturational aspect
+-adult-one muscle은
one motoneuron애 의해 지배
|
+-newborn-polyneuronal
innervation
·newborn에서
adult에 비해 end plate 내에
acetylcholine content적어
diaphragm의
neuromuscular transmission susceptibility↓
·newborn
infant의 chest wall이 아주
complaint해서
REM
sleep에 특히 paradoxic respiration
→어떤이는
이것이 muscle fatigue와
respiratory failure가 newborn에서
잘 생기는 중요한 이유라고 생각
The Newborn And Young Respond Differently To Stimuli
Compared With Mature Subject
·O2
low에 대한 반응이 neonate와
adult에서 차이가 있는데,
이유:1)hypoxia
동안 metabolic rate차이
2)lung &
airway의 mechanical property의 차이
3)centeral
neuron의 cellular &
membrance property의 alteration
Clinical Implications
Apnea
;
각각의 age의 infant or child의
mean breath time에 3 standard deviation 이상
resp. pause가 있을때
(2)adult보다
O2 consumption이 높고, 비교적 lung vol이 적으며,
O2
store가 적어서very young or premature에서는
short resp pause에도
serious consequence을 가져올 수 있다.
(3)sleep
〉waking state ---+
| apnea발생빈도↑
REM sleep 〉quiet sleep ----+
Upper Airway Obstruction
(1)children
①cause:·tonsillar
& adenoidal hypertrophy
due to repeated upper resp infaction
·craniofacial malformation
·micrognathia
·muscular hypotonia
(2)adulat: 불분명
(3)UAO의
usual site :oropharynx
( post Pharyngeal wall, soft
palate, genioglossus
사이)
(4)sleep
동안 long-standing sign &
Sx of UAO
→Rt
ventricular failure & cor pulmonale
Chapter 321. Respiratory Function & Approach To Respiratory Disease
Mechanism Of Breathing
1. Elastic properties of the
respiratory system and restrictive disaese
1)resp.system이
elastic behavior 보이는 이유
(1)air
space 내에 surfactant가 정상적인 양이 들어 있어도 surface tension
은 lung의
elastic recoil의 65% 정도 기여한다.
→surfactant없으면
elastic recoil이 markedly increase하며
atelectasis 유발:respiratory distress
syndrome of the newborn
(2)lung
& chest wall의
fibrous network가 elastic property가짐.
→pul.fibrosis, lung overdistention
2)restrictive
lung disease cause
(1)surface
tension이 비정상적으로 증가
→respiratory distress synd of the
newborn.
(2)interstitial
edema, pneumonitis, fibrosis 같이 lung의
soild
structure or composition의 change
(3)alveolar
edema, pneumonia 같이 alveolar space가
liquid or
inflammatory cell로 차있을때
(4)restrictive
chest wall
:abdominal distention, cong
malformation, neuromuscular
disease
2. Resistive properties of the
respiratory system
and obstructive disease.
(1)motion에 의해 유발된
molecular interaction 결과로 resistive
생각
3. Response to respiratory disease:efficiency
of the developing
respiratory
system.
1)respiratory work load ↑시
2type responses
(1)respiratory
muscle contraction 증가
→substrate
availability와 muscle의
maximal contraction force
ability에 의해 제한
(2)respiratory
pattern을 변화시켜 respiratory efficiency↑
Gas Exchange
pulmonary
capillary and the neighboring portion of the air space로 구성된 몇 백만의
small unit에서 생긴다.
#
PCO2
; *propotional to carbon dioxide production and inversly propotional
to alveolar ventilation
#
aleveolar ventilation
; minute ventilation - dead
space ventilation
#
PO2
#
*regional differences in
ventilation/perfusion ratios exist in normal lungs
#
respiratory disease
; *increase alveolar-arteriolar PO2 difference
PaO2 =
PIO2 - PaCo2/0.8
PIO2:partial
pressure of inspired oxygen
P2Co2:arterial
partial pressure of carbon dioxide
0.8:respiratory
quotient(carbon dioxide production/oxygen
consumption)
321.1 Diagnostic Approach To Respiratory Disease
Physical Examination
1. breathing pattern의
alteration
:breathing
rate 증가, chest wall retraction, nasal
flaring
2. restrictive disease:breathing
rate↑
expiratory grunt
obstructive disease:slover
deeper breaths
extrathoracic의 경우 inspiratory stridor
3. stridor
rales or crackles
wheezes
Blood Gas Analysis
1. cyanosis:skin
perfusion and blood hemoglobin concentration
영향받음
hypoxia의 unreliable sign.
2. arterial Po2, PCo2, PH의
direct measurement
3. skin surface Po2 determination으로
arterial oxygenation 측정시
skin perfusion에 영향받음.
Respiratory Function Test
1.
restrictive disease
;
typically total lung capacity (TLC)의 감소
→TLC는
residual vol포함하므로, gas dilution method,
plethysmography로
indirectly measure.
;
vital capacity(VC)감소
→spirometry로 측정
2.
obstructive disease
;
residual vol ↑ functional residual capacity↑
Ventilation/Perfusion
Studies
:radionuclide
tracer에 의해 도움받음.
Exercise Testing
Sleep Studies
1.
newborn young infant에서 특히 respiration function에 중요한 영향을 미친다.
2.
Polysomnographic studies:
1)central
respiratory control abnormality
2)muscle
disorder
3)gastroesophageal
reflux에 의한 resp. complication시 유용.
Chapter 322. Resp. Failure
Etiology
1)
intercurrent acute illness (eg. influenza)
2)
이전의 건강한 아이
① pn.
② epiglottitis
③ status asthmaticus
④ aspiration
⑤ poisoning
⑥ severe heart failure
3)
cystic fibrosis or severe scoliosis, bronchopulmonary dysplasia
4)
acute CNS ds.
5)
severe m. ds & thoracic abnormality
6)
CHD with large Rt. to Lt. shunt
Clinical Manifestation and Diagnosis
·sit
up & lean forward
1) Hypercapnia →
central depression : impaired consciousness
& confusion
2)+- PaCO2 40mmHg↑→
ARF 가능성
| PaCO2 50mmHg↑→
imminent
+- PaCO2
55mmHg↓ in room air
blood의 O2 content가
vital
organ의 요구를 충족시키기에 부적당
3) ①
severe headache
acute hypoxemia & hypercapnia
→ dilat of cerebral blood의
O2 content가 vital organ의 요구를
충족시키기에
부적당
②
cold extremites
③
restlessness
④
dizziness
⑤
impaired thought
4) multisystem Cx. i)
GI hemorrhage
ii) cardiac arrhythmia
iii) renal failure
iv)
malnutrition
Treatment
1) Theophylline :
improve diaph. strength
COPD pt에 유용
2) mecha. vent. :
pneumonia child에서 hypoxia & hypercarbia
develop시
3) 100% O2 by bag
& mask/endotrach. intubation
: apnea나 gasping시
* PEEP : alv. collpse방지
* Goal of Tx
i) 적당한 oxygen saturation 유지
ii) n'l PaCO2 유지 (using 최소한의
pr. & lowest FiO2)
4) Bedside measurement
of tidal vol. & VC & (-)inspiratory force
*
direct O2 toxicity의 risk는
Fi O2 70∼100%시 매우↑
(40%↓에서 증명)
Chapter 323. Defence Mechanism Of Lung
#
infancy이후 collateral alveolar ventilation이 일어남
a) pore of Kohn between alveoli
- lobule 사이
or caillary 사이의 gas passage 되게 함
b) canal of Lambert beetween bronchiol
& alveoli
→
atelectasis 방지
#
Defense a) filtering of particle
b) warming & humidify of inspired air
c) noxious fame & gas를 vascular upper airway에서 흡수
d) temporary cessation of breathing
shllow breathing
laryngospasm or bronchospasm
swallowing & closure of epiglottis
Clearance Of Particle
1) mucocillary
mech에 의해
2) phagocytosis
by alv. macrophage
Defense Against Microbial Agent
- phinciple by
macrophage
phagocytosis Ab in resp. secretion - Ig A
- 1Mo에 adult level에 도달
·lysozyme,
lactoferrin, interferon도 defense role
Impaired Defense Mechanism
1) macrophage
phagocytic activity & mucociliary clearance↓
a)
ethanol
b)
smoking
c)
hypoxemia starvation chilling
d)
corticosteroid nitrogen dioxide ozone narcotics some anesthetics
2) antibacterial
killing capacity of macrophage↓
a)
acidosis b) azotemia
c)
recent viral inf. - 특히 rubella, influenza
3) toxic to epi.
cell
- beryllium, asbestos, organic dust from cotton & sufarcan
- sulfur, N20, ozone, chlorine, ammonia, cigar
4) mucociliary
clearance↓
a) hypothermia & hyperthermia
b) morphine, codeine
c) hypothyroidism
5) resp. epi.
damage
a) reversible - rhinitis, sinusitis, bronchitis, bronchiolitis
resp. inf. with air pollution
asthma, bronchospasm, edema, congestion
mild surf. ulceration
b) permanent - ① servere ulcer
② bronchiectasis bronchiolectasis
③ squamous cell metaplasia &
fibrosis
c) other adverse effect : hyperventilation, alveolar hypoxia,
pulmonary thromboembolism, alveolar, pulmonary
thromboembolism, pul edema, hypersensitivity reaction,
salicylate 같은 agent
323.2 Metabolic Function Of Lung
1) (1)Lung은
40개의 cell type 가짐
이 중
lung에만 특수한 것 +-① type I,II pneumocyte
| ② alv. macrophage
+-③
clara cell
(2)lung이 합성하는
lipid & protein
① glycoprotein,
② secretory
③ interferon
④ proteolytic & fibrinolytic
enzyme & activator
⑤ collagen
⑥ elastin
(3) ①
thromboplastin ⇒
lung에 많음
② megakaryocyte
(4)①
serotonin
② bradykinin
⇒ 대개 pul. circulation을 통해
③ ATP
완전 제거 or inactivation
④ PGE1 E2 E3
(5)①
EPi
② PGA1 A2
⇒ minimally affected
③ Angiotensin 2
④ vasopressin
Chapter 324. Diagnostic Procedures
Radiologic Technique
Chest X-Ray
CT & MRI
Upper Airway Film
xerography soft tissue
Sinus, Nasal Films
Fluorscopy
* useful (1) stridor시
(2) abn'l move. of diaph. or mediat
(3) needle asp. or biopsy of peri. lesion
Contrast Study
Barium swallow
; Ix
①
recurrent pn.
② 원인 불명의 persistent cough
③ stridor
④ persistant wheezing
eg.
H-TEF시 simple barium swallow는 불충분
cath.를 통해
eso.의 몇 부위에 barium inj.
if
eso. atreesia 의심시 0.5ml↑은
X.
Bronchogram
; ※Indication
-
suspected bronchiectasis
-
airway anomalies
Pul. Arteriogram
; Dx
-
cong.anomaly
①
lobar agenesis
②
unilat. hyperlucent lung
③
vascular ring
-
solid or cystic lesion
Aortogram
: vas. ring or
pul. sequestration
Pneumoperitoneum, Pneumothorax
: diaph.
eventration시 Diaph.의
outline 결정
Radionuclide Lung Scan
·iv
inj. of macroaggregated human serum alb.
·useful i) pul. embolism
ii) cong. cardiov. & pul. defect
·method
: iv inj. of 133Xe
+- inj.후 조기에 Xe이 나타남
: perfusion 측정
+- breathing동안의 washout rate :
ventilation 측정
324.1 Endoscopy
Laryngoscopy
; *evalution of stridor & local upper airway abnormality
; infant & small children
→ direct laryn
;
older CH & adult → indirect laryn
Bronchoscopy
#
★Indication Of Diagnositic Bronchoscopy
1) recurrent/persistent
pneumonia or atelectasis
2)
suspected foreign body
3)
unexplained & persistent wheeze & infiltrates
4)
hemoptysis
5) *pneumonia in the immunocompromised host
6)
suspected cong. anomalies
7) mass lesions
8)
unexplained interstitial disease
#
★Indication Of Therapeutic Bronchoscopy
1) removal of FB & mucus
plug
2) bronchial toilet
3)
bronchopul. lavage
#
*extration of FB, massive hemoptysis,
removal of tissues mass에서는 open rigid
bronchoscope을 사용해야
한다.
#
small flexible fiberoptic broncho.의 잇점
1) easy insertion
2)↑ peripheral range
3)↓ Cx
4) general anesth. 불필요
#
postbronchoscopy croup의 Tx
1) O2
2) mist
3) vasoconstrictor aerosol (racemic epi.)
4) corticosteroid
#
★Bronchoscopy Complication
1)
transient hypoxia
2)
cardiac arrhythmias
3)
laryngospasm
4)
bronchospasm
5)
iatrogenic inf
6)
bleeding
7)
pneunothorax
8) pneumomediastinum
Bronchoalveolar Lavage
;
obtain a representative specimen of fluid and secretion from lower respiratory
tract
;
*useful for cytologic and
micorbiologic diagnosis of lung diseases
Throacoscopy
324.2 Thoracentesis
1.
Method 1) sitting
position
2) 1.5 inch, No 22 gauge needle
3) rib margin 상부
2.
Cx
1) inf.
2) pneumothorax
3) bleeding
4) puncture or laceration of capsule of liver (Rt)
& capsule of spleen (Lt)
3.
transudate : pleural fluid의 formation이나
reabsorption에 영향을
주는 mechanical factor에 의함
1) total protein 3g/dl↓
2) pleural protein/serum pr. 0.5↓
3) leukocyte count 2,000↓: mononu. 우세
4.
exudate : pleural surf.나 lung의
infl.이나 ds.
1) protein↑
2) PMNI 우세
except Tb, malignancy
ex.
Tb - glucose↓ & cholesterol↑
324.3. Percutaneous Lung Tap
;
*▲direct
method of obtaining bacteriologic specimens from the pulmonary parenchyma
;
major Ix
- *X-ray infiltrates of undetermined etiology, esp. unresponsive to
therapy in immunosuupressed patients
;
pneumothorax Cx이 thoracentesis 보다↑
324.4. Lung Biopsy
;
*▲appropriate
when there is diffuse lung disease such as Pneumocystis pneumonia
;
infant & small children : open sung. biopsy
;
older : transbronchial. bx.
324.5. Transillumination Of Chest Wall
1) 6Mo↓시
fiberoptic light probe로 transill하여
pneumothorax Dx
2) unreliable in (1)older pt.
(2) subcut. emphysema
324.6. Microbiology
1. method 1) nasopharyngeal or throat swab
2) sputum (expectoraton X→ cough후
deep throat swab
3) nasotracheal asp.
heavy contamination
transtracheal
asp.
어린이에는 위험
4) percut. lung tap or open biopsy
2. exam. of secretion
1) alveolar macrophage : hallmark of tracheobr. sec.
2) early morning gastric aspirate → AFB smear &
culture
3) sputum의
Wright stained smear시 PMNL(-)
→ lower RT의
bact. inf.
4) eosino. : allergic ds
5) iron stain상 macrophage내
hemosiderin granule
: pul. hemosiderosis
6) viral pn. : wright stain에서 intranu나
cytoplasmic inclusion body
324.7. Blood Gas Analysis
#
arterial bl. gas
; *▲most useful test of
pul. function
#
arterialized cap. bl.
1) may be used if tissue perfusion is
good
2) vasodil. in finger, heel, ear lobe by
warming or nitroglycerin
or nicotinic acid
cream
#
venos PCO2
; 6∼8mmHg↑
than arterial PCO2
;
pH는 약간↓
324.8. Pulmonary Funcion Testing
Measurement Of Ventilatory Function
# Flow Rate By Spirometer
; FEV1
-
첫 1초간 expired한
vol
; MMEF (max. midexp. flow
rate)
; MEFV (max. exp. flow vol.
curve)
-
75% VC↓의 lung vol.에서의
flow rate는 effort와 무관
-
50% VC↓의 flow rate는
small airway에 영향받음
-
25% VC
/
index of small airway function
#
Airway resistance Raw by plethysmograph
- cm H2O/L/sec
* SRaw (specific airway R)
= Raw X lung
volume
:
n'l 7sec/cmH2O↓
: 6세 이상은 일정
Measurement Of Gas Exchange
#
DLCO
; Diffusing capacity for
carbon monoxide
;
method
-
rebreathing from container having a known intial conc. of CO
-
single breath technique
; ↓경우
-
effective alv. cap. surf. area↓
-
alv-cap. memb.을 통한 gas의 diffusability↓
#
regional gas exchange
: P/V Xe scan
#
arterial blood gases
: alv. gas exchange의
effectiveness
Measurement Of Perfusion
·pul.
blood flow 측정 by i) cardiac catb.
ii) NO의 uptake
→ pul. arteriogram이나
radioisotope으로 distribution 측정
Clinical Use Of PFT
;
6세 이후는 어려움 없이 test 가능
1) defining the type of process
(eg. obst. rest)
2) defining degree of functional impairment
3) estimating the prog.
4) preop. evaluation
5) confirmation of functional
impairment in pt. with subjective complaints. but n'l P/E
section 2. upper respiratory tracts
Chapter. 325. Congenital Disorders Of Nose
#
Down synd.
;
nasal passage의 narrowing
→
① URI시
airflow의 severe obst.
②
chr. or recurrent hypoventilation
Choanal Atresia
;
*▲common
anomaly of nose
;
nose와 pharynx 사이에
unilateral or bilateral bony or membranous septum으로 구성.
;
*50% with other cong. anomaly
- ★CHARGE
syndorme
/
coloboma
/
heart disease
/
atresia choanae
/
retarded growth & development and/or CNS anomalies
/
genital anomalies and/or hypogonadism
/
ear anomalies and/or deafness
;
unilat.시 resp. inf.전까지 오래동안
aSx일 수 있다.
;
Diagnosis
- *inability to pass firm catheter through each nostril 3-4cm
-
fiberoptic rhinoscopy로 직접 봄
-
CT scan
;
Treatment
- oral airway 유지
or open mouth
-
feeding
/
nipple : large hole
/ assited airway없이 breathing과
eating이 될 때까지 (대개
2∼3주) gavage feeding
- elective
op. correction
/
수주나 수개월후
/ bilat.C.A.시 immediate op.는 드뭄.
/ unilat.시 수년 늦을 수도 있다.
Cong. Defect Of Nasal Septum
- rare
1)
perforation (1) develpmental
(2) 2°to
syphilis, Tbc
2)
septal deviation : op. collection은 midface growth
disturb.를
피하기 위해 대개 연기
3)
cong. midline nasal mass : dermoids, gliomas, encephaloceles
Chapter 326. Acquired Disorder Of Nose
326.1 Foreign Body
1)
initial Sx : local obstr. sneezing. mild discomfort. rarely pain
2)
unilat. nasal discharge & obst. : FB시사
326.2 Epistaxis
·rare
in infancy
·common
in childhood
·↓after
puberity
※91 Etiology
;
*trauma
- *▲common
- picking nose &
FB
;
*adenoidal hypertrophy, allergic
rhinitis, sinistis, polyp, acute infection
;
disease with paroxysmal & forceful cough
- cystic fibrosis
;
congenital vascular abnormalities
- telangiectasia,
varicosities
;
thrombocytopenia, def. of clotting factor, hypertension, renal failure, venous
congestion
;
adolescent girls with menarche
Clinical Manifestation
·source (1)vascular
plexus of ant septum(kiesselbach
plexus)
(2) mucosa of ant.portion of turbinates.
※주 Treatment
; compression on nares &
quiet
-
erect position with head forward
; *0.25-1% neosynephrine with or without topical thrombin
; ant nasal pack
-
bleeding persist시
-
bleeding이 post, rare에 있을시combined
ant & post packing
; *cautery with silver nitrate
-
bleeding site를 알때
; bl.transfusion
-
severe or repeated epistaxis시
; otolaryngologic evaluation
-
bilat, bleeding, no arising from Kiesselbach plexus
; clotting factor replacement
#
Juvenile nasopharyngeal angiofibroma
·peak:adol.
& preadol.boys
·특징:profuse epistaxis with
nasal mass
·Dx:CT
scan with contrast
·Tx:arteriography,
embolization, extensive surgery
Chap. 327 Infection Of Upper Respiratory Tract
Etiology
; virus &
mycoplasma
-
*▲common
-
예외 :epiglottitis
; *Streptococci & Diphtheria
-
major bacteria of primary pharyngeal ds
1)
RSV:⅓ of bronchiolitis
2)parainfl.
ⅴ:croup
3)
influenza ⅴ
4)
adenovirus:10%↓of resp.ds
pharyngitis & PCF가 TMC in children
5)rhinov.
& coronavirus:“common
cold”synd
6)
Coxackie ⅴ. A,B:nasopharynx의
Ds
7)
Mycoplasma:upper &
lower resp. ds
bronchiolitis, ph, bronchitis, pharyn-
gotonsillitis, myringitis, OM
327.1 Acute Nasopharyngitis(=URI,
Common Cold)
;
*▲common
infectious condition of children
;
*more extensive than adult
;
*significance depend on frequency in
which complication occur
Etiology
;
*rhinovirus
- *principal agent
;
coronav
- 10%
;
period of infectivity
;
bacteria
- *Group A streptococci : principle
bacterias
- Coryn. diphtheria
-
Mycop. pn.
- N. meningitidis
-
n. gonorrhea
Epidemiology
;
children
- *average of five to eight infection a year
3)
Nursery, school & day care center:epidemic
Pathology
1)
edema & vasodilation in submucosa
2)
cilia의 structural &
functional change
→ mucus clearance에 지장 초래
Clinical Manifestation
3
Mo-3Yr:inf.초기에 fever
purulent
Cx은 age 어릴수록↑
#
3 Mo ↑
(1) initial Sx:fever,
irritability, restlessness, sneezing
→수
hr내 nasal discharge &
obst
- 2-3일:ear
drum congestion & fluid behind drum
(2)febrile phase:몇
hr-3 days
#
older children
(1) initial Sx:dryness &
irritation of nose
→ 수 hr:sneezing, chill,
m.ache, thin nasal discharge
때로 coughing, headache, malaise,
anorexia, low grade
fever
- 1일 내 secretion thicker, sore throat
acute phase 2-4 days지속
Differential Diagnosis
#
initial Sx of measles, pertussis
#
poliomyelitis, hepatitis, mumps
#
※Bloody
Persistent Nasal Discharge
;
foreign body
; diphtheria
; choanal atresia
; congenital syphilis
#
allergic rhinitis
;
fever (-)
; not become purulent
; persistent sneezing &
itching of eyes & nose
; nasal mucous memb:pale
; nasal smear:eosino
多
; antithistamine →
Sx사라짐
Complication
1) cervical lymphadenitis
2) mastoiditis
3) peritonsillar cellulitis or
periorbital cellulitis
4) OM - 25% of small infant
-
TMC Cx
-
fever recur시 suspect
5) LTB, bronchiolitis or pneumonia
Prevention
:γ-globulin, vit.C …not
recommend
Treatment
;
no specific Tx
;
AB
- *not affect course & reduce incidence of bacterial complication
;
bed rest
;
acetaminophen:첫 1-2일 irritability, aching,
malaise↓
;
aspirin
- not recommend
;
nasal instillation
- sterile saline
/
infant
- phenylephrine (0.125-0.25%)
- *AB, C-S, antithistamine addition은 효과가
없다.
-
15-20min before feeding and at bed time
/
supine with neck extesion
→
1-2 drop을 각각nostril에
→ 5-10분후 다시
1-2drop
- cotton application not
recommend
- *sterile saline이외에는 4-5일이상
사용하면 안된다.
#
In infant
; suction with soft bulb
syringe
;
prone position
;
highly humidified environment
#
Oral decongestant
;
pseudoepherine
;
antihistamine + adrenergic agonist
327.2 Acute Pharyngitis
;
tonsillitis 와 pharyngotonsillitis 를 포함한
pharynx의 모든 acute infection
- principal involvement : throat
- uncommon under 1 Yr
- peak : * 4-7 세
#
★Prominent Pharyngeal Involvement
; *diphtheria, herpangina, adenovirus infection, infectious
mononucleosis
Etiology
1) virus : 대부분
2) Group A B-hemolytic streptococcus
: only common bacterial agent
( 15%이하)
Clinical Manifestations.
Viral Pharyngitis
① gradual onset
② early sign : fever,
malaise, anorexia, throat pain.
③ sore throat : present
intially, peak 2-3rd day
④ hoarseness, cough,
rhinitis.
⑤ pharyngeal
inflammation : slight. occasionally
severe - small ulcers on
soft palate, post
pharyngeal wall.
⑥ exudate : on lymphoid
follicles of palate and tonsil.
⑦ cervical LN : enlarged
and firm.
*
⑧ laryngeal involvement : common.
⑨ WBC : 6000- 30000,
predominantly polymorphonuclear cells in early phase.
⑩ entire illness : 보통
5일 이상 계속되지 않음.
Streptococcal Pharyngitis
; 2세이상.
;
headache, abdominal pain, vomiting 으로 시작.
; 수시간내
sorethroat.
;
1/3 에서 tonsillar enlargement ,
exudation, pharyngeal erythema.
;
2/3 에서 mild erythema, no enlargement of
tonsil without exudate.
;
ant. cervical lymphadenopathy.
;
fever : as high as 40 o C . 1-4일 지속.
very severe case- as
long as 2 weeks.
; ♥
Physical Finding Asso. With Streptococcal Disease
- diffuse redness of
tonsil and tonsillar pillars.
- petechial mottling
of soft palate.
; ★conjunctivitis,
rhinitis, cough, hoarseness
-
rarely symptom
-
*2개 또는
그이상의 증상이
나타나면 viral pharyngitis시사
Streptococcosis
① B-hemolytic streptococcus
의 early inf. 과 관계된
acute . inf. 이 있을시
systemic variation.
② infant: 1 주 이하로 지속되는 mild episode
특징: variable fever, mucoserous nasal
discharge, pharyngeal
infection.
③ 6 Mo- 3 Yr : most severely ill,
- 초기: coryza with postnasal discharge,
reddened pharynx, fever,
vomiting, loss of appetite.
- fever : 38-39.5 o C ,* 4- 8 주간
- cervical node : enlarge and tender, adenopathy 는
fever와 같이존재.
Diagnosis and Differential Diagnosis
1) Dx : by rapid detection
method for streptococcal antigen.
by culture after pharyngeal swabbing
2) purulent nasal discharge,
pharyngitis, fever - pneumococci or H. influenza.
3) mambranous exudate in
tonsil - diphtheria, infectious mononucleosis
4) vesiculoulcerative
lesions on ant. pillars, fauces, soft palate- herpangina.
5) Agranulocytosis
①
first manifestation : acute pharyngitis 증상.
②
tonsil and post. pharyngeal wall: covered by yellow or dirty white
exudate.
③
mucous membranes under exudate-->necrotic and ulceration extends to
mouth and tongue : very painful.
④
dysphagia : severe.
⑤ enlargement of cervical lymph node.
⑥ mucosal hemorrhages.
6) Smoke tobacco or
marijuana : pharyngeal inflammation and sorethroat.
7) allergic rhinitis : cause
sore throat.
8) gonococcal pharyngeal
infeciton : asymptomatic.
Complication
1) purulent bacterial OM :
viral
2) chr. ulcer in pharynx : viral
and strep.
3) peritonsillar abscess,
sinusitis, OM, meningitis : strep.
4) glomerulonephritis ,
rheumatic fever : strep.
5) Mesentric adenitis :
viral or bacterial
Treatment
1) viral origin : no
specific Tx.
2) strep. pharyngitis 시
①
oral PC ( 125-250 mg pc v tid for
10 days )
- 24시간내 defervescense, course of illness 를
1.5일 정도 shorten.
- pc Tx 시작후 수시간내 noninfectious.
②
EM : 만일 환자가 pc 에 allergic 한경우.
3) acetaminopen or ibuprofen :
pain이 심한경우.
4) gargling with warm saline
solution : old children 시.
5) inhalation of steam : younger
children.
6) cool bland, liquids :
acceptable than solids or hot foods.
7) rheumatic fever 의 과거력이 있는경우
: AB prophylaxis 필요.
327.3 Acute Uvulitis.
- fever, pain with swallowing, drooling
- most case: Gr A strep. or H. influenza
type b.
strep. uvulitis
: 5 세이상.
H.
influenza : 5 세 이하.
327.4 Chronic Rhinitis And Nasopharyngitis
Chronic Rhinitis
#
★Underlying Disturbance
;
nasal polyps , chronic sinusitis , chronically infected adenoids, cystic
fibrosis, dysmotile cilia syndrome, allergy, foreign bodies, deviated septum,
various congenital malformation, nasal diphtheria, syphilis
; chronic debilitating infection,
nutritional immunologic or metabolic deficiency
Clinical Manifestation
①
chronic nasal discharge 가 주증상.
* ② bloody discharge : i)
syphilis,
ii) diphtheria
iii)
foreign bodies
iv) persistent nose picking
③
disturbance of taste and smell
④
fever : 감염이 병발하지 않으면 열은 별로 없다.
⑤
persistent allergic rhinitis : common and seasonal.
⑥
rhinitis medicamentosa : 장기간 topical nasal
decongestants를 사용한경우.
⑦
atrophic rhinitis : i) uncommon
ii) associated with general debilitating condition or long-
continued nasal infection.
iii) sense of smell: impaired
iv)
crusting and sense of dryness
v) foul nasal discharge ( ozena )
Treatment
①
lanoline, silicone, petrolatum-base ointment : protects against skin
excoriation.
②
humidified air
③
mucosa - shrinking solutions ( eg phenylephrine ): symptomatic relief.
also causes further damage
④
local AB : avoid
systemic AB : Ix in selected cases.
Chronic Pharyngitis
- rare
- secondary to chronic
infections of sunuses, adenoids, tonsils.
- 편도 절제후에도
발생.
Clinical Manifestations
① throat discomfort :
dryness and raspy irritation.
② throat clearing (잦은 헛기침)
and irritative cough.
③ mucous membrane :
inflamed, pale, blood vessel 이 prominent.
④ pharyngeal wall :
mucopurulent secretion
lymphoid tissue : hypertrophied --> pebbled appearance.
Treatment
① directed toward any
disturbance.
② general nutriton and
hygiene.
327.5 Retropharyngeal Abscess
#
★4세이하에 잘
오는 이유
; 4세이전에
post pharyngeal wall과 prevertebaral fascia 사이의
space에 small lymph nodes 가 존재
-->
lymphatic channel communicating with portion of nasopharynx as well as post.
nasal passages
-->
nasopharynx infection이 spread
; *3-4세이후에 사라진다.
Etiology
; *bacterial pharyngitis
;
vertebral osteomyelitis
; wound infeciton.
; ※96 pathogens
①
Group A hemolytic streptococci
② oral anaerobes
③ S. aureus
Clinical
Manifestations
;
abrupt onset of high fever with difficulty in swallowing
;
refusal of feeding.
;
severe distress with throat pain.
;
hyperextension of head.
;
noisy, gurgling respirations.
;
labored respiration.
;
drooling.
; *bulge in posterior pharyngeal wall : digital exam. with Trendelenburg
position.
;
lateral roentegnogram of nasopharynx or neck
-
reveal retropharyngeal mass.
-
air may be seen.
- loss of normal cervical lordosis.
; ※96 Death
-
aspiration
-
airway obstruction
-
erosion into major blood vessels
-
mediastinitis
★Differential Diagnosis
1)
croup
;
larynx 에 압박시 stridor and high fever
2) meningismus : limited neck
motion
3) nonfluctuant lymphadenitis
4) Tbc of cervical spine
Treatment
1)
prefluctuant stage
①
semisynthetic penicillin.
②
single agent with clindamycin or ampicillin - sulbactam
③
analgesic drugs : for pain
④
narcotics : use only with great care.
2)
fluctuance.
: incision and AB.
327.6 Lateral Pharyngeal Abscess.
1) occurs in space lateral to pharynx
--> extends from hyoid bone to base of
skull.
2) carotid vessel and jugular vein
associated
3) Sx : ①high fever, trismus,
ill app. , severe pain, difficulty swallowing.
②bulge in lat. pharyngeal wall
③cervical
adenitis
④torticollis toward side of abscess
due to muscular spasm.
4) Tx: lat. neck drainage.
327.7 Peritonsillar Abscess
;
occurs *space between sup.
constrictor muscle and tonsil
Etiology
; *Group A β-hemolytic streptococcus or oral anaerobes.
Clinical Manifestations
; *preceded by attack of acute pharyngotonsillitis
; afebrile interval of
several days or not subside fever
; severe throat pain, trismus
(due to spasm of pterygoid muscles)
; refuse to swallow or speak
; torticollis
; fever
- septic and reach 40.5℃
;
*affected swollen and inflamed
tonsillar area
; uvula
- dsiplaced to opposite side.
; untreated Pt
- abscess becomes fluctuant --> spontaneous rupture.
Treatment
1) AB (usually penicillin ) and I
& D or aspiration.
2) Hx of chronic tonsillitis (-)
--> no tonsillectomy.
3) Hx of prior tonsillitis or
previous abscess (+) --> immediate tonsillectomy.
327.8 Sinusitis
#
full-size 시기
; *maxillary antra and ant. post. ethmoid cell - infancy
; *frontal sinus - 6-10세
; sphenoid sinus - 3-5세
;
incidence of acute and chronic sinus infection : childhood 후반기에 증가.
#
sinus infection 을 증가시키는 factor
① allergic factor
② poor sinus drainage with septal
deviation or adenoid hypertrophy.
③ hereditary condition.
④ immunosuppression.
⑤ environmental factor.
Acute Purulent Sinusitis
- Sx or sign 은
acute rhinitis 후 3-5일에 나타남.
Clinical Manifestation
;
suggestion
- "cold" (감기)
seems more severe than usual ( fever > 39 C, periorbital edema, facial pain
)
- " cold" lingers
for more than 10days
;
nightime cough : viral upper resp. inf.
- *daytime cough : suggestive of
sinusitis.
;
*headache, facial pain, tenderness,
edema : uncommon.
#
topical decongestant 후 exam.상
; pus in middle meatus
-
involvement of maxillary, frontal , ant ethmoid sinus
; pus in sup. meatus
-
involvement of sphenoid or post. ethmoid cell
;
★postnasal discharge
-->
*sore throat, persistent cough at
night
#
acute ethmoiditis in infants and small children
; periorbital cellulitis with
edema or soft tissues
;
redness of skin
#
★Complication
; epidural or subdural
abscess
;
meningitis.
;
cavernous sinus thrombosis
;
optic neuritis
; periorbital or orbital
cellulitis and abscess
;
osteomyelitis
Diagnosis
#
X-ray
; often used but
misinterpreted
; *▲common findings
-
air-fluid level.
- complete opacification
- *mucosa width of 4 mm or
more : bacteria in sinus.
#
CT scan
; *▲sensitive
indicators
; Indication
-
before surgery
- Cx of sinusitis
#
antral puncture
; *유일한 믿을만한 method for bacterial culture
; ★Ix for
sinus aspiration
①
Tx에 무반응.
②
immunocompromised hosts
③
life threatening Cx
; ※92 Organism
①
S. pneumoniae.
②
M. catarrhalis
③
nontypable H. influenza.
#
nasal swab culture : sinus aspirate culture 와 일치하지 않는다.
Treatment
;
*Amoxicillin
- *initial choice
;
H. influenza , M catarrhalis producing B-lactamase or treatment failure
--> i) bactrim
ii) amoxicillin with
potassium clavuanate,
iii) EM + sulfonamide.
iv) 2nd and 3rd
generation cephalosporin.
;
*치료기간 -
14-21 days
;
*decongestant and antihistamine - not
heipful
;
★Sinus Drainage And Irrigation Ix
- fail usual Tx
-
intraorbital, intracranial or other Cx
-
intense pain
Chronic Sinusitis.
- underlying disease : ① nasal deformity.
② polyp
③ infected and hypertrophied adenoids
④ infected teeths
⑤ sinus polyp or mucocle.
⑥ allergy, cystic fibrosis, dyskinetic
cilia.
*
- common in absence of secretory Ab ( IgA ) and immunodeficiency state.
1) Clinical manifestation.
①low
grade fever.
②malaise,
easy fatigability , anorexia.
③nasal
discharge.
④swelling
of middle turbinates--> causes nasal obstruction.
⑤postnasal
discharges in abscence of infected adenoids or aucte URI
--> diagnostistic .
⑥watery
nasal discharge or sneezing --> allergic rhinitis.
** ⑦sinobronchitis
-relationship between sinus and lower resp. tract. Sx
-underlying ds.
i). reactive airway.
ii). cystic fibrosis.
iii). immunodeficiency.
iv). dyskinetic cilia.
⑧
sinusitis 가 asthma 를
aggravate 함
2) Eti.
①acute
sinusitis 균종.
②a-hemolytic
strep.
③S.
aureus.
④anaerobes
3)Tx
①antimicrobials
for * 6 weeks.
②antihistamine
and decongestant.
③OP.
Chapter 328. Nasal Polyps
Etiology
;
benign pedunculate tumors formed from edematous, chronically inflammed nasal
mucosa
;
originate from
- ethmoid sinus, middle
meatus, maxillary antrum
;
extend to nasopharynx (antrochonal polyp)
;
associated disease
1) *cystic
fibrosis(25 %) : *▲common
2) chr. sinusitis
3) chr. allergic rhinitis
4) asthma
Clinical Manifestation
;
*obstructon of nasal passage
;
hyponasal phonation
;
mouth breathing
;
mucoid or mucopurulent rhinorrhea
;
glistening, gray, grape-like mass
- distinguished from
well-vascularized turbinate tissue : pink or red
Treatment
;
local or systemic decongestants
- not effective.
;
corticosteroid nose spray
- *not helpful , although warranted in recurrent case.
;
surgical removal
- Indication
①
complete obstruction.
② uncontrolled rhinorrhea.
③ deformity of nose appears.
;
*antihistamine : helpful
Chapter 329. Tonsil And Adenoids
-
adenoid : nasopharyngeal tonsil.
-
Waldeyer ring: 1) consists of ①
lingual tonsil
② two faucial tonsil
③ adenoid
④ lymphoid tissue on post.
pharyngeal wall.
2) defense against infections.
-
seperate tonsillectomy and adenoidectomy : 4-5세전
-
infancy 에는 tonsillar disturbance가 드뭄.
-
neoplasm of tonsil -- Waldeyer ring; non-Hodgkin lymphoma.
nasopharynx: rhabdomyosarcoma.
Chronic Tonsillits (Chronically Hypertrophic And Infected Tonsils)
Clinical Manifestation
①recurrent or persistent
sore throat.
②obstruction to
swallowing or breathing.
③sense of dryness and
irritation in throat.
④breath : offensive.
⑤ obstructing upper
airway ( rarely ) --> resp. distress, chronic hypoxemia,
pulmonary hypertension.
Indication For Tonsillectomy
#
Decision for removal of tonsils
;
based on Sx and sign of hypertrophy, obstruction, chronic infection
#
★chr. infection 의
reliable guide
;
persistent hyperemia of ant. pillars
-
*more reliable sign
; enlargement of cervical LN
;
persistent enlargement of node just below and in front of angle of jaw
#
♥Only Absolute Ix For Tonsillectomy
; rule out tumor
;
severe aerodigestive tract obstruction
#
age relation
; *postpone after 2-3yr
#
active infection relation
; *postpone until 2-3wks after subsidence of infection
except ①
acute resp. obstruction with pul. artery HT.
② cor pulmonale
Complication of tonsillectomy
(1) postop. sorethroat ( for 5
days )
(2) referred ear pain and
halitosis.
(3) minor hemorrhage.
(4) postop throat inf. or
anesthetic Cx.
(5) severe hemorrhage or life
threatening Cx.
(6) pul. edema.
Adenoidal hypertrophy
(=hypertrophy
of pharyngeal tonsil: " adenoid" )
Clinical Manifestation
*
① mouth breathing and persistent rhinitis : 가장 특징적
Sx.
② chronic
nasopharyngitis.
③ voice : nasal,
muffled.
④ breath: offensive.
⑤ taste and smell :
impaired.
⑥ harassing cough : at
night.
⑦ impaired hearing :
common.
⑧ chronic OM
⑨ snort and snore loudly
: sign of resp. distress.
⑩ respiratory
insufficiency ( hypoxemia, hypercapnia, acidosis ) : during sleep.
--> pul. a. HT
--> cor pulmonale.
# upper airway obstruction
in sleep --> mimicking adenoidal hypertrophy syn.
①
very obses children ( e.g. Prder-Willi-Robin syn. )
②
large or post. placed tongue ( e.g. Pierre-Robin syn. )
③
cow's milk hypersensitivity.
④
Down syn : macroglossia, tonsillar enlargement, skull base anomaly.
Diagnosis
①
digitial palpation
②
indirect visualization with pharyngeal mirror.
③
fiberoptic bronchoscopie
④
lat. pharyngeal X-ray.
Treatment
#
♥Ix of adenoidectomy
① persistent mouth
breathing
②nasal speech
③adenoid facies
④repeated attacks of OM
(esp. when accompanied by a conductive hearing loss)
⑤persistent or recurrent
nasopharyngitis related to infected hypertrophic adenoid tissue
Chapter 330 Obstructive
Sleep Apnea And Hypoventilation In Children
- combination of prolonged partial upper
airway obstruction and intermittent
complete obstruction (
obstructive apnea ) --> disrupts normal ventilation
and sleep patterns.
#
habitual snoring
; *▲common Sx
;
8-10 % of all young school children
- severe OSA/H : 1 % of snoring
children.
- peak age : 2-5 Yr.
- incidence in male and female.
①
prepubertal children: similar.
②
adults: male predominance.
Pathogenesis.
1) normally during sleep.
dsepite
pharyngeal airway collapse and upper airway muscle tone decrease , especially
during REM sleep.--> upper airway patency : maintained and
ventilatory output and oxygenation not impaired.
--> Pa 02
decrease and Pa 02 increase : only slightly.
2) certain anatomic factor (
adenotonsillar hypertrophy, nasal obstruction, obesity,
craniofacial anomaly )
or neurologic condition ( hypotonia in trisomy 21,
cranial nerve weakness ) --> occur OSA/ H
3)
cascade of events.
① upper airway muscle
activity decreases, upper airway narrows and resistance
increase in
anatomic or neurologic factor.
② partial or complete
airway obstruction --> impaired gas exchange with
hypoxemia and hypercapnia.
③ potent stimuli for
increased ventilatory effort and upper airway muscle
activity.
④ increased effort and
airway muscle tone lead to resumption of airway potency.
⑤ arousal from sleep
occur --> helps restoring blood gas.
⑥ airflow restored,
oxygen and carbon dioxide level return to normal.
⑦ sleep re-established ,
upper airway muscle activity decrease -->
cycle starts again.
Figure 330-1 Pathophysiology of OSA/H in
children.)
4)
OSA/H 의 serious cardiorespiratory and
neurobehavioral consequence.
(1) chronic hypoxemia lead to
① polycythemia
② growth failure
③ increased pulmonary artery
pressure.
④ pulmonary hypertension.
⑤ Rt. heart failure.
⑥
arrythmia.
⑦ death.
(2) recurrent arousal lead to
① sleep fragmentation.
② loss of normal sleep pattern.
③ excessive daytime sleepiness.
(3) hypersomnolence
① behavoral problems.
② impaired school performance.
③ accidents.
(4) sleep fragmentation.
① suppress arousal response.
② further impair ability to
reestablish upper airway
patency and restore gas exchange.
5)
Anatomic factor lead to obstruction in childrem.
① adenotonsillar
hypertrophy : most common.
② micrognathia,
retrognathia, macroglossia.
③ fat deposition from
obesity.
④ congenitally small
airway narrow nasopharynx
Clinical manifestation
1) daytime hypersomnolence
- most common Sx in adults.
- rare in children.
2) chronic mouth breathing , snoring ,
restlessness during sleep with or without
awakening.
3) unusual sleep position
- neck hyperextended or
bottom up in air.
4)breath normally while awake in most
children with OSA/H,
but, more severe presentation 시 : nosisy, labored
awake breathing
--> worsen with sleep.
5) snoring very loud. followed by
silience. snort, arousal, resumption of snoring.
6) triad of Sx --> highly suggestive
of OSA/H
① snoring
② nocturnal breathing difficulty.
③ witnessed respratory pauses.
7) behavioral problems and poor school
performance.
8) secondary enuresis
9) underweight or present with failure to
thrive in some children.
-- contribute factor ①
dysphagia from large tonsil.
② chronic hypoxemia.
③ higher metabolic expenditure from
increased work of
breathing.
④
insufficiency growth hormone release in absence of deep
NREM sleep.
10) unexplained Rt. heart failure.
11) more severe case ; respiratory
failure.
Diagnosis and Assessment
#
♥Delayed Dx due to Several Reasons
① absence of awake
symptoms
② failure to obtain
sleep history
③ symptoms of snoring or
restless sleep are considered inconsequential
④ parents may be unaware
of problem because child's most severe symptoms appear during REM sleep in the
last 3rd of night
⑤ young children may not
generate loud, disruptive snoring noises
#
P/Ex
(1) features associated with
OSA/H
①
unusual facies.
②
month breathing
③
hyponasal speech.
④
macroglossia.
⑤
cleft palate.
⑥
enlarged tonsil.
⑦
not consistent feature of obesity
(2) stridor or hoarse voice
: indicate cranial nerve dysfunction.
3)
Lab. finding
①
polycythemia or metabolic alkalosis : absence in majority of pediatric pt.
4)
ECG : Rt. ventricular hypertrophy.
5)
Lat. soft tissue radiograph of neck: identify adenoidal tissue.
6)
CT or MRI of nasopharynx.
7)
fluroscopy or endosccopy
#
★polysomnography (PSG)
; *" gold standard " for Dx of
OSA/H
;
overnight recording of multiple physiologic sensors during sleep.
; provide powerful ,
quantitative, noninvasive assessment of
i) gas
exchange impairment.
ii)
respiratory pattern.
iii)
thoraco-abdominal movement.
iv) sleep
disruption.
; useful i) confirming Dx
ii) determing severity of OSA/H
iii) decumenting efficacy of Tx.
#
DDx
①
nocturnal asthma.
②
upper airway obstruction from gastroesophageal reflux.
③
esophageal foreign body.
④
laryngomalacia, vascular ring, intraluminal mass
⑤
vocal cord dysfunction.
⑥
night terrors or nocturnal seizures.
⑦
narcolepsy and restless leg syn.
Treatment
①
adenotonsillectomy
:
risk for incomplete resolution of OSA/H after adeno-tonsilletomy
i) trisomy 21
ii) craniofacial disorders.
iii) extreme obesity
iv) neuromuscular disorders
such as cerebral palsy or Chiari
malformation .
v) present before 2 Yr of age.
②
nasal continous airway pressure ( CPAP )
: option in children who fail adenotonsillectomy.
③
supplemental oxygen.
④
snoring : treated with nasal decongestants and topical steroids.
⑤
medroxyprogesterone acetate.
i) Tx of daytime hypoventilaton associated with
obesity-hypoventilation
syndrom
ii) adverse effects: growth and pubertal developments.
⑥
protriptyline : nonsedating antidepressant with REM suppressant activity in
adult.-- not recommended
⑦ tracheostomy.
: serious upper airway obstruction in both wakefulness and sleep.
SECTION 3. Lower Respiratory Tract
Chapter 331. Congenital Anomalies
331.1 Laryngeal Anomalies
1.
complete atresia of larynx
: incompatible with life.
2.
laryngeal webs.
(1) uncommon , occasionally familial
(2) resulting from incomplete separation of
fetal mesenchyme between two
side of larynx .
(3) most webs : between vocal cords.
(4) Sx : ① respiratory
distress with severe stridor.
② cry: weak and abnormal.
③ obstruction 이
incomplete 한경우 : mild stridor and dyspnea.
(5) Dx : direct laryngoscopy.
(6) Tx : ① lysis with carbon
dioxide laser.
② OP.
3.
Laryngotracheoesophageal cleft.
(1) rare congenital lesion.
(2) long connection between airway and
esophgus.
(3) caused by failure of dorsal fusion of
cricoid - normally complete by 8th
wk gestation.
(4) type
①
type 1 : above sup. portion of post. cricoid plate.
②
type 2 : extend to inf. aspect of post. cricoid palate.
③
type 3 : involve " cervical trachea"
④
type 4 : extend to thoracic trachea and below.
(5) Sx
① chronic aspiration.
②
gagging during feeding
③
pneumonia ( H-type tracheoesophageal fistula )
(6) Dx
① roentgenographic study of
swallowing.
② endoscopy.
331.2 Congenital Laryngeal Stridor (=Laryngomalacia And Tracheomalacia)
;
congenital deformities or flabbiness of epiglottis and supraglottis aperture.
:
weakness of airway wall.
=> inspiration 시 collapse and airway obstruction 야기.
;
*▲common
congenital laryngeal abnormality
Clinical Manifestation
;
*noisy , crowing resp. sound in
inspiration
- common in neonate and first
1yr
;
stridor at birth
- may not appear utill 2
months
;
male : female = 2.5:1
;
worse lies on back
;
noisy breathing, laryngeal " crow " hoarseness or aphonia.
;
dyspnea, inspiratory retracton
;
severe dyspnea 시 undernutrition and poor wt. gain.
;
substantial stridor
- *persist for several months to 1 Yr
- *worse in first few months and then
gradually disappearing with airway growth and development
Diagnosis
#
direct laryngoscopy
#
★Differential Diagnosis
; congenital laryngeal
disturbance from neonatal tetany
; laryngeal edema secondary
to trauma or aspiration
; others
①
malformation of laryngeal cartilages or vocal cords
② intraluminal webs
③ generalized severe chondromalacia
of larynx and trachea
④ Tm of larynx
⑤ mucus retention cyst
⑥ bronchial cleft cyst
⑦ thyroglossal duct remnant
⑧ hypoplasia of mandible
⑨ macroglossia
⑩ hemangioma, lymphangioma, Pierre
Robin syn., congenital goiters, vascular anomalies
#
*4mo이후에
증상을 나타나내는
경우에는 other respiratory
anomalies를 동반할
수 있다.
Treatment
; *no specific Tx
-
resolves spontaneously
;
small nipple dropper 드물게 gavage.
; *more comfortable or less noisy in prone
position
(4) severe Sx ->
nasotracheal intubation or thacheostomy.
Prognosis
;
*18 mo에 clinically resolve
- some degree of inspiratory
obstruction persist a little longer
;
pulmonary function test 상 teen age 까지
minor abnormality.
--> not
clinically problem.
--> not
require Tx.
Other anomalies
1) bifid epiglottis
: resulting from
cleavage of two thirds or more of epiglottis.
2) total absence of
epiglottis : extremly rare.
3) laryngeal cyst and
laryngoceles
: tx with
endoscopic " unroofing"
331.3 Agenesis or Hypoplasia Of Lung
#
bilat. pul. agenesis or hypoplasia.: incompatable with life
#
associated disorders of bilat. pul. hypoplasia
① anecephaly.
② diaphragmatic hernia
③ urinary tract anomaly.
④ thumb anomaly.
⑤ deformity of thoracic spine and rib cage
( thoracic dystrophy)
⑥ renal anomaliles.
⑦ Rt. sided heart malformation.
⑧ congenital pleural effusion.
#
unilat. agenesis or hypoplasia : few Sx
- Lt. sided lesions : more common.
- No specific Tx : older pt. 의경우
- AB for pulmonary infection.
- annual influensa vaccine
- Px 는 associated anomaly 에 의존
- right lung involve 시
mortality 증가
- death : ① overwhelming pul. inf.
② CHD 와 연관된 pul. HT 의
Cx.
331.4 Pulmonary Sequestraton
#
sequestration
; nonfunctioning embryonic
and cystic pul. tissue mass
; entire blood supply from
systemic circulation
#
associated anomalies
; diaphragmatic hernia,
esophageal cysts
Intralobar Sequestraton
; lower lobe
; *ass. with infection
; *hemoptysis in older pt
; mass lesion and air- fluid
level in X-ray
; Treatment
-
removal operation
Extralobar Sequestration
; *more common in male & Lt. lobe
; *ass. with diaphragmatic hernia
; *mostly asymptomatic
-
others : respiratory Sx or heart failure.
; Tx : op. removal.
Diagnosis
1) phy/finding :
① dullness to percussion and breath
sound 감소.
② infection 시
rales
③ continuous or purely systolic
murmur heard over back.
2) chest X-ray
3) bronchography
4) ultrasound : rule out diaphragmatic
hernia.
5) aortography :
① confirm diagnosis.
② lesions 의
blood supply를 규명.
6) Doppler ultrasonography and MRI.
331.5 Bronchoenic Cyst
*
cilliated epi. 으로 lined - inf. 시 소실되어
pathologic Dx 곤란.
*
midline structure 에서 가깝게 발생( eg. trachea, eso.,
carina )
*
Sx ① fever
②
chest pain
③
productive cough
*
X-ray : cyst - contain air fluid level.
*
Tx for Sx cyst : 적당한 AB후
surgical excision.
*
ASx 시 no Tx.
331.6 Bronchobiliary Fistula
1)
Def. : Rt. middle lobe bronchus와 Lt. hepatic ductal system사이의
fistula.
2)
Sx: recurrent severe bronchopul inf. starting in early infancy.
3)
Dx: endoscopy and bronchography or exploratory surgery.
4)
Tx: surgical excision of entire intrathoracic portion of fistula.
331.7 Congenital Pulmonary Lymphangiectasis.
1)
Def. : dilated lymphatic duct throughout lung (신생아기에 dyspnea and cyanosis)
2)
2 form of disease
① lung 에 국한된
abnormality.
② 20 to pulmonary venous obstructon
: 3rd form - pulmonary
lymphangiectasis with other organ disease.
3)
Dx : lung biopsy.
4)
no specific Tx.
331.8 Cystic Adenomatoid Malformation.
;
*2nd ▲common congenital lung disease
- lobar emphysema가
most common
#
★Sx
; neonatal respiratory distress.
;
recurrent respiratory infeciton.
;
pneumothorax
2)
Most pt: symptomatic and die in newborn period.
3)
Dx
①P/Ex : diminished
breath sound with mediastinal shift away.
②X-ray ; cystic mass
with mediastinal shift
air-fluid level -> lung abscess 시사.
4)
DDx : diaphragmatic hernia.
5)
Tx: surgical exicision.
after
surgery -> increased risk for primary pulmonary neoplasm.
Chapter 332. Acute Inflammatory Upper Airway Obstruction
General Consideration
* infant and small children 에서는
airway 가 작으므로 older child와 같은 정도의
inflammation에도 더
narrow 해진다.
* larynx : composed of four cartilage (
i. e. thyroid, circoid, arytenoid, epiglottic)
* cricoid cartilage : encircle just
below vocal cords
narrowest portion of pediatric upper airway.
* inflammation involving vocal cords and
structures inf. to cords : called
laryngitis, laryngotracheitis, laryngotracheobronchitis.
* inflammation of structures sup. to
cords ( i. e. arytenoids, aryepiglottic fold,
epiglottis )
#
croup 의 특징.
①
brassy or " croupy" cough with or without inspiratory stridor.
②
hoarseness.
③
sign of respiratory distress.
332.1 Infectious Upper Airway Obstruction
Etiology and epidemiology
#
※92
Virus
; *▲common agents
; *parainfluenza virus : 75 % of case
; adenovirus
;
respiratory syncyital
;
influenza
;
measles viruses
#
Mycoplasma pneumoniae : 3.6 %
#
★Cause Of Acute Epiglottis
; *H. influenza type b : usual cause
; strep. pyogens
;
strep. pneumoniae
;
staph. aureus
;
virus : rare
#
Age
; *viral croup : 3 mo- 5 yr
; *H. influenza & corynebacterium
diphtheria croup : 3-7 yr
#
incidence
; *higher in male
;
common cold season
; *15 % croup family Hx
;
laryngitis : recur 잘함.
Clinical Manifestation
Croup (=Laryngotracheobronchitis)
; *▲common form of acute
upper airway obstruction
; URI before cough
Clinical Manifestation
; at first, mild brassy cough
with intermittent inspiratory stridor
; as increasing obstruction
-
worsening cough, nasal flaring & chest retraction
-
respiratory difficulty
-
labored & prolonged expiratory phase of respiration
; *slight elevated fever
; *worsening at night & often recur with decreasing intensity for
several days
; older children : not seriously
ill.
; *다른 가족중 mild respiratory illness를 가짐.
; duration
-
*from several days to rarely several
weeks
; recurrence
-
freguent from 3-6yr
; agitation & crying :
aggrevate Sx.
; prefer to sit up or
upright.
; air hunger &
restlessness.
; severe hypoxemia,
hypercapnia, weakness.
; eventual death from
hypoventilation.
; hypoxemic child 에
tongue depressor를 사용하는 pharynx의manupulation
은sudden cardiorespiratory arrest 야기할수 있다.
; X-ray of nasopharynx &
upper airway
-
*typical subglottic narrowing
“steeple sign”
※91 Acute Epiglottitis (
Supraglottitis )
; dramatic , lethal condition
; usually occurs in 2-7yr,
peak at 3.5yr
; 특징
-
*fulminating course of high fever,
sorethroat, dyspnea, rapidly progressive respiratory obstruction, prostration
- *respiratory distress :
first manifestation
; 수시간에서
적절한 치료를 하지 않으면 death.
; 적절한 치료시
2-3일간 경과는 드뭄.
; younger child
-
well at bedtime
-->
*awaken later in the evening, high
fever, aphonia, drooling, respiratory distress with stirdor
; *no URI family history
; older children
-
*initial : sorethroat, dysphagia
--> severe resp. distress within minutes or hours with
inspiratory stridor, hoarseness, brassy cough, irritability, restlessness
; neck : hyperextended.
; prefer sitting position,
leaning forward, mouth open, tongue protuding
; progress rapidly to
shocklike state : pallor , cyanosis, impaired consciousness.
Physical Exam
moderate
to severe resp. distress with insp. & exp. stridor.
inflamed
pharynx with abundance of mucus, saliva
-> rhonchi
-> 진행시 stridor & breath
sound 감소 ( 환자가 tiring )
-> air hunger with restlessness,
agitation
-> cyanosis, coma, death.
때로 mild hoarseness &
large , shiny, cherry red epiglottis.
Diagnosis
; *Direct exam or laryngoscopy
-
*large, swollen cherry-red epiglottis
-
some patients
/
reflex laryngospasm, acute complete obstruction, aspiration of secretions,
cardiorespiratory arrest during or after exam.
-->
*full preparation for endotracheal
intubation한 뒤에
검사를 해야
한다.
; ABGA
-
*after definite diagnosis and
establishment of artificial airway
; *lat. X-ray of nasopharynx & upper airway
-
*before P/Ex of pharynx
Treatment
; nasotracheal intubator or
tracheostomy 로 airway 확보.
; acute epiglotitis 는
2-3 일간 intubated.
; parentral AB
-
cefotaxime, ceftriaxone, apmicillin with sulbactam ( unasyn )
; concomitant infection.
-
meningitis, pneumonia, cervical adeonpathy, OM,-rarely occur.
Acute Infectious Laryngitis
common
illness
대부분 virus에 의함(except
for diphtheria)
Clinical
Manifestation
①
sorethroat, cough, hoarseness.
②
generally mild.
③
respiratory distress: unusual except young infant.
④
hoarseness and loss of voice
⑤
severe case : severely inspiratory stridor, retraction, dynpnea,
restlessness.-> 진행시 air hunger &
fatigue,
agitation 과 exhaustion 반복.
P/Ex:
①
pharyngeal inflammation
②
resp. distress
③
evidence of high respiratory obstruction.
Laryngoscopy
: inflammatory edema of vocal cord & subglottic tissue.
Principal
site of obstruction : subglottic area.
Acute Spasmodic Laryngitis (Spasmodic Croup)
; often 1-3yr
; *similar to croup except findings of absence of infection of pt
& family
; ★Suggestive
Causes
-
viral origin
-
allergic & psychologic factor
-
gasroesophageal reflux
/
important role in spasmodic croup
; pathology
①
intact epithelium. ( unlike acute infectious laryngotracheobronchitis )
②
pale , watery edema.
; familial predisposition (+)
; Sx
-
evening 이나 night 때 발생
( sudden onset ): coryza 와 hoarseness
-
barking, metallic cough, noisy insp. , resp. distress. anxious, frightened
-
대개 afebrile , cool & moist skin.
-
severity of Sx diminish within several hrs.-> 다음날은 appear well
-
종종 recur.
★Differential Diagnosis
1) *bacterial tracheitis : ▲importnat
DDx
2) diphtheritic croup
①
preceded by URI
②
slow developed Sx
③
serous or serosanguineous nasal discharge
④
P/Ex 상 gray white memb. on pharynx
3) measles croup
4) aspiration of FB
5) others
-
retropharyngeal or peritonsillar abscess, ext. compression of airway,
intraluminal obst. from mass, endotracheal intubation 후의
edema, angioedema of subglottic area as anaphylaxis, hypocalcemic tetany, IM,
trauma, Tm, malformation of larynx.
Complication
1)
15 % of viral croup.
①
inf. of middle ear, terminal bronchioles, pul. parenchyma : most common.
②
bacterial tracheitis
③
interstitial pneumonia
④
bronchopneumonia.
⑤
secondary bacterial pneumonia.
⑥
supprative tracheobronchitis.
2)
epiglottitis ( during the course )
①
pneumonia
②
cervical lymphadenitis
③
otitis, meningitis, septic arthritis.
3)
tracheotomy 후의 TMC Cx.
①
mediastinal emphysema.
②
pneumothorax
Prognosis
#
death from
; laryngeal obstruction.
; Cx of tracheostomy.
#
unTx epiglottitis
; mortality 6 %
#
acute LTB, laryngitis, spasmodic croup
; excellent prognosis
Treatment
;
maintaining or providing for adequate resp. exchange
;AB
for Bacterial form
Treatment Of Croup
;
shower or vaporizer or cold steam
--> terminates acute
laryngeal spasm & respiratory distress within minutes
--> same effect observed
by child out into cold night air
;
induction of vomiting by coughing or by syrup of ipecac
--> decreased laryngeal
spasm
;
after laryngeal spasm diminished
- use of warm or cool
humidification
- near child's bed for 2-3
Days
;
㉿Hospitalization
indication
-
actual or suspected epiglottis
-
progressive stridor
- *severe stridor at rest
-
respiratory distress
- hypoxemia
- restlessness
- cyanosis
- pallor
- *depressed sensorium
- *high fever in toxic- appearing child
;
watched carefully for Sx of resp. obstruction
;
continous monitering of resp. rate.
-
increasing tachypnea -> first sign of hypoxemia & tatal
;
parentral fluid.
;
sedative
- contraindication
;
opiate
- contraindication
;
oxygen
;
expectorants, bronchodilatory agent, antihistamine
- *not helpful
Treatment For Laryngotracheobronchitis &
Spasmodic Croup.
; not response to AB
;
racemic epinephrine by aerosol.-> transient relief of Sx.
;
nasotrhcheal intubation or tracheotomy : rarely
★Corticosteroid
; *indicated for hospitalized child with croup
; *reduce inflammatory edema
;
prevent destruction of ciliated epithelium
Treatment For Epiglottitis
; medical emergency
;
immediately artificial airway
;
oxygen
; *ineffective racemic epinephrine &
corticosteroid
-
artificial airway 의 필요성을 감소시키지 않음.
-
delay definitive Tx.
; ceftriaxone or cefotaxime
or ampicillin with sulbactam: contunued for 7-10 days
Treatment For Acute Laryngeal Swelling On Allergic
Basis
; epinephrine
-
1: 1000 dilution in dose of 0.01ml/kg to maxium of 0.3ml/dose
- subcutaneously
; isoproterenol by aerosol
;
corticosteroid ( 1-2 mg/kg/24hr of prednisone every 6h )
; endotracheal intubation Ix
( under general anesthesia )
* reactive
mucosal swelling.
* severe stridor
* resp. distress
unresponsive mist Tx.
Tracheostomy & Endotracheal Intubation
# epiglottitis
;
routine introduction
# ♥Ix of
impending resp. failure
;
> pulse rate 150/min
; elevated Pco2 , especially in tiring child.
# useful to faciliate
extubation .
; hydrocortisone ( 50-100 mg/ 24hr )
;
dexamethasone ( 0.25-0.5mg/kg/dose every 6 hr )
; racemic
epinephrine
332.2 Bacterial Trachetis
#
원인균
; *S. aureus - ▲common
;
parainfluenza virus type I , Moraxella catarrhalis
;
H. influenza
;
대부분 3세 이하.
;
viral ds 의 bacterial Cx ( rather than 10
bacterial illness )
Clinical Manifestation
; brassy cough, high fever,
toxicity with respiratory distress.
; *croup 의 usual Tx 는 ineffective
;
usually tracheotomy or intubation
; major pathology
-
mucosal swelling at cricoid cart. level
-
copicous, thick, purulent secretion.
Diagnosis
1) bacterial upper airway dis. evidence.
① mod. leukocytosis with band form
② high fever
③ purulent airway secrection.
2) absence of classic finding of
epiglottitis.
Treatment
① antimicrobial Tx
includes antistaphylococcal agent.
② artificial airway.
③ supplemental oxygen.
Complication
; X-ray 상
patchy infiltrate & focal density.
;
subglottic narrowing
; *rough-ragged tracheal air column
; cardiorespiratory arrest
; Toxic-shock synd.
Prognosis
① excellent.
② 적절한 antimicrobial Tx 후
afebrile within 2-3 days
③ hospitalization 의
meanduration: 12일.
Chapter 333. Foreign Bodies In The Larynx, Trachea, And Bronchi
Tracheal FB
1)
특징
① wheeze
② audible slap
③ palpable thud at
subglottic level.
2)
definite Dx : broncoscopy.
Bronchial FB
Clinical manifestations
; cough, wheeze, blood
wtreaked sputum, metallic taste with metallic FB
; slight obstruction ( e. g.
bypass valve )
-
passing of air in both direction
-
only slight interference
-
wheeze
; obstruction allows air
entry but not exit ( i. e. check valve or ball valve )
-
obstructive overinflation
; complete obstruction allows neither air entry not exit
-
obstruction atelectasis
;
Rt. and left mainstem bronchial foreign body aspiration
-
*equal frequency
;
episode of chocking, gaging, paroxysmal coughing
; if acute episode not occur,
latent period of minutes to months with only occasional cough or slight
wheezing
-->
recurrent lobar pneumonia , intractable asthma & episode of status
asthmaticus.
; Homoptysis
-
months or years after aspiration
#
physical exam
;
tracheal shift.
;
breath sound : decreased on side of obstruction.
#
♥Vegetal Or Arachidic Bronchitis
; *severe condition due to vegetable
foreign body(e.g. peanuts)
; cough, septic type of
fever, dypnea
Diagnosis
#
history
#
※94
Physical Signs Of Bronchial Obstruction From Foreign Body
;
limited chest expansion.
; *decreased vocal fremitus
;
impaired ( i. e. atelectasis ) or hyperresonant ( overinflation ) percussion.
;
diminished breath sound distal to FB
;
crakles on uninvolved side ( than involved one )
#
X-ray
; check valve obstruction
-
obstructive overinflation
-
localize bronchial FB by fluoroscopy.
-
obstructed lung : expanded during expiration.
-
heart & mediastinum : shift to opposite side.
-
diaphragm : low, flattened, fixed on obstructed side.
-
X-ray 상 두 lung 의 현저한 차이
( 특히 expiration 시
)
; stop valve obstruction
(complete obstruction)
-
obstructive atelectasis
-
heart, mediastinum : drawn toward obstructed side ( both phase of respiration
-
diaphragm: - obstructed side : high
- unobstructed side : more normally.
-
X-ray 상 only slight difference at end of
inspiration & expiration.
#
Direct visualization by bornchoscopy
; definitive diagnosis
; *rigid or open- tube bronchoscopy
-
diagnostic instrument of choice
Prevention
① 제거하지 않으면 serious problem 야기.
② 대부분 safely removal
③ 만일 진단이 24시간 이상 지연된경우
Cx 의 incidence 증가.
Cx: i) aspiration pneumonia
ii)
airway trauma
iii) need
for tracheostomy.
Treatment
;
★endoscopy & removal of FB under direct vision
- *rigid open- tube bronchoscope as soon as possible
;
*pulmonary physiotherapy &
bronchodilator
- *not recommanded
-
due to
/
risk of dislodging distal FB -> obstruct larger airway.
/
endoscopy delay 시켜 morbidity 증가.
#
emergency procedure for aphonic & not breathing children
; for infants ( < 1Yr )
① 4 back blow & 4
chest thrust 반복.
② abdominal thrust : not
used
③ 4 back blow : head 를 낮추고
scapula사이를 heel of hand로
4 blow
--> loosen FB
④ 4 chest thrust : back
blow 이후 돌려서 hand position 을
closed cardiac
compression 과 같이 하여
4 chest thrust.
--> increase
intrathoracic pressure
--> expulsion of FB.
⑤ blind finger sweep of
month : not used in infant & young children.
⑥ 4 chest thrust 이후
mouth opened & vusualized FB
--> grasped &
removed.
⑦ after each sequence,
resque breathing for unconscious Pt.
⑧ if unsuccessful,
repeated.
; young child ( > 1 Yr )
① placed on back
② rescuer kneels next to
pt.
③ heels of one hand 를 사용하여,
umbilicus 와 rib cage 사이중간에서, 6-10
abdominal thrust by
pushing upward & inward from midabdomen.
④ 실패시 mouth opened by using
tongue - jaw lift --> visualized FB removed.
Chapter 334 Subglottic Stenosis
334.1 Acute Subglottic Stenosis
1.
result from ①
acute infection producing edema of subglottic, epiglottic,
arytenoid region
② inflammation secondary to inspriration
of vegetal FB
③
edema of allergic reaction.
④
FB lodged in larynx
2.
TX
① intubation or tracheotomy
② medical Tx
334. 2 Chronic Subglottic Stenosis
Etiology
① sequele of high tracheotomy
(damage
of first tracheal ring or cricoid cartilage)
②
larygeal diphtheria
③ syphilis
④ TB
⑤ radiation burns
⑥ external trauma
⑦ neonatal intubation : most common
cause
⑧
congenital laryngeal stenosis : autosomal dorminent trait
⑨ "silent"
gastroesophageal reflux
Clinical manifestation
①
dyspnea with stridor, suprasternal, supraclavicular, intercostal retraction
②
limited to inability to decannulate patience's tracheotomy
or remove endotracheal tube
③
scarring and stenosis in subglottic region
④
necrosis of cartilage : occassionally
Diagnosis
①
direct laryngoscopy
②
X-ray
Treatment
(1) milder
case : not need Tx
(2) mild case of
difficulty in decanulating pt's tracheostomy
①
replacing tracheostomy cannula with smaller one and closure of this tube
--> reeducate pt to mouth breathing
--> removal of cannula
②
dilation through direct laryngoscope
(3) external surgery
Prognosis
: good, but treatment require months or
years
Chapter 335. Trauma To The Larynx
Birth Trauma
Postnatal Trauma
Chapter 336. Neoplasms Of The Larynx
#
Papilloma
; *▲common laryngeal tumor
Chapter 337. Bronchitis
337.1 Acute Bronchitis
Clinical Manifestation
Treatment
; no specific therapy
; *pulmonary drainage by frequent shifting in position
; high humidity
-
not shortening the duration of illness
; cough suppressants
(including codein)
-
symptomatic relief
; *antihistamines, expectorants
-
★not helpful
; AB
-
*not shortening the duration of viral
illness or decrease the incidence of bacterial complication
; ※Repeated Attacks 시
고려 질환
-
respiratory tract anomalies, foreign bodies, bronchiectasis, immune deficiency,
tuberculosis, allergy, sinusitis, tonsillitis, adenoiditis, cystic fibrosis
337.2 Chronic Bronchitis
Chapter 338. Bronchiolitis
; during 1st 2yr of life
-
*peak incidence : 6mo
Etiology And Epidermiology
# ★RSV
;
*more than 50%
# parainfluenza 3 virus, mycoplasma, some adenoviruses
Pathophysiology
#
bronchial obstruction
; *due to edema and accumulation of mucus and cellular debris
*and by invasion of the smaller
bronchial radicles by virus
#
★ball valve obstruction
; early air trapping and
overinflation
Clinical Manifestation
; Hx of exposure to older
children or adults with minor respiratory diseases within a week
; initially mild URI symptoms
-
serous nasal discharge and sneezing
; *diminished appetite and fever 38.5-39℃
; *gradual development of respiratory distress
-
*paroxysmal wheezy cough, dyspnea,
irritability
#
※94
X-ray findings
; hyperinflation of the lungs
; increased AP diameter on
lateral view
; scattered areas of
consolidation - 30%
; atelectasis
Differential Diagnosis
; bronchial asthma
-
*▲common
confused disorder
-
㉿DDx
points
/
FHx
/
*repeated episodes : ▲important
/
sudden onset without preceding infection
/
markedly prolonged expiration
/
eosinophilia
/
immediate favorable reponse to single dose of aeroxolized albuterol
; congestive heart failure
; FB in the trachea
; pertussis
; organophosphate poisoning
; cystic fibrosis
; bacterial bronchopneumonias
Course And Prognosis
#
*▲critical
phase
; *during 1st 48-72hr
#
recovery
; *complete in a few days
#
case fatality rate
; *1%
#
※Death
; prolonged apneic spells
; severe uncompensated
respiratory acidosis
; profound dehydration
secondary to loss of water vapor from tachypnea, inability to drink fluids
※90,91,92 Treatment
#
if respiratory distress, hospitalization
#
supportive treatments
; only
#
ribavirin (virazole)
#
bronchodilator
#
AB
; *no benefits
#
corticosteroids
; *no benefits
Chapter 339. Bronchiolitis Obliterans
Pathogenesis
; brochioles, small airway
injury
-->
granulation tissue & fibrosis during repair
-->
airway obstruction
#
★Associated Conditions
; inhalation of oxides of
nitrogen
; connective tissue diseases
; drug (e.g. penicillamine)
; pul. infection
-
meales, influenza, adenovirus, mycoplasma, pertussis
;
lung transplantation complication
Clinical Manifestation
① 초기 ; cough, respiratory
distress, cyanosis
② 진행시 ; dyspnea가 증가,
productive cough, wheezing
Diagnosis
; X-ray
-
range from normal to miliary Tbc pattern
-
★cf) Swyer-James syndrome
/
10%
/
*unilateral hyperlucency and decrease
in pulmonary vascular marking
; Bronchography
-
bronchioles의 폐쇄와 함께 lung의
periphery에 no contrast.
; CT ; Bronchiectasis
; ★lung biopsy
-
*confirmed diagnosis
Treatment
; no specific Tx
cf> corticosteroid Tx - 성인에서는 효과가 있으나 소아에서는 입증된 data가 없음.
Prognosis
; 대부분 생존하나 소수는 빠르게 진행되어 초기증상 발현 수주내에 사망.
339.1 Follicullar Bronchitis
1.
Etiology ; unknown
2.
2주내에 tachypnea와
cough를 보임
3.
청진상 diffuse crackles
4.
X-ray ; diffuse interstitial pattern.
5.
CT ; subtle interstitial nodules
6.
진단은 lung biopsy로
7.
Px ; 대부분 점차적으로 호전되나 소수는 respiratory failure로
life threatening.
8.
Tx ; corticosteroid에 반응하는 예도 있음.
Chapter 340. Aspiration Pneumonia & GER Related Respiratory Disease
* GI content의
respiratory tract내로의 흡입을 막는 여러 가지 기전
(Table 340-1)에도 불구하고
dysfunctional swallowing 및 GER의 많은
예에서
respiratory ds를 야기하거나 악화시킨다.
* reflux와 관련된 호흡기 질환의 기전은
aspiration 및 mechanical &
chemical effect 그리고
airway 및
esophagus로부터의 신경학적인 영향 등이다. ( Fig 340-1)
340.1 Aspiration Pneumonia
Aspiration Of Food & Vomitus
#
★Predisposing Factors
; with obstruction
-
esophageal atresia, duodenal obstruction
; without no obstruction
-
hypotonic, weak & debilitated infants & children
;
familial dysautonomia
; impaired consciousness
Clinical Manifestation
; ★brief
latent period
-
*hydrochloric acid is important
determinants
-
90%이상 1시간내에 Sx 출현
- *거의모두 2시간내에 Sx 출현
; *fever, tachypnea, cough
; Apnea, Shock
;
P/E ① diffuse crackles,
wheezing
② cyanotic
;
X-ray ; alveolar & reticular infiltration
Treatment
① 기도내의 즉각적인
suction
②
Oxygen
③
Endotracheal intubation with suction
& mechanical ventilation
- severe case시
; AB
-
★previously healthy nonhospitalized patients
/
*Clindamycin or PC
-
chronically ill hospitalized patients
/
*added to Aminoglycoside
Prognosis
; *대개 2 주내에 infiltrates가 소실
;
mortality rate ; 약 25%
Aspiration Of Baby Powder
; Zinc stearate
-
*드물지만 가장 dangerous
② Tx ; 고습도하에서의 oxygen therapy
③ 그외 magnesium silicate,
calcium undecylemate
④ Talc ; i) asbestos와 관련이 있으며
malignancy 유발 가능성
ii) severe dyspnea시 systemic corticosteroid Tx가 유용.
Pneumonitis From Other Chemicals
① +-high concentration ; 염증반응,
세포 침윤, acute respiratory distress 야기.
+- low
concentration ; 육아종 형성의 chr. interstitial
pneumonitis
② 예 ; Shellac,
polyvinylpyrrolidone, gum arubic, beryllium, mercury vapors,
chlorine
③ corticosteroids가 치료에 효과.
340.2 Hydrocarbon Pneumonia
Etiology
; furniture polish (광택제),
kerosene, charcoal lighter fluid, gasoline
Pathogenesis
; interact with pul.
surfactant
-->
alveolar collapse
; alveolar macrophage injury
Clinical Manifestation
; *cough, vomiting follow ingestion immediately
; *fever 38-40℃ within hours
② pul. Sx ; dyspnea,
↓resonance on percussion
↓B/S, rale
③ pul. involve는
P/E보다 chest X-ray에서 더 자주
disclosed
④ 대부분 2-5일이면
recover
⑤ systemic Sx :
sommlence, convulsion, coma
Complication
① pneumothorax
②
subcutaneous emphysema
③
pleural effusion, emphysema
④
pneumatocele - 1주후에
⑤
20 inf. with bacteria or virus
Treatment
;
*never sent home in less than 6hr
although asymptomatic
;
♥Admission Ix
-
symptomatic on first exam
-
symptomatic during 1st 6hr obseration
-
ingestion of toxic agent (eg. furniture polish)
;
*no pulmonary therapy before symptoms
develops
;
induction of vomiting or gastiric lavage
- contraindication
- *large volume hydrocarbon in stomach 일때는
실시
/
CNS toxicity 막기위해
;
AB
- not recommended as routine
use
;
corticosteroid
- *no benefit
Prognosis
Cx없이 대개
survive하지만 일부는 resp. failure와
death로 진행
Px factor ① volume of ingestion or aspiration
② specific agent
③ medical care의
adequacy
340.3 Lipoid Pneumonia
;
lipoid material의 aspiration으로 인한
chr. interstial, prolif. inflammation
;
deblilitated Pt.에 ↑
Pathogenesis
#
aspiration 관련 factor
①
intranasal instillation of oil
②
cleft palate, debilitation, feeding시 horizontal position
③
forced feeding
: 특히 우는 아이에
cod liver oil, castor oil, mineral oil을 먹일 시.
#
흡입된 oil의 종류에 따라 pul. reaction의 정도가 차이남.
;
vegetable oil +- olive, cotton
seed, sesame oils
+- ↓ irritation, minimal inflammation
cf) chaulmoogra(인도산 나무) - extensive damage
;
animal oil
-
cod liver oil, milk
- *▲damage
; liquid petrolatum, lip
gross
#
lung reaction
①
initial : interstitial proliferative inflammation, exudative pneumonia가능
②
2nd stage : diffuse, chr. proliferative fibrosis
때로 acute infectious bronchopneumonia
③
3rd stage : multiple localized nodules
tumor-like paraffinoma
Clinical Manifestation
1) cough : TMC
2) severe case 시
dyspnea
3) 2o bronchopneumonia가
common
#
X-ray findings
; mild involvements
-
*increase in density & extent of
hilar shadows
; severe involvements
-
*greater density of perihilar shadow
widen all direction
; maybe limited Rt. lung
-
recumbent시 (RUL)
Prevention
1) oily vehicle의
intranasal medication을 피함.
2) 가능한 minimal oil, cod liver
oil, castor oil의 복용을 피할 것.
3) 자주 regurgitation 및
vomiting을 보이는 infant는
prone position으로 둘 것.
Treatment
1) no specific Tx
2) position change → ↓hydrostic
pneumonia
340.4 ★Respiratory
Disorders Caused Or Worsened By GER Or It's Treatment
Aspiration pneumonia
특히 의식이 감소되어 있는 환자에서 흔함.
chemical pneumonitis,
asthma-like Sx 야기
Asthma
천식환아는
정상아에 비해 reflex정도가
abnormal
reflex는
vagal pathway에 의해 천식을 야기하거나 악화시킴
Bronchopulmonary dysplasia (BPD)
reflex는
BPD의 course를 지연시키며
이것의 치료시 pul. function이 호전됨
Cystic fibrosis
이 질환자의 많은 수에서
GER를 가짐.
Tracheoesophageal Fistula
모든 환자들은
esophageal dysmotility를 가지며 대부분 reflex를 보임
Obstructive Apnea
Central Apnea & Apparent Life-Threatening Events
Stridor
laryngomalacia와 같은
mild airway compromise의 경우, reflex시
stridor를
보이며
antireflex therapy시 stridor가 감소되어짐.
Hoarseness
성인에서 후두의 염증과 부종이
reflex와 관련이 있으며,
acid suppression therapy에 후두증상이
호전됨.
소아의 경우에도 관련성이 가능
Cough
reflex의 증상으로 가능하며,
antireflex 치료로 호전됨.
Hiccup
Respiratory Side Effects Of Antireflex Tx
Bethanechol의 경우
bronchospasm을 야기
Chapter 341. Silo filler Ds
1.
정의 : N2O의
inhalation에 의한 acute or subacute interstitial
Pn
2.
Dx : ① exposure Hx (4주이내)
②
Sx : dyspnea, wheezing, cough, nausea, choking or fatique
P/E : 청진상 rales (약
1/3에서)
③
X-ray : infiltration or edema
④
biopsy or autopsy
3.
Tx : corticosteroid
Chapter 342. Paraquat Lung
1. 제초제로 사용되는 dipyridylium compoud로
lung에 선택적으로 축적되며,
high toxic
2. 수일-수주내
resp. failure로 사망
3. pul. lesion : ①
2o to systemic absorption by GI, skin or lung
(오염된 마리화나 흡연)
②
prolif. bronchiolitis, alveolitis,
intraalveolar hyaline membrane & fibrosis를 보임
Treatment
; no treatment except
supportive Tx
; *O2 --> increase pul. toxicit
Chapter 343. Hypersensitivity To Inhaled Materials
organic
dust의 반복된 inhalation →
chr. pneumonitis
Etiology
① moldy hay ( farmer's
lung)
② maple bark (maple bark
stripper's ds)
③ sugar cane fiver (
bagassosis )
④ red-wood tree bark
⑤ pigeon dropping &
feather ( pigeon breeder's ds )
⑥ cheese
⑦ desiccated pituitary
powder
⑧ dusty output from air
conditioner
⑨ fungus or mod
Clinical Manifestation
: 노출 수시간내에 cough, dyspnea, chest pain, fever
- Ag 에 계속 contact시 severe dyspnea와 cyanosis로 진행
( 이때 X-ray : diffuse, fine, intestitial or nodular
density &
peripheral alveolar infiltrates )
- 때로
pulmonary function의 irreversible loss
** suspect
: cough,
fever 때로 dyspnea같은
mild Sx을 가진 어린이에서
bronchopneumonia가 AB로 적절히 치료함에도 지속될 때
Pathology
1)
조직학적으로 plasma cells, lymphocytes,
epitheliod cell 그리고 giant cell의
축적과 함께
subacute granulomatous inflammation으로 구성
2)
계속 노출시 fibrosis로
replaced
Diagnosis
1) moderate to marked leukocytosis (
acute attack시 )
2) serum Ig * ( G,M,A )
3) PFT상 restrictive pattern
4) hypoxemia without hypercapnia
5) skin test상
delayed hypersensitivity response
6) 피부생검에 의해 Arthus reaction이 증명
7) 주어진 Ab 에 대한 serum precipitin 증명
8) lung biopsy ; diffuse fibrotic or
granulomatous respose
9) inhalation challange test
Chapter 344. Pulmonary Aspergillosis
#
Allergic bronchopumonary aspergillosis (ABPA)
; *allergy to organism(aspergillus
fumigntus)
; *ABPA without infection or tissue invasion
-
*▲common
aspergillus-related disease in children
; mostly in patients with
chronic pulmonary disease
Clinical Manifestation
;
*immunosupressed or chr. illed child가 acute onset of cough, wheezing, low grade fever
;
productive cough
- *occasionally brown plug containing hypae
;
immediate skin reaction : strong (+)
- Arthus type III가
skin test후 증명
;
Aspergillus의 strong suspect 경우
①
aspergillus Ag에 대한 Ab의 precipitation
②
(+) skin test
③
serum IgE ↑
#
★Definite Diagnosis
; substantial eosinphilia
; aspergillus specific IgE or
IgG in serum
Treatment
#
Aerosolized amphotericin or tracheal direct insfillation of amphotericin
; not estabilished
#
systemic amphotericin B (0.5-1 mg/kg/24hr iv) or 5-fluorocytosine (50-150
mg/kg/24hr)
#
*systemic corticosteroids
; *predenisone 0.5mg/Kg/day for 2wks and then same dose on alternate
day for 3mo
; *Tx of choice
#
Intraconazole + systemic corticosteroid
#
aspergilloma
; surgical resection with
local instillation of amphotericin B
Px factor : underlying chr. illness
invasive
aspergillosis시 antifungal Tx는 효과 없을 수도 있음
;
amphotericin B + 5-FC * for
2-3wks
Chapter 345. Loeffler Syndrome (= Eosinophilic Pneumonia )
#
★Characteristics
; widespread transitory
pulmonary infiltrates
-
variable size but *resemble miliary
Tbc
; eosinophilia (70%까지)
#
clinical course
① 심하지 않으면서 몇일에서 몇달까지 다양.
② paroxysmal attack of
cough, dyspnea, pleurisy, little or no fever
③ hepatomegaly ( 특히
infant & young children에서 )
④ hyperglobullinemia -
i) hepatic dysfunction
ii) parasitic invasion에 대한 response로
Etiology
; helminthic infection
-
*▲common
i) toxocara canis
(TMC) & cati
ii) roundworm
; Ascaris
lumbricoides, Strongyloides stercoralis
hookworm
iii) paragonimiasis
; Drug reaction
: aspirin, PC,
sulfonamide, imipramine
#
hypereosinophilic synd.
① 소아에서는 rare
② eosinophilia가
6개월이상 지속
③ acute lymphoblastic
leukemia의 초기증상으로서 가능
#
variant of eosinophilic pn.
: 최근에는 더 acute course of fever와
rapid progression to
severe hypoxia,
eosinophilia, diffuse pulmonary infiltration
→
oral C-S에 빨리 response하며
relapse도 없다.
Differential Diagnosis
Chapter 346. Pulmonary Involvement In Collagen Ds
#
rheumatic pneumonia
1) fatal rare, Cx of acute RF,
rheumatoid arthritis, or other CT ds.
2) 특징 ① extensive pulmonary
consolidation &
rapid progressive functional deterioration을 보이며
② pathology i) alveolar exudate
ii) interstitial infiltrate
iii) necrotizing arteritis
3) X-ray ; pul. edema와 유사한
infiltration이 일시적으로
4) Tx ; no spesific , but
immunosuppressive drug가 효과있다.
Chapter 347. Desquamative Interstitial Pneumonitis
#
pathologically Characteristics
; massive proliferation &
desquamation of TypeII alveolar cell
; thickening of alveolar wall
;
many macrophages filling alveolar spaces
#
lonstanding DIP 3→ chr. interstitial fibrosis로 진행
#
대개 URI 선행
#
congenital rubella와 관련된 2 case있음
#
circulating immune complex와 alveolar deposit of Ig G &
complement
→ 이 질환의 immune basis를 시사
Clinical Manifestation
;
usually slowly developed
; tachypnea & dyspnea
;
non productive cough, anorexia, wt. loss
;
cyanosis
Laboratory Finding
1) X-ray
①
diffuse, hazy, ground glass appearance at lung bases
② poorly defined hilar density
2) Hypoxemia ;
ventilation-perfusion abnormality에 의해서
→ diffuse defect →
severe exercise intolerance
#
Definite Diagnosis
; open lung biopsy
Treatment
1) often recover spontaneously
(but 1세 이전에 진단시 주목 ! )
2) pulmonary status악화나
X-ray상 빠른 deterioration시
→
open lung biopsy로 definit Dx후
→
C-S ① Sx의 빠른 resolution
② X-ray의
gradual improvement
3) corticosteroid-resistant Pt.의 경우에
chloroquime phosphate가 효과
( 10mg/Kg/24hr)
4) Tx가 빨리 stop될 경우
relapse 가능
Chapter 348. Hypostatic Pneumnia
1.
발병 ① marasmic state에서 혹은 수술 후
prolonged passive pulmonary
congestion후 생김
② one position으로 오래 누워있을 때
2.
P/E ; dullness on percussion, 약한 호흡음, 수포음
3.
specific Tx는 없고 prophylaxis가 가장 중요
: frequent position change
Chapter 349. Pulmonary Hemosiderosis
;
abnormal accumulation of hemosiderin in the lungs
- resulting from diffuse
alveoli hemorrhage
#
♥4 Type of Primary Pul. Hemosiderosis
① idiopathic form
② form asso. with cow's
milk hypersensitivity (Heiner synd.)
③ form asso. with
myocarditis
④ form asso. with
progressive GN (Goodpature synd.)
#
♥3 Type of Secondary Pul. Hemosiderosis
① asso. with mitral
stenosis & chr. LVF
② asso. with collagen
ds.
③ asso. with hemorrhagic
ds.
Idiopathic Primary Pul. Hemosiderosis
1) onset ; 대개 childhood
2) Sx ; ①
recurrent or chr. ds.로서 cough, hemoptysis, dyspnea,
wheezing
때로는 cyanosis 보임
② acute attack시는 대개
2-4일 지속되며, fever 를 보이기도 함.
③ 소수에서 초기에
chr. iron deficiency anemia와 관련된 Sx를 보임
④ microcytic, hypochromic anemia
Diagnosis
; ★Open
Lung Biopsy
-
intra-alveolar hemorrhage
-
*large numbers of hemosiderin-laden
macrophages
-
alveolar epithelial hyperplasia
-
interstitial fibrosis
-
sclerosis of small vessels
-
absence of Ig or complement deposition on the alveolar basement membrane
; closed-needle biopsy
; BAL
-
hemosiderin-laden macrophage
② X-ray ; minimal infiltration에서부터
2차적인 atelectasis, emphysema
그리고 hilar lymphadenopathy를 동반한
massive pul. involvement까지 다양
③
open lung biopsy
- 조직학적으로 intra-alveolar hemorrhage,
hemosiderin을 함유한 macrophage,
alveolar epithelial hyperplasia, intestitial fibrosis 그리고 small vessels의
sclerosis를 볼 수 있음
④ Bronchoalveolar lavage - hemosiderin을 함유한 macrophage를 발견
Prognosis
- Pt.의 약
1/2에서 급성 폐출혈 및 진행적인 폐부전으로 1-5년내에 사망
Treatment
- corticosteroid ( prednisone, 1mg/Kg/24hr )
Primary Pul. Hemosidrosis With Hypersensitivity To Cow's Milk
(Heiner Synd.)
; typical pictures of
idiopathic hemosiderosis
; *high serum titers of precipitiins to cow's milk
; *positive results on intradermal skin
test to cow's milk protein
; chr. rhinitis, recurrent OM,
GI symptoms, growth retardation
; Treatment
-
식이요법 ; cow's milk를 제거
ii) corticosteroid
iii) cyclophosphamide
; 다른
form에 비하여 Px는 좋음
Primary Pul. Hemosiderosis With Myocarditis
- heart enlargement와 함께
idionpathic hemosiderosis
Primary Pul. Hemosiderosis With Gn (Goodpasture Synd.)
;
*young adult male
;
initial Sx
- similar to idiopathic type
;
*usually proliferative or membranous
GN at initial attack
;
renal biopsy
- IgG deposit along alveolar
& glomerular basement membrane
;
*anti-GBM Ab in serum
;
*mostly progressive renal disease
with hypertension & eventual renal failure and death
Chapter 350. Pulmonary Alveolar Proteinosis
;
rapidly progress to respiratory failure
;
*alveolar space filled with periodic
acid-Schiff(PAS)-positive proteinaceous material, rich in lipid
#
2 clinical form
①
sporadic type
②
congenital form
Congenital Alveolar Proteinosis
; *full-term newborn develops rapidly progressive respiratory distress
; similar to RDS
; Etiology
-
*SP-B (surfactant apoprotein B)의 genetic homozygous deficiency
; pathology
-
alveolar proteinosis
-
desquamation & hyperplasia of alveolar septum
- interstitial fibrosis
-
impared alveolarization
;
Clinical Manifestation
-
rapid progressive respiratory distress
; X-ray
-
*fine, diffuse infiltrate from hilum
to periphery(“butterfly distribution”)
-
later nodular or lobar density, infiltration
; PET (Positron emission
tomography)
-
vascular permeability와 protein flux가 증가
; ★DDx
-
*persistent fetal circulation,
meconium aspiration, hyaline membrane ds., alveolar capillary dysplasia, CHD (
esp. TAPVR )
Diagnosis
; conform by lung biopsy
;
RFLP analysis of polymerase chain reaction-amplified gemomic DNA
;
molecular assays of chorionic villus biopsy
A/F에서 surfactant protein의 측정
→ 가족력이 있을때
antenatal diagnosis로 가능
Treatment
; *replacement therapy - not effective
; current therapy
-
ventilatory support & ECMO
-->
*lung transplantation
Aduldt Form Of Alveolar Proteinosis
1) 소아에서는 rare
2) male에서 female보다 3배 더 많다
3)
2 form 의 차이점 |
distribution of pathologic process |
amount of alveolar SP-A |
1o form |
diffuse |
abundant |
2o form |
patchy |
scant |
4) Sx : dyspnea, fatigue, cough,
wt. loss, chest pain, hemoptysis
→ 말기에는 cyanosis와 digital clubbing을 보임
5) Lab. 1 PFT ; restrictive pattern
2 ABGA ; marked hypoxemia with respiratory alkalosis
6) Dx - lung biopsy
7) Tx - whole lung bronchoalveolar
lavage
Chapter 351. Idiopathec Diffuse Intestitial Fibrosis Of Lung
(=Hamman
Rich Syndrome)
1.
기전 : uncontrolled imflammatory
process
→ chr. imflammation
→ progressive fibrosis
2.
Sx
① incidious onset of
dyspnea (처음에는 운동시 나타나나
진행시 휴식상태에서도
② dry cough가 주
, 때로 productive of blood
③ 대개 aferile
④ 진행시 anorexia, Wt. loss,
fatigability
→
finally cyanosis, clubbing, cor pulmanale, Rt. heart failure
⑤ 청진시 lung은 대개
clear하나 종종 rale도
detect
⑥ death : intercurrent
pulmonary infection으로 인한 resp. failure로
3.
X-ray : progressive widespread granular or reticular mottling
or small nodular densities
4.
67Ga scan 상 (+)
5.
Tx
① C-S는
Symptomatic relief는 가능하나 ds.의
progress를 바꾸거나
pul. function 호전은 없다.
② immunosuppressant drug
: some adult에서 benefit
Chapter 352. Pulmonary Alveolar Microlithiasis
① rare ds. of unknown
eti.
② familial incidence ( 약
50% )
③ no secific metabolic
abnormality
S-Ca &P ;
n'l
④ Dx ; lung biopsy
⑤ Tx ; 유용한 방법은 없다.
⑥ i) Pt. 발견시 가족구성원의 screening
ii) respiratory
infection에 대한 즉각적인 치료
iii) 금연 및 매연 노출주의
iv) 철저한 immunization (measles,
pertussis, influenza )
Chapter 353. Atelectasis
Acquired Atelectasis
★Etiology
;
3group
External Pressure
; direct interference with
expansion of lungs
-
*pleural effusion, pneumthorax,
intrathoracic tm., diaphragmatic hernia
; compression of bronchus or
bronchiole
-
enlarged LN, Tm, cardiac enlargement
Intrabronchial Or Intrabronchiolar Obstruction
; intrabronchial
①
foreign body
② neoplasm
③
granulomatous tissue ; Tbc
④
secretion (mucus plug)
:
cystic fibrosis, bronchiectasis, pul. abscess, asthma, chr. bronchitis, acute
laryngotracheobronchitis
; intrabronchiolar
-
*bronchiolitis, interstitial
pneumonitis, asthma
Reduced Amplitude Of Respiratory Excursion Or
Respiratory Paralysis
; neuromuscular abnormalities
-
cerebral palsy, poliomyelitis, spinal muscular atrophy, MG
; osseous deformities
-
rickets, scoliosis, kyphosis, scleroderma, overly restrictive casts, surgical
dressings
Pathology
Atelectatic area - firm
& deep red
Clinical Manifestation
1) small area - aSx
2) large area of previously
n'l lung에 발병시
;
dyspnea with rapid shallow respiration,
tachycardia, cyanosis
3) area of severe
pre-existing ds.에 발병시
;
transient pain, 기존질환의 이학적 소견을 보임.
Diagnosis
① X-ray
② Brinchoscopic exam.
Prognosis
:
① atelectatic area - susceptible to
infection
∵ mucociliary clearance가 결여,
cough가 ineffective
② 지속시 Cx ; pul. abscess
Treatment
1) ♥Bronchoscopic Exam Indication
;
*FB, any other bronchial obstruction
-->
immediately
;
*persist for several wks : 8wks
2) position change & deep
breathing
3) O2 : dyspnea시
(95%O2 = 5%CO2 혼합한 것)
4) morphine과
atropine은 가능한 피함
5) postural drainage
6) AB도 때로
7) asthma시
: bronchodilator & C-S
8) lobectomy
;
★Indication
-
chr. infection threating to remainder lung
- bronchiectasis
- systemic Sx(e.g. anorexia, fatique)
Massive Pul. Atelectasis
Etiology
; postop. Cx
-
*▲common
; trauma / asthma / pneumonia
/ tension pneumothorax / FB asporation
;
paralysis in diphtheria or poliomyelitis
Clinical Manifestation
1) op. 후
24시간내에 onset : dyspnea, cyanosis,
tachycardia
2) 매우
anxious, chest pain 호소, prostration, fever(39.5-40oC)
3. P/E
1) affected chest : flat
2) ↓respiratory
excursion
3) dullness to percussion
4) (-) or feeble breath
sound
4. X-ray
1) lower lobe가 흔히
involve
2) heart & mediastinum이 affected side로 displace
3) collapsed
4) elevation of diaphragm
5) narrowing of intercostal
space
Prevention
1) op중
- 마취중 충분한 ventilation
2) op후 ① position change 자주
② oropharynx의
secretion 을 aspirate
③ 의식회복 후 deep breathing
Treatment
1) bilat. atelectasis시 즉시 bronchoscopic
aspiration 시행
2) unilat. atelectasis시
① 건강한
lung쪽으로 위치하여 forced coughing or
crying시킴
②
bronchoscopic aspiration ← ①에 실패시
* relapse 많다.
Chapter 354. Emphysema & Overinflation
#
emphysema
; distension with
irreversible rupture of alveoli
#
overinflation
; reversible disttension
without alveolar rupture
Localized Obstructive Overinflation
Etiology
①
FB & inflammatory reaction
②
intrabronchial Tbc or Tbc of tracheobronchial LN
③
intrabronchial or mediastinal Tm
④
abnormally thick mucus ; asthma, cystic fibrosis
Unilateral Hyperlucent Lung
★Etiology
; pneumonia
-
more than 1/2
; adenovirus infection
; *anomalous location of Lt. pul. a. (=pulmonary slings)
-
overinflation of all 3 lobes of Rt. lung
; HMD
; absent pul. valvetype of
TOF
; 2nd aneurysmal dilatation
of pul. a.
Clinical Manifestation
② 대개
Pn의 Sx및 Sg을 보이지만 소수에서는
hemoptysis
③
P/F : hyperresonance & decreased BS
④
Tx : no specific Tx
Congenital Lobar Emphysema
; *usually apparent in neonatal periods
-
5% appear 5-6mo
; severe respiratory distress
; ★Lt.
upper lobe
-
*▲common
(4)
Tx
①
medical management with (selective) intubation or
high
frequently ventilation
②
immediate op. & excision of lobe
← cyanosis와 심한 respiratory distress가 나타나면
354.1 Generalized Obstructive Overinflation
;
reversible
;
infant에 많다.
Etiology
①
asthma
② CF
③ acute bronchiolitis
④ interstitial
pneumonitis
⑤ atypical form of acute
LTB
⑥ aspiration of zinc
stearate powder
⑦ miliary Tbc
Clinical Manifestation
①
expiratory type of dyspnea
② respiratory rate ↑&
↓ respiratory excursion
③ air hunger, chest wall
retraction
④ severe한 경우
cyanosis
⑤ percussion시 hyper-resonant
⑥ Fine or medium
crackles
#
X-ray
1) both diaph. low & flattened
2) wide intercostal space
3) lung : hyperlucent
4) fluoroscopic exam.
①
restricted diaph. movement
②
exp.동안 n'l downing of diaph ↓
③
flattened diaph.
④
exp. 동안 lung의
air retention ↑
354.2 Bullous Emphysema (= Pneumatocele)
Etiology
; overdistension &
rupture of alveoli during birth of 직후
② sequele of pneumonia or other
inf.
③ Tbc
2.
DDx : pul. abscess
3.
대부분 수개월 내 자연 소실
cf> severe respiratory & cardiac
embarrassment의 경우 Aspiration or surgery
354.3 Subcutaneous Emphysema
Etiology
①
fx of orbit (nasal sinus로부터 air leakage)
② tracheotomy
③ deep ulceration in the
pharyngeal region
④ esphageal wound
⑤ perforating lesion of
larynx or trachea
⑥ Cx of thoracentesis
⑦ asthma의 Cx
⑧ abdominal op의
Cx
⑨ gas producing bacteria
2.
self-limited & no-specific Tx
:
드물게 trachea 주위의
soft tissue의 air로 인해 tracheal
compression
→ op. 요함.
354.4 α1-Antitrypsin Deficiency & Emphysema
;
α1-antitrypsin homozygous
deficiency로
--> early onset of severe
pancinar emphysema
;
소아에서는 pul. ds.로
rare한 cause
#
α1-antitrypsin
-
lung의 dead bacteria나
leukocyte로부터 유리되는 proteolytic enzyme을inactivation시킴
→
deficiency시 pul. tissue의
proteolytic destruction과 emphysema야기
3.
Type : genotype, Pi type
+- n'l : Pi type MM
+- abn'l : null / null ZZ,
SZ → early onset emphysema
4.
Tx
1) Danazol ( testosterone analog )
; hepatic α1-antitrypsin
synthesis ↑
2) α1-antitrypsin
Chapter 355. Pulmonary Edema
1.
Eti. : pul. capillary로부터 alveolar space와
bronchiole로의
fluid transudation에 의해서
1) LVF : ↑ pul. venous pr.
2) hypervolemia
3) acute or chr. nephritis
4) pneumonic & other inf. with
toxicity (rare)
5) poisoning by barbiturate, morphine,
epinephrine, alcohol
6) inhalation of toxic gas :
illuminating gas, ammonia, NO2
7) ingestion & aspiration of highly
volatile hydrocarbon
( e. lighter
fluid )
2.
Cl/m
1) 대부분 rapid onset
2) Sx ; ① breathing difficulty,
chest discomfortness or chest pain
② cough with frothy, pink-tinged
sputum
③ tachypnea, rapid & week
pulse, pale, 때로 cyanotic
3) P/E상 +- dullness to percussioin
+- moist, bubbly rale on lower chest, 초기에 wheezing가능
4) X-ray ; ①
diffuse perihilar infiltrate - butterfly distribution
② peripheral & horizontal line
- Kerley B
3.
Tx
1) ↑O2 by IPPB
2) morphine sulfate (0.1mg/Kg)
; O2와 함께
dyspnea relief
3) 만일 2o to
excessive fluid/blood IV administration or cardiac failure
→ ①
diuretics (furosemide 1mg/Kg)
②
digitalis
③
bronchodilator
④
tourniquet to extremities
⑤
withdrawal of blood
** High altitude pulmonary edema
1. children & adolescent
at altitude above 2700m (8860ft)
2. ① cough, chortness of
breath, vomiting, chest pain : TMC Sx
→ exposure 수시간내에
② X-ray ; bilat. patchy pul. infiltration
③
recovery : 48시간내
3. Tx ; O2, Bed rest,
diuretics, antibiotics & corticosteroid
Chapter 356. Pul. Embolism & Infarction
#
*uncommon in infant, children
Etiology
#
thrombi
; often from femoral &
pelvic vein
; *children, adolescent에서는 abd.
& head vein에서도 올
수 있다.
#
★Asso. Condition
; scoliosis surgery
; spinal cord injury
; severe burn
;
prolonged inactivity
; complication of IV infusion
; ★Sick Neonate
-
*medical device (e.g. IV line), AV
fistula, implanted device
/
*▲often
-
CHD & infant of DM mother
- infarcted placenta
-
thrombus in umbilical vein
-
asphyxia
-
sub sequent resp. distress
; adolescence
①
recent abortion