Pulm

Question 1

Asthma definition and types

Answer 1

Asthma: chronic inflammatory disease characterized by bronchial hyperresponsiveness, episodic exacerbations, & reversible airflow obstruction
▪︎5-10% of US population, black > white

PATHO: inflammatory disease driven by T-helper 2 (TH2)
▪︎♂ > ♀ in patients <18yo cells in individuals w/ a genetic predisposition

Allergic Asthma (MC): begins w/ intermittent symptoms
➀ airway hyperreactivity
in childhood & usually associated w/ atopy
➁ inflammation
▪︎IgE-mediated type 1 hypersensitivity to an allergen ➂ bronchoconstriction
▪︎mast cell degranulation & histamine release
Risk Factors: ATOPY**

Nonallergic Asthma (uncommon): onset >40yo, not
▪︎family hx, tobacco smoke
related to atopy, poor response to standard treatment
▪︎obesity, pollution, male

Nitric Oxide (NO): eosinophilic airway inflammation associated w/ asthma leads to up-regulation of NO synthase in the respiratory mucosa, which generates ⇡ amounts of NO gas in the exhaled breath

Occupational Asthma (OA): begins in adulthood, induced by immunologic/nonimmunologic stimuli in the workplace
▪︎Immunologically-Mediated OA: IgE & non-IgE-mediated responses following chronic exposure & respiratory
sensitization to high or low molecular weight agents (e.g., flour, latex)
▪︎Nonimmunologic, Irritant-Induced Asthma (IIA): chronic, caused by multiple exposures to an irritant (e.g., chlorine,
dyes & bleaches, tobacco/wood smoke) *reactive airway dysfunction syndrome (RADS) is acute form of IIA

TRIGGERS:
Allergic (Extrinsic) Asthma: Nonallergic (Intrinsic) Asthma:
▪︎cardinal risk factor ⇢ atopy ▪︎viral respiratory infections, cold air, exercise, GERD
▪︎environmental: pollen, dust mites, animal dander, mold ▪︎ASA/NSAIDs, beta blockers, stress & anxiety

Asthma Exacerbation: a typically reversible episode of lower airway obstruction (bronchospasm) characterized by a worsening of asthma symptoms within a short period of time & accompanied by a change in baseline lung function
Status Asthmaticus: severe exacerbations that progress rapidly & do not respond to standard acute asthma therapy

Question 2

Asthma sx

Answer 2

4 classic sx: wheezing, cough, SOB, chest tightness

HX: pattern of respiratory symptoms that occur following exposure to triggers (e.g., allergen, exercise, viral infection) & resolve w/ trigger avoidance or asthma medication

PE: widespread, high-pitched, musical wheezes
▪︎MC w/ expiration, characteristic of asthma
▪︎usually absent between exacerbations
Other possible findings:
▪︎prolonged expiratory phase
▪︎hyperinflation, hyperresonance to percussion

Severe (exacerbation/status asthmaticus):
▪︎tachypnea >30, tachycardia >120bpm
▪︎accessory muscle use, tripod, diaphoresis
▪︎poor air movement ⇢ “silent chest”
▪︎pulsus paradoxus (SBP ⇣ >12mmHg w/ inspiration)

Question 3

Signs of impending respiratory failure

Answer 3

Cyanosis
inability to maintain respiratory effort
depressed mental status
SPO2 less than 90
PEF less than 25%
PaCO2 greater than 40

Question 4

Asthma dx

Answer 4

DX: asthma S/SXS + reversible airflow obstruction

Pulmonary function tests (PFTs):
➀ Spirometry ⇢ obstructive pattern
⇣ FEV1/FVC ratio, ⇣ FEV1, FVC ~normal

FEV1 > 70 = mild
FEV1 50-70 = moderate
FEV1 35-50% = severe
FEV1<35% = very severe

➁ Bronchodilator response ⇢ reversible obstruction
⊕reversibility = ⇡ FEV1 ≥12% after SABA
➂ Bronchoprovocation ⇢ airway hyperresponsiveness
▪︎provocative stimulus (e.g., inhaled methacholine,
inhaled mannitol, exercise)
⊕hyperresponsiveness = ≥20% ⇣ FEV1 after stimulus

Nitric Oxide: fraction exhaled NO ⇢ FENO
⊕ = ⇡ FENO (≥40-50ppb) *normal level does not exclude asthma

DX: asthma exacerbation ⇢ ABG
▪︎initial: respiratory alkalosis, +/- hypoxemia
▪︎late/severe: respiratory acidosis, PaO2 <60mmHg,
PaCO2 >40-45mmHg

Peak expiratory flow (PEF):
▪︎best method to assess exacerbation severity/response
▪︎normal ~400-600 L/min, differs w/ age & sex
Severe obstruction ⇢ <200 L/min
PEF ≤50% predicted

Question 5

Asthma tx

Answer 5

Initiating TX: based on frequency & severity of symptoms, Monitoring: routine f/u q1-6mo depending on symptom severity
history of exacerbations, & results of PFTs & adequacy of control; assess symptoms over last 4wks each visit
▪︎LABAs NEVER USED AS MONOTHERAPY, ALWAYS W/ ICS* ▪︎inadequate response ⇢ always check inhaler technique*
TX:
1. SABA PRN ⇢ all patients*
▪︎nighttime awakenings ≤2x/m
2. + low-dose ICS
3. + low-dose ICS/LABA
4. + medium-dose ICS/LABA
5 + high-dose ICS/LABA
6+ high-dose ICS/LABA + PO steroids

IV magnesium ⇢ indications: life-threatening exacerbations or severe exacerbations w/ no improvement after 1h of intensive

Question 6

SABA MOA and meds

Answer 6

Albuterol (ProAir HFA, ProAir RespiClick, Ventolin HFA, Proventil HFA)
Levalbuterol (Xopenex)

MOA: binding at beta-2 receptors causes relaxation of bronchiole smooth muscle/bronchodilation
Indications: ALL PATIENTS W/ ASTHMA, used PRN for acute symptoms (quickly reverses bronchospasm)

Caution: CVD, glaucoma, hyperthyroidism, seizures, diabetes
ADRs: nervousness, tremor, tachycardia, palpitations, cough, hyperglycemia, hypokalemia

Question 7

SAMA meds, MOA, ADR

Answer 7

Ipratropium (Atrovent HFA)

MOA: block constricting action of acetylcholine at M3 receptors in bronchial smooth muscle resulting in bronchodilation; also ⇣ mucus secretion
Indications: may be used in combination w/ SABAs during exacerbations

Warnings: Myasthenia gravis, narrow-angle glaucoma, urinary retention, BPH, bladder neck obstruction
ADRs: dry mouth, blurred vision, thirst, dry eyes

Question 8

Inhaled Corticosteroids (ICS) meds, MOA, ADR

Answer 8

Fluticasone (Flovent HFA/Diskus, Arnuity Ellipta)
Budesonide DPI (Pulmicort Flexhaler)
Beclomethasone (Qvar)
Mometasone (Asmanex HFA)
Ciclesonide (Alvesco HFA)

MOA: block late-phase reaction to allergen, reduce airway hyperresponsiveness, potent & effective anti-inflammatory medications; ⇣ symptoms, ⇡ lung function, improve QOL, & reduce risk of exacerbations
Indications: FIRST LINE for long-term maintenance therapy, initiated in step 2

Contraindications: primary treatment of status asthmaticus or acute episodes of asthma

Warning: high doses for prolonged periods may cause adrenal suppression; ⇡ risk of fractured, stunted growth in children
ADRs: dysphonia (difficulty speaking), sore throat, reflex cough, oral candidiasis, bronchospasm

Monitoring: s/sxs of thrush, adrenal insufficiency, BMD

Question 9

PO Steroids meds, MOA, ADR

Answer 9

Methylprednisolone
Prednisone
Prednisolone

Indications: short courses used for acute exacerbations
IV ⇢ indicated in patients w/ impending or actual respiratory arrest or intolerant to PO steroids

ADRs: HTN, hyperglycemia, sodium/fluid retention

Question 10

Leukotriene Receptor Antagonists (LTRAs) meds, MOA, ADR

Answer 10

Montelukast (Singulair)
Zafirlukast (Accolate)
Zileuton (Zyflo)

MOA: inhibit leukotriene mediators of airway inflammation; help ⇣ airway edema, constriction, & inflammation
▪︎Montelukast: inhibits leukotriene D4
▪︎Zafirlukast: inhibits leukotriene DR & E4
▪︎Zileuton: a lipoxygenase inhibitor & inhibits leukotriene formation
Indications: effective for exercise-induced asthma & aspirin-induced asthma

Contraindications (zafirlukast, zileuton): hepatic impairment

Warnings: neuropsychiatric events (aggression, agitation, hallucinations, depression, suicidality)

ADRs: HA, dizziness, ⇡ LFTs

Question 11

Mast Cell Stabilizers meds, MOA, ADR

Answer 11

Cromolyn sodium
Nedocromil sodium

MOA: prevent release of inflammatory mediators from mast cells
Indications: prophylaxis before exercise or allergen exposure, effective 1-2h after dose

ADRs: throat irritation, cough

Question 12

Methyl-xanthines meds, MOA, ADR

Answer 12

Theophylline

MOA: blocks phosphodiesterase causing ⇡ cAMP & release of epinephrine from adrenal medulla cells; results in bronchodilation but also causes diuresis, CNS/cardiac stimulation, & gastric acid secretion

Indications: least desirable option for add-on therapy d/t significant ADRs, drug interactions, & need for close level monitoring *narrow TI ⇢ toxicity causes arrhythmias & seizures

Warnings: may exacerbate CVD, hyperthyroidism, PUD, & seizure disorders
ADRs: N/V, HA, tachycardia, insomnia, tremor, nervousness

Question 13

Anti-IgE monoclonal antibody meds, MOA, ADRs

Answer 13

Omalizumab (Xolair)

MOA: inhibits IgE binding to IgE receptor on mast cells & basophils; prevents activation/release of mediators in the allergic response
Indications: IgE 30-700IU/mL, ⊕skin test to perennial allergen, & incomplete symptom control w/ ICS

BOXED WARNING: anaphylaxis
ADRs: injection site reactions, arthralgias, generalized pain, dizziness, fatigue

Question 14

Anti-IL5 monoclonal antibodies meds, MOA, ADR

Answer 14

Mepolizumab (Nucala)
Reslizumab (Cinqair)
Benralizumab (Fasenra)

MOA: IL5 is a major cytokine responsible for growth, differentiation, recruitment, activation, & survival of eosinophils which are associated w/ inflammation & an important component in asthma pathogenesis
Indications:
▪︎Mepolizumab ⇢ peripheral blood eosinophils ≥150/µL
▪︎Reslizumab ⇢ peripheral blood eosinophils ≥400/µL
▪︎Benralizumab ⇢ peripheral blood eosinophils ≥150/µL

BOXED WARNING: anaphylaxis

ADRs: injection site reactions, HA, human anti-human antibody (HAHA) development, fever, hypersensitivity

Question 15

Anti-IL4 monoclonal antibody meds, MOA, ADR

Answer 15

Dupilumab (Dupixent)

MOA: inhibits IL4 & IL13 type 2 cytokines that play a key role in allergy & asthma through blockade of IL4 receptor; reduces asthma exacerbations, enables PO steroid tapering, & improves lung function
Indications: peripheral blood eosinophils ≥150/µL

Warnings: arthralgia including gait disturbances, eosinophilia & vasculitis
ADRs: HAHA development, injection site reactions, conjunctivitis, keratitis, oral HSV infection

Question 16

Acute Bronchiolitis definition, sx, dx, tx

Answer 16

*infection & inflammation of the bronchioles

Etiologies: RSV MCC
*Rhinovirus, Adenovirus, Influenza virus, Parainfluenza virus

Risk Factors: infants 2mo-2yrs MC affected
*<6mo in age, exposure to cigarette smoke, lack of breastfeeding, prematurity (<37wks), crowded conditions (day care)

sx
Viral prodrome (fever, URI sxs) for 1-2d 🡪 respiratory distress
*wheezing, tachypnea
*nasal flaring, cyanosis
*retractions, rales

Signs of severity:
*hypoxemia
*apnea
*respiratory failure

dx
Clinical

CXR: *nonspecific
*hyperinflation, peribronchial cuffing or thickening, atelectasis
*not routinely performed but may be used to r/o other causes

Nasal washings 🡪 monoclonal antibody testing

*pulse ox single best predictor of disease in children

tx
*supportive measures
*humidified oxygen
*IV fluids
*nebulized saline/racemic epi
*antipyretics

ADMIT:
*O2 sat <95-96%, <3mo, RR >70, nasal flaring, retractions, to atelectasis on CXR

Prevention in high-risk:
*Palivizumab during the first year of life for children <29wks, symptomatic chronic lung disease of prematurity, congenital heart disease, neuromuscular difficulties, immunodeficiency

Question 17

Bronchiectasis definition, patho, causes, sx

Answer 17

Bronchiectasis: irreversible & abnormal dilation of bronchial tree that produces chronic respiratory symptoms
Acute Exacerbation: a deterioration in symptoms that require a change in regular treatment (e.g., adding antibiotics, ⇡ airway clearance techniques)

PATHO: 2 requirements
➀ an infectious insult
➁ impaired drainage, airway obstruction, or defect in host defense

Acquired bronchial obstruction: Congenital anatomical defects:
▪︎FB aspiration, tumors, COPD ▪︎bronchomalacia, bronchial cyst
▪︎hilar LAD (TB, histoplasmosis, sarcoidosis)
▪︎cartilage deficiency (Williams-Campbell)
▪︎allergic bronchopulmonary aspergillosis (ABPA)
Viral infections: adenovirus, influenza, HSV

Immunodeficiency states: Bacterial infections: S. aureus, pseudomonas
▪︎chronic granulomatous disease, IgG/IgA deficiency

Abnormal secretion clearance: ▪︎non-TB mycobacteria (MAC MC), smoking
▪︎primary ciliary dyskinesia (Kartagener syndrome)
▪︎cystic fibrosis ⇢ MC congenital cause

Classic S/SXS: chronic productive cough w/ mucopurulent & tenacious sputum + HX of exacerbations
▪︎cough most days of the week for months to years
▪︎cough (98%), daily sputum production, dyspnea
▪︎rhinosinusitis, hemoptysis, recurrent pleurisy

MC Exam Findings: crackles (MC, 75%), wheezing, digital clubbing (2%)

Question 18

Bronchiectasis dx, tx

Answer 18

LABS: CBC, IgG, IgM, IgA, sweat chloride test for CF, sputum smear/culture for bacteria, mycobacteria, & fungi

PFTs: obstructive impairment MC
▪︎normal/⇣ FVC, ⇣ FEV1, ⇣ FEV1/FVC

CXR (nondiagnostic): linear atelectasis, dilated & thickened airways (tram or parallel lines, ring shadows on cross section), irregular peripheral opacities that may represent mucopurulent plugs

Multidetector CT (MDCT) or HRCT:
▪︎lack of tapering of bronchi (tram track appearance)
▪︎signet-ring sign: dilated, air-filled bronchus & pulmonary artery ⇢ airway-to-arterial ratio ≥1.5
▪︎airway visibility within 1cm of a costal pleural surface or
touching the mediastinal pleura

tx
▪︎smoking cessation
▪︎regular chest physiotherapy to clear secretions
▪︎nebulized hypertonic saline

Exacerbation prevention ⇢ ABX
▪︎indications: ≥3 exacerbations/year
▪︎duration: at least 3mo

⊖Pseudomonas ⇢ macrolide (azithromycin)
*sputum stains/culture to r/o
non-TB mycobacteria first

⊕Pseudomonas ⇢ inhaled ABX (tobramycin)
▪︎alt: aztreonam, colistin

⊕non-TB mycobacteria ⇢ triple ABX therapy
▪︎macrolide + rifampicin + ethambutol x1y

Other therapies in select patients:
▪︎bronchodilators, steroids

Vaccines: influenza annually, pneumococcal

Question 19

Croup (Laryngeo-tracheitis) definition, sx, dx, tx

Answer 19

*inflammation of the larynx & subglottic airway
MC 6mo-6yrs; esp. in fall & winter

Etiologies:
*Parainfluenza type 1 MCC
*RSV (2nd MCC); adenovirus, rhinovirus

sx
*”seal-like barking” cough
*inspiratory stridor, hoarseness
*dyspnea, low-grade fever

URI sxs (coryza) 🡪 prior, during, or after

dx
Clinical dx
Frontal cervical x-ray:
*steeple sign

tx
Mild (no stridor at rest, no respiratory distress):
*supportive ⇢ cool humidified air mist, hydration, oxygen if SpO2 <92%
*dexamethasone

Moderate (stridor at rest w/ mild-mod retractions):
*dexamethasone PO or IM + supportive
*nebulized Epi
*observe 3-4hrs

Severe (stridor at rest w/ marked retractions):
*dexamethasone + nebulized Epi + hospitalization

Question 20

Cystic Fibrosis definition, sx, dx, tx

Answer 20

Autosomal recessive exocinopathy

MC in Caucasians & Northern Europeans

PATHO: mutation in the CFTR gene leads to abnormal chloride & water transport across exocrine glands throughout the body, leading to thick, viscous secretions of the lungs, pancreas, sinuses, intestines, liver, & GU tract

sx
Infancy:
*meconium ileus (bowel obstruction)
*FTT
*diarrhea from malabsorption (may lead to rectal prolapse)

Pulmonary:
*MCC of bronchiectasis in the US (cough, sputum)

GI:
*malabsorption of fat-soluble vitamins ADEK
*steatorrhea, diarrhea
*recurrent pancreatitis (may lead to pancreatic insufficiency)
*distal intestinal obstruction
*biliary cirrhosis

*infertility due to azoospermia
*sinusitis

dx
Elevated sweat chloride (test of choice, most accurate)
*admin of pilocarpine (cholinergic drug = sweating)
*(+) = Cl ≥60mmol/L on 2 occasions

CXR: bronchiectasis, hyperinflation of the lungs

PFT: obstructive pattern
*hyperinflation: ↑ TLC, RV, RV/TLC, FRC
*obstruction: ↓ FEV1 (greater decrease), FVC, FEV1/FVC

DNA analysis: genotyping is not as accurate as sweat chloride testing because there are more types of mutations than those tested w/ genotyping

Low fecal elastase

tx
Antibiotics often needed
*macrolides (azithromycin, clarithromycin)
*cephalosporins (cefuroxime, cefixime)
*Amoxicillin-clavulanate
*FQs
*inhaled aminoglycosides

Airway clearance treatment
*inhaled bronchodilators, decongestants
*mucolytics
*inhaled recombinant human DNA (breaks down large amounts of DNA in the respiratory mucus that clogs up the airways)

Supportive:
*pancreatic enzyme replacement
*vitamin supplementation (ADEK)
*vaccinations (pneumococcal, flu)

*lung transplant
*pancreatic transplant

Question 21

Foreign Body Aspiration definition, sx, dx, tx

Answer 21

Occurs when a foreign body enters the airways & causes choking
MC food – can be life-threatening
80% in mainstem or lobar bronchus right > left

Risk Factors: institutionalization, advanced age, poor dentition, alcohol, sedative use

sx
*inspiratory stridor (if high in airway)
*wheezing
*decreased breath sounds (if low in airway)

dx
CXR (expiratory radiograph)
*regional hyperinflation of the affected side

ABG: necessary for appropriately evaluating ventilation, may be useful for following the progression of respiratory failure when it is of concern

tx
Remove foreign body w/ a bronchoscope
*rigid bronchoscopy (children)
*flexible (adults)

Complications: pneumonia, ARDS, asphyxia

Question 22

Nasal Foreign Body definition, sx, dx, tx

Answer 22

Button batteries & paired disc magnets can cause serious damage to nasal structures & merit urgent removal

MC children

sx
*persistent foul-smelling purulent unilateral nasal discharge in a young child
*absence of other respiratory sxs

dx
Visualization through PE
Sometimes 🡪 rigid or flexible fiberoptic endoscopy
Plain radiographs (button batteries, magnets)

tx
Removal w/ nasal speculum & Hartmann nasal forceps
*oxymetazoline prior to removal – shirks mucous membrane

Otolaryngology referral: non-visualized posterior FBs, impacted FBs, unsuccessful initial attemps at FB removal

Question 23

Foreign Body in Ear definition, sx, dx, tx

Answer 23

Insects must be immobilized prior to removal 🡪 drown w/ mineral oil or viscous lidocaine before attempting removal

sx
Irrigation of the external ear can be uncomfortable for the child
Aggressive flushing can cause tympanic membrane perforation, so caution is advised while irrigating

dx: Visualization through PE

tx
Removal w/ warm irrigation w/ syringe, alligator forceps
*after each flush 🡪 check the external canal for retained FB fragments (can occur w/ insects)
*topical pain agents: benzocaine-anti-pyrene

Question 24

Ocular Foreign Body definition, sx, dx, tx

Answer 24

Any object embedded in or adhering to the conjunctiva or cornea

Intraocular penetration can occur w/ seemingly minor trauma, particularly when FB result from high speech machines (drills, says, metal-on-metal), hammering, or explosions

sx
Metallic FB 🡪 rust ring
Trapped under lid 🡪 corneal abrasions (worsen w/ blinking)

dx
*slit-lamp exam w/ fluorescein staining w/ cobalt light illumination
Globe penetration 🡪 x-ray or CT

tx
*first 🡪 install topical anesthetic
*then 🡪 removal attempt w/ irrigation
*can attempt to remove w/ swab after visualization

Intraocular FB 🡪 immediate surgical removal by ophthalmologist
*systemic & topical abx indicated

Rust ring 🡪 treat as corneal abrasion
*ring will resorb gradually on its own

Question 25

Hyaline Membrane Disease (Respiratory Distress Syndrome) definition, sx, dx, tx

Answer 25

Common problem in preterm infants (<30wks)

PATHO: deficiency of pulmonary surfactant in an immature lung resulting in high surface tension leading to instability of the lung at end-expiration, low lung volume, & decreased compliance 🡪 hypoxemia d/t atelectasis

Surfactant expressed in lung starting around 20th week of gestation

sx
*preterm infant!!!!!

Signs of respiratory distress:
*tachypnea
*nasal flaring
*expiratory grunting
*intercostal, subxiphoid, & subcostal retractions
*cyanosis

dx
CXR:
*low lung volume
*diffuse reticulogranular ground glass appearance
*air bronchograms

ABGs:
*hypoxemia that responds to oxygen admin
*PCO2: initially nml/slightly elevated *increases as disease worsens
*progression 🡪 hyponatremia

tx
*antenatal corticosteroids in all preterm infants (betamethasone IM x2)

Initial management
*positive pressure (nCPAP, NIPPV)
*supplemental oxygen

Surfactant administration
*endotracheal intubation

Question 26

Bacterial Tracheitis “Bacterial Croup” definition, sx, dx, tx

Answer 26

*Invasive exudative bacterial infection of the soft tissues of the trachea
MCC: staphylococcus aureus
MC ages 3-5yrs

sx
“croup that doesn’t respond to croup tx”

*viral prodrome *cold-like sxs
*airway obstruction: stridor, barky cough, respiratory distress
*fever, odynophagia, dysphagia, hoarseness
*TOXIC APPEARING

dx
x-ray: “steeple sign”
endotracheal intubation & bronchoscopy
*used to confirm dx & obtain bacterial cultures

tx
*clindamycin or vancomycin PLUS a second-generation cephalosporin should be started promptly
*supportive measures

Question 27

Pneumonia types/causes, MC ages

Answer 27

Community Acquired Pneumonia (CAP):
*S. pneumo MCC overall

Neonates (<28d):
Bacterial: group B strep & E. coli MC, Listeria monocytogenes, Chlamydia trachomatis (seen >2wks)
Viral: CMV, HSV

1-3mo: viral MC
Bacterial: S. pneumoniae, C. trachomatis, Bordetella pertussis
Viral: RSV, parainfluenza viruses

3mo-5yrs: viral MC
Bacterial: S. pneumoniae, H. flu (rare b/c vac), S. aureus, S. pyogenes, Mycoplasma pneumoniae
Viral: RSV (MC), rhinovirus, influenza, parainfluenza viruses, coronavirus, adenovirus

> 5yrs: bacterial MC
Bacterial: S. pneumoniae, M. pneumoniae, Chlamydia pneumoniae
Viral: influenza

Uncommon CAP pathogens in peds: M. catarrhalis, Klebsiella, Legionella, Pseudomonas

HAP (≥48h of admit): gram (-) rods, S. aureus (MRSA)

Special Populations:
Cystic Fibrosis: S. aureus, Pseudomonas, H. flu

Question 28

Pneumonia sx

Answer 28

*FEVER + COUGH
*tachypnea, retractions, nasal flaring, grunting

Neonates/young infants: difficulty feeding, restlessness, fussiness

Neonates/infants/<5y: fever + leukocytosis may be only s/sxs

Older children/adolescents: pleuritic chest pain

PE: crackles, ↓ breath sounds, +egophony, +bronchophony, +whispered pectoriloquy, ↑ tactile fremitus,

Pathogen-specific s/sxs:
M. pneumoniae: often associated w/ extrapulmonary sxs (HA, photophobia)
Legionella: hyponatremia, GI sxs (diarrhea)

Atypicals: M. pneumoniae, Chlamydia, Legionella

Clues to Etiology:
Wheezing: atypical or viral
Afebrile: C. trachomatis

Sputum:
S. pneumo: rust-colored
S. aureus: salmon-colored
Klebsiella: currant jelly sputum

*M. pneumoniae MCC of “walking pneumonia”

Question 29

Pneumonia dx

Answer 29

Clinical dx – other testing can be done for confirmation

CXR:
*lobar: bacterial
*interstitial: viral

Labs: only for hospitalized pts
*CBC: WBC >15,000 suggests bacterial
*CRP: >35-60mg/L suggests bacterial
*Procalcitonin: elevation suggests bacterial
*electrolytes: assess degree of dehydration

Microbiological Testing in Hospitalized Pts:
*blood culture
*sputum gram stain/culture
*PCR, immunofluorescence

Gram stain:
*S. pneumoniae: gram + diplococci
*H. flu: gram (-) coccobacilli
*S. aureus: gram + cocci in clusters
*Moraxella: gram (-) diplococci
*Klebsiella: plump gram (-) rods
*Pseudomonas: thin gram (-) rods

Indications for Admission:
*infants <3-6mo (exception: viral or C. trachomatis)
*hypoxemia; SpO2 <90% on room air
*dehydration
*mod/severe respiratory distress
*complications (effusion, abscess, etc.)

Question 30

Pneumonia tx

Answer 30

CAP:
Neonates: ampicillin + gentamicin
*C. trachomatis: erythromycin

Outpatient, >3mo: amoxicillin +/- azithromycin
*PCN allergy: clindamycin, levofloxacin

Inpatient, >3mo: ampicillin +/- azithromycin
*PCN allergy: clindamycin, levofloxacin

Complicated: clindamycin + ceftriaxone

ICU: vancomycin + ceftriaxone

Atypical: typical tx + azithromycin

HAP: aminoglycoside (usually gentamicin) + (Bactrim, meropenem, ceftazidime, cefepime, or clindamycin)

VACCINATIONS:
PCV13: pts 6wks-5yrs
*2, 4, 6, 12-15mo

PPSV23: all pts ≥65yrs, younger pts w/ conditions that increase the risk for developing complications

Question 31

RSV definition, sx, dx, tx

Answer 31

MCC of lower respiratory tract infections in children worldwide; virtually all children contract it by age 3

Leading cause of pneumonia & bronchiolitis in infants

sx
*rhinorrhea
*wheezing/cough *can persist months
*low-grade fever
*nasal flaring & retractions
*nail bed cyanosis

dx
Nasopharyngeal secretions RSV antigen test
CXR: diffuse infiltrates

tx
Indications for hospitalization: moderate tachypnea w/ feeding difficulties, visible retractions, & oxygen desaturation
*supportive: albuterol via nebulizer, antipyretics, humidified oxygen
*steroids (controversial)
*sxs resolve within 5-7d

Palivizumab (Synagis) Prophylaxis:
*infants born ≤28wks, 6d gestational age & <12mo at the start of RSV season
*infants <12mo w/ chronic lung disease of prematurity
*infants ≤12mo w/ hemodynamically significant CHD
*infants/children <24mo w/ chronic lung disease of prematurity necessitating medical therapy within 6mo prior to the beginning of RSV season

Also suggested for:
*infants <12mo w/ congenital airway abnormality or neuromuscular disorder that decreases the ability to manage airway secretions
*infants/children <24mo w/ cystic fibrosis
*infants/children <24mo who are profoundly immunocompromised
*infants/children <24mo undergoing cardiac transplantation during RSV season