Module 2 Flashcards
1
Q
4 components of a physical exam for respiratory assessment
A
- inspection
- palpation
- percussion
- auscultation
2
Q
Normal findings for respiratory assessment (observe, inspect, palpate, percussion, auscultation)
A
-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
3
Q
Extrapulmonary signs (4)
A
-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
4
Q
Kussmaul respirations
A
rapid LARGE VOLUME breathing = intense stimulation of respiratory center r/t metabolic ACIDosis
5
Q
Cheyne-stokes respirations
A
RHYTHMIC, waxing/waning of rate and RV, regular periods of APNEA (seen in end-stage LV failure, neurological dx, sleeping at high altitude
6
Q
What is wheezing a powerful indicator for?
A
obstructive lung disease (asthma, COPD)
7
Q
Does rhonchi clear after cough?
A
YES
8
Q
Risk factors for CAP
A
older age, hx of etoh/tobacco, asthma/COPD/immunocompromised
9
Q
Timing of CAP (in relation to the hospital)
A
Occurs prior to admission (to the hospital) or within 48 hours of admission
10
Q
Sx of CAP
A
-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)
11
Q
What bacteria is primarily responsible for CAP?
A
S pneumoniae
12
Q
Viruses that cause CAP?
A
RSV, Influenza A/B, adenovirus/parainfluenza virus, human metapneumonvirus
13
Q
Is diagnostic testing required/recommended for outpatient management of CAP? Why?
A
NO (only hospitalized patients). Empiric abx is almost always effective in this population w/o need for dx tests
14
Q
What 3 widely available rapid point of care tests are used to ID causative organism in CAP?
A
- Sputum gram stain
- Urinary antigen tests (S pneumonia, legionella species)
- COVID RT-PCR/Rapid Test
15
Q
Why should you obtain a rapid flu test when dx CAP?
A
Because positive flu tests reduce unnecessary abx use
16
Q
What imaging is required to establish a dx of CAP?
A
Pulmonary opacity on chest x-ray
17
Q
CAP - Can a CXR identify causative organism or distinguish bacterial from viral pneumonia?
A
NO
18
Q
CAP - If CXR shows SIGNIFICANT pleural fluid collections, what should the NP do?
A
REFER (thoracentesis)
19
Q
CAP - If CXR shows cavitary opacities, what should the NP do?
A
ISOLATE and REFER to ED - to rule out TB
20
Q
Recommended outpatient abx choice for CAP patient who was previously healthy with no recent (90 day) antibiotic use?
A
Amoxicillin
Doxycycline (100mgBIDx5days)
**do not use fluroquinolones in ambulatory pt w/o comorbidities or recent abx use - RISK OF TENDON RUPTURE
21
Q
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?
A
-Macrolide or doxy PLUS oral beta-lactam (Augmentin) OR
-Oral respiratory fluoroquinolone (moxifloxacin, gemifloxacin, levofloxiacin)
*if abx <90days, choose new one from different class
22
Q
CAP - what is the typical abx tx for adults?
A
5 days (continue abx until pt is afebrile for 40-72hrs)
-cough, fatigue may last up to 4 weeks
23
Q
Prevention techniques against CAP?
A
PPSV23, PCV13 (PCV15), influenza, COVID19
24
Q
CURB-65
A
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.
25
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
26
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)
27
Does anaerobic pneumonia have insidious or gradual onset?
Insidious
28
Symptoms of anaerobic pneumonia
insidious onset of fever, weight loss, malaise, COUGH WITH FOUL-SMELLING SPUTUM = anaerobic
29
What diagnostic test is used for anaerobic pneumonia?
Chest X-ray
30
Treatment for anaerobic pneumonia?
IV clindamycin or Augmentin q12 hr; or Pen G and Flagyl. Treat until resolution on X-ray.
31
What is a major determining factor regarding the lung zone affected at time of aspiration for anaerobic pneumonia?
Body position
32
What does an air-filled cavity in lung suggest?
Abscess
33
What does the presence of multiple areas of cavitation within an area of consolidation lead the NP to suspect?
Necrotizing pneumonia
34
The presence of purulent pleural fluid accompanying either lung abscess or necrotizing pneumonia would indicate what complication (anaerobic pneumonia)?
Empyema
35
Treatment for anaerobic pneumonia
1st line: IV clindamycin q8hr OR Augmentin q12hr
Alternative: Amox or PCN G + metronidazole (flagyl)
36
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)
37
Key symptoms of pleuritis
localized pain, sharp, fleeting - worse with coughing, sneezing, deep breaths or movement; diaphragmatic involvement = referred ipsilateral shoulder pain
38
Cause of pleuritis in healthy, young adults?
viral resp infection or pneumonia; simple rib fracture
39
Treatment for pleuritis
Treat underlying dx
-Pain: analgesics/NSAIDs (indomethacin, etc.)
-Control cough: codeine or other opioid; promitozine cough syrup
40
What would you do if pleural effusion, pleural thickening, or air in pleural space observed?
REFER!!
41
Definition of Pleuritis
Inflammation of pleural lining
42
Definition of Pleural effusion
collection of fluid in pleural space
43
Risk factors associated with pleural effusion
chest pain + pleuritis, trauma, or infection
44
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
45
Sx associated with pleural effusion?
Unilateral chest pain, worse with inspiration or deep breathing; dullness to percussion; dec/absent breath sounds where effusion located
46
Pulmonary infiltrates - how do you diagnose in immunocompromised patient?
Sputum culture!
47
If no clinically apparent cause for pleural effusion, how is it diagnosed?
Thoracentesis
48
Symptoms of spontaneous pneumothorax
Acute UNILATERAL chest pain, dyspnea
UNILATERAL chest expansion
Decreased tactile fremitus
Hyperresonance
49
Types of spontaneous pneumothorax
Primary
Secondary
50
Signs and symptoms of small pneumothorax
mild tachycardia
51
Signs and symptoms of large pneumothorax
diminished breath sounds, decreased tactile fremitus, decreased movement of chest
52
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
53
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
54
Treatment for tension pneumothorax
chest tube under water seal drainage with suction (removed after air leaks subsides)
55
What causes risk of reoccurrence of pneumothorax?
Smoking, high altitudes, flying in unpressurized aircraft, scuba diving
56
What coexists with obstructive sleep apnea?
Obesity-hypoventilation syndrome (blunted ventilatory drive and increased mechanical load imposed upon the chest by obesity)
57
Patients with pulmonary venous thromboembolism have a history of what?
DVT
58
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)
59
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
60
Substances that could embolize to lung circulation causing PE?
-Air
-Amniotic fluid
-Fat
-Foreign bodies
-Parasite eggs
-Septic emboli
-Tumor cells
61
Risk factors for thrombus formation
-Venous stasis
-Injury to vessel wall
-Hypercoagulability
-Immobility
-Inc CVP ((Dec CO states, pregnancy)
-Inherited dx (factor V Leiden)
62
Labs/Diagnostic tests for suspected PE?
ECG
ABG
d-dimer
CXR
CT angiogram
Venous ultrasound (rule out proximal DVT)
63
Profound hypoxia with normal CXR in absence of lung disease - what are you suspicious for?
PE
64
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)
65
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)
66
What is the appropriate duration of therapy for patients with PE?
No standard
67
What is a major complication from treatment of PE? What should you be monitoring?
Hemorrhage; INR (target INR = 2.0-3.0)
68
What medication therapy is instituted for an established PE?
Rt-PA
Alteplase: thrombolytic therapy (high risk pts) --> choose if needs lifesaving tx
69
ABSOLUTE CONTRAINDICATIONS FOR THROMBOLYTIC THERAPY
active internal bleeding
stroke w/i past 2 months
70
MAJOR CONTRAINDICATIONS TO THROMBOLYTIC THERAPY
uncontrolled HTN
Surgery/trauma within past 6 weeks
71
Symptoms of RSV
-low-grade fever
-tachypnea
-wheezing
-apnea
-increased mucous secretion
72
Physiologic sx of RSV
hyperinflated lungs, decreased gas exchange, increased WOB
73
At what ages is RSV mortality highest?
<5yrs; >65yrs
74
Risk factors for RSV
prematurity
early RSV bronchiolitis in kids + family hx of asthma --> persistent airway reactivity in life
75
Wells Score - for patients with Modified Wells
1. Age <50yrs
2. HR <100bpm
3. Oxyhemoglobin saturation on room air >equal 95%
4. No prior hx of venous thromboembolism
5. No recent (w/i 4 weeks) trauma or surgery requiring hospitalization
6. No presenting hemoptysis
7. No estrogen therapy
8. No unilateral leg swelling
76
How is seasonal influenza spread?
Droplet
77
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
78
How long is the incubation period for seasonal influenza?
1-4 days
79
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
80
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
81
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
82
Treatment for avian influenza
Tamiflu
83
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
84
Adenovirus infections - when are you most likely to get sick with this illness?
Throughout the year
85
Incubation period of adenovirus
4-9 days
86
Type of adenovirus that is severe/fatal for chronic lung dx patients
Type 14
87
What virus is commonly associated with AOM?
RSV
88
What is a complication of seasonal influenza with kids?
Reye syndrome (type B)
89
Tx for influenza and how quickly it should be started
1. Tamiflu (drug of choice)
2. Zanamivir (relenza)
3. Adamantanes (amantadine & rimantadine) (not recommended d/t resistance in influenza A & B)
**begin medication within 48 hours of illness onset
90
Key symptoms of pneumococcal pneumonia (adults)
-productive cough
-fever
-rigors
-dyspnea
-early pleuritic chest pain
-bronchial breath sounds = EARLY SIGN
91
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
92
What type of bacteria is seen with pneumococcal pneumonia?
gram+ diplococci
93
What is the most common cause of community-acquired pyogenic bacterial pneumonia?
Pneumococcal
94
Risk factors for pneumococcal
alcoholism, asthma, HIV+, sickle cell, splenectomy, hematologic disorders
95
Tx for pneumococcal
Empiric abx pending isolation and identification of causative agent
-PO amoxicillin: uncomplicated cases; cephalosporins; PCN allergy = "mycins"
96
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
97
Bordetella pertussis "whooping cough" - age that this bacteria impacts
<2yrs
-adults and adolescents are reservoirs for infection
98
How is Bordetella pertussis spread? (mode of transmission)
Droplets
99
How long to sx last for Bordetella pertussis?
How many stages of Bordetella pertussis is/are there? What is/are the stages?
1. 6 weeks
2. 3 stages
-Stage 1 (Catarrhal)
-Stage 2 (paroxysmal)
-Stage 3 (convalescent)
100
Catarrhal stage of Bordetella pertussis
Stage 1
Insidious onset - lacrimation, sneezing, coryza (head cold), anorexia, malaise, hacking night cough that becomes diurnal
101
Paroxysmal stage of Bordetella pertussis
Stage 2
Bursts of rapid, consecutive coughs followed by deep, high-pitched inspiration (whoop)
102
Convalescent stage of Bordetella pertussis
Stage 3
Begins 4 weeks after onset with decrease in frequency and severity of paroxysms of cough
103
Is Bordetella pertussis gram+ or gram-?
Gram -
104
Is pneumococcal pneumonia caused by gram+ or gram- bacterial?
Gram +
105
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
106
Treatment for haemophilus species: sinusitis, otitis, respiratory tract infection
Amoxicillin PO
107
Treatment for haemophilus species: beta lactamase strains
Augmentin PO
108
Who is at risk to develop Legionnaires disease?
Immunocompromised, smokers, chronic lung disease
109
Symptoms of Legionnaires disease
high fever
grossly purulent sputum
pleuritic chest pain
toxic appearance
110
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)
111
What is the 3rd most common cause of CAP?
Legionnaires disease
112
How is Legionnaires disease spread?
Contaminated water sources, air conditioning cooling towers
113
What do labs show for Legionnaires disease? (3)
-hyponatremia
-elevated liver enzymes
-elevated CK (enzyme)
114
Treatment for Legionnaires disease
Azithromycin PO
Clarithromycin
Fluoroquinolone
*for 10-14 days
**NO ERYTHROMYCIN
115
What antibiotic do you not use to treat Legionnaires disease?
Erythromycin - failure of tx and SE
116
Treatment for haemophilus species: more seriously ill patient (toxic patient with multilobe pneumonia)
ceftriaxone IV
117
Treatment for Bordetella Pertussis
Abx: erythromycin, azithromycin, clarithromycin, or Bactrim
118
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)
119
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
120
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
121
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
122
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
123
Empiric antibiotics for CAP bacterial (outpatient) - comorbidities
1. Macrolide or doxycycline + oral beta-lactam (Augmentin, cefpodoxime, cefuroxime)
2. Oral fluoroquinolone
124
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)
125
Pediatrics: 4 components of a respiratory exam
1. inspection
2. palpation
3. auscultation
4. percussion
126
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
127
How much longer is expiratory time vs inspiratory time?
2x longer
128
What imaging test remains the FOUNDATION of investigating pediatric thorax?
CXR
129
What CXR views should be ordered?
Frontal (posterior and anterior) and lateral
130
What does a CXR show in pediatric patients? (5)
Chest wall abnormalities, heart size and shape, mediastinum, diaphragm, and lung parenchyma
131
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)
132
When an FNP wants to differentiate croup from epiglottitis, what should the FNP order?
Lateral neck radiographs
-can see "thumbprint sign" with epiglottitis
133
When assessing vascular or bronchial anatomical abnormalities, what should FNP order?
MRI
134
When assessing regional ventilation and perfusion - detect vascular malformations and pulmonary emboli, what should the FNP order?
Ventilation-perfusion scans
135
OSA in children - higher risk when have any of the following comorbities
obesity
down syndrome
craniofacial abnormalities
Neuromuscular disorders
Sickle cell disease
mucopolysaccharidoses
136
How is OSA dx?
polysomnogram (PSG)
137
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
138
Foreign body aspiration (upper airway) key findings
abrupt onset, hx of child running with food in mouth or playing with seeds/small coins/toys
139
Symptoms of foreign body aspiration (upper airway)
inability to vocalize or cough, cyanosis with distress (complete obstruction)
drooling, stridor
140
Highest risk (age) for foreign body aspiration upper airway?
6mo-3yr
141
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)
142
Complete obstruction FB upper airway >1yr - what should be done
abdominal thrusts (heimlich maneuver)
143
Complete obstruction (any age) FB upper airway - what should be done if unresponsive?
-finger sweep?
CPR
**never perform a blind finger sweep
144
Foreign body aspiration (lower airway) key onset
sudden onset of coughing, wheezing, respiratory distress
-asymmetrical breath sounds (decreased) or localized wheezing
145
What should we suspect if child has chronic cough, persistent wheezing, or recurrent pneumonia?
Foreign body aspiration (lower airway)
146
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
147
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
148
If CXR is normal, does that rule out FB?
NO!
149
FB aspiration dx is based on 2 or 3 findings:
1. hx of possible aspiration
2. focal abnormal lung exam
3. abnormal CXR
=REFER for bronchoscopy
-if suspected FB aspiration, admit to hospital for evaluation
150
What is given to the pediatric patient who had FB aspiration after removal?
b-adrenergic neb treatments + chest PT
151
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
152
what is the character presentation of croup? (3)
is evaluation urgent, emergency, or casual?
inspiratory stridor, barking "seal" cough and retractions at rest
URGENT
153
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
154
What physiologic changes does croup cause to the airway?
edema in subglottic space
155
What precedes croup?
URI (leads to barking cough and stridor)
156
What finding should you not see with croup?
Fever
157
A patient with mild croup becomes agitated during physical exam, what do you expect to occur?
Stridor
158
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)
159
What signs in a patient would indicate a diagnosis of croup vs epiglottitis?
Presence of cough and absence of drooling
160
What diagnostic imaging should the FNP obtain for patient with suspected croup?
Classic presentation of croup does not require CXR
161
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
162
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
163
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
164
Epiglottitis key symptoms
Sniffing dog position/tripod position; sudden onset of high fever, dysphagia, drooling, muffled voice, inspiratory retractions, cyanosis, soft stridor
165
What vaccination helps fight against epiglottitis?
HiB
166
What are the causative agents of epiglottitis?
H influenzae (in unimmunized children) OR nontypeable H influenzae, N meningitis, or Streptococcus species (immunized population)
167
With epiglottitis, the FNP knows a definitive dx can be made by?
direct inspection of epiglottis during intubation by airway specialist
168
What physical finding is observed in patient with epiglottitis?
Cherry-red and swollen epiglottis and swollen arytenoids
169
In stable patient with epiglottitis, what type of imaging should FNP order? What classic sign is observed?
-CXR lateral neck
-Thumbprint sign
170
Intervention of epiglottitis in children?
Intubation (keep as calm as possible)
171
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
172
What can viral croup progress into? What does that progress into?
Bacterial tracheitis; SUDDEN RESPIRATORY ARREST
173
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
174
If patient is managed outpatient for CAP, what does the follow-up timeline look like?
Close follow-up w/i 12hr-5d
175
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)
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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)
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Peds: What is the MOST common organism associated with empyema?
S pneumoniae
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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
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Peds: With large effusions, what does the FNP expect to see?
tracheal deviation to the contralateral side
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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)
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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
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What is the MOST common organism associated with mycoplasma pneumonia?
M pneumoniae
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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
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What treatment should be provided for mycoplasma pneumonia?
Supportive measures and macrolide abx
-azithromycin
-Ciprofloxacin is alternative
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What is the gold standard for diagnostic testing for mycoplasma pneumonia?
PCR (depends on clinic)
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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)
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What is the most common serious acute respiratory illness in infants and young children?
Bronchiolitis
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What are the common causes of bronchiolitis (pediatrics)?
RSV (viral), parainfluenza, influenza, adenovirus, human metapneumovirus, several bacterial causes less common
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S/S bronchiolitis in pediatrics
Starts as URI: fever, rhinorrhea, and cough
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Risk factors for severe bronchiolitis?
age <12 weeks, hx of prematurity (<35 weeks), underlying cardiopulmonary disease, and immunodeficiency
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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
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What antiviral treatment is reserved for severely ill children with immune or anatomic cardiopulmonary defects?
Ribavirin antiviral aerosol treatment
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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
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When does SUID deaths peak? (at what age?)
2-4 months, most deaths occur at night
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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
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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
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Acute lymphonodular pharyngitis
-cause
-sx
-tx
-coxsackievirus A10
-febrile pharyngitis with NONULCERATIVE yellow-white posterior pharyngeal papules linearly along posterior palate
-supportive tx
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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
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Do you administer antibiotics, decongestants, expectorants, albuterol or systemic corticosteroids (unless asthmatic or premature infant) in pediatric patients with RSV?
NO
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Common sx in infants with meningitis
high-pitched cry
