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Pediatrics > Lecture 8: Pulm and Ophthalmology > Flashcards

Lecture 8: Pulm and Ophthalmology Flashcards

1
Q

What is the leading cause of infant hospitalization?

A

Bronchiolitis

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2
Q

Overview of Bronchiolitis

A
  • Clinical syndrome of resp distress < 2 yo
  • Lower respiratory tract infection
  • Prodrome of viral URI symptoms for 1-3 days
  • Followed by LRI symptoms of wheezing, crackles, hyperinflation, and tachypnea.
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3
Q

MCC of bronchiolitis

A

RSV (50-95% of cases)

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4
Q

What age do most cases of bronchiolitis occur during?

A

1st year of life, esp 1-10mo old.

80% of cases are 1st year.

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5
Q

RFs for HIGH RISK bronchiolitis

A
  • PREEMIE
  • Age < 12 wks
  • Cardiopulm disorders

Guidelines for high risk are different than regular!

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6
Q

If an infant has had multiple instances of wheezing, how do we approach in terms of bronchiolitis tx?

A

Do not follow bronchiolitis guidelines for a recurrent wheezer.

Bronchiolitis is primarily referring to the initial episode.

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7
Q

Dx of bronchiolitis

A
  • Clinically
  • O2 sat (helps)
  • NP swab (helps)
  • No imaging necessary

NP swab is really only for pts getting admitted/checking co-infection

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8
Q

Tx of nonsevere/mild bronchiolitis

A
  • Supportive care
  • Hydration
  • Relieving nasal congestion
  • Avoid OTC decongestants and cough meds
  • Monitor for worsening

It is viral.

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9
Q

Indications for hospitalizing bronchiolitis

A
  • Increasing respiratory effort
  • Hypoxemia < 92% (disclaimer: might drop when sleeping, thats ok)
  • Apnea
  • Acute resp failure
  • Toxic looking
  • Poor feeding
  • Lethargy
  • Dehydration
  • Parents can’t care for child at home (social concerns)

Assess them WITHOUT a fever! Fever will change presentation.

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10
Q

Inpatient management of bronchiolitis

A
  • Hydration
  • Nasal suctioning
  • Supplemental O2 between 90-92%
  • CPAP if risk of resp failure
  • ETT last resort

If they are febrile, control fever and reassess after its controlled.

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11
Q

When is an antiviral used in bronchiolitis and which one?

A

Ribavirin can be used for significant immunocompromised pts only

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12
Q

Discharge criteria for bronchiolitis

A
  1. RR < 60 for < 6mo old
  2. Stable on RA (>=90% for 12h)
  3. Caretaker knows how to bulb suction
  4. Adequate PO intake
  5. Caretakers can take care at home
  6. Resources at home are sufficient
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13
Q

What is to be AVOIDED in bronchiolitis?

A
  • Inhaled BDs
  • Systemic glucocorticoids
  • Inhaled saline
  • ABX
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14
Q

Pt education pearls for bronchiolitis

A
  • Improvement within a few days
  • Discharge takes 3-7 days
  • Cough/congestion takes 1-2 weeks to resolve.

It will get worse and then better.

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15
Q

Prevention of bronchiolitis

A
  • Palivizumab (Beginning of RSV and monthly throughout RSV season)
  • Nirsevimab (single shot and cheaper!)

Do not need to memorize recommendations!!

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16
Q

Can you coadminister the MABs for bronchiolitis with other childhood vaccines?

A

Yes

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17
Q

Overview of CF

A
  • Autosomal recessive inheritance
  • MC Lethal genetic disease
  • Develops bronchiectasis and thick mucus over time.
  • MC in caucasians
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18
Q

Where is the mutation for CF?

A

Chromosome 7, defect in CF gene that regulates CFTR channels

Essentially an inability to clear mucus properly.

CF transmembrane conductance regular protein

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19
Q

How do we dx CF?

A
  • Newborn screening
  • Meconium ileus
  • Respiratory symptoms
  • Failure to thrive

Delay in passing meconium

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20
Q

What part of the newborn screen checks for CF?

A

Heelstick

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21
Q

What sign is virtually diagnostic of CF until a confirmatory test is performed?

A

Meconium Ileus = CF until we do a chloride sweat test or genotyping/

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22
Q

What is the primary underlying cause for failure to thrive in a CF pt?

A

Pancreatic failure of the acini cells (digestive), overall leading to malabsorption

Pancreatic insufficiency + malabsorption + recurrent pancreatitis

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23
Q

Gold standard test to Dx CF

A

Sweat chloride test, showing > 60 mmol/L for a positive test, and 40-60 as borderline/retest!

Normal is < 30 mmol/L

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24
Q

When is genotyping done for CF?

A
  1. After sweat chloride is positive
  2. Checking carrier status or borderline sweat chlorides
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25
Q

How do we check for pancreatic insufficiency in CF patients?

A

Fecal elastase, which is absent in most CF pts.

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26
Q

Referrals for CF pts

A
  • Peds
  • Peds pulm
  • RT
  • Diet/Nutriton
  • Social Work
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27
Q

What can help with improving mucociliary clearance in CF?

A
  • Pulmozyme (mucolytic)
  • Hypertonic saline
  • Inhaled BDs
  • Chest physiotherapy
  • Antipseudomonals (inhaled tobramycin)
  • CFTR modulators
  • Vaccinations
28
Q

Tx of GI issues in CF

A
  • High calorie diet: proteins and fat
  • Daily vitamins
  • Calorie supplements
  • Consider G-tube if FTT.
29
Q

S/S of acute CF exacerbations

A
  • New/increased cough
  • New/increased sputum production or chest congestion
  • Decreased exercise tolerance or DOE
  • Increased fatigue
  • Decreased appetite
  • Dyspnea at rest/increased RR
  • Change in sputum appearance
  • Increased nasal congestion
30
Q

Tx of acute CF exacerbations

A

Cover pseudomonas with 2 drugs, + one per bacteria cultured.

Common: Tobramycin + Ceftazidime + Vanco (MRSA)

31
Q

5-year survival rate of lung transplant for CF

A

50-60%

32
Q

What kind of infant does IRDS (Infant respiratory distress syndrome/hyaline membrane disease) MC occur in?

A

Preterm infants

Can affect term if mother has DM

33
Q

Deficiency in ____ is the primary cause of IRDS?

A

Pulmonary surfactant in an immature lung

34
Q

Clinical features of IRDS

A
35
Q

Dx of IRDS

A
  1. Clinical
  2. CXR: low lung volume + Diffuse ground-glass appearance
  3. Pulse ox
  4. ABG

TTN instead has pleural effusions

36
Q

Tx of IRDS

A
  • Supportive care
  • Nasal CPAP (ideal initial intervention)
  • Surfactant replacement (primarily if intubated or hypoxemic)

Early PPV is mainstay of tx

37
Q

How do we help prevent IRDS?

A

Dexamethasone to mother at least 7d prior to delivery

Will help develop lungs quicker

38
Q

What are thyroglossal duct cysts?

A
  • Remnants of epithelium
  • MC congenital neck mass
  • Midline mass at level of thyrohyoid bone
39
Q

Clinical presentation of TDC

A
  • Upper midline neck mass with cystic features
  • Preceding URI can make it bigger
  • Potentially can be infection
40
Q

Dx of TDC

A
  • CT of neck w/ con
  • FNA to r/o ddx
  • MRI
  • US
41
Q

Tx of TDC

A
  • Sistrunk procedure (resection)
  • Can only tx after infection/inflammation is controlled.
  • ABX for infection/inflammation (Augmentin, Clinda, Keflex)
42
Q

How is vision for a newborn?

A
  1. Starts at 20/200 - 20/400
  2. 20/60 by the age of 3
  3. 20/20 by age of 5 ideally
  4. Infant should be able to track by 3mo
43
Q

Amblyopia

A

Functional reduction in VA either unilateral or bilateral d/t misuse/disuse during visual development

MCC of visual impairment in children

44
Q

Why does VA loss occur in amblyopia?

A

Improper/lack of stimulation between brain and eye => brain learns to see poorly.

45
Q

RFs for amblyopia

A
  • Prematurity
  • 1st degree relative
  • SGA
  • Neurodevelopmental delays
46
Q

Classifications of amblyopia

A
  • Strabismus: misalignment of visual axes
  • Refractive: 1 or more eyes having a refractive error
  • Deprivational: Obstruction by cataract or complete ptosis affecting retinal development
47
Q

Describe strabismic amblyopia

A
  • One eye moves weirdly
  • Brain will turn off the bad eye, lowering vision in it.
  • Long-term suppression of the affected eye results in strabismic amblyopia
48
Q

MCC of refractive amblyopia

A

Asymmetric refractive glasses

Esp in people who are farsighted.

49
Q

What is the rarest form of amblyopia?

A

Deprivational amblyopia

50
Q

What causes deprivational amblyopia?

A

Obstruction essentially distorting an eye’s fovea/visual axis

Your eye is deprived of stimuli

51
Q

When is refractive amblyopia most commonly caught?

A

4-5, when we start screening VA with letters.

52
Q

How do you check for amblyopia in a non-verbal child?

A
  • Fixation reflex (checking tracking of each eye separately)
  • Amblyopia shows as inability to maintain tracking with amblyopic eye when both are uncovered
  • Differential occlusion objection test: child will cry when better eye is covered.

AKA they cry cause they can’t see ):

53
Q

How do you check for amblyopia in a verbal child? (3yo+ usually)

A
  • Allen or snellen chart

Start at 20/40 and move up if they miss 2+

54
Q

When you should refer for amblyopia?

A
  • VA worse than 20/40 in 3-5 or 20/30 in 6y+
  • VA difference of more than two lines (i.e. 20/20 20/40)
  • Strabismus
  • Abnormal red reflex
  • Asymmetry of vision
  • Unilateral ptosis

You are normally 20/20 by age 5

AKA not meeting benchmarks or sus of something more neuro

55
Q

Tx of amblyopia

A
  • Start ideally prior to 7, up to age 10
  • Elimination of obstructions (tx of deprivational)
  • Correction of refractive errors (tx of refractive)
  • Encourage use of amblyopic eye
56
Q

What are the 4 descriptions for strabismus?

A
  • Nasal: Eso
  • Temporal: Exo
  • Upward: Hyper
  • Downward: Hypo

Exo = out, hyper up

___tropia

57
Q

What can mimic strabismus in children?

A

Prior to 3mo, children tend to naturally have unstable ocular alignment.

Intermittent strabismus = NORMAL prior to 3mo of age.

58
Q

What is pseudostrabismus?

A
  • Apparent esotropia in children (asian) with wide nasal bridges or large epicanthal folds
  • Optical illusion, not real.
59
Q

What is a red flag in addition to strabismus?

A

Abnormal head postures

They are compensating too much

60
Q

What is the primary screening technique for strabismus?

A

Corneal reflex test (hirschberg)

61
Q

What is the cover test?

Strabismus testing

A
  • If they have it, the uncovered eye will refixate when you cover their other eye
  • AKA, if the good eye is covered, the bad eye will refixate and move to the center.
  • If the bad eye is covered, the good eye just remains normal.

Watch the vid if this is unclear

62
Q

What is the cover/uncover test?

A
  • Affected eye covered will be deviated when it is rapidly uncovered, before it refixates.
  • Indicated when the strabismus is not clear, but you suspect it

Without something to fixate on, it will naturally deviate.

Looks for latent strabismus

63
Q

What is the bruckner red reflex test?

Strabismus

A
  • Simultaneous red reflex test
  • Misaligned reflexes via fundoscope on largest diameter light.
64
Q

Indications to refer for strabismus

A
  • Constant
  • Intermittent after 6mo
  • Positive test of any of the 3 (corneal, cover, cover/uncover)
  • Positive bruckner (red reflex)
  • Deviations changing with gaze
  • Torticollis not explained by muscle spasm
  • Eye fatigue
  • Prematurity/genetic disorder
  • Parental concern
65
Q

Tx of strabismus

A
  • Corrective lenses
  • Patching (of the good eye)
  • Surgery: recession/repositioning to adjust EOMs (decreasing effect on globe)
  • Surgery: resection to shorten EOMs (increasing effect on globe)

Pediatrics (23 decks)

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