Module 2 Flashcards
4 components of a physical exam for respiratory assessment
- inspection
- palpation
- percussion
- auscultation
Normal findings for respiratory assessment (observe, inspect, palpate, percussion, auscultation)
-observe pattern of breathing (RR 12-14rr/min) and rhythm (regular with a sigh every 90 breaths or so), depth of breathing/tidal volume, relative time spent inspiration and expiration (ratio 2:3)
-inspect for extrapulmonary signs of pulmonary disease –> use what you find to perform more detailed exam
-palpate: 1. trachea at suprasternal notch 2. posterior chest wall (gauge fremitus/transmission through lungs of vibrations of spoken words) 3. anterior chest wall (assess cardiac impulse)
-percussion: identifies dull areas or hyperresonant areas
-auscultation of lung sounds
Extrapulmonary signs (4)
-digital clubbing (lung abscess, empyema, bronchiectasis, CF, idiopathic pulmonary fibrosis, AV malformations; late presentation: concomitant lung cx
-Cyanosis: blue or bluish-gray discoloration of skin & mm due to inc amounts of unsaturated HgB in capillary blood (anemia: may prevent cyanosis from appearing; polycythemia: cyanosis in mild hypoxemia) –> cyanosis not reliable indicator of hypoxemia = get arterial PO2 or HgB saturation measured
-Inc CVP: indirectly measures pulmonary HTN (major complication of chronic lung dx); impaired ventricular function, pericardial effusion, or restriction, valvular heart dx, COPD
-BLE edema: indirectly measures pulmonary HTN (major complication of chronic lung dx) w/ chronic lung disease = RV failure
Kussmaul respirations
rapid LARGE VOLUME breathing = intense stimulation of respiratory center r/t metabolic ACIDosis
Cheyne-stokes respirations
RHYTHMIC, waxing/waning of rate and RV, regular periods of APNEA (seen in end-stage LV failure, neurological dx, sleeping at high altitude
What is wheezing a powerful indicator for?
obstructive lung disease (asthma, COPD)
Does rhonchi clear after cough?
YES
Risk factors for CAP
older age, hx of etoh/tobacco, asthma/COPD/immunocompromised
Timing of CAP (in relation to the hospital)
Occurs prior to admission (to the hospital) or within 48 hours of admission
Sx of CAP
-Acute or subacute onset of fever (low in elderly) (FEVER)
-Cough (w/ or w/o sputum) (COUGH)
-Dyspnea/tachypnea (sensitive sign in elderly) (DYSPNEA)
-Mental status change (elderly) (MENTAL)
-Rales, bronchial breath sounds or inspiratory crackles (SOUNDS)
-Parenchymal opacity on x-ray (X-RAY)
What bacteria is primarily responsible for CAP?
S pneumoniae
Viruses that cause CAP?
RSV, Influenza A/B, adenovirus/parainfluenza virus, human metapneumonvirus
Is diagnostic testing required/recommended for outpatient management of CAP? Why?
NO (only hospitalized patients). Empiric abx is almost always effective in this population w/o need for dx tests
What 3 widely available rapid point of care tests are used to ID causative organism in CAP?
- Sputum gram stain
- Urinary antigen tests (S pneumonia, legionella species)
- COVID RT-PCR/Rapid Test
Why should you obtain a rapid flu test when dx CAP?
Because positive flu tests reduce unnecessary abx use
What imaging is required to establish a dx of CAP?
Pulmonary opacity on chest x-ray
CAP - Can a CXR identify causative organism or distinguish bacterial from viral pneumonia?
NO
CAP - If CXR shows SIGNIFICANT pleural fluid collections, what should the NP do?
REFER (thoracentesis)
CAP - If CXR shows cavitary opacities, what should the NP do?
ISOLATE and REFER to ED - to rule out TB
Recommended outpatient abx choice for CAP patient who was previously healthy with no recent (90 day) antibiotic use?
Amoxicillin
Doxycycline (100mgBIDx5days)
**do not use fluroquinolones in ambulatory pt w/o comorbidities or recent abx use - RISK OF TENDON RUPTURE
Recommended outpatient abx choice for CAP patient with previous risk of drug resistance (abx<90 days, >65yrs old, comorbid illness (COPD/CHF/DM/Cx/Chronic renal/liver), alcoholism, immunosuppression, exposed to child in daycare?
-Macrolide or doxy PLUS oral beta-lactam (Augmentin) OR
-Oral respiratory fluoroquinolone (moxifloxacin, gemifloxacin, levofloxiacin)
*if abx <90days, choose new one from different class
CAP - what is the typical abx tx for adults?
5 days (continue abx until pt is afebrile for 40-72hrs)
-cough, fatigue may last up to 4 weeks
Prevention techniques against CAP?
PPSV23, PCV13 (PCV15), influenza, COVID19
CURB-65
Screening tool for CAP
Assess 5 predictors to calculate a 30 day predicted mortality rate
-Confusion
-Urea: BUN >7mmol/L (20mg/L)
-Respiratory rate: >30/min
-BP: systolic <90, diastolic <60
-Age: >65 years old
0 = outpt tx is probably safe
1-2 = admit to hospital for care
3-4 = URGENT REFERRAL! Admit to ICU.
PSI
Screening tool for CAP
Pneumonia severity index
-Age, gender, nursing home status, comorbid conditions, physical exam, and labs (including blood pH) to determine hospitalization
Anaerobic pneumonia risk factors
hx of predisposition of aspiration (nocturnal asthma, chemical pneumonitis, bronchiectasis, AMS (drugs/ETOH), seizures, general anesthesia, CNS disease, neuromuscular dx, ET tube/NG tube, poor dentition)
Does anaerobic pneumonia have insidious or gradual onset?
Insidious
Symptoms of anaerobic pneumonia
insidious onset of fever, weight loss, malaise, COUGH WITH FOUL-SMELLING SPUTUM = anaerobic
What diagnostic test is used for anaerobic pneumonia?
Chest X-ray
Treatment for anaerobic pneumonia?
IV clindamycin or Augmentin q12 hr; or Pen G and Flagyl. Treat until resolution on X-ray.
What is a major determining factor regarding the lung zone affected at time of aspiration for anaerobic pneumonia?
Body position
What does an air-filled cavity in lung suggest?
Abscess
What does the presence of multiple areas of cavitation within an area of consolidation lead the NP to suspect?
Necrotizing pneumonia
The presence of purulent pleural fluid accompanying either lung abscess or necrotizing pneumonia would indicate what complication (anaerobic pneumonia)?
Empyema
Treatment for anaerobic pneumonia
1st line: IV clindamycin q8hr OR Augmentin q12hr
Alternative: Amox or PCN G + metronidazole (flagyl)
Length of treatment for:
-Anaerobic pneumonia
-Lung abscess
-Empyema
-until CXR improves (month or more)
-until CXR resolution of abscess cavity is demonstrated
-REFER (must have tube thoracostomy)
Key symptoms of pleuritis
localized pain, sharp, fleeting - worse with coughing, sneezing, deep breaths or movement; diaphragmatic involvement = referred ipsilateral shoulder pain
Cause of pleuritis in healthy, young adults?
viral resp infection or pneumonia; simple rib fracture
Treatment for pleuritis
Treat underlying dx
-Pain: analgesics/NSAIDs (indomethacin, etc.)
-Control cough: codeine or other opioid; promitozine cough syrup
What would you do if pleural effusion, pleural thickening, or air in pleural space observed?
REFER!!
Definition of Pleuritis
Inflammation of pleural lining
Definition of Pleural effusion
collection of fluid in pleural space
Risk factors associated with pleural effusion
chest pain + pleuritis, trauma, or infection
Common findings related to pleural effusion
dyspnea (large effusions –> dullness to percussion and decreased/absent breath sounds over effusion); CXR shows pleural effusion; diagnostic findings on thoracentesis
Sx associated with pleural effusion?
Unilateral chest pain, worse with inspiration or deep breathing; dullness to percussion; dec/absent breath sounds where effusion located
Pulmonary infiltrates - how do you diagnose in immunocompromised patient?
Sputum culture!
If no clinically apparent cause for pleural effusion, how is it diagnosed?
Thoracentesis
Symptoms of spontaneous pneumothorax
Acute UNILATERAL chest pain, dyspnea
UNILATERAL chest expansion
Decreased tactile fremitus
Hyperresonance
Types of spontaneous pneumothorax
Primary
Secondary
Signs and symptoms of small pneumothorax
mild tachycardia
Signs and symptoms of large pneumothorax
diminished breath sounds, decreased tactile fremitus, decreased movement of chest
Lab findings related to pneumothorax
-ABG: hypoxemia, resp alkalosis
-EKG: left-sided primary pneumothorax = QRS axis and precordial T wave changes - can appear like MI
Treatment for pneumothorax (primary, secondary, small, large)
*treat cough and pain (serial CXR q 24 hrs)
-Small, stable spontaneous pneumothorax: observation alone may be appropriate
-Large, progressive pneumothorax: needle decompression (16g needle) –> place chest tube (small-bore tube) attached to one-way Hemlich valve (provides protection against development of tension pneumothorax); may permit observation from home
Treatment for tension pneumothorax
chest tube under water seal drainage with suction (removed after air leaks subsides)
What causes risk of reoccurrence of pneumothorax?
Smoking, high altitudes, flying in unpressurized aircraft, scuba diving
What coexists with obstructive sleep apnea?
Obesity-hypoventilation syndrome (blunted ventilatory drive and increased mechanical load imposed upon the chest by obesity)
Patients with pulmonary venous thromboembolism have a history of what?
DVT
Symptoms of pulmonary venous thromboembolism
-dyspnea
-chest pain worse with inspiration
-cough
-hemoptysis
-syncope
-tachypnea
-widened alveolar-arterial PO2 difference (hypoxemia with right-to-left shunting)
How to diagnose PE (what diagnostic tests)?
-d-dimer (increased)
-CT pulmonary angiography (abnormalities/VQ Scan-for those who cannot tolerate contrast dye)
-EKG (ST or T wave change, tachycardia), then REFER
Substances that could embolize to lung circulation causing PE?
-Air
-Amniotic fluid
-Fat
-Foreign bodies
-Parasite eggs
-Septic emboli
-Tumor cells
Risk factors for thrombus formation
-Venous stasis
-Injury to vessel wall
-Hypercoagulability
-Immobility
-Inc CVP ((Dec CO states, pregnancy)
-Inherited dx (factor V Leiden)
Labs/Diagnostic tests for suspected PE?
ECG
ABG
d-dimer
CXR
CT angiogram
Venous ultrasound (rule out proximal DVT)
Profound hypoxia with normal CXR in absence of lung disease - what are you suspicious for?
PE
What is the clinical prediction tool for determining patient probability of PE?
Wells Clinical Prediction rule (modified Wells score of 4 or mess who meet all PERC criteria ORDER a d-dimer)
What is a form of secondary prevention (med) for PE?
Heparin anticoagulation therapy (standard regimen) followed by 6 month PO warfarin (another effective drug is LMWH - recommended for patients’ with cancer)
What is the appropriate duration of therapy for patients with PE?
No standard
What is a major complication from treatment of PE? What should you be monitoring?
Hemorrhage; INR (target INR = 2.0-3.0)
What medication therapy is instituted for an established PE?
Rt-PA
Alteplase: thrombolytic therapy (high risk pts) –> choose if needs lifesaving tx
ABSOLUTE CONTRAINDICATIONS FOR THROMBOLYTIC THERAPY
active internal bleeding
stroke w/i past 2 months
MAJOR CONTRAINDICATIONS TO THROMBOLYTIC THERAPY
uncontrolled HTN
Surgery/trauma within past 6 weeks
Symptoms of RSV
-low-grade fever
-tachypnea
-wheezing
-apnea
-increased mucous secretion
Physiologic sx of RSV
hyperinflated lungs, decreased gas exchange, increased WOB
At what ages is RSV mortality highest?
<5yrs; >65yrs
Risk factors for RSV
prematurity
early RSV bronchiolitis in kids + family hx of asthma –> persistent airway reactivity in life
Wells Score - for patients with Modified Wells <equal 4 who meet ALL of the following criteria, PE is excluded, follow off anticoagulation, and search for alternative dx. List criteria (8)
- Age <50yrs
- HR <100bpm
- Oxyhemoglobin saturation on room air >equal 95%
- No prior hx of venous thromboembolism
- No recent (w/i 4 weeks) trauma or surgery requiring hospitalization
- No presenting hemoptysis
- No estrogen therapy
- No unilateral leg swelling
How is seasonal influenza spread?
Droplet
Symptoms of seasonal influenza in relation to:
-unvaccinated adults
-kids with type B
-elderly
-abrupt onset of fever, chills, HA, malaise, myalgias, runny/stuffy nose, sore throat, hoarseness, cough, substernal soreness
-GI complaints
-Lassitude, confusion, w/o fever or respiratory sx
How long is the incubation period for seasonal influenza?
1-4 days
When to suspect secondary bacterial infection during seasonal influenza illness
Recurrent fever or persistent fever >4 days w/ productive cough and WBC >10,000
-most common = pneumococcal pneumonia; staph pneumonia = most serious
Treatment for seasonal influenza
Tamiflu
75mg by mouth BID 5 days
-most effective if given w/i 2 days of sx start
Relenza: inhalation powder (oral inhalation). Used for influenza A and B
-contraindicated with asthma
Primary risk factor for avian influenza
Direct of indirect exposure to infected live or dead poultry or contaminated environments (live bird markets); slaughtering or handling carcasses of infected poultry
Treatment for avian influenza
Tamiflu
How to dx avian flu?
-patient history (exposure to dead/il birds or live poultry markets in prior 10 days
-PCR test w/i 7d onset
Adenovirus infections - when are you most likely to get sick with this illness?
Throughout the year
Incubation period of adenovirus
4-9 days
Type of adenovirus that is severe/fatal for chronic lung dx patients
Type 14
What virus is commonly associated with AOM?
RSV
What is a complication of seasonal influenza with kids?
Reye syndrome (type B)
Tx for influenza and how quickly it should be started
- Tamiflu (drug of choice)
- Zanamivir (relenza)
- Adamantanes (amantadine & rimantadine) (not recommended d/t resistance in influenza A & B)
**begin medication within 48 hours of illness onset
Key symptoms of pneumococcal pneumonia (adults)
-productive cough
-fever
-rigors
-dyspnea
-early pleuritic chest pain
-bronchial breath sounds = EARLY SIGN
What does CXR show in patient with pneumococcal pneumonia?
How is organism determined?
Consolidating lobar pneumonia
Sputum culture or rapid urinary antigen test for s pnumoniae
What type of bacteria is seen with pneumococcal pneumonia?
gram+ diplococci
What is the most common cause of community-acquired pyogenic bacterial pneumonia?
Pneumococcal
Risk factors for pneumococcal
alcoholism, asthma, HIV+, sickle cell, splenectomy, hematologic disorders
Tx for pneumococcal
Empiric abx pending isolation and identification of causative agent
-PO amoxicillin: uncomplicated cases; cephalosporins; PCN allergy = “mycins”
Complications of pneumococcal pneumonia
-treatment of complications
-parapneumonic effusion (causes recurrence or persistence of fever)
-empyema
-pneumococcal pericarditis –> tamponade = EMERGENCY
Thoracentesis; echocardiogram; endocarditis - penicillin G IV; prosthetic valve implantation for moderate-severe HF d/t valve regurgitation
Bordetella pertussis “whooping cough” - age that this bacteria impacts
<2yrs
-adults and adolescents are reservoirs for infection
How is Bordetella pertussis spread? (mode of transmission)
Droplets
How long to sx last for Bordetella pertussis?
How many stages of Bordetella pertussis is/are there? What is/are the stages?
- 6 weeks
- 3 stages
-Stage 1 (Catarrhal)
-Stage 2 (paroxysmal)
-Stage 3 (convalescent)
Catarrhal stage of Bordetella pertussis
Stage 1
Insidious onset - lacrimation, sneezing, coryza (head cold), anorexia, malaise, hacking night cough that becomes diurnal
Paroxysmal stage of Bordetella pertussis
Stage 2
Bursts of rapid, consecutive coughs followed by deep, high-pitched inspiration (whoop)
Convalescent stage of Bordetella pertussis
Stage 3
Begins 4 weeks after onset with decrease in frequency and severity of paroxysms of cough
Is Bordetella pertussis gram+ or gram-?
Gram -
Is pneumococcal pneumonia caused by gram+ or gram- bacterial?
Gram +
What strain/bacteria is responsible for most disease in adults in regard to Haemophilus species?
H influenzae (sinusitis, otitis, bronchitis, epiglottis, pneumonia, cellulitis, arthritis, meningitis, endocarditis
Treatment for haemophilus species: sinusitis, otitis, respiratory tract infection
Amoxicillin PO
Treatment for haemophilus species: beta lactamase strains
Augmentin PO
Who is at risk to develop Legionnaires disease?
Immunocompromised, smokers, chronic lung disease
Symptoms of Legionnaires disease
high fever
grossly purulent sputum
pleuritic chest pain
toxic appearance
How is Legionnaires disease dx?
CXR: focal patchy infiltrates or consolidation (blood, urine are other options)
Gram-stain of sputum - polymorphonuclear leukocytes (no organisms shown (show up poorly) = not a good test for dx)
What is the 3rd most common cause of CAP?
Legionnaires disease
How is Legionnaires disease spread?
Contaminated water sources, air conditioning cooling towers
What do labs show for Legionnaires disease? (3)
-hyponatremia
-elevated liver enzymes
-elevated CK (enzyme)
Treatment for Legionnaires disease
Azithromycin PO
Clarithromycin
Fluoroquinolone
*for 10-14 days
**NO ERYTHROMYCIN
What antibiotic do you not use to treat Legionnaires disease?
Erythromycin - failure of tx and SE
Treatment for haemophilus species: more seriously ill patient (toxic patient with multilobe pneumonia)
ceftriaxone IV
Treatment for Bordetella Pertussis
Abx: erythromycin, azithromycin, clarithromycin, or Bactrim
Vaccination against Bordetella pertussis
11-18 yrs
>64 yrs
Pregnancy
-If completed DTP or DTaP, receive single dose of either Tdap product instead of Td for booster immunization
-Single dose of Tdap
-during each pregnancy, receive single dose of Tdap regardless of prior vaccine hx (27-36wks)
Epiglottis (in relation to Haemophilus species) symptoms
abrupt onset of high fever, drooling, inability to handle secretions
-complaint of severe sore throat despite unimpressive exam of pharynx
Complications of epiglottis and how to dx it
Treatment
-laryngeal obstruction (stridor = respiratory distress ==> emergency)
-direct visualization of cherry-red swollen epiglottis with laryngoscopy (only performed in ICU)
ceftriaxone 1g IV
Meningitis (in relation to Haemophilus species): treatment
Initial treatment: ceftriaxone IV 4g/day (treated for 7 days) until strain if proved not to produce beta-lactamase
Dexamethasone IV q6hr to reduce long-term sx of hearing loss
Empiric antibiotics for CAP bacterial (outpatient) - healthy
For previously healthy patients with no risk factors for MRSA or pseudomonas
1. Amoxicillin
2. Doxycycline
3. Macrolide
Empiric antibiotics for CAP bacterial (outpatient) - comorbidities
- Macrolide or doxycycline + oral beta-lactam (Augmentin, cefpodoxime, cefuroxime)
- Oral fluoroquinolone
Pneumococcal vaccine timing for adults (for those who never received a pneumococcal vaccine or those with unknown vaccination hx)
-PCV20
-PCV15
-PPSV23
-PCV20: vaccination complete
-PCV15: follow with one dose of PPSV23 (interval 8wks - 1 year*)
-PPSV23: administer either PCV15 or PCV20 (interval 1 year)
Pediatrics: 4 components of a respiratory exam
- inspection
- palpation
- auscultation
- percussion
Abnormalities in child’s physical exam for respiratory illness (6)
-tachypnea, abnormalities of attentiveness, inconsolability, respiratory effort, color (mottled, bluish), movement had good diagnostic accuracy in detecting hypoxemia
-Shift in tracheal position
-Tactile fremitus
-Wheezing; prolonged expiratory compared to inspiratory time
-Unilateral crackles
-Extrapulmonary signs: cyanosis, altered mental status, signs of chronic respiratory insufficiency (growth failure, clubbing, osteoarthropathy); evidence of cor pulmonale
How much longer is expiratory time vs inspiratory time?
2x longer
What imaging test remains the FOUNDATION of investigating pediatric thorax?
CXR
What CXR views should be ordered?
Frontal (posterior and anterior) and lateral
What does a CXR show in pediatric patients? (5)
Chest wall abnormalities, heart size and shape, mediastinum, diaphragm, and lung parenchyma
When a foreign body is suspected, what should FNP order?
Forced expiratory radiographs
-shows focal air trapping and shift in mediastinum to the contralateral side)
When an FNP wants to differentiate croup from epiglottitis, what should the FNP order?
Lateral neck radiographs
-can see “thumbprint sign” with epiglottitis
When assessing vascular or bronchial anatomical abnormalities, what should FNP order?
MRI
When assessing regional ventilation and perfusion - detect vascular malformations and pulmonary emboli, what should the FNP order?
Ventilation-perfusion scans
OSA in children - higher risk when have any of the following comorbities
obesity
down syndrome
craniofacial abnormalities
Neuromuscular disorders
Sickle cell disease
mucopolysaccharidoses
How is OSA dx?
polysomnogram (PSG)
Is diagnosing OSA in children different than adults? If so, how so?
Yes
The occurrence of more than 1 apneic or hypopneic event per hour with duration of at least 2 respiratory cycles = ABNORMAL
Children with apnea-hypopnea index >5 events per hour = CLNIICALLY SIGNIFICANT OSA
Foreign body aspiration (upper airway) key findings
abrupt onset, hx of child running with food in mouth or playing with seeds/small coins/toys
Symptoms of foreign body aspiration (upper airway)
inability to vocalize or cough, cyanosis with distress (complete obstruction)
drooling, stridor
Highest risk (age) for foreign body aspiration upper airway?
6mo-3yr
Complete obstruction FB upper airway <1yr - what should be done
place face down over rescuers arm, deliver 5 rapid back blows, followed by rolling infant over and delivering 5 rapid chest thrusts (repeat until obstruction is relieved)
Complete obstruction FB upper airway >1yr - what should be done
abdominal thrusts (heimlich maneuver)
Complete obstruction (any age) FB upper airway - what should be done if unresponsive?
-finger sweep?
CPR
**never perform a blind finger sweep
Foreign body aspiration (lower airway) key onset
sudden onset of coughing, wheezing, respiratory distress
-asymmetrical breath sounds (decreased) or localized wheezing
What should we suspect if child has chronic cough, persistent wheezing, or recurrent pneumonia?
Foreign body aspiration (lower airway)
If child has FB in lower airway with coughing that goes away, can it come back again?
Yes, comes back as chronic cough, persistent wheezing, monophonic wheezing, asymmetrical breath sounds on chest examination, or recurrent pneumonia in 1 location
Lab/diagnostic imagining for FB lower airway (type)?
CXR
However, CXR might be normal, so need positive forced expiratory study.
Complete obstruction of distal airway can lead to atelectasis and related volume loss
If CXR is normal, does that rule out FB?
NO!
FB aspiration dx is based on 2 or 3 findings:
- hx of possible aspiration
- focal abnormal lung exam
- abnormal CXR
=REFER for bronchoscopy
-if suspected FB aspiration, admit to hospital for evaluation
What is given to the pediatric patient who had FB aspiration after removal?
b-adrenergic neb treatments + chest PT
Viral croup key symptoms
-age
-sx
-late signs
-young children 6mo-5yr with recent MRI
-parainfluenza virus serotypes; new onset stridor in setting of an upper resp illness or fever (mild stridor: agitated; severe stridor: at rest)
*retractions, air hunger, cyanosis are late signs
what is the character presentation of croup? (3)
is evaluation urgent, emergency, or casual?
inspiratory stridor, barking “seal” cough and retractions at rest
URGENT
What are the causative agents of croup?
-parainfluenza virus serotypes (most important cause of croup in kids)
-RSV
-Rhinovirus
-Adenovirus
-Influenza A/B
-M pneumoniae
What physiologic changes does croup cause to the airway?
edema in subglottic space
What precedes croup?
URI (leads to barking cough and stridor)
What finding should you not see with croup?
Fever
A patient with mild croup becomes agitated during physical exam, what do you expect to occur?
Stridor
What would be an indication that the patient’s condition with croup has worsened?
Stridor at rest (early sign of worsening obstruction) –> retractions, air hunger, cyanosis (late signs)
What signs in a patient would indicate a diagnosis of croup vs epiglottitis?
Presence of cough and absence of drooling
What diagnostic imaging should the FNP obtain for patient with suspected croup?
Classic presentation of croup does not require CXR
If a patient presents with an atypical presentation for croup, what would you expect to see on CXR that you wouldn’t find in tracheitis?
Subglottic narrowing “steeple sign” without irregularities
Tx for mild-moderate croup
1 single dose dexamethasone (0.15mg/kg PO or 0.6mg/kg IM)
D/C from ED <3hr if sx resolve
Tx for moderate-severe croup
Humidified O2
Dexamethasone (0.6mg/kg IMx1)
Inhaled budesonide
Nebulized racemic epinephrine
If recurrent epi tx needed = admit to hospital for observation and continued neb tx PRN
Epiglottitis key symptoms
Sniffing dog position/tripod position; sudden onset of high fever, dysphagia, drooling, muffled voice, inspiratory retractions, cyanosis, soft stridor
What vaccination helps fight against epiglottitis?
HiB
What are the causative agents of epiglottitis?
H influenzae (in unimmunized children) OR nontypeable H influenzae, N meningitis, or Streptococcus species (immunized population)
With epiglottitis, the FNP knows a definitive dx can be made by?
direct inspection of epiglottis during intubation by airway specialist
What physical finding is observed in patient with epiglottitis?
Cherry-red and swollen epiglottis and swollen arytenoids
In stable patient with epiglottitis, what type of imaging should FNP order? What classic sign is observed?
-CXR lateral neck
-Thumbprint sign
Intervention of epiglottitis in children?
Intubation (keep as calm as possible)
How long are children intubated with epiglottitis?
How long should abx be continued with epiglottitis?
-24-48hrs
-2-3 days of IV abx, followed by 10 days PO abx
What can viral croup progress into? What does that progress into?
Bacterial tracheitis; SUDDEN RESPIRATORY ARREST
What patients should be hospitalized for CAP?
-all infants <3months for abx (IV or PO)
-any child with apnea, hypoxemia, poor feeding, effusion of CXR, moderate or severe respiratory distress, or clinical deterioration on treatment
If patient is managed outpatient for CAP, what does the follow-up timeline look like?
Close follow-up w/i 12hr-5d
CAP bacterial pediatrics: treatment
-Empiric abx treatment aimed at S pneumonia: amox 80-90mg/kg/day divided BID for 5-10 days (alternatives are cephalosporins or macrolides - may be resistant)
-Children >5yrs - depends on cause: amox 80-90mg/kg divided BID for 7-10 days or Azithromycin (mycoplasma)
CAP viral pediatrics: treatment
PO abx used to cover co-existent bacterial pneumonia (usually indicated)
RSV - supportive measures
Influenzae A/B - Tamiflu (age >equal 1 yr) or Relenza (age >equal 7)
Peds: What is the MOST common organism associated with empyema?
S pneumoniae
Peds: What can be expected to occur during a chest exam with effusion?
Dullness to percussion on the affected side, child prefers to lie on affected side
Peds: With large effusions, what does the FNP expect to see?
tracheal deviation to the contralateral side
Peds: what laboratory /diagnostic findings are expected in empyema?
Elevated WBC with left shift
+blood cultures
Neutrophils in pleural fluid cells retrieved by thoracentesis (<7.2pH and low glucose)
Peds: Mycoplasma pneumonia - “walking pneumonia”
-age
-symptoms
->5years
-fever, dry cough at onset - changes with sputum production with progression of illness; HA, malaise, rales and chest pain
-interstitial or bronchopneumonic infiltrates in middle/lower lobes; pleural effusions
What is the MOST common organism associated with mycoplasma pneumonia?
M pneumoniae
What is the typical lab/diagnostic findings associated with mycoplasma pneumonia?
Normal total WBC w/ diff
-enzyme immunoassay (EIA) and complement fixation sensitive and specific for M pneumoniae
What treatment should be provided for mycoplasma pneumonia?
Supportive measures and macrolide abx
-azithromycin
-Ciprofloxacin is alternative
What is the gold standard for diagnostic testing for mycoplasma pneumonia?
PCR (depends on clinic)
Key symptoms of bronchiolitis (pediatrics)
-age
-common cause
-sx
-<2yr old
-RSV; usually begins with URI (fever rhinorrhea, cough)
-tachypnea, rapid/shallow breathing, wheezing –> irritability, poor feeding, vomiting –> crackles, nasal flaring, retractions, hypoxia
(usually current bacterial pneumonia dx)
What is the most common serious acute respiratory illness in infants and young children?
Bronchiolitis
What are the common causes of bronchiolitis (pediatrics)?
RSV (viral), parainfluenza, influenza, adenovirus, human metapneumovirus, several bacterial causes less common
S/S bronchiolitis in pediatrics
Starts as URI: fever, rhinorrhea, and cough
Risk factors for severe bronchiolitis?
age <12 weeks, hx of prematurity (<35 weeks), underlying cardiopulmonary disease, and immunodeficiency
Current AAP recommendations in relation to bronchiolitis instruct the FNP to forgo what testing?
-viral nasal swab for routine RSV testing should not be conducted unless infant has been on prophylaxis with Palivizumab as test dose not change treatment
-no CXR if no respiratory distress present
-albuterol tx and corticosteroids NOT recommended
-antibiotics not recommended unless bacterial infection present or strongly suspected
What antiviral treatment is reserved for severely ill children with immune or anatomic cardiopulmonary defects?
Ribavirin antiviral aerosol treatment
First line of treatment of OSA in children
Adenotonsillectomy (improves clinical status in nonobese children with normal craniofacial structure)
If obese or craniofacial abnormalities, neuromuscular disorders –> CPAP
When does SUID deaths peak? (at what age?)
2-4 months, most deaths occur at night
Risk factors associated with SUID
ethnic/racial minority, Socioeconomically disadvantaged; males; premature birth, low birth weight, recent infection, young maternal age, high paternal parity, maternal tobacco or drug use, crowded living conditions
**RECENT IMMUNIZATION IS NOT A FACTOR
Herpangina
-cause
-sx
-tx
-coxsacki A viruses (epidemic) or coxsackie B/echovirus (sporadic cases)
-acute onset fever an dposterior pharyngeal grayish white vesicles –> quickly form ulcers (<20 in number) linearly along posterior palate, uvula, tonsillar pillars; dysphagia, drooling, vomiting, abd pain
-rest, fluids, pain relievers
Acute lymphonodular pharyngitis
-cause
-sx
-tx
-coxsackievirus A10
-febrile pharyngitis with NONULCERATIVE yellow-white posterior pharyngeal papules linearly along posterior palate
-supportive tx
HFM
-cause
-sx
-tx
-coxsacki virus (A5, A10, A16)
-vesicles or red papules are found on tongue, oral mucosa, hands, and feet; near the nails and heels; fever, sore throat, mild malaise
-supportive tx
Do you administer antibiotics, decongestants, expectorants, albuterol or systemic corticosteroids (unless asthmatic or premature infant) in pediatric patients with RSV?
NO
Common sx in infants with meningitis
high-pitched cry
