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Part 19. The Respiratory System

ÀüÀº¿µ

PART 19. RESPIRATORY SYSTEM

section 1. development and function

# respiratory systemÀÇ  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 splanchnopleura°¡ ÀÌ ±â°£¿¡ lungÇü¼º¿¡ ÇʼöÀûÀÎ ¿ªÇÒ.

2) *pseudoglandular period

    ; 6-16wks

    ; *TEF, CDH(Bochdale)ÀÇ congental malformation ÀÌ ½Ã±â¿¡ »ý±è

3) canalicular period

    ; 16-28wks

    ; accessory structure£¨cart,.gl,m.£©¿Ï¼ºtype¥°¥±pneumocytes.

4) saccular period

    ; 28-36wks

    ; terminal sac ¿Ï¼º

5) alveolar period

    ; *after 36ÁÖ

  ;  at birth 50 million alveoli¡æadult 300 million.

    ; acinusÇü¼º¿¡ fetal lung³»ÀÇ liguid¿¡ ÀÇÇÑ stretch¿Í respiratory muscleÀÇ period distensionÀÌ ÇʼöÀû.

    ; lung or chest compress£¨diaphragmatic hernia or oligohydramnios£©or fetal breathing abolished£¨spinal cord lesion£©½Ã pulmonary hypoplasia.

Adaptation To Air Breathing.

# Pulmonary Surfactant

  ; *hetergenous mixture of phospholipid and protein

    ; synthesis by type¥± pneumocyte

           - first recognized *as early as 24wks

           - *not detectable in amniotic fluid until 30wks : chronologic gap

    ; apoprotein£º3°¡Áö type £¨SP-A, SP-B, SP-C£©

    ; glucocorticoid

           - apoprotein £¦lipid ÇÕ¼º¡è

           - parenteral administration to prevent RDS

  ; thyroid H

           - phospholipid ÇÕ¼º¡è

  ; ¥â-adrenergic agonists £¦ other agent

           - apoprotein £¦phosphatidylcholine secretion¡è

    ; ¡Úinsulin, hyperglycemia, ketosis, androgen

           - *surfactant ÇÕ¼º¿¡ negative effect

    - DM motherÀÇ infant or male infant¿¡¼­ respiratory distress syndrome high incidence.

# pu.l resistance

    ; high¡ælow resistance

    ; ¿øÀÎ

           ¨ç lung tissue expanding¿¡ ÀÇÇØ pulmonary vascular wall¿¡ mechanical forces.

           ¨è alveolaÀÇ oxygen ³óµµ¿¡ ÀÇÇØ pul arterial smooth muscleÀÇrelaxation, vasodilatorÀÇ endogenous release.

    ; foramen ovale £¦ ductus arteriosus°¡ closureµÇ¹Ç·Î pulmonary¿Í system circulation ¿ÏÀüÈ÷ ºÐ¸®

Postnatal Development

first phase£º¨ç Ãâ»ýÈÄ¡­18°³¿ù

¨è gas exchange¿¡ °ü¿©ÇÏ´Â compartmentÀÇ surface £¦ volume¡è

¨é air space volº¸´Ù capillary volÀÌ ´õ ¸¹ÀÌ¡è

second phase£º¨ç alveolar £¦ capillary surface¡è.

Chap 320. ¡ÚRegulation Of Respiration

The Respiratory Control System Is Negative Feedback System With A Central Controller

   ¡¤ Co2¡è½Ã ventilation Áõ°¡½ÃÄÑ Co2 ¡é.

   ¡¤ feedback system

       afferent limb : airway, carotid °°Àº receptor endingÀ» °¡Áö´Â 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 controller´Â ¾Æ¸¶ neuron groupÀÌ emergent network¸¦ Çü¼ºÇÏ          µçÁö, endogenous or conditional bursterÀÏ °ÍÀÌ´Ù.

     2) medullary neuron. two group : nucleus tractus solitarius

                                      nucleus ambiguus

        ¢¡ respiration initiationÀÇ potential site

     3) medulla (pre-B  tzinger) : respiration Á¶Á¤¿¡ Áß¿ä

Afferent Information In Not Necessary For Initiating Respiration But Plays An Important Role In Modulating Breathing

    1£©peripheral nerve sys

     £¨1£©larynx £¦ upper airwayÀÇ chemoreceptor £¦ mechanoreceptor

        £ºmucosa¿¡ stretch, air temp, chemical change

        ¡æsuperior laryngeal nerve £¦ 10th cranial nerve.

     £¨2£©Carotid £¦ aortic bodies£ºo2 or co2 tension

     £¨3£©Skin or mucosal receptor hypothalamic neuron£ºthermal or  metabolic             change

    2£©high brain center

     £¨1£©medulla oblongataÀÇ ventral surface£ºco2 sense

     £¨2£©limbic system

          £ºemotion £¦ changes in mood

Centeral Integration And Processing In The Brain Stem Hierachical

    ¡¤´Ù¾çÇÑ ¿ä±¸¿¡ ÀÇÇÑ neurophysiologic signalsÀÌ ÀÖÀ»¶§,

        central  controller´Â stimuli¿¡ µû¶ó ¹ÝÀÀÀ» Çâ»ó½Ã۱â·Î ÇÏ°í °¨¼â½Ã۱⠠         µµ ÇÑ´Ù.

      ex£©trigeminal afferent impulse´Â REM sleep or ±ú¾î ÀÖÀ»¶§ º¸´Ù

          quiet sleep½Ã¿¡ cortical influenceÀ» ´ú ¹Þ¾Æ ´õ respiration¿¡           

          trigeminal stimulationÀÌ Àú¸íÇØ Áø´Ù.

Respiratory Muscles And Chest Wall Properties(E.G. Efferent Organ) Undergo Postnatal Maturation And Can Fatigue

    ¡¤respiratory muscle innervationÀÇ maturational aspect

     +-adult-one muscleÀº one motoneuron¾Ö ÀÇÇØ Áö¹è

     |

     +-newborn-polyneuronal innervation

    ¡¤newborn¿¡¼­ adult¿¡ ºñÇØ end plate ³»¿¡ acetylcholine contentÀû¾î

      diaphragmÀÇ neuromuscular transmission susceptibility¡é

    ¡¤newborn infantÀÇ chest wallÀÌ ¾ÆÁÖ complaintÇØ¼­

        REM sleep¿¡ ƯÈ÷ paradoxic respiration

      ¡æ¾î¶²ÀÌ´Â À̰ÍÀÌ muscle fatigue¿Í respiratory failure°¡ newborn¿¡¼­

        Àß »ý±â´Â Áß¿äÇÑ ÀÌÀ¯¶ó°í »ý°¢

The Newborn And Young Respond Differently To Stimuli Compared With Mature Subject

    ¡¤O2 low¿¡ ´ëÇÑ ¹ÝÀÀÀÌ neonate¿Í adult¿¡¼­ Â÷À̰¡ Àִµ¥,

      ÀÌÀ¯£º1£©hypoxia µ¿¾È metabolic rateÂ÷ÀÌ

            2£©lung £¦ airwayÀÇ mechanical propertyÀÇ Â÷ÀÌ

            3£©centeral neuronÀÇ cellular £¦ membrance propertyÀÇ  alteration

Clinical Implications

Apnea

; °¢°¢ÀÇ ageÀÇ infant or childÀÇ mean breath time¿¡ 3 standard deviation ÀÌ»ó resp. pause°¡ ÀÖÀ»¶§

    £¨2£©adultº¸´Ù O2 consumptionÀÌ ³ô°í, ºñ±³Àû lung volÀÌ ÀûÀ¸¸ç, O2

         store°¡ Àû¾î¼­very young or premature¿¡¼­´Â short resp pause¿¡µµ

         serious consequenceÀ» °¡Á®¿Ã ¼ö ÀÖ´Ù.

    £¨3£©sleep ¡µwaking state      ---+          

                                      | apnea¹ß»ýºóµµ¡è        

         REM sleep ¡µquiet sleep  ----+          

Upper Airway Obstruction

    £¨1£©children

      ¨çcause£º¡¤tonsillar £¦ adenoidal hypertrophy

                 due to repeated upper resp infaction

               ¡¤craniofacial malformation

               ¡¤micrognathia

               ¡¤muscular hypotonia

    £¨2£©adulat£º ºÒºÐ¸í

    £¨3£©UAOÀÇ usual site £ºoropharynx

                             £¨ post Pharyngeal wall, soft palate, genioglossus                                  »çÀÌ£©

    £¨4£©sleep µ¿¾È long-standing sign £¦ Sx of UAO

        ¡æRt 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.systemÀÌ elastic behavior º¸ÀÌ´Â ÀÌÀ¯

     £¨1£©air space ³»¿¡ surfactant°¡ Á¤»óÀûÀÎ ¾çÀÌ µé¾î À־ surface tension             Àº lungÀÇ elastic recoilÀÇ 65£¥ Á¤µµ ±â¿©ÇÑ´Ù.

        ¡æsurfactant¾øÀ¸¸é elastic recoilÀÌ markedly increaseÇϸ砠     

          atelectasis À¯¹ß£ºrespiratory distress syndrome of the newborn

     £¨2£©lung £¦ chest wallÀÇ fibrous network°¡ elastic property°¡Áü.

         ¡æpul.fibrosis, lung overdistention

    2£©restrictive lung disease cause

     £¨1£©surface tensionÀÌ ºñÁ¤»óÀûÀ¸·Î Áõ°¡

         ¡ærespiratory distress synd of the newborn.

     £¨2£©interstitial edema, pneumonitis, fibrosis °°ÀÌ lungÀÇ soild

          structure or compositionÀÇ change

     £¨3£©alveolar edema, pneumonia °°ÀÌ alveolar space°¡ liquid or

          inflammatory cell·Î Â÷ÀÖÀ»¶§

     £¨4£©restrictive chest wall

          £ºabdominal distention, cong malformation, neuromuscular

            disease

  2. Resistive properties of the respiratory system

                                   and obstructive disease.

    £¨1£©motion¿¡ ÀÇÇØ À¯¹ßµÈ molecular interaction °á°ú·Î resistive

         »ý°¢

  3. Response to respiratory disease£ºefficiency of the developing

                                    respiratory system.

  1£©respiratory work load ¡è½Ã 2type responses

   £¨1£©respiratory muscle contraction Áõ°¡

        ¡æsubstrate availability¿Í muscleÀÇ maximal contraction force

          ability¿¡ ÀÇÇØ Á¦ÇÑ

   £¨2£©respiratory patternÀ» º¯È­½ÃÄÑ respiratory efficiency¡è

Gas Exchange

pulmonary capillary and the neighboring portion of the air space·Î ±¸¼ºµÈ ¸î ¹é¸¸ÀÇ small unit¿¡¼­ »ý±ä´Ù.

# 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£ºpartial pressure of inspired oxygen

P2Co2£ºarterial partial pressure of carbon dioxide

0.8£ºrespiratory quotient£¨carbon dioxide production£¯oxygen

     consumption£©

321.1 Diagnostic Approach To Respiratory Disease

Physical Examination

   1. breathing patternÀÇ alteration

     £ºbreathing rate Áõ°¡, chest wall retraction, nasal flaring

   2. restrictive disease£ºbreathing rate¡è

                        expiratory grunt

     obstructive disease£ºslover deeper breaths

                         extrathoracicÀÇ °æ¿ì inspiratory stridor

  3. stridor

    rales or crackles

    wheezes

Blood Gas Analysis

  1. cyanosis£ºskin perfusion and blood hemoglobin concentration

              ¿µÇâ¹ÞÀ½

              hypoxiaÀÇ unreliable sign.

  2. arterial Po2, PCo2, PHÀÇ direct measurement

  3. skin surface Po2 determinationÀ¸·Î arterial oxygenation ÃøÁ¤½Ã

    skin perfusion¿¡ ¿µÇâ¹ÞÀ½.

Respiratory Function Test

1. restrictive disease

  ; typically total lung capacity £¨TLC£©ÀÇ °¨¼Ò

    ¡æTLC´Â residual volÆ÷ÇÔÇϹǷÎ, gas dilution method,

      plethysmography·Î indirectly measure.

  ; vital capacity£¨VC£©°¨¼Ò

    ¡æspirometry·Î ÃøÁ¤

2. obstructive disease

  ; residual vol ¡è functional residual capacity¡è

Ventilation£¯Perfusion Studies

    £ºradionuclide tracer¿¡ ÀÇÇØ µµ¿ò¹ÞÀ½.

Exercise Testing

Sleep Studies

1. newborn young infant¿¡¼­ ƯÈ÷ respiration function¿¡ Áß¿äÇÑ ¿µÇâÀ» ¹ÌÄ£´Ù.

2. Polysomnographic studies£º

     1£©central respiratory control abnormality

     2£©muscle disorder

     3£©gastroesophageal reflux¿¡ ÀÇÇÑ resp. complication½Ã À¯¿ë.

Chapter 322. Resp. Failure

Etiology

1) intercurrent acute illness (eg. influenza)

2) ÀÌÀüÀÇ °Ç°­ÇÑ ¾ÆÀÌ

  ¨ç pn.

  ¨è epiglottitis

  ¨é status asthmaticus

  ¨ê aspiration

  ¨ë poisoning

  ¨ì 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 ¡æ central depression : impaired consciousness

                                          & confusion

     2)+- PaCO2 40mmHg¡è¡æ ARF °¡´É¼º

       |  PaCO2 50mmHg¡è¡æ imminent

       +- PaCO2 55mmHg¡é in room air        bloodÀÇ O2 content°¡ vital

           organÀÇ ¿ä±¸¸¦ ÃæÁ·½ÃŰ±â¿¡ ºÎÀû´ç

     3) ¨ç severe headache

            acute hypoxemia & hypercapnia

          ¡æ dilat of cerebral bloodÀÇ O2 content°¡ vital organÀÇ ¿ä±¸¸¦

               ÃæÁ·½ÃŰ±â¿¡ ºÎÀû´ç

        ¨è cold extremites

        ¨é restlessness

        ¨ê dizziness

        ¨ë impaired thought

     4) multisystem Cx. i) GI hemorrhage

                        ii) cardiac arrhythmia

                        iii) renal failure

                        iv) malnutrition

Treatment

     1) Theophylline : improve diaph. strength

                      COPD pt¿¡ À¯¿ë

     2) mecha. vent. : pneumonia child¿¡¼­ hypoxia & hypercarbia

                      develop½Ã

     3) 100% O2 by bag & mask/endotrach. intubation

         : apnea³ª gasping½Ã

            * PEEP : alv. collpse¹æÁö

            * Goal of Tx

               i) Àû´çÇÑ oxygen saturation À¯Áö

               ii) n'l PaCO2 À¯Áö (using ÃÖ¼ÒÇÑÀÇ pr. & lowest FiO2)

     4) Bedside measurement of tidal vol. & VC & (-)inspiratory force

        * direct O2 toxicityÀÇ risk´Â Fi O2 70¡­100%½Ã ¸Å¿ì¡è

           (40%¡é¿¡¼­ Áõ¸í)

Chapter 323. Defence Mechanism Of Lung

# infancyÀÌÈÄ collateral alveolar ventilationÀÌ ÀϾ

  a) pore of Kohn between alveoli

     - lobule »çÀÌ or caillary »çÀÌÀÇ gas passage µÇ°Ô ÇÔ

  b) canal of Lambert beetween bronchiol & alveoli

     ¡æ atelectasis ¹æÁö

# Defense  a) filtering of particle

           b) warming & humidify of inspired air

           c) noxious fame & gas¸¦ vascular upper airway¿¡¼­ Èí¼ö

           d) temporary cessation of breathing   

              shllow breathing                

              laryngospasm or bronchospasm   

              swallowing & closure of epiglottis 

Clearance Of Particle

      1) mucocillary mech¿¡ ÀÇÇØ

      2) phagocytosis by alv. macrophage

Defense Against Microbial Agent

      - phinciple by macrophage

         phagocytosis Ab in resp. secretion - Ig A

                                           - 1Mo¿¡ adult level¿¡ µµ´Þ

      ¡¤lysozyme, lactoferrin, interferonµµ defense role

Impaired Defense Mechanism     

      1) macrophage phagocytic activity & mucociliary clearance¡é

        a) ethanol  

        b) smoking  

        c) hypoxemia starvation chilling

        d) corticosteroid nitrogen dioxide ozone narcotics some anesthetics

      2) antibacterial killing capacity of macrophage¡é

        a) acidosis    b) azotemia

        c) recent viral inf. - ƯÈ÷ rubella, influenza

      3) toxic to epi. cell

         - beryllium, asbestos, organic dust from cotton & sufarcan

         - sulfur, N20, ozone, chlorine, ammonia, cigar

      4) mucociliary clearance¡é

         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 - ¨ç servere ulcer

                        ¨è bronchiectasis bronchiolectasis

                        ¨é squamous cell metaplasia & fibrosis

         c) other adverse effect : hyperventilation, alveolar hypoxia,

                 pulmonary thromboembolism, alveolar, pulmonary

                 thromboembolism, pul edema, hypersensitivity reaction,

                 salicylate °°Àº agent

323.2 Metabolic Function Of Lung

   1) (1)LungÀº 40°³ÀÇ cell type °¡Áü

        ÀÌ Áß lung¿¡¸¸ Ư¼öÇÑ °Í  +-¨ç type I,II pneumocyte

                                  | ¨è alv. macrophage

                                  +-¨é clara cell

      (2)lungÀÌ ÇÕ¼ºÇÏ´Â lipid & protein

         ¨ç glycoprotein,

         ¨è secretory

         ¨é interferon

         ¨ê proteolytic & fibrinolytic enzyme & activator

         ¨ë collagen

         ¨ì elastin

      (3) ¨ç thromboplastin   ¢¡ lung¿¡ ¸¹À½

         ¨è megakaryocyte    

      (4)¨ç serotonin         

         ¨è bradykinin         ¢¡ ´ë°³ pul. circulationÀ» ÅëÇØ

         ¨é ATP                  ¿ÏÀü Á¦°Å or inactivation

         ¨ê PGE1 E2 E3     

      (5)¨ç EPi

         ¨è PGA1 A2          ¢¡ minimally affected

         ¨é Angiotensin 2

         ¨ê vasopressin

Chapter 324. Diagnostic Procedures

Radiologic Technique

Chest X-Ray

CT & MRI

Upper Airway Film

 xerography soft tissue

Sinus, Nasal Films

Fluorscopy

   * useful (1) stridor½Ã

            (2) abn'l move. of diaph. or mediat

            (3) needle asp. or biopsy of peri. lesion

Contrast Study

Barium swallow

    ; Ix  

           ¨ç recurrent pn.

    ¨è ¿øÀÎ ºÒ¸íÀÇ persistent cough

    ¨é stridor

    ¨ê persistant wheezing

eg. H-TEF½Ã simple barium swallow´Â ºÒÃæºÐ

     cath.¸¦ ÅëÇØ eso.ÀÇ ¸î ºÎÀ§¿¡ barium inj.

if eso. atreesia Àǽɽà 0.5ml¡èÀº X.

Bronchogram

    ; ¡ØIndication

           - suspected bronchiectasis

           - airway anomalies

Pul. Arteriogram

    ; Dx

           - cong.anomaly

                   ¨ç lobar agenesis

                ¨è unilat. hyperlucent lung

                ¨é vascular ring

           - solid or cystic lesion

Aortogram

      : vas. ring or pul. sequestration

Pneumoperitoneum, Pneumothorax

      : diaph. eventration½Ã Diaph.ÀÇ outline °áÁ¤

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.ÈÄ Á¶±â¿¡ XeÀÌ ³ªÅ¸³² : perfusion ÃøÁ¤

               +- breathingµ¿¾ÈÀÇ washout rate : ventilation ÃøÁ¤

324.1 Endoscopy

Laryngoscopy

    ; *evalution of stridor & local upper airway abnormality

    ; infant & small children ¡æ direct laryn

  ; older CH & adult ¡æ indirect laryn

Bronchoscopy

# ¡ÚIndication 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

# ¡ÚIndication Of Therapeutic Bronchoscopy

    1) removal of FB & mucus plug

    2) bronchial toilet

  3) bronchopul. lavage

# *extration of FB, massive hemoptysis, removal of tissues mass¿¡¼­´Â open rigid bronchoscopeÀ» »ç¿ëÇØ¾ß ÇÑ´Ù.

# small flexible fiberoptic broncho.ÀÇ ÀÕÁ¡

 1) easy insertion

 2)¡è peripheral range

 3)¡é Cx

 4) general anesth. ºÒÇÊ¿ä

# postbronchoscopy croupÀÇ Tx

 1) O2

 2) mist

 3) vasoconstrictor aerosol (racemic epi.)

 4) corticosteroid

# ¡ÚBronchoscopy 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 »óºÎ

2. Cx        1) inf.

             2) pneumothorax

             3) bleeding

             4) puncture or laceration of capsule of liver (Rt)

               & capsule of spleen (Lt)

3. transudate : pleural fluidÀÇ formationÀ̳ª reabsorption¿¡ ¿µÇâÀ»

              ÁÖ´Â mechanical factor¿¡ ÀÇÇÔ

             1) total protein 3g/dl¡é

             2) pleural protein/serum pr. 0.5¡é

             3) leukocyte count 2,000¡é: mononu. ¿ì¼¼

4. exudate : pleural surf.³ª lungÀÇ infl.À̳ª ds.

             1) protein¡è

             2) PMNI ¿ì¼¼        except Tb, malignancy

        ex. Tb - glucose¡é & cholesterol¡è

324.3. Percutaneous Lung Tap

; *¡ãdirect 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 CxÀÌ thoracentesis º¸´Ù¡è

324.4. Lung Biopsy

; *¡ãappropriate 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¡é½Ã fiberoptic light probe·Î transillÇÏ¿© 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¡æ coughÈÄ deep throat swab

                3) nasotracheal asp.        heavy contamination

                  transtracheal asp.        ¾î¸°ÀÌ¿¡´Â À§Çè

                4) percut. lung tap or open biopsy

    2. exam. of secretion

         1) alveolar macrophage : hallmark of tracheobr. sec.

         2) early morning gastric aspirate ¡æ AFB smear & culture

         3) sputumÀÇ Wright stained smear½Ã PMNL(-)

            ¡æ lower RTÀÇ bact. inf.

         4) eosino. : allergic ds

         5) iron stain»ó macrophage³» hemosiderin granule

             : pul. hemosiderosis

         6) viral pn. : wright stain¿¡¼­ intranu³ª cytoplasmic inclusion body

324.7. Blood Gas Analysis

# arterial bl. gas

    ; *¡ãmost 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¡è than arterial PCO2

  ; pH´Â ¾à°£¡é

324.8. Pulmonary Funcion Testing

Measurement Of Ventilatory Function

# Flow Rate By Spirometer          

    ; FEV1

           - ù 1Ãʰ£ expiredÇÑ vol

    ; MMEF (max. midexp. flow rate)

    ; MEFV (max. exp. flow vol. curve)

       - 75% VC¡éÀÇ lung vol.¿¡¼­ÀÇ flow rate´Â effort¿Í ¹«°ü

        - 50% VC¡éÀÇ flow rate´Â small airway¿¡ ¿µÇâ¹ÞÀ½

       - 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¡é

        : 6¼¼ ÀÌ»óÀº ÀÏÁ¤

Measurement Of Gas Exchange

# DLCO

    ; Diffusing capacity for carbon monoxide

  ; method 

           - rebreathing from container having a known intial conc. of CO

           - single breath technique

    ; ¡é°æ¿ì  

           - effective alv. cap. surf. area¡é

       - alv-cap. memb.À» ÅëÇÑ gasÀÇ diffusability¡é

# regional gas exchange

 : P/V Xe scan

# arterial blood gases

 : alv. gas exchangeÀÇ effectiveness

Measurement Of Perfusion

        ¡¤pul. blood flow ÃøÁ¤ by   i) cardiac catb.

                                   ii) NOÀÇ uptake

           ¡æ pul. arteriogramÀ̳ª radioisotopeÀ¸·Î distribution ÃøÁ¤

Clinical Use Of PFT

; 6¼¼ ÀÌÈÄ´Â ¾î·Á¿ò ¾øÀÌ test °¡´É

   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 passageÀÇ narrowing

         ¡æ ¨ç URI½Ã airflowÀÇ severe obst.

                 ¨è chr. or recurrent hypoventilation

Choanal Atresia

; *¡ãcommon anomaly of nose

; nose¿Í pharynx »çÀÌ¿¡ unilateral or bilateral bony or membranous septumÀ¸·Î ±¸¼º.

; *50% with other cong. anomaly

    - ¡ÚCHARGE syndorme

           / coloboma

           / heart disease

           / atresia choanae

           / retarded growth & development and/or CNS anomalies

           / genital anomalies and/or hypogonadism

           / ear anomalies and/or deafness

; unilat.½Ã resp. inf.Àü±îÁö ¿À·¡µ¿¾È aSxÀÏ ¼ö ÀÖ´Ù.

; Diagnosis

    - *inability to pass firm catheter through each nostril 3-4cm

  - fiberoptic rhinoscopy·Î Á÷Á¢ º½

  - CT scan

; Treatment

    - oral airway À¯Áö or open mouth

  - feeding

           / nipple : large hole

    / assited airway¾øÀÌ breathing°ú eatingÀÌ µÉ ¶§±îÁö (´ë°³ 2¡­3ÁÖ) gavage feeding

  - elective op. correction

           / ¼öÁÖ³ª ¼ö°³¿ùÈÄ

    / bilat.C.A.½Ã immediate op.´Â µå¹³.

    / unilat.½Ã ¼ö³â ´ÊÀ» ¼öµµ ÀÖ´Ù.

Cong. Defect Of Nasal Septum

          - rare

        1) perforation  (1) develpmental

                       (2)  2¡Æto syphilis, Tbc

        2) septal deviation : op. collectionÀº midface growth disturb.¸¦

                           ÇÇÇϱâ À§ÇØ ´ë°³ ¿¬±â

        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. : FB½Ã»ç

326.2 Epistaxis

        ¡¤rare in infancy

        ¡¤common in childhood

        ¡¤¡éafter puberity

¡Ø91 Etiology

; *trauma

    - *¡ãcommon

    - 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.

¡ØÁÖ Treatment

    ; compression on nares £¦ quiet

           - erect position with head forward

    ; *0.25-1% neosynephrine with or without topical thrombin

    ; ant nasal pack

           - bleeding persist½Ã

         - bleedingÀÌ post, rare¿¡ ÀÖÀ»½Ãcombined ant £¦ post packing

    ; *cautery with silver nitrate

           - bleeding site¸¦ ¾Ë¶§

    ; bl.transfusion

           - severe or repeated epistaxis½Ã

    ; otolaryngologic evaluation

           - bilat, bleeding, no arising from Kiesselbach plexus

    ; clotting factor replacement

# Juvenile nasopharyngeal angiofibroma

  ¡¤peak£ºadol. £¦ preadol.boys

  ¡¤Æ¯Â¡£ºprofuse epistaxis with nasal mass

  ¡¤Dx£ºCT scan with contrast

  ¡¤Tx£ºarteriography, embolization, extensive surgery

Chap. 327 Infection Of Upper Respiratory Tract

Etiology

    ; virus £¦ mycoplasma

           - *¡ãcommon

           - ¿¹¿Ü £ºepiglottitis

    ; *Streptococci £¦ Diphtheria

           - major bacteria of primary pharyngeal ds

1) RSV£º¨÷ of bronchiolitis

2)parainfl. ¥¥£ºcroup

3) influenza ¥¥

4) adenovirus£º10£¥¡éof resp.ds

               pharyngitis £¦ PCF°¡ TMC in children

5)rhinov. £¦ coronavirus£º¡°common cold¡±synd

6) Coxackie ¥¥. A,B£ºnasopharynxÀÇ Ds

7) Mycoplasma£ºupper £¦ lower resp. ds

                 bronchiolitis, ph, bronchitis, pharyn-

                 gotonsillitis, myringitis, OM

327.1 Acute Nasopharyngitis£¨=URI, Common Cold£©

; *¡ãcommon 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£ºepidemic

Pathology

1) edema £¦ vasodilation in submucosa

2) ciliaÀÇ structural £¦ functional change

 ¡æ mucus clearance¿¡ ÁöÀå ÃÊ·¡

Clinical Manifestation

3 Mo-3Yr£ºinf.Ãʱ⿡ fever

purulent CxÀº age ¾î¸±¼ö·Ï¡è

# 3 Mo ¡è

 (1) initial Sx£ºfever, irritability, restlessness, sneezing

    ¡æ¼ö hr³» nasal discharge £¦ obst

    - 2-3ÀÏ£ºear drum congestion £¦ fluid behind drum

         (2£©febrile phase£º¸î hr-3 days

# older children

         (1) initial Sx£ºdryness £¦ irritation of nose

           ¡æ ¼ö hr£ºsneezing, chill, m.ache, thin nasal discharge

                ¶§·Î coughing, headache, malaise, anorexia, low grade

                fever

           - 1ÀÏ ³» secretion thicker, sore throat

             acute phase 2-4 daysÁö¼Ó

Differential Diagnosis

# initial Sx of measles, pertussis

# poliomyelitis, hepatitis, mumps

# ¡ØBloody 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£ºpale

    ; nasal smear£ºeosino Òý

    ; antithistamine ¡æ Sx»ç¶óÁü

Complication

 1) cervical lymphadenitis

 2) mastoiditis

 3) peritonsillar cellulitis or periorbital cellulitis

 4) OM - 25£¥ of small infant

        - TMC Cx

        - fever recur½Ã suspect

 5) LTB, bronchiolitis or pneumonia

Prevention

         £º¥ã-globulin, vit.C ¡¦not recommend

Treatment

; no specific Tx

; AB

    - *not affect course & reduce incidence of bacterial complication

; bed rest

; acetaminophen£ºÃ¹ 1-2ÀÏ irritability, aching, malaise¡é

; aspirin

    - not recommend

; nasal instillation

    - sterile saline

           / infant

    - phenylephrine (0.125-0.25%)

    - *AB, C-S, antithistamine additionÀº È¿°ú°¡ ¾ø´Ù.

  - 15-20min before feeding and at bed time              

         / supine with neck extesion

            ¡æ 1-2 dropÀ» °¢°¢nostril¿¡

         ¡æ 5-10ºÐÈÄ ´Ù½Ã 1-2drop

    - cotton application not recommend

    - *sterile salineÀ̿ܿ¡´Â 4-5ÀÏÀÌ»ó »ç¿ëÇÏ¸é ¾ÈµÈ´Ù.

# In infant

    ; suction with soft bulb syringe

  ; prone position

  ; highly humidified environment

# Oral decongestant

  ; pseudoepherine

  ; antihistamine +  adrenergic agonist

327.2 Acute Pharyngitis

; tonsillitis ¿Í pharyngotonsillitis ¸¦ Æ÷ÇÔÇÑ pharynxÀÇ ¸ðµç acute infection

  - principal involvement : throat

  - uncommon under 1 Yr

  - peak : * 4-7 ¼¼

# ¡ÚProminent Pharyngeal Involvement

    ; *diphtheria, herpangina, adenovirus infection, infectious mononucleosis

Etiology

    1) virus : ´ëºÎºÐ

    2) Group A  B-hemolytic streptococcus : only common bacterial agent

      ( 15%ÀÌÇÏ)      

Clinical Manifestations.

Viral Pharyngitis

  ¨ç gradual onset

  ¨è early sign : fever, malaise, anorexia, throat pain.

  ¨é sore throat : present intially, peak 2-3rd day

  ¨ê hoarseness, cough, rhinitis.

  ¨ë pharyngeal inflammation : slight.  occasionally severe - small ulcers on

     soft palate, post pharyngeal wall.

  ¨ì exudate : on lymphoid follicles of palate and tonsil.

  ¨í cervical LN : enlarged and firm.

* ¨î laryngeal involvement : common.

  ¨ï WBC : 6000- 30000, predominantly polymorphonuclear cells in early phase.

  ¨ð entire illness : º¸Åë 5ÀÏ ÀÌ»ó °è¼ÓµÇÁö ¾ÊÀ½.

Streptococcal Pharyngitis

    ; 2¼¼ÀÌ»ó.

  ; headache, abdominal pain, vomiting À¸·Î ½ÃÀÛ.

  ; ¼ö½Ã°£³» sorethroat.

  ; 1/3 ¿¡¼­ tonsillar enlargement , exudation, pharyngeal erythema.

  ; 2/3 ¿¡¼­ mild erythema, no enlargement of tonsil without exudate.

  ; ant. cervical lymphadenopathy.

  ; fever : as high as 40 o C . 1-4ÀÏ Áö¼Ó.

     very severe case- as long as 2 weeks.

    ; ¢¾ Physical Finding Asso. With Streptococcal Disease

     - diffuse redness of tonsil and tonsillar pillars.

     - petechial mottling of soft palate.

    ; ¡Úconjunctivitis, rhinitis, cough, hoarseness

           - rarely symptom

           - *2°³ ¶Ç´Â ±×ÀÌ»óÀÇ Áõ»óÀÌ ³ªÅ¸³ª¸é viral pharyngitis½Ã»ç

Streptococcosis

      ¨ç   B-hemolytic streptococcus ÀÇ early inf. °ú °ü°èµÈ acute . inf. ÀÌ ÀÖÀ»½Ã

          systemic variation.

      ¨è  infant: 1 ÁÖ ÀÌÇÏ·Î Áö¼ÓµÇ´Â mild episode

                 Ư¡: variable fever, mucoserous nasal discharge, pharyngeal                       infection.

      ¨é  6 Mo- 3 Yr : most severely ill,

         - Ãʱâ: coryza with postnasal discharge, reddened pharynx, fever,

                 vomiting,  loss of appetite.

         - fever : 38-39.5 o C ,* 4- 8 ÁÖ°£

         - cervical node : enlarge and tender, adenopathy ´Â fever¿Í °°ÀÌÁ¸Àç.

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

        ¨ç first manifestation : acute pharyngitis Áõ»ó.

        ¨è tonsil and post. pharyngeal wall: covered by yellow or dirty white  

           exudate.

        ¨é mucous membranes under exudate-->necrotic and ulceration extends to

           mouth and tongue : very painful.

        ¨ê dysphagia : severe.

        ¨ë   enlargement of cervical lymph node.

        ¨ì  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 ½Ã

       ¨ç oral  PC ( 125-250 mg pc v tid for 10 days )

            - 24½Ã°£³» defervescense, course of illness ¸¦ 1.5ÀÏ Á¤µµ shorten.

            - pc Tx ½ÃÀÛÈÄ ¼ö½Ã°£³» noninfectious.

       ¨è EM : ¸¸ÀÏ È¯ÀÚ°¡ pc ¿¡  allergic ÇѰæ¿ì.

   3) acetaminopen or ibuprofen : painÀÌ ½ÉÇѰæ¿ì.

   4) gargling with warm saline solution : old children ½Ã.

   5) inhalation of steam : younger children.

   6) cool bland, liquids : acceptable than solids or hot foods.

   7) rheumatic fever ÀÇ °ú°Å·ÂÀÌ Àִ°æ¿ì : AB prophylaxis ÇÊ¿ä.

327.3  Acute Uvulitis.

  - fever, pain with swallowing, drooling

  - most case: Gr A strep. or H. influenza type b.

      strep. uvulitis : 5 ¼¼ÀÌ»ó.

      H. influenza  : 5 ¼¼ ÀÌÇÏ.

327.4 Chronic Rhinitis And Nasopharyngitis

Chronic Rhinitis

# ¡ÚUnderlying 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

    ¨ç chronic nasal discharge °¡ ÁÖÁõ»ó.

  * ¨è bloody discharge : i) syphilis,                                           

                         ii) diphtheria

                         iii) foreign bodies

                         iv) persistent nose picking

    ¨é disturbance of taste and smell

    ¨ê fever : °¨¿°ÀÌ º´¹ßÇÏÁö ¾ÊÀ¸¸é ¿­Àº º°·Î ¾ø´Ù.

    ¨ë persistent allergic rhinitis : common and seasonal.

    ¨ì rhinitis medicamentosa : Àå±â°£ topical nasal decongestants¸¦ »ç¿ëÇѰæ¿ì.

    ¨í 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

    ¨ç lanoline, silicone, petrolatum-base ointment : protects against skin

         excoriation.

    ¨è humidified air

    ¨é mucosa - shrinking solutions ( eg phenylephrine ): symptomatic relief.

                                                      also causes further damage

    ¨ê local AB : avoid

         systemic AB : Ix in selected cases.

Chronic Pharyngitis

   - rare

    - secondary to chronic infections of sunuses, adenoids, tonsils.

    - Æíµµ ÀýÁ¦ÈÄ¿¡µµ ¹ß»ý.

Clinical Manifestations

   ¨ç throat discomfort : dryness and raspy irritation.

   ¨è throat clearing (ÀæÀº Çê±âħ) and irritative cough.

   ¨é mucous membrane : inflamed, pale, blood vessel ÀÌ prominent.

   ¨ê pharyngeal wall : mucopurulent secretion

                       lymphoid tissue : hypertrophied --> pebbled appearance.

Treatment

   ¨ç directed toward any disturbance.

   ¨è general nutriton and hygiene.

327.5 Retropharyngeal Abscess

# ¡Ú4¼¼ÀÌÇÏ¿¡ Àß ¿À´Â ÀÌÀ¯

    ; 4¼¼ÀÌÀü¿¡ post pharyngeal wall°ú prevertebaral fascia »çÀÌÀÇ space¿¡ small lymph nodes °¡ Á¸Àç

           --> lymphatic channel communicating with portion of nasopharynx as well as post. nasal passages

           --> nasopharynx infectionÀÌ spread

    ; *3-4¼¼ÀÌÈÄ¿¡ »ç¶óÁø´Ù.

Etiology

    ; *bacterial pharyngitis

  ; vertebral osteomyelitis

    ; wound infeciton.

    ; ¡Ø96 pathogens

           ¨ç Group A hemolytic streptococci                

    ¨è oral anaerobes

    ¨é 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.

    ; ¡Ø96 Death

           - aspiration

           - airway obstruction

           - erosion into major blood vessels

           - mediastinitis

¡ÚDifferential Diagnosis

  1) croup

           ; larynx ¿¡ ¾Ð¹Ú½Ã stridor and high fever

    2) meningismus : limited neck motion

    3) nonfluctuant lymphadenitis

    4) Tbc of cervical spine

Treatment

  1) prefluctuant stage

    ¨ç semisynthetic penicillin.

    ¨è single agent with clindamycin or ampicillin - sulbactam

    ¨é analgesic drugs : for pain

    ¨ê 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 : ¨çhigh fever, trismus, ill app. , severe pain, difficulty swallowing.

          ¨èbulge in lat. pharyngeal wall

          ¨écervical adenitis

          ¨êtorticollis 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 ¥â-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¡É¡¡¡¡¡¡

    ; *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 ½Ã±â

    ; *maxillary antra and ant. post. ethmoid cell - infancy

    ; *frontal sinus - 6-10¼¼

    ; sphenoid sinus - 3-5¼¼  

; incidence of acute and chronic sinus infection : childhood ÈĹݱ⿡ Áõ°¡.

# sinus infection À» Áõ°¡½ÃŰ´Â factor

    ¨ç  allergic factor

    ¨è  poor sinus drainage with septal deviation or adenoid hypertrophy.

    ¨é  hereditary condition.

    ¨ê  immunosuppression.

    ¨ë  environmental factor.

Acute Purulent Sinusitis

  - Sx or sign Àº acute rhinitis ÈÄ 3-5ÀÏ¿¡ ³ªÅ¸³².

Clinical Manifestation

; suggestion

    - "cold" (°¨±â) 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 ÈÄ exam.»ó

    ; pus in middle meatus

           - involvement of maxillary, frontal , ant ethmoid sinus

    ; pus in sup. meatus

           - involvement of sphenoid or post. ethmoid cell

; ¡Úpostnasal discharge

           --> *sore throat, persistent cough at night

# acute ethmoiditis in infants and small children

    ; periorbital cellulitis with edema or soft tissues

  ; redness of skin

# ¡ÚComplication

    ; epidural or subdural abscess   

  ; meningitis.

  ; cavernous sinus thrombosis

  ; optic neuritis

    ; periorbital or orbital cellulitis and abscess

  ; osteomyelitis

Diagnosis

# X-ray

    ; often used but misinterpreted

    ; *¡ãcommon findings

           - air-fluid level.

    - complete opacification

    - *mucosa width of 4 mm or more : bacteria in sinus.

# CT scan

  ; *¡ãsensitive indicators

    ; Indication

           - before surgery

    - Cx of sinusitis

# antral puncture

    ; *À¯ÀÏÇÑ ¹ÏÀ»¸¸ÇÑ method for bacterial culture

    ; ¡ÚIx for sinus aspiration

        ¨ç Tx¿¡ ¹«¹ÝÀÀ.

        ¨è immunocompromised hosts

        ¨é life threatening Cx

  ; ¡Ø92 Organism

        ¨ç S. pneumoniae.

        ¨è M. catarrhalis

        ¨é nontypable H. influenza.

# nasal swab culture : sinus aspirate culture ¿Í ÀÏÄ¡ÇÏÁö ¾Ê´Â´Ù.

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.

; *Ä¡·á±â°£ - 14-21 days

; *decongestant and antihistamine - not heipful

; ¡ÚSinus Drainage And Irrigation Ix

    - fail usual Tx

  - intraorbital, intracranial or other Cx

  - intense pain

Chronic Sinusitis.

  - underlying disease : ¨ç  nasal deformity.

                        ¨è  polyp

                        ¨é  infected and hypertrophied adenoids

                        ¨ê  infected teeths

                        ¨ë  sinus polyp or mucocle.

                        ¨ì  allergy, cystic fibrosis, dyskinetic cilia.

* - common in absence of secretory Ab ( IgA ) and immunodeficiency state.

  1) Clinical manifestation.

    ¨çlow grade fever.

    ¨èmalaise, easy fatigability , anorexia.

    ¨énasal discharge.

    ¨êswelling of middle turbinates--> causes nasal obstruction.

    ¨ëpostnasal discharges in abscence of infected adenoids or aucte URI                                            --> diagnostistic .

    ¨ìwatery nasal discharge or sneezing --> allergic rhinitis.

**  ¨ísinobronchitis

        -relationship between sinus and lower resp. tract. Sx

        -underlying ds.

          i).  reactive airway.

          ii). cystic fibrosis.

          iii). immunodeficiency.

          iv). dyskinetic cilia.

     ¨î sinusitis °¡ asthma ¸¦ aggravate ÇÔ

 

  2) Eti.

    ¨çacute sinusitis ±ÕÁ¾.

    ¨èa-hemolytic strep.

    ¨éS. aureus.

    ¨êanaerobes

  3)Tx

    ¨çantimicrobials for * 6 weeks.

    ¨èantihistamine and decongestant.

    ¨éOP.

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 %) : *¡ãcommon

  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

           ¨ç complete obstruction.

    ¨è uncontrolled rhinorrhea.

    ¨é deformity of nose appears.

; *antihistamine : helpful

Chapter 329. Tonsil And Adenoids

 

- adenoid : nasopharyngeal tonsil.

- Waldeyer ring: 1) consists of  ¨ç lingual tonsil

                                ¨è two faucial tonsil

                                ¨é adenoid

                                ¨ê lymphoid tissue on post. pharyngeal wall.

                  2) defense against infections.

- seperate tonsillectomy and adenoidectomy : 4-5¼¼Àü

- infancy ¿¡´Â tonsillar disturbance°¡ µå¹³.

- neoplasm of tonsil -- Waldeyer ring; non-Hodgkin lymphoma.

                        nasopharynx: rhabdomyosarcoma.

Chronic Tonsillits (Chronically Hypertrophic And Infected Tonsils)

Clinical Manifestation

   ¨çrecurrent or persistent sore throat.

   ¨èobstruction to swallowing or breathing.

   ¨ésense of dryness and irritation in throat.

   ¨êbreath : offensive.

   ¨ë 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

# ¡Úchr. infection ÀÇ 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

# ¢¾Only 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  ¨ç acute resp. obstruction with pul. artery HT.

               ¨è 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

* ¨ç mouth breathing and persistent rhinitis : °¡Àå Æ¯Â¡Àû Sx.

  ¨è chronic nasopharyngitis.

  ¨é voice : nasal, muffled.

  ¨ê breath: offensive.

  ¨ë taste and smell : impaired.

  ¨ì harassing cough : at night.

  ¨í impaired hearing : common.

  ¨î chronic OM

  ¨ï snort and snore loudly : sign of resp. distress.

  ¨ð respiratory insufficiency ( hypoxemia, hypercapnia, acidosis ) : during sleep.

     --> pul. a. HT --> cor pulmonale.

    # upper airway obstruction in sleep --> mimicking adenoidal hypertrophy syn.

      ¨ç very obses children ( e.g. Prder-Willi-Robin syn. )

      ¨è large or post. placed tongue ( e.g. Pierre-Robin syn. )

      ¨é cow's milk hypersensitivity.

      ¨ê Down syn : macroglossia, tonsillar enlargement, skull base anomaly.

Diagnosis

    ¨ç digitial palpation

    ¨è indirect visualization with pharyngeal mirror.

    ¨é fiberoptic bronchoscopie

    ¨ê lat. pharyngeal X-ray.

Treatment

# ¢¾Ix of adenoidectomy

  ¨ç persistent mouth breathing

  ¨ènasal speech

  ¨éadenoid facies

  ¨êrepeated attacks of OM (esp. when accompanied by a conductive hearing loss)

  ¨ëpersistent 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

    ; *¡ãcommon 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.

     ¨ç prepubertal children: similar.

     ¨è 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.

  ¨ç upper airway muscle activity decreases, upper airway narrows and resistance

      increase in anatomic or neurologic factor.

  ¨è partial or complete airway obstruction --> impaired gas exchange with            hypoxemia and hypercapnia.

  ¨é potent stimuli for increased ventilatory effort and upper airway muscle              activity.

  ¨ê increased effort and airway muscle tone lead to resumption of airway potency.

  ¨ë arousal from sleep occur --> helps restoring blood gas.

  ¨ì airflow restored, oxygen and carbon dioxide level return to normal.

  ¨í sleep re-established , upper airway muscle activity decrease -->

     cycle starts again.

 Figure 330-1   Pathophysiology of OSA/H in children.)

 

4) OSA/H ÀÇ serious cardiorespiratory and neurobehavioral consequence.

  (1) chronic hypoxemia lead to

                              ¨ç polycythemia

                              ¨è growth failure

                              ¨é increased pulmonary artery pressure.

                              ¨ê pulmonary hypertension.

                              ¨ë Rt. heart failure.

                              ¨ì arrythmia.

                              ¨í death.

  (2) recurrent arousal lead to   

                              ¨ç sleep fragmentation.

                              ¨è loss of normal sleep pattern.

                              ¨é excessive daytime sleepiness.

  (3) hypersomnolence

                              ¨ç behavoral problems.

                              ¨è impaired school performance.

                              ¨é accidents.

  (4) sleep fragmentation.

                              ¨ç suppress arousal response.

                              ¨è further impair ability to reestablish upper airway

                                 patency and restore gas exchange.

      

5) Anatomic factor lead to obstruction in childrem.

  ¨ç adenotonsillar hypertrophy : most common.

  ¨è micrognathia, retrognathia, macroglossia.

  ¨é fat deposition from obesity.

  ¨ê 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 ½Ã : 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

                    ¨ç snoring

                    ¨è nocturnal breathing difficulty.

                    ¨é 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 ¨ç dysphagia from large tonsil.

                        ¨è chronic hypoxemia.

                       ¨é higher metabolic expenditure from increased work of                                 breathing.

                       ¨ê insufficiency growth hormone release in absence of deep

                           NREM sleep.

 10) unexplained Rt. heart failure.

 11) more severe case ; respiratory failure.

Diagnosis and Assessment

# ¢¾Delayed Dx due to Several Reasons

   ¨ç absence of awake symptoms

   ¨è failure to obtain sleep history

   ¨é symptoms of snoring or restless sleep are considered inconsequential

   ¨ê parents may be unaware of problem because child's most severe symptoms appear during REM sleep in the last 3rd of night

   ¨ë young children may not generate loud, disruptive snoring noises

# P/Ex

    (1) features associated with OSA/H

      ¨ç unusual facies.

      ¨è month breathing

      ¨é hyponasal speech.

      ¨ê macroglossia.

      ¨ë cleft palate.

      ¨ì enlarged tonsil.

      ¨í not consistent feature of obesity

    (2) stridor or hoarse voice : indicate cranial nerve dysfunction.

3) Lab. finding

      ¨ç 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

# ¡Úpolysomnography (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

    ¨ç nocturnal asthma.

    ¨è upper airway obstruction from gastroesophageal reflux.

    ¨é esophageal foreign body.

    ¨ê laryngomalacia, vascular ring, intraluminal mass

    ¨ë vocal cord dysfunction.

    ¨ì night terrors or nocturnal seizures.

    ¨í narcolepsy and restless leg syn.

Treatment

    ¨ç 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.

    ¨è nasal continous airway pressure ( CPAP )

           : option in children who fail adenotonsillectomy.

    ¨é supplemental oxygen.

    ¨ê snoring : treated with nasal decongestants and topical steroids.

    ¨ë medroxyprogesterone acetate.

            i) Tx of daytime hypoventilaton associated with obesity-hypoventilation                  syndrom

            ii) adverse effects: growth and pubertal developments.

    ¨ì protriptyline : nonsedating antidepressant with REM suppressant activity in

                      adult.-- not recommended

    ¨í 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 : ¨ç respiratory distress  with severe stridor.

             ¨è cry: weak and abnormal.

             ¨é obstruction ÀÌ incomplete ÇѰæ¿ì : mild stridor and dyspnea.

    (5)  Dx : direct laryngoscopy.

    (6)  Tx : ¨ç lysis with carbon dioxide laser.

              ¨è 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

        ¨ç type 1 : above sup. portion of post. cricoid plate.

        ¨è type 2 : extend to inf. aspect of post. cricoid palate.

        ¨é type 3 : involve " cervical trachea"

        ¨ê type 4 : extend to thoracic trachea and below.

     (5)  Sx

        ¨ç chronic aspiration.

        ¨è gagging during feeding

        ¨é pneumonia ( H-type tracheoesophageal fistula )

     (6)  Dx

         ¨ç roentgenographic study of swallowing.

         ¨è endoscopy.

331.2 Congenital Laryngeal Stridor (=Laryngomalacia And Tracheomalacia)

; congenital deformities or flabbiness of epiglottis and supraglottis aperture.

        : weakness of airway wall.

          => inspiration ½Ã collapse and airway obstruction ¾ß±â.

; *¡ãcommon 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 ½Ã 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

# ¡ÚDifferential Diagnosis

    ; congenital laryngeal disturbance from neonatal tetany

    ; laryngeal edema secondary to trauma or aspiration

    ; others

           ¨ç malformation of laryngeal cartilages or vocal cords

    ¨è intraluminal webs

    ¨é generalized severe chondromalacia of larynx and trachea

    ¨ê Tm of larynx

    ¨ë mucus retention cyst

    ¨ì bronchial cleft cyst

    ¨í thyroglossal duct remnant

    ¨î hypoplasia of mandible

    ¨ï macroglossia

    ¨ð hemangioma, lymphangioma, Pierre Robin syn., congenital goiters, vascular anomalies

# *4moÀÌÈÄ¿¡ Áõ»óÀ» ³ªÅ¸³ª³»´Â °æ¿ì¿¡´Â other respiratory anomalies¸¦ µ¿¹ÝÇÒ ¼ö ÀÖ´Ù.

Treatment

    ; *no specific Tx

           - resolves spontaneously

  ; small nipple dropper µå¹°°Ô gavage.

  ; *more comfortable or less noisy in prone position

    (4) severe Sx -> nasotracheal intubation or thacheostomy.

Prognosis

; *18 mo¿¡ clinically resolve

    - some degree of inspiratory obstruction persist a little longer

; pulmonary function test »ó teen age ±îÁö 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

   ¨ç  anecephaly.

   ¨è  diaphragmatic hernia

   ¨é  urinary tract anomaly.

   ¨ê  thumb anomaly.

   ¨ë  deformity of thoracic spine and rib cage ( thoracic dystrophy)

   ¨ì  renal anomaliles.

   ¨í  Rt. sided heart malformation.

   ¨î  congenital pleural effusion.

# unilat. agenesis or hypoplasia : few Sx

  - Lt. sided lesions : more common.

  - No specific Tx  : older pt. Àǰæ¿ì - AB for pulmonary infection.

                                      - annual influensa vaccine

  - Px ´Â associated anomaly ¿¡ ÀÇÁ¸

  - right lung involve ½Ã mortality Áõ°¡

  - death : ¨ç  overwhelming pul. inf.

            ¨è  CHD ¿Í ¿¬°üµÈ pul. HT ÀÇ 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 :

           ¨ç dullness to percussion and breath sound °¨¼Ò.

           ¨è infection ½Ã rales

           ¨é continuous or purely systolic murmur heard over back.

  2) chest X-ray

  3) bronchography

  4) ultrasound : rule out diaphragmatic hernia.

  5) aortography :

           ¨ç confirm diagnosis.

           ¨è lesions ÀÇ blood supply¸¦ ±Ô¸í.

  6) Doppler ultrasonography and MRI.

331.5 Bronchoenic Cyst

* cilliated epi. À¸·Î lined - inf. ½Ã ¼Ò½ÇµÇ¾î pathologic Dx °ï¶õ.

* midline structure ¿¡¼­ °¡±õ°Ô ¹ß»ý( eg. trachea, eso., carina )

* Sx ¨ç fever

      ¨è chest pain

      ¨é productive cough

 

* X-ray : cyst - contain air fluid level.

* Tx for Sx cyst : Àû´çÇÑ ABÈÄ surgical excision.

* ASx ½Ã no Tx.

331.6 Bronchobiliary Fistula

1) Def. : Rt. middle lobe bronchus¿Í Lt. hepatic ductal system»çÀÌÀÇ 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 (½Å»ý¾Æ±â¿¡ dyspnea and cyanosis)

2) 2 form of disease

  ¨ç lung ¿¡ ±¹ÇÑµÈ abnormality.

  ¨è 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 ¡ãcommon congenital lung disease

    - lobar emphysema°¡ most common 

# ¡ÚSx

    ; neonatal respiratory distress.

  ; recurrent respiratory infeciton.

  ; pneumothorax

2) Most pt: symptomatic and die in newborn period.

3) Dx

  ¨çP/Ex : diminished breath sound with mediastinal shift away.

  ¨èX-ray ; cystic mass with mediastinal shift

            air-fluid level -> lung abscess ½Ã»ç.

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 ¿¡¼­´Â airway °¡ ÀÛÀ¸¹Ç·Î older child¿Í °°Àº  Á¤µµÀÇ

    inflammation¿¡µµ ´õ narrow ÇØÁø´Ù.

  * 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 ÀÇ Æ¯Â¡.

    ¨ç brassy or " croupy" cough with or without inspiratory stridor.

    ¨è hoarseness.

    ¨é sign of respiratory distress.

332.1 Infectious Upper Airway Obstruction

Etiology and epidemiology

# ¡Ø92 Virus

    ; *¡ãcommon agents

    ; *parainfluenza virus : 75 % of case

    ; adenovirus

  ; respiratory syncyital

  ; influenza

  ; measles viruses

# Mycoplasma pneumoniae : 3.6 %

# ¡ÚCause 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 ÀßÇÔ. 

Clinical Manifestation

Croup (=Laryngotracheobronchitis)

    ; *¡ãcommon 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.

    ; *´Ù¸¥ °¡Á·Áß mild respiratory illness¸¦ °¡Áü.

    ; 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 ¿¡ tongue depressor¸¦ »ç¿ëÇÏ´Â pharynxÀÇmanupulation Àºsudden cardiorespiratory arrest ¾ß±âÇÒ¼ö ÀÖ´Ù.

    ; X-ray of nasopharynx & upper airway

           - *typical subglottic narrowing ¡°steeple sign¡±

¡Ø91 Acute Epiglottitis ( Supraglottitis )

    ; dramatic , lethal condition

    ; usually occurs in 2-7yr, peak at 3.5yr

    ; Ư¡

       - *fulminating course of high fever, sorethroat, dyspnea, rapidly progressive respiratory obstruction, prostration

    - *respiratory distress : first manifestation

    ; ¼ö½Ã°£¿¡¼­ ÀûÀýÇÑ Ä¡·á¸¦ ÇÏÁö ¾ÊÀ¸¸é death.

    ; ÀûÀýÇÑ Ä¡·á½Ã 2-3Àϰ£ °æ°ú´Â µå¹³.

    ; 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

 -> ÁøÇà½Ã stridor & breath sound °¨¼Ò ( ȯÀÚ°¡ tiring )

 -> air hunger with restlessness, agitation

 -> cyanosis, coma, death.

 ¶§·Î 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 intubationÇÑ µÚ¿¡ °Ë»ç¸¦ ÇØ¾ß ÇÑ´Ù.

    ; 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 ·Î airway È®º¸.

    ; acute epiglotitis ´Â 2-3 Àϰ£ intubated.

    ; parentral AB

           - cefotaxime, ceftriaxone, apmicillin with sulbactam ( unasyn )

    ; concomitant infection.

        - meningitis, pneumonia, cervical adeonpathy, OM,-rarely occur.

Acute Infectious Laryngitis

common illness

´ëºÎºÐ virus¿¡ ÀÇÇÔ(except for diphtheria)

Clinical Manifestation

     ¨ç sorethroat, cough, hoarseness.

     ¨è generally mild.

     ¨é respiratory distress: unusual except young infant.

     ¨ê hoarseness and loss of voice

     ¨ë severe case : severely inspiratory stridor, retraction, dynpnea,

                     restlessness.-> ÁøÇà½Ã air hunger & fatigue,

                     agitation °ú exhaustion ¹Ýº¹.

P/Ex:

     ¨ç pharyngeal inflammation

     ¨è resp. distress

     ¨é 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

    ; ¡ÚSuggestive Causes

           - viral origin

           - allergic & psychologic factor

           - gasroesophageal reflux

                   / important role in spasmodic croup

    ; pathology

     ¨ç intact epithelium. ( unlike acute infectious laryngotracheobronchitis )

     ¨è pale , watery edema.

    ; familial predisposition (+)

    ; Sx       

           - evening À̳ª night ¶§ ¹ß»ý ( sudden onset ): coryza ¿Í hoarseness

           - barking, metallic cough, noisy insp. , resp. distress. anxious, frightened

         - ´ë°³  afebrile , cool & moist skin.

           - severity of Sx diminish within several hrs.-> ´ÙÀ½³¯Àº appear well   

         - Á¾Á¾ recur.

¡ÚDifferential Diagnosis

    1) *bacterial tracheitis : ¡ãimportnat DDx

    2) diphtheritic croup

    ¨ç preceded by URI

    ¨è slow developed Sx

    ¨é serous or serosanguineous nasal discharge

    ¨ê P/Ex »ó 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 ÈÄÀÇ edema, angioedema of subglottic area as anaphylaxis, hypocalcemic tetany, IM, trauma, Tm, malformation of larynx.

Complication

1) 15 % of viral croup.

    ¨ç inf. of middle ear, terminal bronchioles, pul. parenchyma : most common.

    ¨è bacterial tracheitis

    ¨é interstitial pneumonia

    ¨ê bronchopneumonia.

    ¨ë secondary bacterial pneumonia.

    ¨ì supprative tracheobronchitis.

2) epiglottitis ( during the course )

    ¨ç pneumonia

    ¨è cervical lymphadenitis

    ¨é otitis, meningitis, septic arthritis.

3) tracheotomy ÈÄÀÇ TMC Cx.

    ¨ç mediastinal emphysema.

    ¨è 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

; ¢ÞHospitalization 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

¡ÚCorticosteroid

    ; *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 ÀÇ Çʿ伺À» °¨¼Ò½ÃŰÁö ¾ÊÀ½.

       - 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

    # ¢¾Ix 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

# ¿øÀαÕ

    ; *S. aureus - ¡ãcommon

  ; parainfluenza virus type I , Moraxella catarrhalis

  ; H. influenza

; ´ëºÎºÐ 3¼¼ ÀÌÇÏ.

; viral ds ÀÇ bacterial Cx ( rather than 10 bacterial illness )

Clinical Manifestation

    ; brassy cough, high fever, toxicity with respiratory distress.

  ; *croup ÀÇ usual Tx ´Â ineffective

  ; usually tracheotomy or intubation

    ; major pathology

           - mucosal swelling at cricoid cart. level

           - copicous, thick, purulent secretion.

Diagnosis

 1) bacterial upper airway dis. evidence.

              ¨ç mod. leukocytosis with band form

              ¨è high fever

              ¨é purulent airway secrection.

 2) absence of classic finding of epiglottitis.

Treatment

  ¨ç antimicrobial Tx includes antistaphylococcal agent.

  ¨è artificial airway.

  ¨é supplemental oxygen.

Complication

    ; X-ray »ó patchy infiltrate & focal density.

  ; subglottic narrowing

    ; *rough-ragged tracheal air column

    ; cardiorespiratory arrest

    ; Toxic-shock synd.

Prognosis

  ¨ç excellent.

  ¨è ÀûÀýÇÑ antimicrobial Tx ÈÄ afebrile within 2-3 days

  ¨é hospitalization ÀÇ meanduration: 12ÀÏ.

Chapter 333. Foreign Bodies In The Larynx, Trachea, And Bronchi

Tracheal FB

1) Ư¡

  ¨ç wheeze

  ¨è audible slap

  ¨é 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.

# ¢¾Vegetal Or Arachidic Bronchitis

  ; *severe condition due to vegetable foreign body(e.g. peanuts)

    ; cough, septic type of fever, dypnea

Diagnosis

# history

# ¡Ø94 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 »ó µÎ lung ÀÇ ÇöÀúÇÑ Â÷ÀÌ ( ƯÈ÷ expiration ½Ã )

    ; 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 »ó only slight difference at end of inspiration & expiration.

# Direct visualization by bornchoscopy

    ; definitive diagnosis

  ; *rigid or open- tube bronchoscopy

           - diagnostic instrument of choice

Prevention

 ¨ç Á¦°ÅÇÏÁö ¾ÊÀ¸¸é serious problem ¾ß±â.

 ¨è ´ëºÎºÐ safely removal

 ¨é ¸¸ÀÏ Áø´ÜÀÌ 24½Ã°£ ÀÌ»ó Áö¿¬µÈ°æ¿ì Cx ÀÇ incidence Áõ°¡.

    Cx: i) aspiration pneumonia

        ii) airway trauma 

       iii) need for tracheostomy.

Treatment

; ¡Úendoscopy & 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 ½ÃÄÑ morbidity Áõ°¡.

# emergency procedure for aphonic & not breathing children

    ; for infants ( < 1Yr )

  ¨ç 4 back blow & 4 chest thrust ¹Ýº¹.

  ¨è abdominal thrust : not used

  ¨é 4 back blow : head ¸¦ ³·Ãß°í scapula»çÀ̸¦ heel of hand·Î 4 blow

    --> loosen FB

  ¨ê 4 chest thrust : back blow ÀÌÈÄ µ¹·Á¼­ hand position À» closed cardiac

     compression °ú °°ÀÌ ÇÏ¿© 4 chest thrust.

    --> increase intrathoracic pressure

    --> expulsion of FB.

  ¨ë blind finger sweep of month : not used in infant & young children.

  ¨ì 4 chest thrust ÀÌÈÄ mouth opened & vusualized FB

     --> grasped & removed.

  ¨í after each sequence, resque breathing for unconscious Pt.

  ¨î if unsuccessful, repeated.

    ; young child ( > 1 Yr )

  ¨ç placed on back

  ¨è rescuer kneels next to pt.

  ¨é heels of one hand ¸¦ »ç¿ëÇÏ¿©, umbilicus ¿Í rib cage »çÀÌÁß°£¿¡¼­, 6-10

     abdominal thrust by pushing upward & inward from midabdomen.

  ¨ê ½ÇÆÐ½Ã mouth opened by using tongue - jaw lift --> visualized FB removed.

Chapter 334  Subglottic Stenosis

334.1 Acute Subglottic Stenosis

1. result from  ¨ç acute infection producing edema of subglottic, epiglottic,   

                  arytenoid region

               ¨è inflammation secondary to inspriration of vegetal FB

               ¨é edema of allergic reaction.

               ¨ê FB lodged in larynx

2. TX

               ¨ç intubation or tracheotomy

                ¨è medical Tx

334. 2 Chronic Subglottic Stenosis

Etiology

            ¨ç  sequele of high tracheotomy

                (damage of first tracheal ring or cricoid cartilage)

         ¨è larygeal diphtheria

            ¨é syphilis

            ¨ê TB

            ¨ë  radiation burns

            ¨ì external trauma

            ¨í neonatal intubation : most common cause

            ¨î congenital laryngeal stenosis : autosomal dorminent trait

            ¨ï "silent" gastroesophageal reflux

Clinical manifestation

    ¨ç dyspnea with stridor, suprasternal, supraclavicular, intercostal retraction

    ¨è limited to inability to decannulate patience's tracheotomy

            or remove endotracheal tube

    ¨é scarring and stenosis in subglottic region

    ¨ê necrosis of cartilage : occassionally                                      

Diagnosis

       ¨ç direct laryngoscopy

    ¨è X-ray

Treatment

       (1) milder case : not need Tx

       (2) mild case of difficulty in decanulating pt's tracheostomy

        ¨ç replacing tracheostomy cannula with smaller one and closure of this tube

                --> reeducate pt to mouth breathing

               --> removal of cannula

        ¨è 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

    ; *¡ãcommon 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

           - ¡Únot helpful

    ; AB

           - *not shortening the duration of viral illness or decrease the incidence of bacterial complication

    ; ¡ØRepeated Attacks ½Ã °í·Á Áúȯ

           - 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

# ¡ÚRSV

    ; *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

# ¡Úball 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¡É

    ; *gradual development of respiratory distress

           - *paroxysmal wheezy cough, dyspnea, irritability

# ¡Ø94 X-ray findings

    ; hyperinflation of the lungs

    ; increased AP diameter on lateral view

    ; scattered areas of consolidation - 30%

    ; atelectasis

Differential Diagnosis

    ; bronchial asthma

           - *¡ãcommon confused disorder

           - ¢ÞDDx points

                   / FHx

                   / *repeated episodes : ¡ãimportant

                   / 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

# *¡ãcritical phase

    ; *during 1st 48-72hr

# recovery

    ; *complete in a few days

# case fatality rate

    ; *1%

# ¡ØDeath

    ; prolonged apneic spells

    ; severe uncompensated respiratory acidosis

    ; profound dehydration secondary to loss of water vapor from tachypnea, inability to drink fluids

¡Ø90,91,92 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

# ¡ÚAssociated 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

 ¨ç Ãʱâ ; cough, respiratory distress, cyanosis

 ¨è ÁøÇà½Ã ; dyspnea°¡ Áõ°¡, productive cough, wheezing

Diagnosis

    ; X-ray

           - range from normal to miliary Tbc pattern

           - ¡Úcf) Swyer-James syndrome

                   / 10%

                   / *unilateral hyperlucency and decrease in pulmonary vascular marking

    ; Bronchography

           - bronchiolesÀÇ Æó¼â¿Í ÇÔ²² lungÀÇ periphery¿¡ no contrast.

    ; CT ; Bronchiectasis

  ; ¡Úlung biopsy

           - *confirmed diagnosis

Treatment

 ; no specific Tx

 cf> corticosteroid Tx -  ¼ºÀο¡¼­´Â È¿°ú°¡ ÀÖÀ¸³ª ¼Ò¾Æ¿¡¼­´Â ÀÔÁõµÈ data°¡ ¾øÀ½.

Prognosis

 ; ´ëºÎºÐ »ýÁ¸Çϳª ¼Ò¼ö´Â ºü¸£°Ô ÁøÇàµÇ¾î ÃʱâÁõ»ó ¹ßÇö ¼öÁÖ³»¿¡ »ç¸Á.

339.1 Follicullar Bronchitis

1. Etiology ; unknown

2. 2ÁÖ³»¿¡ tachypnea¿Í cough¸¦ º¸ÀÓ

3. ûÁø»ó diffuse crackles

4. X-ray ; diffuse interstitial pattern.

5. CT ; subtle interstitial nodules

6. Áø´ÜÀº lung biopsy·Î

7. Px ; ´ëºÎºÐ Á¡Â÷ÀûÀ¸·Î È£ÀüµÇ³ª ¼Ò¼ö´Â respiratory failure·Î life threatening.

8. Tx ; corticosteroid¿¡ ¹ÝÀÀÇÏ´Â ¿¹µµ ÀÖÀ½.

Chapter 340. Aspiration Pneumonia & GER Related Respiratory Disease

    * GI contentÀÇ respiratory tract³»·ÎÀÇ ÈíÀÔÀ» ¸·´Â ¿©·¯ °¡Áö ±âÀü

      (Table 340-1)¿¡µµ ºÒ±¸Çϰí dysfunctional swallowing ¹× GERÀÇ ¸¹Àº

      ¿¹¿¡¼­ respiratory ds¸¦ ¾ß±âÇϰųª ¾ÇÈ­½ÃŲ´Ù.

    * reflux¿Í °ü·ÃµÈ È£Èí±â ÁúȯÀÇ ±âÀüÀº aspiration ¹× mechanical &

      chemical effect ±×¸®°í

      airway ¹× esophagus·ÎºÎÅÍÀÇ ½Å°æÇÐÀûÀÎ ¿µÇâ µîÀÌ´Ù. ( Fig 340-1)

340.1 Aspiration Pneumonia

Aspiration Of Food & Vomitus

# ¡ÚPredisposing Factors

    ; with obstruction

           - esophageal atresia, duodenal obstruction

    ; without no obstruction

           - hypotonic, weak & debilitated infants & children

  ; familial dysautonomia

    ; impaired consciousness

Clinical Manifestation

    ; ¡Úbrief latent period

           - *hydrochloric acid is important determinants

       - 90%ÀÌ»ó 1½Ã°£³»¿¡ Sx ÃâÇö 

    - *°ÅÀǸðµÎ 2½Ã°£³»¿¡ Sx ÃâÇö

    ; *fever, tachypnea, cough

    ; Apnea, Shock

  ; P/E   ¨ç diffuse crackles, wheezing

           ¨è cyanotic

  ; X-ray ; alveolar & reticular infiltration

Treatment

    ¨ç ±âµµ³»ÀÇ Áï°¢ÀûÀÎ suction

  ¨è Oxygen

  ¨é Endotracheal intubation with suction

    & mechanical ventilation - severe case½Ã

    ; AB

           - ¡Úpreviously healthy nonhospitalized patients

                   / *Clindamycin or PC

           - chronically ill hospitalized patients

                   / *added to Aminoglycoside

Prognosis

    ; *´ë°³ 2 ÁÖ³»¿¡ infiltrates°¡ ¼Ò½Ç

  ; mortality rate ; ¾à 25%

Aspiration Of Baby Powder

    ; Zinc stearate

        - *µå¹°Áö¸¸ °¡Àå dangerous

  ¨è Tx ; °í½ÀµµÇÏ¿¡¼­ÀÇ oxygen therapy

  ¨é ±×¿Ü magnesium silicate, calcium undecylemate

  ¨ê Talc ; i) asbestos¿Í °ü·ÃÀÌ ÀÖÀ¸¸ç malignancy À¯¹ß °¡´É¼º

           ii) severe dyspnea½Ã systemic corticosteroid Tx°¡ À¯¿ë.

Pneumonitis From Other Chemicals

  ¨ç  +-high concentration ; ¿°Áõ¹ÝÀÀ, ¼¼Æ÷ ħÀ±, acute respiratory distress ¾ß±â.

      +- low concentration ; À°¾ÆÁ¾ Çü¼ºÀÇ chr. interstitial pneumonitis

  ¨è ¿¹ ; Shellac, polyvinylpyrrolidone, gum arubic, beryllium, mercury vapors,

          chlorine

  ¨é corticosteroids°¡ Ä¡·á¿¡ È¿°ú.

340.2  Hydrocarbon Pneumonia

Etiology

    ; furniture polish (±¤ÅÃÁ¦), 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¡É within hours

  ¨è pul. Sx ;  dyspnea,

               ¡éresonance on percussion

               ¡éB/S, rale 

  ¨é pul. involve´Â P/Eº¸´Ù chest X-ray¿¡¼­ ´õ ÀÚÁÖ disclosed

  ¨ê ´ëºÎºÐ 2-5ÀÏÀ̸é recover

  ¨ë systemic Sx : sommlence, convulsion, coma

Complication 

¨ç pneumothorax

       ¨è subcutaneous emphysema

       ¨é pleural effusion, emphysema

       ¨ê pneumatocele - 1ÁÖÈÄ¿¡

       ¨ë 20 inf. with bacteria or virus

Treatment

; *never sent home in less than 6hr although asymptomatic

; ¢¾Admission 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 À϶§´Â ½Ç½Ã

           / CNS toxicity ¸·±âÀ§ÇØ

; AB

    - not recommended as routine use

; corticosteroid

    - *no benefit

Prognosis

      Cx¾øÀÌ ´ë°³ surviveÇÏÁö¸¸ ÀϺδ resp. failure¿Í death·Î ÁøÇà

      Px factor  ¨ç  volume of ingestion or aspiration

                 ¨è  specific agent

                 ¨é  medical careÀÇ adequacy

340.3  Lipoid Pneumonia

; lipoid materialÀÇ aspirationÀ¸·Î ÀÎÇÑ chr. interstial, prolif. inflammation

; deblilitated Pt.¿¡ ¡è

Pathogenesis 

# aspiration °ü·Ã factor

    ¨ç intranasal instillation of oil

    ¨è cleft palate, debilitation, feeding½Ã horizontal position

    ¨é forced feeding

     : ƯÈ÷ ¿ì´Â ¾ÆÀÌ¿¡ cod liver oil, castor oil, mineral oilÀ» ¸ÔÀÏ ½Ã.

# ÈíÀÔµÈ oilÀÇ Á¾·ù¿¡ µû¶ó pul. reactionÀÇ Á¤µµ°¡ Â÷À̳².

  ; vegetable oil  +- olive, cotton seed, sesame oils

                      +- ¡é irritation, minimal inflammation

                      cf) chaulmoogra(Àεµ»ê ³ª¹«) - extensive damage

  ; animal oil

           - cod liver oil, milk

    - *¡ãdamage

    ; liquid petrolatum, lip gross

# lung reaction

     ¨ç initial : interstitial proliferative inflammation, exudative pneumonia°¡´É

     ¨è 2nd stage : diffuse, chr. proliferative fibrosis

                   ¶§·Î acute infectious bronchopneumonia

     ¨é 3rd stage : multiple localized nodules

                  tumor-like paraffinoma

Clinical Manifestation

   1) cough : TMC

   2) severe case ½Ã dyspnea

   3) 2o bronchopneumonia°¡ 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

           - recumbent½Ã (RUL)

Prevention

   1) oily vehicleÀÇ intranasal medicationÀ» ÇÇÇÔ.

   2) °¡´ÉÇÑ minimal oil, cod liver oil, castor oilÀÇ º¹¿ëÀ» ÇÇÇÒ °Í.

   3) ÀÚÁÖ regurgitation ¹× vomitingÀ» º¸ÀÌ´Â infant´Â prone positionÀ¸·Î µÑ °Í.

Treatment

   1) no specific Tx

   2) position change ¡æ ¡éhydrostic pneumonia

340.4  ¡ÚRespiratory Disorders Caused Or Worsened By GER Or It's Treatment

Aspiration pneumonia

     ƯÈ÷ ÀǽÄÀÌ °¨¼ÒµÇ¾î Àִ ȯÀÚ¿¡¼­ ÈçÇÔ.

     chemical pneumonitis, asthma-like Sx ¾ß±â

Asthma

     õ½Äȯ¾Æ´Â Á¤»ó¾Æ¿¡ ºñÇØ reflexÁ¤µµ°¡ abnormal

     reflex´Â vagal pathway¿¡ ÀÇÇØ õ½ÄÀ» ¾ß±âÇϰųª ¾ÇÈ­½ÃÅ´

Bronchopulmonary dysplasia (BPD)

     reflex´Â BPDÀÇ course¸¦ Áö¿¬½Ã۸ç À̰ÍÀÇ Ä¡·á½Ã pul. functionÀÌ È£ÀüµÊ

Cystic fibrosis

     ÀÌ ÁúȯÀÚÀÇ ¸¹Àº ¼ö¿¡¼­ GER¸¦ °¡Áü.

Tracheoesophageal Fistula

     ¸ðµç ȯÀÚµéÀº esophageal dysmotility¸¦ °¡Áö¸ç ´ëºÎºÐ reflex¸¦ º¸ÀÓ

Obstructive Apnea

Central Apnea & Apparent Life-Threatening Events

Stridor

     laryngomalacia¿Í °°Àº mild airway compromiseÀÇ °æ¿ì, reflex½Ã stridor¸¦

     º¸À̸ç antireflex therapy½Ã stridor°¡ °¨¼ÒµÇ¾îÁü. 

Hoarseness

     ¼ºÀο¡¼­ ÈĵÎÀÇ ¿°Áõ°ú ºÎÁ¾ÀÌ reflex¿Í °ü·ÃÀÌ ÀÖÀ¸¸ç,

     acid suppression therapy¿¡ ÈĵÎÁõ»óÀÌ È£ÀüµÊ.

     ¼Ò¾ÆÀÇ °æ¿ì¿¡µµ °ü·Ã¼ºÀÌ °¡´É

Cough

     reflexÀÇ Áõ»óÀ¸·Î °¡´ÉÇϸç, antireflex Ä¡·á·Î È£ÀüµÊ.

Hiccup

Respiratory Side Effects Of Antireflex Tx

     BethanecholÀÇ °æ¿ì bronchospasmÀ» ¾ß±â

Chapter 341.  Silo filler Ds

1. Á¤ÀÇ : N2OÀÇ inhalation¿¡ ÀÇÇÑ acute or subacute interstitial Pn 

2. Dx : ¨ç exposure Hx (4ÁÖÀ̳»)

        ¨è Sx : dyspnea, wheezing, cough, nausea, choking or fatique

           P/E : ûÁø»ó rales (¾à 1/3¿¡¼­)

        ¨é X-ray : infiltration or edema

        ¨ê biopsy or autopsy

3. Tx : corticosteroid

Chapter 342.  Paraquat Lung

  1. Á¦ÃÊÁ¦·Î »ç¿ëµÇ´Â dipyridylium compoud·Î lung¿¡ ¼±ÅÃÀûÀ¸·Î ÃàÀûµÇ¸ç,

      high toxic

  2. ¼öÀÏ-¼öÁÖ³» resp. failure·Î »ç¸Á

  3. pul. lesion : ¨ç 2o to systemic absorption by GI, skin or lung

                    (¿À¿°µÈ ¸¶¸®È­³ª Èí¿¬) 

                 ¨è prolif. bronchiolitis, alveolitis,

                    intraalveolar hyaline membrane & fibrosis¸¦ º¸ÀÓ

Treatment

    ; no treatment except supportive Tx

    ; *O2 --> increase pul. toxicit

Chapter 343.  Hypersensitivity To Inhaled Materials

organic dustÀÇ ¹Ýº¹µÈ inhalation ¡æ chr. pneumonitis

Etiology

   ¨ç moldy hay ( farmer's lung)

   ¨è maple bark (maple bark stripper's ds)

   ¨é sugar cane fiver ( bagassosis )

   ¨ê red-wood tree bark

   ¨ë pigeon dropping & feather ( pigeon breeder's ds )

   ¨ì cheese

   ¨í desiccated pituitary powder

   ¨î dusty output from air conditioner

   ¨ï fungus or mod

Clinical Manifestation

   : ³ëÃâ ¼ö½Ã°£³»¿¡  cough, dyspnea, chest pain, fever

    - Ag ¿¡ °è¼Ó  contact½Ã severe dyspnea¿Í  cyanosis·Î ÁøÇà

     ( À̶§  X-ray : diffuse, fine, intestitial or nodular density &

                     peripheral alveolar infiltrates )

    - ¶§·Î pulmonary functionÀÇ irreversible loss

    ** suspect

       : cough, fever ¶§·Î dyspnea°°Àº mild SxÀ» °¡Áø ¾î¸°ÀÌ¿¡¼­

        bronchopneumonia°¡  AB·Î ÀûÀýÈ÷  Ä¡·áÇÔ¿¡µµ Áö¼ÓµÉ ¶§

Pathology

  1)  Á¶Á÷ÇÐÀûÀ¸·Î plasma cells, lymphocytes, epitheliod cell ±×¸®°í giant cellÀÇ

      ÃàÀû°ú ÇÔ²² subacute granulomatous inflammationÀ¸·Î ±¸¼º

  2)  °è¼Ó ³ëÃâ½Ã fibrosis·Î replaced

Diagnosis

  1) moderate to marked leukocytosis ( acute attack½Ã )

  2) serum Ig * ( G,M,A )

  3) PFT»ó restrictive pattern

  4) hypoxemia without hypercapnia

  5) skin test»ó delayed hypersensitivity response

  6) ÇǺλý°Ë¿¡ ÀÇÇØ Arthus reactionÀÌ Áõ¸í

  7) ÁÖ¾îÁø  Ab ¿¡ ´ëÇÑ serum precipitin  Áõ¸í

  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

           - *¡ãcommon aspergillus-related disease in children

    ; mostly in patients with chronic pulmonary disease

Clinical Manifestation

; *immunosupressed or chr. illed child°¡ acute onset of cough, wheezing, low grade fever

; productive cough

    - *occasionally brown plug containing hypae

; immediate skin reaction : strong (+)

    - Arthus type III°¡ skin testÈÄ Áõ¸í

; AspergillusÀÇ strong suspect °æ¿ì

     ¨ç aspergillus Ag¿¡ ´ëÇÑ AbÀÇ precipitation

     ¨è (+) skin test

     ¨é serum IgE ¡è

# ¡ÚDefinite 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 aspergillosis½Ã  antifungal Tx´Â È¿°ú ¾øÀ» ¼öµµ ÀÖÀ½

; amphotericin B + 5-FC   * for 2-3wks

Chapter 345. Loeffler Syndrome (= Eosinophilic Pneumonia )

# ¡ÚCharacteristics

    ; widespread transitory pulmonary infiltrates

           - variable size but *resemble miliary Tbc

    ; eosinophilia (70%±îÁö)

# clinical course

   ¨ç ½ÉÇÏÁö ¾ÊÀ¸¸é¼­ ¸îÀÏ¿¡¼­ ¸î´Þ±îÁö ´Ù¾ç.

   ¨è paroxysmal attack of cough, dyspnea, pleurisy, little or no fever

   ¨é hepatomegaly ( ƯÈ÷ infant & young children¿¡¼­ )

   ¨ê hyperglobullinemia - i) hepatic dysfunction

                         ii) parasitic invasion¿¡ ´ëÇÑ response·Î

Etiology

    ; helminthic infection

           - *¡ãcommon

     i) toxocara canis (TMC) & cati

     ii) roundworm

      ; Ascaris lumbricoides, Strongyloides stercoralis

        hookworm

     iii) paragonimiasis

    ; Drug reaction

      : aspirin, PC, sulfonamide, imipramine

# hypereosinophilic synd.

   ¨ç ¼Ò¾Æ¿¡¼­´Â rare

   ¨è eosinophilia°¡ 6°³¿ùÀÌ»ó Áö¼Ó

   ¨é acute lymphoblastic leukemiaÀÇ ÃʱâÁõ»óÀ¸·Î¼­ °¡´É

# variant of eosinophilic pn.

   : ÃÖ±Ù¿¡´Â ´õ acute course of fever¿Í rapid progression to

     severe hypoxia, eosinophilia, diffuse pulmonary infiltration

    ¡æ oral C-S¿¡ »¡¸® responseÇϸç relapseµµ ¾ø´Ù.

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) Ư¡   ¨ç extensive pulmonary consolidation &

                rapid progressive functional deteriorationÀ» º¸À̸ç

             ¨è pathology    i) alveolar exudate

                            ii) interstitial infiltrate

                            iii) necrotizing arteritis

   3) X-ray ; pul. edema¿Í À¯»çÇÑ infiltrationÀÌ ÀϽÃÀûÀ¸·Î

   4) Tx ; no spesific , but immunosuppressive drug°¡ È¿°úÀÖ´Ù.

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¡æ chr. interstitial fibrosis·Î ÁøÇà

# ´ë°³ URI ¼±Çà

# congenital rubella¿Í °ü·ÃµÈ 2 caseÀÖÀ½

# circulating immune complex¿Í alveolar deposit of Ig G & complement

       ¡æ ÀÌ ÁúȯÀÇ  immune basis¸¦ ½Ã»ç         

Clinical Manifestation

  ; usually slowly developed

    ; tachypnea & dyspnea

  ; non productive cough, anorexia, wt. loss

  ; cyanosis

Laboratory Finding

   1) X-ray

     ¨ç diffuse, hazy, ground glass appearance at lung bases

     ¨è poorly defined hilar density

   2) Hypoxemia ; ventilation-perfusion abnormality¿¡ ÀÇÇØ¼­

                  ¡æ diffuse defect ¡æ severe exercise intolerance

# Definite Diagnosis

    ; open lung biopsy

Treatment

   1) often recover spontaneously (but 1¼¼ ÀÌÀü¿¡ Áø´Ü½Ã ÁÖ¸ñ ! )

   2) pulmonary status¾ÇÈ­³ª X-ray»ó ºü¸¥ deterioration½Ã

     ¡æ open lung biopsy·Î definit DxÈÄ

     ¡æ C-S  ¨ç  SxÀÇ ºü¸¥ resolution

              ¨è X-rayÀÇ gradual improvement

   3) corticosteroid-resistant Pt.ÀÇ °æ¿ì¿¡ chloroquime phosphate°¡ È¿°ú

     ( 10mg/Kg/24hr)

   4) Tx°¡ »¡¸® stopµÉ °æ¿ì relapse °¡´É

Chapter 348. Hypostatic Pneumnia

1. ¹ßº´   ¨ç marasmic state¿¡¼­ ȤÀº ¼ö¼ú ÈÄ prolonged passive pulmonary 

            congestionÈÄ »ý±è

          ¨è one positionÀ¸·Î ¿À·¡ ´©¿öÀÖÀ» ¶§

2. P/E ; dullness on percussion, ¾àÇÑ È£ÈíÀ½, ¼öÆ÷À½

3. specific Tx´Â ¾ø°í prophylaxis°¡ °¡Àå Áß¿ä : frequent position change

Chapter 349. Pulmonary Hemosiderosis

; abnormal accumulation of hemosiderin in the lungs

    - resulting from diffuse alveoli hemorrhage

# ¢¾4 Type of Primary Pul. Hemosiderosis

  ¨ç idiopathic form

  ¨è form asso. with cow's milk hypersensitivity (Heiner synd.)

  ¨é form asso. with myocarditis

  ¨ê form asso. with progressive GN (Goodpature synd.)

# ¢¾3 Type of Secondary Pul. Hemosiderosis

  ¨ç asso. with mitral stenosis & chr. LVF

  ¨è asso. with collagen ds.

  ¨é asso. with hemorrhagic ds.

Idiopathic Primary Pul. Hemosiderosis

   1) onset ;  ´ë°³  childhood

   2) Sx ; ¨ç recurrent or chr. ds.·Î¼­ cough, hemoptysis, dyspnea, wheezing

              ¶§·Î´Â cyanosis º¸ÀÓ

           ¨è acute attack½Ã´Â ´ë°³ 2-4ÀÏ Áö¼ÓµÇ¸ç, fever ¸¦ º¸À̱⵵ ÇÔ.

           ¨é ¼Ò¼ö¿¡¼­ Ãʱ⿡ chr. iron deficiency anemia¿Í °ü·ÃµÈ Sx¸¦ º¸ÀÓ

           ¨ê microcytic, hypochromic anemia

Diagnosis

    ; ¡ÚOpen 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

¨è X-ray ; minimal infiltration¿¡¼­ºÎÅÍ 2Â÷ÀûÀÎ atelectasis, emphysema

                ±×¸®°í hilar lymphadenopathy¸¦ µ¿¹ÝÇÑ 

                massive pul. involvement±îÁö ´Ù¾ç

    ¨é open lung biopsy

      - Á¶Á÷ÇÐÀûÀ¸·Î intra-alveolar hemorrhage,

         hemosiderinÀ» ÇÔÀ¯ÇÑ macrophage,

        alveolar epithelial hyperplasia, intestitial fibrosis ±×¸®°í  small vesselsÀÇ

        sclerosis¸¦ º¼ ¼ö ÀÖÀ½

    ¨ê  Bronchoalveolar lavage - hemosiderinÀ» ÇÔÀ¯ÇÑ  macrophage¸¦ ¹ß°ß

Prognosis

     - Pt.ÀÇ ¾à 1/2¿¡¼­ ±Þ¼º ÆóÃâÇ÷ ¹× ÁøÇàÀûÀÎ ÆóºÎÀüÀ¸·Î 1-5³â³»¿¡ »ç¸Á

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

           - ½ÄÀÌ¿ä¹ý ; cow's milk¸¦ Á¦°Å

           ii) corticosteroid

           iii) cyclophosphamide

  ; ´Ù¸¥ form¿¡ ºñÇÏ¿© Px´Â ÁÁÀ½

Primary Pul. Hemosiderosis With Myocarditis

   - heart enlargement¿Í ÇÔ²² 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  

    ¨ç sporadic type

  ¨è congenital form

Congenital Alveolar Proteinosis

    ; *full-term newborn develops rapidly progressive respiratory distress

    ; similar to RDS

    ; Etiology

           - *SP-B (surfactant apoprotein B)ÀÇ 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 permeability¿Í  protein flux°¡ Áõ°¡

  ; ¡ÚDDx

           - *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/F¿¡¼­   surfactant proteinÀÇ ÃøÁ¤

        ¡æ °¡Á··ÂÀÌ ÀÖÀ»¶§ antenatal diagnosis·Î °¡´É

Treatment

    ; *replacement therapy - not effective

    ; current therapy

           - ventilatory support & ECMO

                   --> *lung transplantation

Aduldt Form Of Alveolar Proteinosis

   1) ¼Ò¾Æ¿¡¼­´Â rare

   2) male¿¡¼­  femaleº¸´Ù 3¹è ´õ ¸¹´Ù 

   3)

    

 2 form ÀÇ Â÷ÀÌÁ¡

 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

           ¡æ  ¸»±â¿¡´Â cyanosis¿Í  digital clubbingÀ» º¸ÀÓ

   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. ±âÀü : uncontrolled imflammatory process

         ¡æ chr. imflammation

         ¡æ progressive fibrosis

2. Sx

   ¨ç incidious onset of dyspnea (óÀ½¿¡´Â ¿îµ¿½Ã ³ªÅ¸³ª³ª

      ÁøÇà½Ã È޽ĻóÅ¿¡¼­µµ

   ¨è dry cough°¡ ÁÖ , ¶§·Î productive of blood

   ¨é ´ë°³ aferile

   ¨ê ÁøÇà½Ã anorexia, Wt. loss, fatigability

     ¡æ finally cyanosis, clubbing, cor pulmanale, Rt. heart failure

   ¨ë ûÁø½Ã lungÀº ´ë°³ clearÇϳª Á¾Á¾ raleµµ detect

   ¨ì death : intercurrent pulmonary infectionÀ¸·Î ÀÎÇÑ resp. failure·Î

3. X-ray : progressive widespread granular or reticular mottling

           or small nodular densities

4. 67Ga scan »ó (+)

5. Tx

  ¨ç C-S´Â Symptomatic relief´Â °¡´ÉÇϳª ds.ÀÇ progress¸¦ ¹Ù²Ù°Å³ª

     pul. function È£ÀüÀº ¾ø´Ù.

  ¨è immunosuppressant drug : some adult¿¡¼­ benefit

Chapter 352. Pulmonary Alveolar Microlithiasis

   ¨ç rare ds. of unknown eti.

   ¨è familial incidence ( ¾à 50% )

   ¨é no secific metabolic abnormality

      S-Ca &P ; n'l

   ¨ê Dx ; lung biopsy

   ¨ë Tx ; À¯¿ëÇÑ ¹æ¹ýÀº ¾ø´Ù.

   ¨ì i) Pt. ¹ß°ß½Ã °¡Á·±¸¼º¿øÀÇ screening

      ii) respiratory infection¿¡ ´ëÇÑ Áï°¢ÀûÀÎ Ä¡·á

      iii) ±Ý¿¬ ¹× ¸Å¿¬ ³ëÃâÁÖÀÇ

      iv)  öÀúÇÑ immunization (measles, pertussis, influenza )

Chapter 353. Atelectasis

Acquired Atelectasis

¡ÚEtiology

; 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

           ¨ç foreign body

           ¨è neoplasm

           ¨é granulomatous tissue ; Tbc

           ¨ê 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 lung¿¡ ¹ßº´½Ã          

        ; dyspnea with rapid shallow respiration,

          tachycardia, cyanosis

    3) area of severe pre-existing ds.¿¡ ¹ßº´½Ã

       ; transient pain, ±âÁ¸ÁúȯÀÇ ÀÌÇÐÀû ¼Ò°ßÀ» º¸ÀÓ.

Diagnosis

  ¨ç X-ray

         ¨è Brinchoscopic exam.

Prognosis

: ¨ç atelectatic area - susceptible to infection

              ¡ñ mucociliary clearance°¡ °á¿©, cough°¡ ineffective

          ¨è Áö¼Ó½Ã  Cx ; pul. abscess

Treatment

    1) ¢¾Bronchoscopic Exam Indication

        ; *FB, any other bronchial obstruction

                   --> immediately

           ; *persist for several wks : 8wks

    2) position change & deep breathing

    3) O2 : dyspnea½Ã (95%O2 = 5%CO2 È¥ÇÕÇÑ °Í)

    4) morphine°ú atropineÀº °¡´ÉÇÑ ÇÇÇÔ

    5) postural drainage

    6) ABµµ ¶§·Î

    7) asthma½Ã : bronchodilator & C-S

    8) lobectomy

       ; ¡ÚIndication

                   - chr. infection threating to remainder lung

         - bronchiectasis

         - systemic Sx(e.g. anorexia, fatique)

Massive Pul. Atelectasis

Etiology

    ; postop. Cx

           - *¡ãcommon

    ; trauma / asthma / pneumonia / tension pneumothorax / FB asporation

  ; paralysis in diphtheria or poliomyelitis

Clinical Manifestation

    1) op. ÈÄ 24½Ã°£³»¿¡ onset : dyspnea, cyanosis, tachycardia

    2) ¸Å¿ì anxious, chest pain È£¼Ò, prostration, fever(39.5-40oC)

  3. P/E

    1) affected chest : flat

    2) ¡érespiratory excursion

    3) dullness to percussion

    4) (-) or feeble breath sound

  4. X-ray

    1) lower lobe°¡ ÈçÈ÷ involve

    2) heart & mediastinumÀÌ affected side·Î displace

    3) collapsed

    4) elevation of diaphragm

    5) narrowing of intercostal space

Prevention

    1) opÁß - ¸¶ÃëÁß ÃæºÐÇÑ ventilation

    2) opÈÄ  ¨ç position change ÀÚÁÖ

             ¨è oropharynxÀÇ secretion À» aspirate

             ¨é ÀǽÄȸº¹ ÈÄ deep breathing

Treatment

    1) bilat. atelectasis½Ã  Áï½Ã bronchoscopic aspiration ½ÃÇà

    2) unilat. atelectasis½Ã

       ¨ç °Ç°­ÇÑ lungÂÊÀ¸·Î À§Ä¡ÇÏ¿© forced coughing or crying½ÃÅ´

       ¨è bronchoscopic aspiration ¡ç ¨ç¿¡ ½ÇÆÐ½Ã

    * relapse ¸¹´Ù.

Chapter 354. Emphysema & Overinflation

# emphysema

    ; distension with irreversible rupture of alveoli

# overinflation

    ; reversible disttension without alveolar rupture

Localized Obstructive Overinflation

Etiology

    ¨ç FB & inflammatory reaction

    ¨è intrabronchial Tbc or Tbc of tracheobronchial LN

    ¨é intrabronchial or mediastinal Tm

    ¨ê abnormally thick mucus ; asthma, cystic fibrosis

Unilateral Hyperlucent Lung

¡ÚEtiology

    ; 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

    ¨è ´ë°³ PnÀÇ Sx¹× SgÀ» º¸ÀÌÁö¸¸ ¼Ò¼ö¿¡¼­´Â hemoptysis

    ¨é P/F : hyperresonance & decreased BS

    ¨ê Tx : no specific Tx

Congenital Lobar Emphysema

    ; *usually apparent in neonatal periods

           - 5% appear 5-6mo

    ; severe respiratory distress

    ; ¡ÚLt. upper lobe

           - *¡ãcommon

(4) Tx

      ¨ç medical management with (selective) intubation or

        high frequently ventilation 

      ¨è immediate op. & excision of lobe

         ¡ç  cyanosis¿Í ½ÉÇÑ respiratory distress°¡ ³ªÅ¸³ª¸é

354.1 Generalized Obstructive Overinflation

; reversible

; infant¿¡ ¸¹´Ù.

Etiology

    ¨ç asthma

  ¨è CF

  ¨é acute bronchiolitis

  ¨ê interstitial pneumonitis

  ¨ë atypical form of acute LTB

  ¨ì aspiration of zinc stearate powder

  ¨í miliary Tbc

Clinical Manifestation

    ¨ç expiratory type of dyspnea

  ¨è respiratory rate ¡è& ¡é respiratory excursion

  ¨é air hunger, chest wall retraction

  ¨ê severeÇÑ °æ¿ì cyanosis

  ¨ë percussion½Ã  hyper-resonant

  ¨ì Fine or medium crackles

# X-ray

  1) both diaph. low & flattened

  2) wide intercostal space

  3) lung : hyperlucent

  4) fluoroscopic exam.

    ¨ç restricted diaph. movement

    ¨è exp.µ¿¾È n'l downing of diaph ¡é

    ¨é flattened diaph.

    ¨ê exp. µ¿¾È lungÀÇ air retention ¡è

354.2 Bullous Emphysema (= Pneumatocele)

Etiology

    ; overdistension & rupture of alveoli during birth of Á÷ÈÄ

          ¨è sequele of pneumonia or other inf.

          ¨é Tbc

2. DDx : pul. abscess

3. ´ëºÎºÐ ¼ö°³¿ù ³» ÀÚ¿¬ ¼Ò½Ç

  cf> severe respiratory & cardiac embarrassmentÀÇ °æ¿ì Aspiration or surgery

354.3 Subcutaneous Emphysema

Etiology

    ¨ç fx of orbit (nasal sinus·ÎºÎÅÍ air leakage)

  ¨è tracheotomy

  ¨é deep ulceration in the pharyngeal region

  ¨ê esphageal wound

  ¨ë perforating lesion of larynx or trachea

  ¨ì Cx of thoracentesis

  ¨í asthmaÀÇ  Cx   

  ¨î abdominal opÀÇ Cx

  ¨ï gas producing bacteria

2. self-limited & no-specific Tx

  :  µå¹°°Ô trachea ÁÖÀ§ÀÇ soft tissueÀÇ air·Î ÀÎÇØ tracheal compression                ¡æ op. ¿äÇÔ.       

354.4 ¥á1-Antitrypsin Deficiency & Emphysema

; ¥á1-antitrypsin homozygous deficiency·Î

    --> early onset of severe pancinar emphysema

; ¼Ò¾Æ¿¡¼­´Â pul. ds.·Î rareÇÑ cause

# ¥á1-antitrypsin

  - lungÀÇ dead bacteria³ª leukocyte·ÎºÎÅÍ À¯¸®µÇ´Â proteolytic enzymeÀ»inactivation½ÃÅ´

    ¡æ deficiency½Ã pul. tissueÀÇ proteolytic destruction°ú emphysema¾ß±â       

3. Type : genotype, Pi type

    +- n'l : Pi type MM

    +- abn'l : null / null ZZ, SZ ¡æ early onset emphysema

4. Tx

  1) Danazol ( testosterone analog )

     ; hepatic ¥á1-antitrypsin synthesis ¡è

  2) ¥á1-antitrypsin

Chapter 355. Pulmonary Edema

1. Eti. : pul. capillary·ÎºÎÅÍ alveolar space¿Í bronchiole·ÎÀÇ

        fluid transudation¿¡ ÀÇÇØ¼­

  1) LVF : ¡è 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) ´ëºÎºÐ rapid onset

  2) Sx ; ¨ç breathing difficulty, chest discomfortness or chest pain

          ¨è cough with frothy, pink-tinged sputum

          ¨é tachypnea, rapid & week pulse, pale, ¶§·Î  cyanotic

  3) P/E»ó  +- dullness to percussioin

            +- moist, bubbly rale on lower chest, Ãʱ⿡ wheezing°¡´É

  4) X-ray ; ¨ç diffuse perihilar infiltrate - butterfly distribution

             ¨è peripheral & horizontal line - Kerley B

3. Tx

  1) ¡èO2 by IPPB

  2) morphine sulfate (0.1mg/Kg)

    ; O2¿Í ÇÔ²² dyspnea relief

  3) ¸¸ÀÏ 2o to excessive fluid/blood IV administration or cardiac failure

    ¡æ ¨ç diuretics (furosemide 1mg/Kg)

       ¨è digitalis

       ¨é bronchodilator

       ¨ê tourniquet to extremities

       ¨ë withdrawal of blood

  ** High altitude pulmonary edema

    1. children & adolescent at altitude above 2700m (8860ft)

    2.  ¨ç cough, chortness of breath, vomiting, chest pain : TMC Sx

         ¡æ exposure ¼ö½Ã°£³»¿¡

       ¨è  X-ray ; bilat. patchy pul. infiltration

       ¨é recovery : 48½Ã°£³»

    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, adolescent¿¡¼­´Â abd. & head vein¿¡¼­µµ ¿Ã ¼ö ÀÖ´Ù.

# ¡ÚAsso. Condition

    ; scoliosis surgery

    ; spinal cord injury

    ; severe burn

  ; prolonged inactivity

    ; complication of IV infusion

  ; ¡ÚSick Neonate

        - *medical device (e.g. IV line), AV fistula, implanted device

                   / *¡ãoften

           - CHD & infant of DM mother

    - infarcted placenta

           - thrombus in umbilical vein

       - asphyxia

           - sub sequent resp. distress

    ; adolescence

    ¨ç recent abortion

    ¨è drug abuse

    ¨é hypercoagulation disorders

    ¨ê oral contraceptives

    ¨ë indwelling central venous catheter

    ¨ì urokinase - rarely

  6) sickle cell anemia

  7) fat embolism from fractured bone

  8) multiple pulmonary infrct from small emboli

    ¨ç severe dehydration in diarrheal ds.

    ¨è CHD

    ¨é bacterial endocarditis

    ¨ê ventriculo-atrial shunt in hydrocephalus

Clinical Manifestation

    ; *dyspnea

           - often transient

    ; chest pain & collapse

    ; large infarction

           - impaired resonance, pleural friction rub

           - decreased breath sound, moist rale

           - classic triad

                   / *pleuritic chest pain, hemoptysis, infiltrate

    ; large emboli

           - acute Rt-side heart failure

    ; abscess formation due to secondary infection

Diagnosis

    ; *normal chest X-ray

    ; pulmonary perfusion study , ventilation scintiphotography, pul. angiogram

Treatment

  ; medical emergency  

  1) initial objective  ¨ç cardiovascular support

                     ¨è prevention of circulatory collapse

                        & pulmonary insuffiency by cardiotonic drug

                        & mechanical ventilation

  2) thrombolytic Tx (heparinization)

   ¡æ fail½Ã emboli source°¡ ºÐ¸íÇØÁö¸é op

# Heparinization

  ; after stabilization, prevent further embolization

    ; IV heparin loading 50-70U/kg

           --> *maintenance 25U/kg/hr for 7-10days

                   / clotting time 2¹è, or aPTT 1.5¹è