9 May

Question 1

5 year old patient presents with labored breathing, difficulty swallowing with drooling, has a muffled voice, and soft stridor, is leaning forward with hands on knees to breathe. What is likely Dx? What should be done with great care on PE and why?

Answer 1

Likely epiglottitis
Care with throat exam as additional irritation of the throat can lead to swelling and closing of the throat. Only perform if rapid intubation is available.

Question 2

What are the causes of epiglottitis?

Answer 2

H. influenza type B most commonly

Possible Strep and other H. flu strains

Question 3

Who gets epiglottits?

Answer 3

Kids 2-7 years

Question 4

Most common symptoms of epiglottits?

Answer 4

Dysphagia, drooling, soft stridor, muffled voice, sudden high fever, inspiratory retractions, erythematous and swollen epiglottis

Question 5

Epiglottitis Dx and treatment

Answer 5

Dx: swab for culture is possible but must be done with care, x-ray shows swollen and edematous epiglottis and obstructed airway
Tx: keep child calm, admit for observation, intubate unless mild (nasotracheal), antibiotics for 7-10 days, possible emergent tracheostomy

Question 6

18 month old patient presents with respiratory distress, wheezing, fever, tachypnea, nasal congestion, cough, prolonged expiration, crackles, hyperresonance to percussion. Likely Dx? Cause? Age? Findings on CXR?

Answer 6

Bronchiolitis
Caused by RSV most commonly, possibly parainfluenza type 3
Usually kids less than 2y
CXR: hyperinflation and patchy infiltrates

Question 7

How is bronchiolitis treated?

Answer 7

Hydration, humidifier
Inhaled bronchodilators and systemic steroids contraindicated
If respiratory distress or hypoxemia, should be admitted for observation

Question 8

32 week gestation neonate presents 1 day after birth with nasal flaring, grunting, intercostal retractions, cyanosis with ABG showing increased CO2 and decreased O2. Likely Dx? Other possible Labs? CXR? Tx?

Answer 8

Respiratory distress syndrome of neonate
Caused by surfactant deficiency of preterm infant leading to decreased lung compliance, atelectasis, and respiratory failure
Present within 2 days of birth with mentioned sx as well as RR over 60/min, crackles, decreased sounds
ABG most helpful lab, but amniotic analysis for lecithin:sphingomyelin ratio may help determine lung maturity when between 34-37 weeks. Always treat when less than 34 weeks
CXR shows ground glass consistent with fluid and atelectasis
Tx: maternal steroids before birth, NICU admission, O2, surfactant replacement, intubation if not responding to treatment or needing excessive O2 to maintain SaO2

Question 9

What findings on amniocentesis indicate immature lungs and need for corticosteroids before delivery?

Answer 9

Lecithin:sphingomyelin ratio less than 2 or
Lack of Phosphatidyl glycerol
Both indicate need for treatment

Question 10

Classic cause of pneumonia in CF?

Answer 10

Pseudomonas

Question 11

Complications of CF?

Answer 11

Recurrent lung infections, chronic sinusitis, pancreatic enzyme deficiencies and malabsorption, problems with reproductive tract

Question 12

Sweat test and CF?

Answer 12

Gold standard for Dx

Will show a high Cl content and high Na content

Question 13

Inheritable pattern of CF?

Answer 13

Autosomal recessive

Question 14

What is normal Hg for men and women?

Answer 14

Men: 13.5-17.5
Women: 12-16

Question 15

Normal Hct for men and women

Answer 15

Men: 40-55
Women: 35-45

Question 16

Normal Pco2

Answer 16

33-45

Question 17

Normal PO2

Answer 17

75-105

Question 18

What tumors account for around 75% of malignant pleural effusions?

Answer 18

Lung carcinoma
Breast carcinoma
Lymphoma

Question 19

What is the first step in management of a pleural effusion?

Answer 19

Thoracentesis
Simple and easy diagnostic procedure that provides decision making information in 90% of cases
Must determine if transudative or exudative
Transudative rules out malignant effusion
Thoracentesis is not needed if classic signs of heart failure where a trial of diuretic is done first

Question 20

If patient has pleural effusion and thoracentesis show exudate, but is non-diagnostic. What are the next steps?

Answer 20

Exudate is common with malignancy. If other sx of malignancy present, do chest CT looking for a mass. If one is present, the next step will be bronchoscopy for dx.
If the thoracentesis is diagnostic for lung cancer, bronchoscopy is not necessary.

Question 21

Ipratropium use in obstructive diseases

Answer 21

Slower onset than beta agonists and not as effective in asthma than in COPD. Therefore, use in asthma is generally not indicated, but is useful for COPD.

Question 22

How should a chronic asthmatic patient be treated after 3 months of good control or very poor control?

Answer 22

Good control: consider step down

Poor: step up and consider short course of prednisone which is also used for exacerbations (the prednisone)

Question 23

What are predisposing factors to aspiration pneumonia?

Answer 23

Altered consciousness leading to reduce cough reflex/glottic closure (dementia, drugs)
Dysphagia from neuro deficits (stroke, etc.)
Upper GI disorders (GERD)
Mechanical compromise of aspiration defenses (NG tube, ET tube)
Protracted vomiting
Large-volume tube feeds in recumbent position

Question 24

What lobes of the lung tend to be involved in aspiration pneumonia?

Answer 24

Lower lobes or R middle lobe if sitting when aspirated

Posterior segments of upper lobes if recumbent when aspirated

Question 25

What are the infectious organisms in aspiration pneumonia and the best treatment?

Answer 25

Oral flora common including aerobic and anaerobic bacteria

Treatment must be broad spectrum with good anaerobic coverage – amoxicillin-clavulanate, clindamycin are good options

Question 26

What should be considered if pneumonia is non-resolving or recurring in the same area?

Answer 26

Obstruction of some kind, possibly external compression due to malignancy

Question 27

How does smoking affect mucocilliary function

Answer 27

Smoking decreases function predisposing to CAP

Question 28

What are classic features of presentation for aspiration pneumonia?

Answer 28

Indolent sx compared to the acute onset in CAP
Foul smelling sputum
Concurrent peridontal disease

Question 29

What is the treatment for anaphylaxis?

Answer 29

IM epinephrine to dilate respiratory tract and to prevent vascular collapse due to vasodilation (IM before IV to limit chance of adverse effects such as arrhythmia)
Fluid resuscitation to compensate for vasodilation
Airway management
Anti-histamines and glucocorticoids

Question 30

What are the classic sx of anaphylaxis?

Answer 30

Classically involves multiple organ systems:
Airway: constriction and edema leading to obstruction and wheezing
Cardiac: vasodilation leading to hypotension and tachycardia
GI: nausea, vomiting, abd pain
Skin: flushing, pruritus, urticaria

Question 31

Normal A-a gradient

Answer 31

less than 15

Elevates with age, but anything over 30 is always abnormal

Question 32

What are risk factors for alveolar hypoventilation?

Answer 32

Recent subdiaphragmatic surgery
Obesity
Narcotic pain medications
CNS disorders (stroke, infxn, brainstem lesions)
Neurological disorders (myasthenia, lambert-eaton, guillain-barre)
Pulmonary disorders (COPD, OSA, scoliosis)

Question 33

What are risk factors for ARDS?

Answer 33

Infection, trauma, massive transfusion, acute pancreatitis

Question 34

What is ARDS?

Answer 34

Lung damage leads to pulmonary edema and leakage of cytokines into the alveoli leading to respiratory distress, impaired gas exchange, decrease lung compliance, PHTN

Question 35

When is the onset of ARDS?

Answer 35

Within 1 week of the insult

Question 36

How is ARDS managed?

Answer 36

Mechanical ventilation with low TV and high PEEP

Question 37

Findings suggestive of ARDS

Answer 37

Respiratory distress
Bilateral crackles
CXR showing diffuse infiltrates
Hypoxemia
Within 1 week of insult

Question 38

How does the PaO2/FiO2 (P/F) ratio change with ARDS?

Answer 38

Arterial O2 is decreased which requires a higher FiO2 leading to a lower ratio indicating an increased severity of ARDS progression with a decreased ratio below 300.