9 May Flashcards
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?
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.
What are the causes of epiglottitis?
H. influenza type B most commonly
Possible Strep and other H. flu strains
Who gets epiglottits?
Kids 2-7 years
Most common symptoms of epiglottits?
Dysphagia, drooling, soft stridor, muffled voice, sudden high fever, inspiratory retractions, erythematous and swollen epiglottis
Epiglottitis Dx and treatment
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
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?
Bronchiolitis
Caused by RSV most commonly, possibly parainfluenza type 3
Usually kids less than 2y
CXR: hyperinflation and patchy infiltrates
How is bronchiolitis treated?
Hydration, humidifier
Inhaled bronchodilators and systemic steroids contraindicated
If respiratory distress or hypoxemia, should be admitted for observation
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?
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
What findings on amniocentesis indicate immature lungs and need for corticosteroids before delivery?
Lecithin:sphingomyelin ratio less than 2 or
Lack of Phosphatidyl glycerol
Both indicate need for treatment
Classic cause of pneumonia in CF?
Pseudomonas
Complications of CF?
Recurrent lung infections, chronic sinusitis, pancreatic enzyme deficiencies and malabsorption, problems with reproductive tract
Sweat test and CF?
Gold standard for Dx
Will show a high Cl content and high Na content
Inheritable pattern of CF?
Autosomal recessive
What is normal Hg for men and women?
Men: 13.5-17.5
Women: 12-16
Normal Hct for men and women
Men: 40-55
Women: 35-45
Normal Pco2
33-45
Normal PO2
75-105
What tumors account for around 75% of malignant pleural effusions?
Lung carcinoma
Breast carcinoma
Lymphoma
What is the first step in management of a pleural effusion?
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
If patient has pleural effusion and thoracentesis show exudate, but is non-diagnostic. What are the next steps?
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.
Ipratropium use in obstructive diseases
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.
How should a chronic asthmatic patient be treated after 3 months of good control or very poor control?
Good control: consider step down
Poor: step up and consider short course of prednisone which is also used for exacerbations (the prednisone)
What are predisposing factors to aspiration pneumonia?
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
What lobes of the lung tend to be involved in aspiration pneumonia?
Lower lobes or R middle lobe if sitting when aspirated
Posterior segments of upper lobes if recumbent when aspirated
What are the infectious organisms in aspiration pneumonia and the best treatment?
Oral flora common including aerobic and anaerobic bacteria
Treatment must be broad spectrum with good anaerobic coverage – amoxicillin-clavulanate, clindamycin are good options
What should be considered if pneumonia is non-resolving or recurring in the same area?
Obstruction of some kind, possibly external compression due to malignancy
How does smoking affect mucocilliary function
Smoking decreases function predisposing to CAP
What are classic features of presentation for aspiration pneumonia?
Indolent sx compared to the acute onset in CAP
Foul smelling sputum
Concurrent peridontal disease
What is the treatment for anaphylaxis?
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
What are the classic sx of anaphylaxis?
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
Normal A-a gradient
less than 15
Elevates with age, but anything over 30 is always abnormal
What are risk factors for alveolar hypoventilation?
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)
What are risk factors for ARDS?
Infection, trauma, massive transfusion, acute pancreatitis
What is ARDS?
Lung damage leads to pulmonary edema and leakage of cytokines into the alveoli leading to respiratory distress, impaired gas exchange, decrease lung compliance, PHTN
When is the onset of ARDS?
Within 1 week of the insult
How is ARDS managed?
Mechanical ventilation with low TV and high PEEP
Findings suggestive of ARDS
Respiratory distress Bilateral crackles CXR showing diffuse infiltrates Hypoxemia Within 1 week of insult
How does the PaO2/FiO2 (P/F) ratio change with ARDS?
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.
