Part 19. The Respiratory System
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 °¨¼â½Ã۱â
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 muscle˼
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
˼ lung˂
elastic recoilÀÇ 65£¥ Á¤µµ ±â¿©ÇÑ´Ù.
¡æsurfactant¾øÀ¸¸é
elastic recoilÀÌ markedly increaseÇϸç
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)Lung˼
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. collection˼ 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 ˼
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 ¿¡ ±¹ÇѵÈ
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 ¾ÇȽÃŲ´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 ¾ÇȽÃÅ´
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 status¾Çȳª
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