Case 13: 6yo - Asthma Flashcards
1
Q
hx for asthma for children = 4yo
A
- Persistent cough and wheeze (sometimes with hx of URI)
- frequent URI
- frequent coughs at night (even when not ill)
- tires / coughs with exercise more than others
2
Q
sxs of asthma
A
wheezing, coughing, dyspnea
- day-to-day
- exacerbations
3
Q
what do the day-to-day asthma sxs come from?
A
persistent inflammation
4
Q
what do the exacerbations asthma sxs come from?
A
intermittent inflammation
d/t allergens or virus infections
5
Q
identify:
- asthma sxs = 2d/w
- asthma sxs = 2nights/month
- >/= 80& FEV1
- <20% variability
and treatment?
A
mild intermittent
6
Q
identify:
- asthma sxs 3-6d/w
- asthma sxs 3-4 nights/month
- >/= 80& FEV1
- 20-30% variability
A
mild persistent
7
Q
identify:
- asthma sxs every day
- asthma sxs >5 nights/month
- 60-80% FEV1
- >30% variability
exercise limitation
A
moderate persistent
8
Q
identify:
- asthma sxs all the time
- asthma sxs night frequently during the month
- = 60% FEV1
- >30% variability
A
severe persistent
9
Q
Risk factors for asthma that require consideration of treatment
A
TREAT PTS WITH IMPAIRMENT
Children = 4yo with frequent wheezing (>/= 4x per year, lasting >1d, that affects sleep)
- sxs >2x/w
- noctural sxs >2x/month
TREAT PTS WITH RISK 1 major: -parental hx of asthma - atopic dermatitis - sensitization to aeroallergens
or 2 minor:
- sensitization of foods
- wheezing outside of colds
- peripheral blood eosinophilia (>4%)
other:
- frequent persistent sxs requiring symptomatic treatment >2d/w for >3w
- significant episodic sxs, with >1 exacerbation requiring systemic steroids within 6mo
- during seasons of viral URI infections
10
Q
epidemiology - how many kids develop sxs of asthma before 5yo?
A
50-80%
11
Q
hx for asthma for children >/= 4yo
A
- seasonal rhinitis sxs
- wheezes during colds
- coughing seasonally (winter / spring) and at night
- physical exam: dark circles under eyes, prolonged expiration on chest exam, with suggestion of wheeze on forced expiration
- FEV1 = 70%
- FEV1/FVC = 75%
showing obstructive pattern
12
Q
what is the cornerstone of asthma therapy? why?
A
inhaled corticosteroids
- improved lung fx (FEV1)
- decreased impairment (better exercise tolerance, decreased “rescue” med use and day/nighttime sxs
- decreased risk and hospitalizations
- decreased inflammation - with epithelial and mucosal mast cell, eosinophil, and submucosal T lymphocytes
13
Q
what are the 2 mechanisms by which asthma causes wheezing?
A
1) constriction of bronchial airways
2) mucus secretion
==> if alveoli have decreased ventilation –> pulmonary arterioles will vasoconstrict & shunt blood ==> V/Q mismatch
14
Q
Does 100% O2 work for shunts (e.g. that you find in asthma)?
A
NO
15
Q
what are the goals of asthma control
A
- minimal / no chronic sxs day / night
- minimal / no exacerbations
- no limitations on activities / missed work or school
- maintain (near) normal pulmonary fx
- minimal use of short-acting inhaled beta2 agonist (<1x/d, <1 canister/month)
- minimal / no adverse effects from medicines
16
Q
at what point would you consider stepping down in asthma management
A
review tx q1-6mo, reassess for stage of asthma
17
Q
at what point would you consider stepping up in asthma management
A
1) review pt med technique, adherence, and environmental control
2) if continue to have sxs that fall within criteria (even on therapy)
18
Q
management of a pt with asthma
A
1) investigate allergies; discuss tobacco exposures (perennial / seasonal)
2) proper use of peak flow meter (effort-dependent) == L/s at which air can be forced out of large airways ==> record peak flow (peak expiratory flow - PEF) + sxs at time of measurement of peak flow
3) daily asthma diary to record sxs and peak flow values
4) Rescue (Albuterol) PRN + control bronchodilators
5) f/up == q2-6w until asthma stabilized, then q1-6mo + for acute visits / worsened asthma sxs ==
7) plan for avoiding triggers; managing flare
8) asthma action plan == (1) daily sxs; (2) peak flow readings @ home and school
9) PREVENTION = seasonal flu vaccine; PCV vaccine; varicella vaccine (d/t increased risk of severe primary varicella infection if on inhaled / systemic corticosteroids)
19
Q
8yo
Seasonal rhinitis symptoms
Wheezes when he gets colds
Coughs throughout winter and spring; nightly cough and wakening
Exam notable for dark circles under eyes and prolonged expiration on chest exam with suggestion of wheeze on forced expiration
FEV 1=70% predicted; FEV 1/FVC=0.75
management?
A
Nightly symptoms
FEV1 < 80%
==> likely moderate persistent
moderate dose of daily inhaled corticosteroids
20
Q
15yo girl
Competitive soccer player
Notes that she gets tight in the chest after running for about 5 minutes and has to stop and rest; some cough and occasional wheeze
No prolonged cough with URI; no history of bronchitis or pneumonia
No chronic night cough
Exam normal
Pulmonary Function Test normal; FEV 1/FVC=0.9
no family history of asthma
nonsmoker
A
Christopher’s syndrome / vocal cord spasm ==> extrathoracic pulmonary obstruction = normal FEV1
Trigger: anxiety, increased competition worsens this
V. exercise and cold induced asthma
==> PRN inhaler
typical exercise-induced asthma would have a drop in the FEV1 at the end of exercise
21
Q
Persistent cough and some wheeze for 2 weeks after URI
In daycare; gets URI at least monthly
Coughs nightly when ill; 1-2 times weekly even if not ill
Seems to tire with exercise more than peers and has cough with exercise even when not ill
management?
A
mild intermittent
rescue albuterol inhaler (SABA)
22
Q
what extra vaccines do kids with asthma need to get?
A
pneumococcal 13
influenza
23
Q
what happens if you put kids <8yo on long-term steroids
A
impaired bone growth
24
Q
side effects of leukotriene modifiers on children
A
poor behavior (mood swings)
25
diffdx for chronic cough in a school aged child
infection
- SINUSITIS = triggered by URI; nasal congestion, PND --> noctural cough; +/- HA, frequent nasal discharge
- BRONCHITIS = prolonged congested cough + URI --> extension of viral inflammation into lower respiratory tree; cough in AM and PM (no aggravating/alleviating), +/- fever, significant sputum production
- ATYPICAL PNEUMONIA (influenza, adenovirus, mycoplasma, pertussis, HIV, fungal)= similar to URI sxs; cough in AM and PM (worsened with exercise, cold air); post-resolution cough can persist 8-12w.
inflammation
- ASTHMA = triggered by URI; cough worse at night, w/ exercise, cold air
- ALLERGIES = nasal congestion, PND --> noctural cough (+/- personal / Fhx atopic diathesis)
irritation - d/t to household smoke, woodstove, pets.
anatomic
psychogenic
cardiac/GI condition
- GERD = infants; older children with neurologic impairments; worse cough at high; +/- nasal reflux --> congestion
26
why is a chronic cough better than an acute cough
acute cough = <4w ==> INFECTIOUS: URI, pneumonia
chronic cough = >4w ==> URI --> leading to airway reactivity for weeks; cough can persist past other sxs
a subacute / chronic cough means the sxs have been tolerated for longer & likely not immediately life-threatening
27
atopic diathesis, relationship to allergies and asthma
Atopy = predisposition to develop IgE-mediated response to common aeroallergens
1) allergic rhinitis
2) asthma
3) atopic dermatitis (eczema)
28
characterization of mucus in a younger child (how is this different v. older / adult)
Small children
1) swallow their mucus rather than spitting it out
2) will usually have "post-tussive emesis" == vomit d/t coughing spell
29
relevant work-up for a patient suspected of having asthma
A. Hx of asthmatic sxs
1) episodic nature of sxs
2) precipitating factors
3) Fhx (+/- atopic diathesis)
B. (PFTs) Spirometry = measure of active lung volume (via rate of flow) --> tidal volume, forced vital capacity, total lung capacity (max inspired), rate of air flow during exhalation, FEV1
C. bronchoprovocation (methacholine/histamine/exercise challenge) ==> where asthma is suspected and spirometry is ~ normal.
D. CXR - to rule out other dangerous conditions
30
NIH/NAEPP asthma severity criteria & stepwise management, and apply them to a pt newly diagnosed with asthma
Mild intermittent
Mild persistent
Moderate persistent
Severe persistent
31
diffdx SOB in children
1) asthma
| 2) CHF / cardiomyopathy
32
signs and sxs of TB in children
usually minimal systemic sxs of night sweats and weight loss, compared to their alarming CXR findings (50% incidentally found on CXR) ==> hilar adenopathy
INFANTS, TODDLERS
- nonproductive cough, mild dyspnea, wheezes (d/t bronchial compression by enlarged regional LN)
- failure to thrive
- severe cough, sputum production + systemic sxs (fever, night sweats, anorexia) ==> INTRAPULMONARY DISSEMINATION
33
CXR findings on TB
- all lobar segments of lung are at risk
- 25% of time --> 2+ primary foci
- primary complex
34
what is the hallmark of TB of the lung found on CXR?
primary complex = relatively large size of hilar lymphadenopathy v. relatively small size of initial lung focus
35
what is the common sequence of TB in CXR findings
1) hilar adenopathy
2) focal hyperinflation
3) atelectasis
(with minimal evidence of primary lung focus itself)
36
CXR findings on TB
- all lobar segments of lung are at risk
- 25% of time --> 2+ primary foci
- primary complex + hilar lymphadenopathy
- small local pleural effusions (LARGE rarely seen in <6yo).
37
what is the hallmark of TB of the lung found on CXR?
primary complex = relatively large size of hilar lymphadenopathy v. relatively small size of initial lung focus
38
what is the common sequence of TB in CXR findings
1) hilar adenopathy
2) focal hyperinflation
3) atelectasis
(with minimal evidence of primary lung focus itself)
39
what is the only practical tool for TB infections in asymptomatic children
PPD
>5mm in high risk
>10mm in moderate risk
>15mm in low risk
40
what is the test of choice for TB infections in asymptomatic children
TB culture from sputum sample or first mornign gastric aspirate
41
Define: allergic shiners
lower eyelids appear darkened due to venous stasis
42
define: allergic salute
transverse nasal crease in the skin across the bridge of the nose caused by repetitive pushing of the nose upward and backward with the hand to relieve nasal itching and obstruction. (usually d/t nasal allergies)
43
define: clubbing
when distal phalanx of finger is rounded and bulbous and angle b/w nail plate & nail fold is increased past 180 degrees ('loss of diamond of light")
==> suggestive of chronic hypoxia
44
define: dennie-morgan lines
infraorbital creases that appear due to intermittent edema caused by allergies
45
signs and sxs of bacterial sinusitis
acute bacterial sinusitis
- persistence of sxs without improvement (b/l nasal discharge, daytime cough) >10d
- improvement, then worsened ("double-sickening")
- high fever, purulent nasal discharge > 3d
46
what would b/l nasal discharge suggest?
| what would u/l nasal discharge suggest?
B/L = bacterial sinusitis v. viral URI
U/L = foreign body
47
physical exam findings in asthma, allergies
ASTHMA
= end-expiratory wheeze
ALLERGIES
- allergic shiners, clear nasal secretions, cobblestoning of posterior pharynx d/t post-nasal drip
- allergic salute
- edematous "boggy" turbinates
- Dennie-Morgan lines
48
triggers for asthma
indoor aeroallergens (house dust mites, animal dander, cockroaches)
outdoor aeroallergens (fungi, grass, ragweed pollens)
49
diffdx of acute cough
Acute cough = <72h
- infectious
- clear precipitating event (trauma / choking)
50
one of the most common causes of chronic cough in school-aged children
asthma
51
assessing child for asthma - her dad has atopy. what is the risk of the child developing an atopic disorder?
1 atopic parent
30% risk of developing atopic d/o -- more likely to be become sensitized when exposed to allergens
52
asthma
- define:
- epidemiology:
- triggers:
- dx:
- tx:
- define: sensitive, hyperactive airways ==> inflamed and narrow= wheeze, cough
- epidemiology: most common pediatric chronic dz (mortality = 5,500/y)
- triggers: allergens, colds, exercise, stress
- dx: CXR to r/out other causes, lung fx tests
- tx: albuterol (smooth muscle relaxation in air passages), anti-inflammatories
53
what anti-inflammatory med is often used for step-up to persistent asthma?
steroids --> inhaled or systemic - daily prophylactic
INHALED = more rapid onset, lower dosage, avoid systemic s/e; BUT take longer to initiate working
= beclomethasone, fluticasone, budesonide
- s/e: HTN, hyperglycemia, growth delay, cataract development
54
pathophysiology of an asthma exacerbation
biphasic inflammatory response
(1) [1st h] early asthmatic rxn - bronchial provocation w/ stimulus --> mast cells and eosinophils release PGEs, LTs --> increased vascular permeability, mucus secretion, bronchoconstriction
(2) [2nd-3rd h], peak @ 4-8h, resolve by 24h --> neutrophils, eosinophil, and lymphocyte infiltration into bronchial epithelium --> epithelial destruction, fibrotic remodeling, hyperplasia of bronchial smooth muscle
+ chronic low-level airway hyper-responsiveness
55
signs of respiratory distress in a child
- appears SOB when talking
- unable to speak in full sentences
- use of accessory respiratory muscles (sternocleidomastoids at rest)
- tacheal deviation ==> mediastinal mass, pneumothorax, foreign body aspiration
- sub/intercostal or supraclavicular retractions ==> severe osbstructive airway dz (asthma, bronchiolitis, foreign body obstruction)
- hyperinflated thorax ("barrel chest") ==> air-trapping (chronic lung dz)
- decreased I:E (nml = 1:2, 1:3) ==> obstructive d/o = prolonged expiration b/c less effective
- abnormal chest sounds on percussion ==> "hyperresonance" (localized air trapping behind mucus plug, foreign body, mass); "dullness" (lobar consolidation d/t pneumonia, atelectasis)
- egophony ==> "ee" --> "ay"; lobar consolidation
- wheezing ==> thru narrowed airways (asthma)
56
assessment of a cough
| - ROS
CHANGE IN VOICE
- chronic rhinitis / GERD ==> dysphonia, hoarseness --> laryngeal irritation
CHEST PAIN
- ? GI cause = bad/acid taste in mouth; food ever comes back up
- infectious myocarditis ==> cough, wheezing
CHOKING EVENT
- foreign body aspiration (choking food / vomiting)
- neurological impairment --> secretions (above) / refluxed gastric contents (below)
FEVER == infectious
- pneumonia ==> in RLQ and LLQ --> abd pain ~ appendicitis
- sinusitis
HEADACHES
- sinusitis ==> frontal/orbital HA = common cause of persistent children (PND - worse at night)
SORE THROAT
- allergies, sinusitis --> PND, pharyngeal irritation +/- nasal congestion, itchy/watery eyes
57
differentiating descriptors of cough and potential causes: dry
- DRY - environmental irritant, asthma, fungal infection
58
differentiating descriptors of cough and potential causes: wet/productive
- WET/PRODUCTIVE - lower respiratory infection
59
differentiating descriptors of cough and potential causes: barking
- BARKING - croup, subglottic dz, foreign body
60
differentiating descriptors of cough and potential causes: brassy/honking
- BRASSY/HONKING - habitual cough; tracheitis
61
differentiating descriptors of cough and potential causes: paroxysmal
- PAROXYSMAL- pertussis, chlamydia, mycoplasma, foreign body
62
differentiating descriptors of cough and potential causes: worse at night
WORSE AT NIGHT - asthma, sinusitis, PND
63
differentiating descriptors of cough and potential causes: disappears at night
DISAPPEARS AT NIGHT - habitual cough
64
differentiating descriptors of cough and potential causes: assoc. with gagging, choking
GERD
65
when does the rate of air flow on exhalation reach its maximum? why
- immediately after exhalation is initiated
- decrease in lung volume --> intrathoracic airways narrow --> increased airway resistance --> progressive decrease in rate of airflow
66
what is the standard time for exhalation
6sec
67
spirometry findings in obstructive lung disease
examples = asthma, cystic fibrosis (adult = COPD) = decreased expiration
==> reduced air flow
==> trapping of air inside thorax behind tight, plugged airways --> low FEV1; low FEV1/FVC ratio
- scalloped shape on exhalation limb of flow-volume curve
68
spirometry findings in restrictive lung disease
examples = autoimme diseases (SLE, pulmonary fibrosis d/t chemotherapy/radiation) = decreased inspiration
==> reduced air flow = low FEV1, low FVC == nml to slightly low FEV1/FVC ratio
69
what are the requirements to be able to test with pulmonary function tests?
== spirometry
children > 5y
- who can accomplish a coordinated, forced expiratory maneuver
--> b/c need to obtain maximal expiration efforts to distinguish restrictive v. obstructive
70
what does "reversibility" mean in pulmonary function testing?
measurements of total lung capacity before and after bronchodilator use --> to determine the amt of reversible airway disease
(asthma)
71
Allergies
- evaluation
- treatment
which are recommended for seasonal allergies
EVALUATION
+/- allergy skin tests for seasonal allergies
TREATMENT
Avoidance of known outdoor and indoor allergens
Medication (oral)
1) antihistamines == sneezing, nasal pruritus, rhinorrhea (esp. newer ones that are less sedating);
YES - seasonal allergies
2) leukotriene receptor antagonists == asthma, allergic rhinitis
3)topical/systemic decongestants == nasal congestion
4) topical/inhaled nasal steroids == allergic rhinitis; NO - seasonal allergies
METERED-DOSE INHALERS AND SPACERS
- lightweight, inexpensive. Need to learn to breathe correctly so that 99% of meds don't just end up at back of throat
- spacer== mask attachment for infants and small children for tight seal; prevent dysphonia / oral thrush with ICS
72
what is the risk of using decongestants in children?
phenylephrine == increase BP
73
long-term goals of asthma therapy
1) On presentation -
SEVERITY-based medications (personal expiratory force -
PEF; forced expiratory volume - FEV)
2) gain control ASAP + step-down as needed
3) minimize use of short-acting inhaled beta2-agonists
4) pt education on self-management and controlling environmental factors that worsen asthma
5) refer to asthma specialist IF difficulties controlling asthma or need >/= Step3
74
what is the concern about over-use of short-acting inhaled beta2-agonists
== 1 canister / month even if not using it every day
--> inadequate control of asthma, need to initiate / intensify long-term control therapy
75
when to use "rescue" meds
= SABA (albuterol) - for 2x per week (max)
monotherapy ==> for children with intermittent and exercise-induced asthma PRN --> wheezing, respiratory distress / tachypnea
76
when to use "maintenance" meds for asthma
- SABA until the maintenance meds have improved nightly coughing --> then use SABA PRN.
1) LABA (salmeterol)
2) medium-dose inhaled corticosteroids
3) NSAID (cromolyn sodium)
```
1 type (trial) ==> for frequent flares of intermittent asthma --> low level of s/e and lack of systemic uptake
1-2 types ==> for moderate persistent and severe asthma
2-3 types ==> for severe, uncontrollable asthma
```
4) leukotriene receptor antagonists; leukotriene synthesis inhibitors (monoleukast) --> block inflammatory airway response to inhaled aeroallergen challenge
- for chronic asthma (+ICS) --> to reduce sxs
77
how to treat patients with more severe forms of exercise-induced asthma
LABA + inhaled steroid therapy
78
Can LABA be used as montherapy (like SABA)?
| or similarly, LT inhibitors?
NO --> need to be added to inhaled steroid therapy = to reduce dose of steroid therapy
b/c not as effective, and would be using it for a more severe form of asthma
79
what vaccines do those with asthma additionally need?
- seasonal flu vaccine
- PCV vaccine
- varicella vaccine (d/t increased risk of severe primary varicella infection if on inhaled / systemic corticosteroids)
80
asthma variants
1) exercise induced bronchospasm == severe bouts of bronchospasm d/t ONLY exercise or cold air --> may be marker for poorly controlled asthma
2) cough-variant asthma (esp in younger children) == ONLY cough, esp. nonproductive, nocturnal
81
what do we use peak expiratory flow for?
peak expiratory flow (PEF) == measured with peak flow monitoring
personal best == average PEF values for 14 consecutive days during period of good control
1) short-term monitoring (NOT diagnosis)
2) managing exacerbations at home and in ED
3) daily long-term monitoring of asthma -- esp moderate to severe
82
describe how a cough works
stimulated voluntarily or via cough receptors in respiratory tract (ear, upper & lower airways, pleura, pericardium, diaphragm)
1) receptors send out signals --> to cough center in medulla
2) --> to vagus, phrenic and spinal motor nerves to produce cough
3) cough can be initiated / suppressed in higher centers
83
diffdx of infant with chronic cough
INFANT
- anatomic malformation = congenital vocal cord
dysfunction, laryngotracheomalacia, vascular ring, laryngeal web, tracheal stenosis, tracheoesophageal fistula
- foreign body aspiration
84
considerations in a cough
- acute v. chronic
- age of pt (infant v. toddler v. child)
- +/- medications
- recently moved to a new area?
- how much school has she missed for this?
- growth parameters --> curves for height and weight ==> is this affecting her growth
- vital signs
- able to speak in full sentences w/out SOB or cough
- day v. night sxs
- FHx
85
heritable conditions causing cough
ASTHMA:
- 25% risk of one parent
- 50% risk if both parents
IMMUNODEFICIENCY
- FHx of chronic sinopulmonary / skin infections in siblings / first degree relatives ==> chronic granulomatous dz; IgG deficiency
- Hx sterility (esp. in males) ==> primary ciliary dyskinesia (immotile cilia syndrome)
- FHx of children with chronic otitis, sinusitis, pneumonia, serious bacterial skin / systemic infections
CYSTIC FIBROSIS
- failure to thrive
- Caucasian ethnicity
* * most first-born children diagnosed with cystic fibrosis have no FHx of the disease
86
Which of the following are specific for acute bacterial sinusitis? (Select all that apply.)
Multiple Choice Answer:
A Green nasal discharge
B Boggy nasal turbinates
C Cobblestoning of the posterior pharynx
D Fever
E Malodorous breath
F Nasal polyps
G X-rays of the sinuses showing mucosal thickening
H CT of the sinuses showing mucosal thickening
I None of the above
I - none of the above
persistence of sxs >10 == bacterial sinusitis (v. URI)
87
diffdx of mucosal thickening of the sinuses on XR or CT
inflammation of the upper respiratory tract from various causes
- viral URIs
- bacterial sinusitis
88
bacterial sinusitis in children
- pathophysiology:
- common organisms:
- dx:
- tx:
- complications:
- pathophysiology: obstruction of sinuses d/t allergies, URIs, trauma, nasal polyps, thickened secretions from cystic fibrosis
- common organisms: S. pneumoniae, H. influenzae, M. catarrhalis. Staph aureus (esp. as complication of acute sinusitis)
- dx: - persistence of sxs without improvement (b/l nasal discharge, daytime cough) >10d; improvement, then worsened ("double-sickening"); high fever, purulent nasal discharge > 3d
- tx: antibiotic therapy for children with severe onset / worsening course (amoxicillin +/- clavulanate). Otherwise, observation x3d
- complications: orbital sinusitis, cavernous sinus thrombosis, meningitis, epidural abscess
89
should you use plain films to diagnose acute bacterial sinusitis in children?
how about nose/nasopharynx/throat cultures?
when are they helpful?
NO XRAYS
- very nonspecific
- inaccurate
==> to evaluate the complications of bacterial sinusitis
NO nose/nasopharynx/throat cultures
- do not accurately perdict the bacteria in infected sinus secretions ==> likely because you aren't sure you're getting the culprits
==> if they don't get better on the antibiotics (amoxicillin +/- clavulanate) i.e. resistant form.
90
The wheezing that is typical of asthma is best described as ?
Musical or polyphonic noises that occur in a continuous fashion during respiration, usually expiratory
91
What do you think is the most reasonable next step in addressing the issue of allergies in Sunita? (Select the answer that seems most appropriate; there is no single best answer.)
Multiple Choice Answer:
A Reduce her exposure to indoor allergens by recommending allergy covers for her mattress and pillow, elimination of stuffed animals and carpeting in her bedroom, and use of a HEPA-filter bag in the vacuum.
B Reduce her exposure to outdoor allergens by having her family keep the windows closed during the spring allergy season, particularly during the midday and afternoon.
C Begin Sunita on a trial of a leukotriene-receptor antagonist such as montelukast.
D Begin Sunita on a trial of oral antihistamines.
E Refer her to an allergist for skin testing.
All of the above area resonable for allergies
92
assessment of a cough
| - CXR
- INFILTRATES ==> pneumonia, TB, CF, foreign body
- VOLUME LOSS ==> foreign body aspiration, significant mucus plugging
- HYPERINFLATION ==> asthma, CF
- MEDIASTINAL/HILAR ADENOPATHY ==> TB, fungal infection, malignancy
93
Inhaled steroids are added to an asthma regimen (select the ONE best answer):
Multiple Choice Answer:
A Only in patients with severe asthma
B In all patients with persistent asthma
C To prevent exercise-induced bronchospasm
D In patients who cannot tolerate systemic steroids
B
not just severe
94
what is the mechanism of inhaled corticosteroids?
1) direct anti-inflammatory effect ==> inhibit binding of certain TFs to cellular DNA that are activated by signals from inflammatory cells
2) upregulate the number of B-adrenergic receptors on bronchial smooth muscle --> improve efficacy of beta agonists
3) in respiratory epithelium, decrease # of inflammatory cells (eosinophils, basophils, PMNs)
95
how long may it take for inhaled corticosteroids to cause noticeable effect histologically on asthma-affected airways?
up to 6 months to reverse the histologic changes present in asthma-affected airways
96
PFTs are indicated in children for the following reasons (select all that apply):
Multiple Choice Answer:
A To assess the response to bronchodilator treatment
B To differentiate between obstructive and restrictive disease
C To determine whether a disease is improving
D To determine if a disease is progressing in response to treatment
All of the above.
97
When is peak flow monitoring recommended for patients with asthma? (Select all that apply.)
Multiple Choice Answer:
A As a tool for the diagnosis of asthma
B To determine the severity of an asthma exacerbation
C To guide therapeutic decisions at home
D To guide therapeutic decisions in the emergency department
E For daily long-term monitoring of asthma severity
B, C, D, E
98
checklist for patient and family education for asthma
Show child and caregivers how to use a peak flow meter correctly. Let the child practice a few times until you are comfortable with her technique.
Recommend maintaining a daily asthma diary to record the child's symptoms and peak flow values daily until the next visit.
Remind caregivers that the diary and all asthma medications should be brought to follow-up visits or any acute visits for worsened asthma symptoms.
Make sure that the caregivers—and the child, if appropriate—understand the Asthma Action Plan.
Review likely triggers for asthma and discuss the plan for managing an asthma flare.
Emphasize the importance of ongoing assessment, and schedule regular follow-up visits.
99
criteria for referral to a fellow-ship trained allergist/pulmonologist
- Has had a life-threatening asthma exacerbation.
- Is not meeting the goals of asthma therapy after 3-6 months of treatment, or earlier if the child appears unresponsive to treatment.
- Signs and symptoms are atypical.
- Other co-morbid medical conditions complicate asthma management.
- Additional testing is needed (i.e., allergy testing, bronchoscopy) or immunotherapy is being considered.
- Additional patient education regarding adherence to medications or allergen avoidance.
- Patient is young (< 3 years old) or has severe asthma.
100
A 4-year-old boy who recently emigrated from eastern Europe presents with his mother to your general pediatrics clinic. His mother reports that he has a chronic nonproductive cough during the day and night, mild wheezing for one month and failure to gain weight (his weight has dropped from the 50th to the 10th percentile for his age). His mother denies any high fevers, rhinorrhea, or night sweats. Which of the following are the next best diagnostic tests?
Single Choice Answer:
Please select one answer.
A Chest x-ray and tuberculin skin test
B CT of nasal sinuses
C Spirometry, before and after bronchodilator therapy
D Chest x-ray and methacholine challenge
E None needed, patient likely has habitual cough
A
- losing weight
Signs and symptoms of primary pulmonary tuberculosis are few to none. Toddlers may present with nonproductive cough, mild dyspnea, wheezing, and/or failure to thrive (defined as weight < 5th percentile or drop in two percentile curves for weight). In children, TB can present without systemic complaints (fever, night sweats, and anorexia), severe cough, and sputum production. Regarding diagnostic tests, the TST is a practical tool for diagnosing TB infections. All children with chronic cough (more than three weeks) should be evaluated with a chest x-ray, as other pathology—such as lung abscess or malignancy—can also be detected on CXR.
101
An 11-year old boy presents to clinic with wheezing. Mom states that in the past he has used inhaled albuterol and it has helped with wheezing and shortness of breath. On further history you find out that the patient experiences shortness of breath three times a week and is awakened at night by these symptoms once a week. What is the most appropriate outpatient therapy?
Single Choice Answer:
Please select one answer.
A Only rescue inhaler PRN
B Low dose inhaled corticosteroids
C Medium dose inhaled corticosteroids and course of oral corticosteroids
D Medium dose inhaled corticosteroids, LABA, and course of oral corticosteroids
E Course of oral corticosteroids
B. Low dose inhaled corticosteroid is correct because this patient has mild persistent asthma. His symptoms occur 3–6 days/week and 3–4 nights/month.
3x per week SOB
1x per week night sxs
mild persistent
102
A 4-year-old patient presents with several months of cough. Mom also reports a history of red skin patches, which are pruritic, and allergies to peanuts, eggs, and mangoes. Which of the following would be characteristic of the cough that this patient would present with?
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Single Choice Answer:
Please select one answer.
A Does not awaken patient from sleep
B Paroxysmal
C Barking cough
D Worse at night
E Associated with crackles on exam
```
D. Asthma frequently presents with nighttime exacerbations. The cough often presents with wheezing and is usually a dry cough.
cough
eczema
allergies
103
A 9-year-old male presents to your clinic with discoloration under his eyes, persistent cough, and skin rashes. He is found to have wheezing on physical exam and increased lung volume bilaterally on chest x-ray. He has struggled with these complaints over the past three years but recently his symptoms have gotten worse, affecting him every other day. He is afebrile. He is found to have wheezing on physical exam and increased lung volume bilaterally on chest x-ray. What would be the most appropriate treatment for him?
Single Choice Answer:
Please select one answer.
A Oral antibiotics
B Short-acting beta agonist PRN
C Short-acting beta agonist PRN with low-dose inhaled corticosteroid
D Short-acting beta agonist PRN with medium-dose inhaled corticosteroid
E Long-acting beta agonist
C.
- allergic shiners
- eczema
- cough - asthma
chest expansion
3-4x per week sxs
==> mild persistent
can't use LABA alone
Persistent cough and wheezing that affect the patient every other day (3-4 days with symptoms/week) are consistent with mild persistent asthma, which is appropriately treated with short-acting beta agonist PRN and low dose inhaled corticosteroid. The swelling under the eyes (allergic “shiners”) and skin rash are other signs of atopy, as mentioned above.
104
10-year-old male comes to the clinic with a chief complaint of progressive cough for two weeks that began gradually. His cough is described as productive and wet with whitish sputum. His mother denies throat pain, vomiting, and diarrhea in his review of systems. His mother reports that he has been febrile up to 101.5°F daily. She thinks he is fatigued and has not eaten well in the past week. On exam, there is air passage throughout all lung fields, with crackles in the lower right lung field, but no other abnormal sounds. What would you likely find in your workup?
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Single Choice Answer:
Please select one answer.
A Response to inhaled beta-agonist
B Hyperinflation in one lung field
C Alevolar consolidation in the RLL
D Positive PCR for pertussis
E Fluffy bilateral infiltrates and a large heart on chest x-ray
```
C
pneumonia
Pneumonia is the most likely cause for his symptoms and a chest x-ray would be a great confirmation of your suspected diagnosis. Eliciting a complete history might reveal history of an upper respiratory infection. Localization of crackles (discontinuous inspiratory sounds) to one lobe makes pneumonia more likely.
