Pulmo Flashcards
Transudate findings
low specific gravity (<1.015)
ratio pleural fluid to serum total protein <0.5
ratio of pleural fluid to serum lactic acid dehydrogenase <0.6
large pneumothorax
American College of Chest Physicians:
>/=3cm lung apex–> cupola
British Thoracic Society:
>/= 2cm lung margin to chest wall at hilum
treatment for Pneumothorax
small or moderate sized: may resolve spontaneously
small pneumothorax: 100% oxygen
*needle aspiration 2nd ICS, midclavicular
treatment for recurrent tension pneumothorax
chest tube drainage sclerosis procedure (talc, doxycycline, iodopovidone
Asthma findings in spirometry
decreased FEV1, FEV1/FVC ratio: <0.80
Asthma response to bronchodilator
FEV1 >12% or predicted value FEV1>10% after SABA
Asthma findings in exercise challenge
worsening FEV1> 15%
Daily PEF or FEV1 monitoring
day to day and/or AM-PM >/= 20%
response to exhaled nitric oxide
<20ppb: unlikely to respond to ICS
20-35: intermediate; may response
>35: respond to ICS
most common pathogens associated with common colds
rhinoviruses
1st symptom of common cold
scratchy throat followed by nasal obstruction and rhinorrhea
management of common cold
symptomatic
- Oseltamivir and Zanamivir have modest effect on duration of symptoms associated with influenza viral infection
- Oseltamivir- reduces frequency of influenza-associated otitis media
*1st gen antihistamines
prolonged use of topical adrenergic agents may cause
rhinitis medicamentosa
most common complication of colds
otitis media
sinus present at birth
ME!!
Maxillary
Ethmoidal - only pneumatized
sinus not pneumatized until 4yrs old
Maxillary sinus
sinus present by 5 yrs of age
sphenoidal sinus
sinuses which begin development at 7-8yrs
frontal sinuses
etiologic agents of sinusitis
S. pneumoniae
nontypable Hib
Moraxella catarrhalis
chronic sinusitis is defined as
history of persistent respiratory symptoms including cough, nasal discharge, or nasal congestion lasting >90 days
only accurate method of diagnosis of sinusitis but not practical for routine use for immunocompromised patients
sinus aspirate culture
treatment for uncomplicated bacterial sinusitis
Amoxicillin
treatment for frontal sinusitis
parenteral Ceftriaxone
gold standard for diagnosing streptococcal pharyngitis
throat culture
prominent sore throat and fever in absence of cough
streptococcal pharyngitis
treatment regimen most effective for eradicating streptococcal carriage
Clindamycin
bulging of the posterior pharyngeal wall
retropharyngeal abscess
- I&D of an abscessed node provides definitive diagnosis
- CT useful in identifying presence of retropharyngeal, lateral pharyngeal or parapharyngeal abscess
- IV antibiotics with or without drainage
treatment for retropharyngeal abscess
3rd en cephalosporins combined with Ampicillin-Sulbactam or Clindamycin
asymmetric tonsilar bulge with displacement of uvula
Peritonsillar abscess
narrowest portion of the upper airway in children less than 10yo
cricoid cartilage
hoarseness, inspiratory stridor and respiratory distress
Croup
most commonly identified etiology of acute epiglotittis
HiB
S. pneumoniae, S. pyogenes, S. aureus - vaccinated children
most common form of acute upper respiratory obstruction
Croup
xray findings in croup
subglottic narrowing or steeple sign
treatment for croup
nebulized racemic epinephrine for moderate or severe
corticosteroids in viral croup
child assumes tripod position, sitting upright and leaning forward with chin up and mouth open
Epiglotittis
- stridor is a late finding
- diagnosis: large, cherry red swollen epiglottis by laryngoscopy
radiograph findings in epiglotittis
thumb sign
indications for Rifampicin prophylaxis
all household members are any contact <48 months of age who is incompletely immunized
any contact <12months who has not received the primary vaccination series
immunocompromised child in the household
etiology of bacterial tracheitis
staphylococcal aureus
brassy cough, high fever and toxicity with respiratory distress
Bacterial tracheitis
most common congenital laryngeal anomaly
laryngomalacia
diagnosis: outpatient flexible laryngoscopy
most common cause of stridor in infants and children
laryngomalacia
diagnosis: outpatient flexible laryngoscopy
3 stages of symptoms from aspiration
- initial event: violent paroxysms of coughing, choking, gagging, possibly airway obstruction immediately
- asymptomatic interval: foreign body becomes lodged, reflexes fatigue and immediate irritating symptoms subside; most treacherous and accounts for large percentage of delayed diagnosis
- complications: obstruction, erosion or infection
Prev healthy adolescent with history of recent pharyngitis who becomes acutely ill with fever, hypoxia, tachypnea and respiratory distress
Lemierre disease
Most episodes of acute pharyngotonsilitis are caused by
Virus
Most common cause of recurrent cough in children
Reactive airway disease
Bronchiolitis obliterans is usually caused by
Adenovirus
Hyperinflation with bilateral interstitial infiltrates and peribronchial cuffing
Viral pneumonia
Most common complaints in patients with bronchiectasis
Cough and production of copious purulent sputum
Treatment for mild pneumonia not needing hospitalization
Amoxicillin
Drug of choice for children with M. Pneumoniae or C. pneumoniae in school aged children
Macrolide such as Azithromycin
Mainstay of therapy for bacterial pneumonia in a hospitalized child
Parenteral Cefotaxime or Ceftriaxone
most common bacterial pathogen for pneumonia in children 3 weeks to 4 yrs old
Streptococcus pneumoniae
most frequent pathogen for pneumonia in children 5 yrs and older
Mycoplasma pneumoniae
Chlamydophila pneumoniae
major causes of hospitalization and death from bacterial pneumonia among children in developing countries
S. pneumoniae
H. influenzae
S. aureus
prominent cause of lower respiratory tract infection in infants and children <5 yrs old
Viral pathogens
attaches to respiratory epithelium, inhibits ciliary action and leads to cellular destruction and inflammatory response in the submucosa
M. pneumoniae
produces local edema that aids in the proliferation of organisms and their spread into adjacent portions of lung, often resulting in characteristic focal lobar involvement
S. pneumoniae
causes more diffuse infection with interstitial pneumonia
Group A streptococcus
manifests in confluent bronchopneumonia
S. aureus
what is recurrent pneumonia?
2 or more episodes in a single year or 3 or more episodes ever with radiographic clearing between occurrences
usually characterized by hyperinflation with bacterial interstitial infiltrates and peribronchial cuffing
Viral pneumonia
confluent lobar consolidation is seen in
Pneumococcal pneumonia
for mildly ill patients with pneumonia who do not require hospitalization
Amoxicillin
what to give in patients with pneumonia caused by M. pneumoniae or C. pneumoniae
Macrolide such as Azithromycin
mainstay of therapy when bacterial pneumonia is suggested in a hospitalized child
Parenteral Cefotaxime or Ceftriaxone
pneumatoceles
staphylococcal pneumonia
initial antibiotic of choice for staphylococcal pneumonia
Vancomycin or Clindamycin
what is the 1st step in determining the reason for delay in response to treatment in pneumonia?
Repeat chest radiograph
most common causes of parapneumonic effusions and empyema
S. aureus
S. pneumoniae
S. pyogenes
what is affected when a child aspirates while recumbent?
right and left upper lobes and apical segment of the right lower lobe which are the dependent areas
primary abscess in the lung is most often seen on the
right side
secondary abscess in the lung is most often seen on the
left side
CT scan findings in patients with lung abscess
thick walled lesion with a low density center progressing to an air fluid level
management for lung abscess
2-3 weeks of parenteral antibiotics for uncomplicated cases followed by oral antibiotics to complete 4-6 weeks
pain is the principal symptom exaggerated by deep breathing, coughing and straining
Dry or Plastic Pleurisy (pleural effusion)
normal fluid in the pleural space
4-12ml of fluid
3 stages of empyema
exudative stage: fibrinous exudate in pleura
fibrinopurulent stage: fibrinous septa causing loculation of fluid and thickening of the parietal pleura
organizational: fibroblast proliferation
treatment for pleural effusion
systematic antibiotics, thoracentesis possible chest tube drainage with or without fibrinolytic agent, VATS or open decortication
occurs without trauma or underlying lung disease
primary spontaneous pneumothorax
complication of an underlying lung disorder but without trauma
secondary spontaneous pneumothorax
small (<5% ) pneumothorax management
may resolve without specific treatment usually within 1 week
recurrent, secondary or under tension pneumothorax is managed by
chest tube drainage
used in chemical pleurodesis
talc
doxycycline
Iopovidone
Best single predictor of death in patients with pneumonia
Presence of retraction on admission
Diagnostic aids requested for PCAP A and B
None
Diagnostic aids for PCAP C and D
Chest xray PA and Lateral WBC count Culture and sensitivity of Blood for PCAP D Pleural fluid Tracheal aspirate upon initial intubation Blood gas and/or pulse oximetry
When is antibiotics needed in pneumonia
PCAP A or B and beyond 2yrs old and having high grade fever without wheeze
PCAP C beyond 2 years old, having high grade fever without wheeze or having alveolar consolidation in the chest xray
PCAP D
Best predictor of underlying etiology of pediatric pneumonia
Age
Treatment for PCAP A or B without previous antibiotic
Oral amoxicillin 40-50mkday in 3 divided doses
Treatment for PCAP C without previous antibiotic and has completed primary immunization against HiB
Pen G 100,000units/kg/day in 4 divided doses
For patients without primary immunization to Hib
IV Ampicillin 100mg/kg/day in 4 divided doses
if viral etiology in pneumonia is strongly suggested, what treatment should be given?
Oseltamivir 2mg/kg/dose for 5 days or Amantadine may be given for Influenza
when is a patient considered as responding to treatment for pneumonia?
decrease in respiratory signs and defervescence within 72 hours after initiation of antibiotic therapy
persistence of symptoms beyond 72 hours of antibiotics requires re-evaluation
end of treatment xray should NOT be done
In patients with Pneumonia not responding to current antibiotic use?
if PCAP A or B:
change initial antibiotics or start oral macrolide
or reevaluate diagnosis
If PCAP C:
consult a specialist
may be S. pneumoniae penicillin resistant; presence of complications, other diagnosis
PCAPD: re-consultation with specialist
how can pneumonia be prevented?
Vaccines
Zinc supplementation 10mg for infants and 20mg for children beyond 2 years of age given 4-6 months
Vitamin A immunomodulators and Vitamin C should not be routinely administered
“fuzzy vessels”
sunburst pattern
peripheral air trapping
TTN
persistent fetal circulation
PPHN
gold standard to confirm PPHN
2D echo:
useful in identifying sites of extrapulmonary shunting and assessing right and left ventricular function
“bubbly lungs”
BPD
prevention of BPD
early use of nasal CPAP (nCAP) early surfactant therapy caffeine to prevent apnea Vitamin A supplementation systemic corticosteroids (not routine)
prevention of BPD
early use of nasal CPAP (nCAP)
early surfactant therapy
CHARGE syndrome
Coloboma Heart anonalies Atresia (choanal) Retarded growth Genital abnormalities Ear abnormalities
VACTERL syndrome
Vertebral defects Anus imperforate Cardiac defect TEF Renal defect Limb anomalies
Acute sinusitis
<30 days
Subacute sinusitis
1-3 months
Chronic sinusitis
> 3 months
Paradise criteria
> /=7 episodes in the previous year
Or >/=5 episodes in each of preceding 2 years
/=3 episodes in each of preceding 3 years
Bronchiolitis is caused by
RSV
Indications for admission for patients with bronchiolitis
Marked respiratory distress Age <12weeks Toxic appearance, poor feeding, lethargy, dehydration Apnea O2 sat <92% History of prematurity Underlying cardiopulmonary, neurologic or immunologic disease Unreliable caregivers
Inflammation of large and medium sized airways of the lungs
Acute bronchitis
Clinical triad of pneumonia
Fever
Cough
Tachypnea
Pneumatocele
Staphylococcal pneumonia
Following tests may be requested for PCAP A and B
Chest radiograph
O2 sat by pulse oximetry
Gram stain, aerobic culture and sensitivity of sputum
Chest ultrasound
Tests may be requested for PCAP C and D
O2 sat by pulse oximetry ABG to assess gas exchange Chest radiograph Blood work up: CRP, Procalcitonin Chest UTZ or radiograph: if with clinical suspicion of multi-lobar consolidation, necrotizing pneumonia. Lung abscess, pleural effusion, air leak
To determine etiology: may do GS/CS sputum, nasopharyngeal aspirate, tracheal aspirate, pleural fluid and/or blood cultures
Preferred management for asthma in 0-3years
pMDI with spacer and face mask
Preferred treatment for asthma in 4-5 years old
pMDI with spacer and mouthpiece
In asthma, consider stepping down if symptoms are controlled for ___months
3 months
Findings in exudate have at least 1 of the ff:
Protein >3g/dL PH <7.20 Pleural fluid:serum protein ratio >0.5 Pleural fluid:serum LDH >0.6 Pleural fluid LDH level >200 IU/L or pleural fluid LDH >2/3 serum LDH upper limit of normal
most common cause of postneonatal infant mortality
SIDS
most common site of epistaxis
kiesselbach plexus
most common form of acute upper respiratory obstruction
Croup
most common laryngeal anomaly
Laryngomalacia
most common cause of stridor in infants and children
Laryngomalacia
most common cause of secondary tracheomalacia
aberrant innominate artery
most common cause of chronic hoarseness in chidlren
vocal nodules
most common presenting symptom of pulmonary embolism in all pediatric patients
unexplained and persistent tachypnea
most common pulmonary malignancy in children
metastatic lesions
Intrathoracic vs Extrathoracic obstruction
Intrathoracic obstructionis most severe during expiration and is relieved during inspiration.
Extrathoracic obstructionis increased during inspiration because of the effect of atmospheric pressure to compress the trachea below the site of obstruction.
Most common cause of pleural effusion in children
Bacterial pneumonia
