Exam 3 - Respiratory Flashcards
What is epiglottitis?
Life threatening illness characterized by inflammation of the epiglottis
Causative organisms of epiglottitis
- GAS
- Strep pneumonia
- Klebsiella sp.
- Staph aureus
What vaccine has made the incidence of epiglottitis low?
Hib vaccine
Clinical findings (history) of epiglottitis
- Abrupt onset fever
- Irritability
- Muffled voice
- Severe sore throat
- Dyspnea
- Dysphagia
- Drooling
- Increased respiratory distress
- Child appears acutely ill and toxic appearing
Epiglottitis physical examination
- Inspiratory and expiratory stridor
- Aphonia (muffled voice)
- Nasal flaring and retractions
- Child assumes a position of hyperextension of the neck
- Sitting in tripod position
What should the provider NOT due during the physical examination of a child with epiglottitis?
Do not examine/swab the throat because of reflex laryngospasm → suffocation
Diagnostic studies for epiglottitis
- Blood culture
- Lateral neck radiograph → “thumb” print sign is (+) for epiglottitis
Epiglottitis management
- Refer to ER → establish airway, start IV antibiotics, oxygen
- Early consultation with pediatric otolaryngology and anesthesiologist
- Do not place child in supine position
Epiglottitis prevention
- Immunization (hib)
- Hand washing
What is bronchiolitis?
Most common respiratory infection in infancy (peak incidence in infants < 6 months)
- Destruction of bronchiole lining + bronchospasm + copious mucus production
- Insidious onset of URI symptoms
Clinical findings (history) of bronchiolitis
- Initial: cough, coryza, rhinorrhea, fever for 1-2 days
- Mild fever, apnea, decreased feeding
- Wheezing, course crackles, tachypnea, mild severe chest retractions starting 1-2 days after URI symptoms and lasts up to 12 days
- Severe cases: cyanosis, air hunger, retractions, nasal flaring
Bronchiolitis physical examination findings
- Upper respiratory → coryza, mild conjunctivitis
- Lower respiratory → tachypnea, retractions, wheezing, crackles, signs of respiratory distress
Bronchiolitis diagnostic studies
- History and physical exam findings
- If severe, chest x-ray to rule out pneumonia or pneumothorax
What is the most common cause of bronchiolitis?
RSV
Bronchiolitis management
- Supportive care → fever control (Tylenol), hydration, nutrition, oxygenation >90%
- Nasal suction
- Saline drops
What is an URI?
Aka common cold
- Can indicate the beginning or advancing signs of a more serious illness
URI clinical findings (history)
Symptoms typically resolve after 10 days
- Nasal congestion, cough, sneezing, rhinorrhea, fever, hoarseness, pharyngitis
- Gradual onset low grade fever
- Sore throat
URI physical exam findings
- Mild conjunctival injection
- Red nasal mucosa
- Mild erythema of pharynx
- Anterior cervical lymphadenopathy <2 cm
- Chest clear to auscultation
URI diagnostic studies
- Throat culture not indicated if there are nasal symptoms with throat pain
- If presenting symptom is sore throat, and not rhinitis, collect rapid strep test
URI management
- Supportive care → antipyretics, pain management, nasal congestion, hydration
What is bronchitis?
Acute and self limiting inflammation of the trachea and bronchi with a cough that lasts 1-3 weeks without pulmonology consolidation (can last 6 weeks)
- Usually viral
Viral vs bacterial bronchitis
- Viral: flu A and B, parainfluenza, RSV
- Bacterial: m. pneumoniae, c. pneumoniae
Acute bronchitis triggers
- Cigarette smoking
- Chemical irritants
- Undiagnosed asthma
Acute bronchitis clinical presentation
- Cough with or without sputum production (sputum may be clear and become mucoid)
- Low grade fever
- Wheezes, rhonchi, coarse rales
- Burning substernal pain with inspiration
- Nasopharyngeal symptoms
Acute bronchitis diagnostic studies
Clinical diagnosis
- Cough with normal vital signs
- Absence of tachypnea, tachycardia, rales, egophony
Acute bronchitis
- Symptom reduction and supportive care → rest, hydration, humidifier, antipyretics, smoking cessation
- WEAK evidence for antitussives and bronchodilators
- Antibiotics only if b. pertussis is suspected (macrolide)
What is a pneumothorax?
Presence of air in the pleural space resulting in loss of negative intrathoracic pressure
What type of pneumothorax is most common in young adults ages 20-30 years?
Spontaneous
Pneumothorax risk factors
- Cannabis or cigarette smoking
- Male
- Underlying lung disease
- Tall
- Thin body hiatus
- Family history
- Pregnancy
Pneumothorax clinical presentation
- Acute onset breathlessness
- Unilateral pleuritic chest pain
Is a pneumothorax a medical emergency?
Tension or large pneumothorax
What are signs/symptoms of a tension or large pneumothorax?
- Acute respiratory distress
- Diaphoresis
- Tachycardia
- Hypoxemia
- Tachypnea
- Tracheal deviation
- Cyanosis
Pneumothorax diagnostic studies
- Chest x-ray
- Gold standard → CT scan (due to ability to differentiate between pneumothorax and bullous lung disease)
- Pulse oximetry and ABGs to determine level of hypoxia
Pneumothorax management
- Observation
- Needle aspiration
- Small bore catheter
- Chest tube (can be with pleurodesis, thoracotomy, or sternotomy)
What conditions would treatment not be indicated for pneumothorax?
- Small (<2 or 3 cm)
- Patient clinically stable
Pneumothorax patient education
- Smoking cessation
- Air travel and scuba diving must be avoided until resolution
What is pneumonia?
Leading cause of morbidity and mortality in the U.S. (especially in older adults and those with chronic conditions)
Causes of typical pneumonia
Strep pneumoniae
- Accounts for 60-70% of all bacterial CAP cases
Causes of atypical pneumonia
- Mycoplasma pneumoniae
- Chlamydophila pneumoniae
- Legionella
- Respiratory viruses
Pneumonia clinical presentation
Diagnosis is made by history and physical examination
- History of fever, chills or rigors, malaise, cough with or without sputum production
- Hemoptysis, dyspnea, pleuritic chest symptoms
Pneumonia physical exam findings
- Chest auscultation reveals rales that do not clear with cough (found in bacterial and atypical pneumonia)
- Bacterial pneumonia
- Consolidation (dullness to percussion)
- Bronchial breath sounds
- Egophony (E to A changes)
Pneumonia diagnostic findings
- Chest x-ray
- CT scan
- Pulse oximetry
- Labs → sputum analysis, viral culture, complement fixation, CBC with diff, CMP, blood culture, ABGs)
- Bronchoscopy
When to consider bacterial pneumonia
Caused by strep pneumoniae
- Leading cause in all age groups
- History of abrupt onset high fever with shaking chills, productive cough with purulent sputum
- Starts with URI, rales on exam, respiratory distress
When to consider atypical pneumonia
- More common in school ages children, military recruits, and college students
- “Walking pneumonia” → more mild (appear less ill appearing than those with bacterial)
- May have fine rales with NO consolidation
- Gradual onset of headache, dry cough, fevers
When to consider viral pneumonias
- More common in infants and children than bacterial
- Fever less prominent
- Coryza, diffuse findings on lung exam including wheezing
- RSV, parainfluenza, influenza
Can the provider always prescribe antibiotics to treat pneumonia?
Can treat for pneumonia if clinical presentation is suggestive, EVEN IF chest x-ray is negative
Pneumonia antibiotic therapy of for patients with no coexisting illnesses and no recent use of antimicrobial agents
- Amoxicillin
- Macrolide
- Doxycycline
Pneumonia antibiotic therapy for patients with coexisting illnesses or recent use of antimicrobial agents
- Fluoroquinolone alone OR
- Beta lactam (augmentin or cephalosporin) + macrolide or doxycycline
What vaccines should be encouraged for older adults to fight against pneumonia?
PPSV23 and PCV13
For adults 65+ years who are not immunocompromised, have a CSF leak, or cochlear implant, when can they receive the PPSV23 vaccine?
- Can get one dose PPSV23 if not previously
- If had gotten one previously, should get one more at least 5 years after last dose
Can older adults receive both the PPSV23 and PCV13 vaccine?
Can administer one PCV13 first then PPSV23 one year later (vice versa)
What is the incubation period of influenza?
1-4 days
When does viral shedding occur with influenza?
24 hours before symptoms onset
- Peaks at day 3 and stops at day 7
- Shedding is longer in school age children (10 days)
Who is considered high risk in catching the flu?
- Children <2 years old
- People over 65 years old
- Immunocompromised
Influenza clinical presentation
- Systemic: fever, chills, headache, malaise, myalgia, loss of appetite
- Fever declines on second or third day
- Respiratory: dry cough, nasal congestion with clear discharge, sore throat
Influenza physical examination findings
- Flushed
- Eyes watery and red
- Skin hot and moist
- Inflamed nasal passages
- Enlarged cervical lymph nodes
- Pharyngeal erythema
- Cough but lung sounds normal
Influenza diagnostics
- A & B nasal and throat swabs (collected within 12-36 hours of onset)
- Gold standard → viral culture or RT-PCR (influenza antigen)
Influenza management
- Symptomatic relief
- Antipyretics and analgesics
- Antiviral therapy within 48 hours of symptom onset (oseltamivir for patients >2 years)
Who is considered high risk for influenza?
- >65 years old
- <2 years old
- Pregnant
- Asthma/COPD
- DM
- Immunocompromised
Pulmonary embolism risk factors
- Recent history of surgery, trauma, travel, period of immobility, previous PE
- Malignancy
- Stroke
- Paralysis
- HF
- Smoking
- Pregnancy or postpartum status
- Estrogen therapy
Pulmonary embolism clinical presentation
- Classic → dyspnea, tachypnea, pleuritic chest pain, calf or thigh pain and swelling
- Hemoptysis, orthopnea, tachycardia, jugular venous distention, abnormal lung sounds
What is the most sensitive clinical sign when it comes to pulmonary embolism?
Tachypnea
Pulmonary embolism physical examination
- Acute respiratory distress
- Tachycardia
- Hypotension
- Abnormal heart sounds
- Jugular vein distention
- Hypoxemia
- Tachypnea
- Cyanosis
- Abnormal lung sounds
What clinical prediction models can be used to determine the risk of pulmonary embolism?
Help determine need for imaging
- Wells score
- Revised Geneva score
- PERC
What tests are not diagnostic for PE but help with identification of other causes?
- ECG → cannot diagnose, but can r/o MI, afib, RVD
- Chest x-ray → identifies pleural effusion, diaphragmatic elevation, Hamptom hump, Westermark sign, atelectasis
Pulmonary embolism diagnostic studies
- V/Q scan
- Gold standard → CT angiography
- Spiral chest CT with IV contrast
- Labs: ABGs, troponin, BNP, d-dimer
Pulmonary embolism management
- Initial: hemodynamic stability and adequate oxygenation (at least 92%)
- Anticoagulation→ heparin, warfarin, (-xabans)
- Surgery → embolectomy or IVCF placement
