Module 7 - respiratory Flashcards
An 18-month-old boy with no known medical conditions is brought in by his parents with a runny nose, cough, fever, and poor feeding for the past two days. He is developing well with no delay in achieving developmental milestones. Vital signs are notable for a heart rate of 160 bpm, respiratory rate of 42 breaths/min, and temperature of 101 F (38.3 C). Examination demonstrates accessory muscle use and wheezing. Rapid influenza testing is negative. What is the most appropriate treatment for this infant’s suspected condition?
1. Supportive care
2. Ribavarin
3. Pavilizumab
4. Respiratory syncytial virus immune globulin intravenous (RSV-IGIV)
- Supportive care
POINTS
- The mainstay of treatment for patients with respiratory syncytial virus (RSV) infection is supportive care.
- The spectrum of supportive care includes nasal suction and lubrication to relieve nasal congestion, antipyretics for fever, assisted hydration in the event of dehydration (assistance may be by mouth, nasogastric tube, or intravenously), and oxygen for patients experiencing hypoxia.
- Ribavirin is an antiviral drug used for severe RSV infection. It can also be used for RSV infection in immunocompromised patients, but the patient in this vignette is immunocompetent.
- Pavilizumab is used for RSV prophylaxis in select patients.
A 16-year-old boy presents with a continuous, productive, and choking cough for the past three days. These coughing spells result in cyanosis, vomiting, and fatigue. In addition, a long inspiratory effort with a high-pitched “whooping” cough is observed. During what time of the year does this disease generally occur?
- Winter and spring
- Spring
- Summer and autumn
- Autumn
- Summer and autumn
POINTS
- Pertussis is a highly contagious disease that tends to occur in cycles every two to five years. Patients present with a continuous, productive, and choking cough.
- These coughing spells result in cyanosis, vomiting, and fatigue. A long inspiratory effort with a high-pitched “whooping” cough is the hallmark of pertussis. The peak incidence of pertussis is during the summer and fall months, although it can occur all year round.
- Neither acquisition of the infection nor vaccination provides 100% immunity.
- Protection wanes after two to five years and is not measurable after 12 years.
A 1-year-old boy presents with low-grade fever, hoarse voice, and barking cough. Vital signs are a temperature of 100 F (37.8 C ), heart rate of 140 bpm, and respiratory rate of 30 breaths/min. Physical examination reveals suprasternal and intercostal retractions with inspiratory stridor. Endoscopy shows deep red mucosa and subglottic edema. The etiology of this patient’s condition is associated with which of the following diseases later in life?
1. Lung cancer
2. Asthma
3. Sarcoidosis
4. Pulmonary fibrosis
- Asthma
POINTS
- The clinical condition described in this infant is croup. The human parainfluenza virus (HPIV) is one of the major causes of this croup.
- Early childhood infection with parainfluenza virus or respiratory syncytial virus is strongly associated with asthma and COPD (chronic obstructive pulmonary disease) later in life. Exacerbations of these diseases correlate with the presence of viral RNA in the lung.
- The HPIV is an enveloped, negative-sense single-stranded RNA virus belonging to the paramyxoviruses family.
- It is classified into four serotypes: HPIV-1, HPIV-2, HPIV-3, and HPIV-4. It can cause upper and lower respiratory tract infections in children, usually under 5 years of age.
A 17-year-old male patient presents with complaints of a persistent night-time cough and wheezing. He has had asthma since childhood. His last visit was three months ago, and his symptoms were well-controlled on medium-dose inhaled corticosteroid and long-acting beta 2 agonist plus as-needed short-acting beta 2 agonists. However, now he is more short of breath with morning dipping of his peak flow readings. On examination, he is mildly dyspneic but able to complete sentences. On auscultation, there are scattered wheezes in his chest. His peak expiratory flow rate is 65% of predicted. What is the most appropriate next step in the management of this patient?
- Add oral theophylline and oral corticosteroid
- Add a long-acting muscarinic antagonist to the current regimen
- High dose inhaled corticosteroid and long-acting beta 2 agonist plus a long-acting muscarinic antagonist or anti-IgE
- Admit to the hospital for continuous nebulized albuterol and intravenous corticosteroids
- High dose inhaled corticosteroid and long-acting beta 2 agonist plus a long-acting muscarinic antagonist or anti-IgE
POINTS
- Initially, the patient may also require oral corticosteroids. High-dose inhaled corticosteroids with long-acting and short-acting beta-agonists would be appropriate. This can be followed by muscarinic antagonists such as ipratropium bromide if needed.
- There are five steps in the management of chronic asthma, treatment is started depending on the severity and then escalated or de-escalated depending on the response to treatment.
- This patient is at step 4 of asthma management which comprises of medium-dose inhaled corticosteroid and long-acting beta 2 agonist plus as-needed short-acting beta 2 agonists.
- His medications need to be escalated to step 5 which includes high dose inhaled corticosteroid and long-acting beta 2 agonist plus a long-acting muscarinic antagonist or anti-IgE.
The mother of a 10-year-old girl calls because the child has been coughing more frequently over the past two days, especially at night. The symptoms improve for about four hours after the child uses albuterol with a metered-dose inhaler. She is still active, does not complain of shortness of breath, and does not seem to be in respiratory distress. The child’s medical history is significant for asthma diagnosed five years ago. She has never been hospitalized and has not been treated in the emergency department in the past year. Her medications include inhaled fluticasone 44 mcg 2 puffs twice a day and albuterol MDI as needed. She has not checked her peak flow rate in the past few days and does not have a written asthma action plan. What advice should be given to the mother as the most appropriate next step in managing this child?
- Bring your daughter to the clinic for a possible five-day course of oral prednisone.
- Take your daughter to the nearest healthcare provider for urgent evaluation.
- Check your daughter’s peak flow rate now and await further instructions.
- Give 2 puffs of albuterol now and again in 15 minutes. Call back if your daughter’s condition does not improve.
- Check your daughter’s peak flow rate now and await further instructions.
POINTS
- The most common chronic illness of childhood is asthma, accounting for more unplanned pediatric admissions than any other disease.
- This child is exhibiting signs of an asthma exacerbation. She has increased nocturnal cough and has been using albuterol every four hours. Checking a peak flow rate will provide more objective data in determining the best next step in management.
- Asthma action plans, including peak flow monitoring, can help guide therapy and escalation of care. An asthma action plan should be tailored to the individual patient, taking into account the patient’s severity of disease and risk factors for a severe or fatal asthma exacerbation.
- This child does not have risk factors associated with a high likelihood of a severe or fatal asthma exacerbation (e.g., history of hospitalization, or recent emergency department visit). She is responding to her current therapy and is not showing obvious signs of distress. Therefore, she does not require emergent evaluation, a course of oral corticosteroids, or multiple doses of albuterol.
A 6-month-old infant was brought to the hospital with recurrent episodes of shortness of breath. These episodes started first at 7 weeks and have occurred many times resulting in previous hospitalizations. Further questioning reveals that during her last admission two months ago, a nasal swab was taken, which came back positive for the respiratory syncytial virus. She was delivered at term, and there were no complications during or after her birth. Vital signs reveal blood pressure 95/75 mmHg, pulse 120/min, temperature 39 C (102.2 F), and oxygen saturation 94% at room air. On auscultation of the chest, a prolonged expiratory phase with an end-expiratory wheeze was heard. A chest x-ray was ordered subsequentially. What is the most likely finding that can be seen on a chest x-ray in this case?
- Bilateral consolidation
- Blunting of costo-phrenic angles
- Hyper-expansion of lungs and interstitial haziness
- Enlarged cardiac silhouette
- Hyper-expansion of lungs and interstitial haziness
POINTS
- Respiratory syncytial virus (RSV) is the most common cause of bronchiolitis in infants. It occurs most frequently in the winter months and affects the lower respiratory tract.
- Bronchiolitis is a clinical diagnosis. A chest x-ray may be indicated depending on the degree of respiratory distress that is present, but further work-up is rarely recommended.
- In cases where a chest x-ray is required, it shows hyper-expansion of lung fields along with interstitial markings consistent with bronchiolitis. The rest of the chest x-ray findings are usually normal.
- The management is usually supportive despite positive chest x-ray findings. Maintaining hydration and oxygen saturation is the mainstay of treatment.
A 4-year-old girl is brought in by her parents with fever, cough, and noisy breathing over the last three days. Her parents report that the noisy breathing is more prominent when she is agitated. There is no reported throat pain, chest pain, drooling, or trauma in their child. She is up to date with her vaccinations. On examination, she is alert and non-ill appearing. Her vitals include a temperature of 101 F (38.3 C) and oxygen saturation of 97% on room air. She demonstrates inspiratory stridor when agitated, which disappears when she is at rest and consoled by her parents. No wheezing is appreciated during lung auscultation. A chest x-ray is negative for acute infiltrates, and a neck x-ray is notable for the steeple sign. Respiratory syncytial virus, influenza virus, and COVID testing are negative. What is the most appropriate treatment for this child?
- Oral dexamethasone monotherapy
- Nebulized epinephrine monotherapy
- Nebulized albuterol monotherapy
- Oral dexamethasone plus nebulized epinephrine
- Oral dexamethasone monotherapy
POINTS
- This patient with inspiratory stridor and the steeple sign is suggestive of croup. The steeple sign refers to a symmetrical narrowing of the subglottic airway seen in croup on an anteroposterior neck radiograph and can be seen in around 50% of patients.
- Croup is another name for laryngotracheobronchitis. It commonly has a viral etiology, the most common being the parainfluenza virus. Other causes include influenza A and B, measles, adenovirus, and respiratory syncytial virus (RSV).
- The most commonly used system for classifying the severity of croup is the Westley croup score ranging from 0 to 17 points divided by five factors: stridor, retractions, cyanosis, level of consciousness, and air entry. This child has a Westley score of 1 (inspiratory stridor on agitation).
- Children with mild croup defined as a Westley croup score of less than 2 are given a single dose of oral dexamethasone.
Children with moderate to severe croup are given oral dexamethasone plus nebulized epinephrine. Nebulized albuterol plays no role in the treatment of croup.
A 16-year-old patient has been on step 2 of asthma management for 5 months, but he keeps getting acute attacks every week. Now he presents with shortness of breath and inability to sleep because of a persistent cough. On examination, respiratory rate is 24/min, oxygen saturation 92% on room air, and rhonchi all over the chest. Which of the following options is most appropriate for the next step in management?
- Oral corticosteroids
- Inhaled corticosteroids
- Long-acting beta-agonist
- Check the correct inhaler technique
- Check the correct inhaler technique
POINTS
- Children with intermittent asthma have respiratory symptoms less than 2 days/week, no nighttime respiratory symptoms, no limitation in day-to-day physical activity, and 0-1 asthma exacerbations/year. These children should be treated with inhaled short-acting bronchodilator medication such as albuterol via inhalation. It should be available for rescue on an as-needed basis. Oral administration of albuterol is not recommended because it has a slower onset of action and a higher rate of side effects as compared to the aerosol preparation. When given as an aerosol, albuterol provides relief of acute asthma symptoms in five to 15 minutes and lasts for approximately four to six hours.
- Children with persistent asthma have respiratory symptoms ranging from greater than 2 days/week to daily or several times/day, night times awakenings greater than 2 times a month, minor to significant limitation to normal daily activity 2 or more asthma exacerbations in 6 months, or wheezing 4 or more times/year lasting for more than 1 day and risk factors for persistent asthma as defined in the introduction. Steps two through four describe controller treatment recommendations for children with persistent asthma. A short-acting beta-2 agonist should also be available for rescue for asthma exacerbations.
- In step two, a low-dose inhaled corticosteroid (ICS) is the preferred initial treatment to achieve asthma control. It should be given for at least three months to establish effectiveness. Although pressured metered-dose inhaler with a dedicated spacer is the preferred device in children, a nebulizer with a facemask/mouthpiece can also be used in children who cannot be taught the effective use of a spacer device.
- Step three is considered if asthma control is not achieved within three months of step two care. In these cases, doubling the initial low dose of ICS may be the best option. Alternatively, the addition of daily leukotriene receptor antagonists (LTRA), such as montelukast, to low-dose ICS can be considered in children with a history of allergic rhinitis or other atopic history. Before any step-up therapy, it is important to consider an alternative diagnosis, check the correct inhaler technique, confirm good medication adherence, and enquire about risk factors such as exposure to allergens or cigarette smoke.
A 17-year-old girl has had a cough associated with exercise for four months. She started an exercise program 4 months ago as part of a weight loss program. Exercise includes walking on a treadmill at the fitness center. She has seasonal allergies with current rhinorrhea and sometimes has a cough at night, for which she takes diphenhydramine. Past medical history includes allergic rhinitis and gastroesophageal reflux disorder. Medications include as-needed famotidine and diphenhydramine. She occasionally has white sputum. Her vitals are normal, and her body mass index (BMI) is 35.6. Exam shows mildly erythematous nasal turbinates and pharynx. Lungs are clear. What is the next best step to elucidate the cause of her cough?
- Chest radiograph
- Spirometry before and after bronchodilator use
- Serum IgE
- Trial of antihistamine
- Spirometry before and after bronchodilator use
POINTS
- This patient with a history of allergies and new onset of cough after starting an exercise program likely has asthma and/or a nasal cause of her cough, including allergic rhinitis, exercise-induced rhinosinusitis, or upper airway cough syndrome versus exercise-induced bronchoconstriction (EIB). Cough that occurs at night is more indicative of asthma, allergic rhinitis, or gastroesophageal reflux disorder. The environment in which she is exercising and the type of exercise, walking, which is less likely to induce the large increase in ventilation that is the root cause of EIB in susceptible individuals, puts her at low risk for EIB. CHEST guidelines recommend the evaluation of cough in adolescent athletes, including asthma, EIB, respiratory tract infection, upper airway cough syndrome, and environmental exposures.
- Spirometry before and after the use of bronchodilators can help to confirm the diagnosis of asthma. Up to 90% of people with asthma experience Exercise-induced bronchoconstriction (EIB). Exercise testing with spirometry, specifically changes in FEV1, can be undertaken in the future for a diagnosis of EIB.
- The patient likely also has an allergic component to her presentation. Upper respiratory tract infections are also more common in people with EIB due to inflammatory changes to the lung tissue, including increased mucus production.
- To appropriately diagnose and treat this patient, the entire airway from nose to lung must be considered.
A 2-year-old child is evaluated due to cough and harsh breathing sounds. The symptoms started with a runny nose and sneezing 3 days ago but have developed into hoarseness, barky cough, and noisy breathing. Medical history is not significant, and family history is noncontributory. Her blood pressure is 95/70 mmHg, pulse 90 beats per minute, respirations 27/minute, and temperature 37.9 C (100.2 F). Physical exam reveals audible stridor at rest and subcostal retractions but no signs of cyanosis or distress. The throat exam is clear and within normal limits. What is the most common cause of her condition?
- Hemophilus influenzae
- Respiratory syncytial virus
- Influenza virus
- Parainfluenza virus
- Parainfluenza virus
POINTS
- Croup, a childhood upper respiratory infection, is most commonly caused by the parainfluenza virus.
- Croup is characterized by a “seal-like barking” cough, stridor, hoarseness, and difficulty breathing, which typically worsens at night. Agitation worsens the stridor, and it can be heard at rest. Other symptoms include fever and dyspnea, but the absence of fever should not reduce suspicion for croup.
- Children with mild croup are given a single dose of dexamethasone. Children with moderate to severe croup are given nebulized epinephrine in addition to dexamethasone.
- The respiratory syncytial virus is a less common cause of croup and is more associated with bronchiolitis. Hemophilus influenza is the most common cause of epiglottitis which is an emergency and presents with more severe scenarios and distressed patients.
A 2-year-old child is suspected of having aspirated a radiolucent foreign body, but the chest radiograph is normal. The child has a cough, and asymmetric breath sounds on exam. Select the correct statement.
1. There could still be a foreign body
2. Bronchoscopy is contraindicated
3. CT of the chest is the best choice for diagnosis
4. Admit the child for observation
- There could still be a foreign body
POINTS
- Chest radiographs are often an initial measure for investigating for foreign body aspiration, given the relatively easy feasibility of obtaining this study. However, multiple studies have shown that chest radiographs in isolation are not sufficiently sensitive to rule out a foreign body aspiration.
- Chest radiographs have been shown to have a mediocre sensitivity and slightly better specificity for investigating for foreign body aspiration. A negative film does not rule out a foreign body aspiration.
- Chest CT is sometimes used in times of clinical ambiguity as opposed to bronchoscopy, given the benefit of not requiring any sedation. However, chest CT has been argued to be not as beneficial given the concern for radiation exposure and lack of therapeutic benefit. In a child with a suggestive history, symptoms, and negative radiographs, bronchoscopy is often performed for a definitive diagnosis.
- Observing the child without performing additional diagnostic workup may delay the diagnosis and place the patient had a higher risk for complications of a retained foreign body in the airways. One study has shown that the longer a foreign body remains in the airway, the higher the likelihood of a complication.
A 6-year-old boy is brought to the outpatient department by his parents due to snoring during his sleep. They state that his snoring has progressively gotten worse over three months. They have also noticed that their son randomly stops breathing during the night. These episodes of absent breathing last 10 to 15 seconds before he gasps and resumes his normal breathing. They also claim that their child has become more irritable and less social over the past few months. He has no significant past medical history other than the occasional sore throat and flu. His family history is positive for diabetes mellitus type 1 in an elder brother and diabetes mellitus type 2 in his father. His vaccinations are up to date, and his vital signs are normal. On examination, the abdomen is soft and non-tender with no organomegaly, S1 and S2 are audible with no added sounds, and the pulse has a normal volume, character, and rhythm. Examination of the head and neck reveals enlarged tonsils. What is the best diagnostic modality for this disease?
- Polysomnography
- MRI of the chest
- CT scan of the head and neck
- Fasting blood sugar level
- Polysomnography
POINTS
- This child most likely has obstructive sleep apnea (OSA).
- Children with obstructive sleep apnea (OSA) can have attention problems and behavioral abnormalities.
- In children, the most common cause of OSA is enlarged tonsils and adenoids.
- The primary treatment for OSA in a child is a tonsillectomy and adenoidectomy.
An 18-month-old girl presents with a 3-day history of cough and fever. She has been taking fluids but is not hungry. She was born in Sudan and came to the United States six months ago. The only medication her parents have given her is acetaminophen. She has no significant medical or travel history. Her temperature is 38.5 C (101.3 F) Physical exam findings are clear mucosa, dullness to percussion over the left lung with rhonchi, but no rashes or cardiac findings. Chest X-ray shows a left lower lobe infiltrate and opacification of the left lower half of the lung. What comorbidity should be considered?
1. Bruton agammaglobulinemia
2. HIV
3. Sickle cell anemia
4. Congenital heart disease
- Sickle cell anemia
POINTS
- Sickle cell disease can present with pneumonia or acute chest syndrome.
- A sickle cell prep or hemoglobin electrophoresis is indicated.
- Bruton agammaglobulinemia X linked and very rare in girls.
- The child has no stated risk factors for HIV.
A 17-year-old man who has had a cough for two months now presents with worsening cough along with green-colored sputum. He has a history of allergic rhinitis. His parents are worried as the cough is not resolving. On examination, his throat is erythematous, the chest is clear on auscultation, and he has hypertrophied lower turbinates bilaterally. The frontal and maxillary sinuses are nontender. What is the cause of his persistent cough?
- Asthma
- Bronchitis
- Sinusitis
- Postnasal drip
- Postnasal drip
POINTS
- Upper airway cough syndrome is the most common etiology of a chronic cough. A broad spectrum of illnesses encompasses this disease, including allergic rhinitis, non-allergic rhinitis, post-infectious, and bacterial or viral rhinosinusitis. Essentially, upper airway cough syndrome is a longstanding post-nasal drip that irritates the upper airway, inducing cough.
- It can be caused by rhinitis, sinusitis, laryngopharyngeal acid reflux, or by a disorder of swallowing.
- Allergic rhinitis is an inflammation of the nasal mucosa secondary to an allergic irritation from the environment. This irritation leads to increased mucus secretion and post-nasal drip. It is the post-nasal drip that irritates the airways, stimulating a cough.
- Post-nasal drip occurs when the sinuses produce excessive mucus.
A 1-month-old girl presents with nasal congestion and increased work of breathing for the last three days. On examination, there is significant rhinorrhea, cough, bilateral wheezing on auscultation, and upper airway sounds in both lung fields. Her elder sister had a cough and flu last week. Her mother is adamant that the child have further blood and radiographic testing. Oxygen saturation is 97%. What is the most appropriate next step in the management of this patient?
1. Obtain a chest radiograph
2. Obtain serum for a viral polymerase chain reaction
3. Admit the patient for continuous pulse oximetry and aggressive pulmonary hygiene
4. Reassure the mother that her child’s condition is a clinical one and is self-limiting
- Reassure the mother that her child’s condition is a clinical one and is self-limiting
POINTS
- Acute bronchiolitis is a clinical diagnosis.
- A good history of present illness and clinical manifestations will aid in the diagnosis.
- A viral study of nasal secretions is the best study to help identify the most commonly affecting virus. Direct immunofluorescent antibody (IFA) staining or an enzyme-linked immunosorbent assay (ELISA) is most commonly used and provides quick results.
- Chest x-rays are not routine. If done, they will show nonspecific findings such as hyperinflation of the lungs, interstitial markings, and peribronchial thickening. The use of chest radiographs and continuous pulse oximetry may lengthen the length of stay and bedside anxiety
