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Pediatric ACNP > Pulmonary Disorders > Flashcards

Pulmonary Disorders Flashcards

1
Q

The parents of a 9-year-old obese boy are concerned that he is falling asleep in school and seems to have decreased energy and attention. He is also reported to snore, especially when in a sound sleep. Which one of the following types of sleep apnea is most likely?
a. Obstructive
b. Central
c. Mixed
d. Hypoxic

3.1

A

Answer: A
Given age and habitus, the most likely explanation is OSA. Central apnea refers to loss of breathing from a primary neurologic problem and mixed apnea would be composed of both central and obstructive. The only method to know whether the child becomes hypoxic during sleep with apnea events is to complete a sleep study with oxygenation saturation monitoring.

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2
Q

Which one of the following diagnostic studies is best to obtain for confirming a diagnosis of OSA?
a. Airway evaluation
b. Polvsomnography
c. Chest radiography
d. pH probe

3.2

A

Answer: B
Although an airway evaluation may help diagnose adenotonsil-lar hypertrophy that may contribute to obstructive apnea, a sleep study or polysomnography is the diagnostic test of choice to evaluate for obstructive apnea and the degree of apnea/hypopnea episodes.

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3
Q

What are the most appropriate initial management strategies for a child who has definitive OSA?
a. Nutrition counseling, exercise, noninvasive ventilation for
sleep
b. Nutrition counseling, immediate tonsillectomy, cardiology referral
C. Exercise, noninvasive ventilation for sleep, chest radiography
d. Immediate tonsillectomy, cardiology referral, and chest radiography

3.3

A

Answer: A
Reduction of body weight would be the first adjustment to managing the sleep apnea along with noninvasive ventilation in the form of CPAP or BiPAP. Adenotonsillectomy would also be a consideration, but after appropriate diagnostic testing and first attempts at weight management.

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4
Q

An 8-year-old weighing 25 kg presents with a 2-day history o cough and respiratory distress, and Initialy requites supple mental oxygen. He is tachypneic with moderate retracion and has an initial SaO, of 88% with bilateral infiltrates presen on chest radiograph. He is placed on NIPPV without signit cant improvement and therefore efforts to intubate him begin The initial ABG reveals a Pao, of 70 mmHg on Fio, 0.6.
The diagnosis of ARDS is made for this child based on which of the following characteristics?
a. Acute onset, bilateral lung infiltrates, and Pao, / Fio, ratio of 200 to 300
b. Progressive onset, hyperinflation on chest X-ray, and Pao,/ Fio, ratio of <200
c. Progressive onset, hyperinflation on chest X-ray, and Pao, / Fio, of 200 to 300
d. Acute onset, bilateral lung infiltrates, and Pao,/ Fio, ratio <200

3.4

A

Answer: D
The definition of ARDS is based on characteristics of acute onset bilateral lung infiltrates, noncardiogenic origin, and Pao,/ Fio, ratio of <200. ALI has similar characteristics but is defined by a Pao,/ Fio, ratio of 200 to 300.

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5
Q

Which of the following studies will assist in confirming the diagnosis of ARDS based on the documented criteria?
a. Complete blood count
b. Bronchoalveolar lavage
C. Chest CT
d. Echocardiogram

3.5

A

Answer: D
Determining the etiology of cardiac versus noncardiac origin of ARDS symptoms requires at least an echocardiogram. Placement of a pulmonary artery catheter is an option to obtain more detail, but is quite invasive, and not always available in every critical care setting, so an echocardiography is often done to evaluate for underlying cardiac disease as the cause of pulmonary edema and respiratory distress.

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6
Q

Which of the following ventilator settings would be the mi appropriate for an 8-year-old who weighs 23 kg with hypes in the initial phase of ARDS?
a. Tidal volume 250, PEEP 10
b. Tidal volume 175, PEEP 10
c. Tidal volume 175, PEEP 6
d. Tidal volume 250, PEEP 6

3.6

A

Answer: B
Numerous studies have been done to determine optimal ventilator settings for managing patients with ARDS. Current evidence confirms the incidence of further injury with the use of particular ventilation strategies including high inspiratory pressures; so based on the objective of protecting the lung, low tidal volumes (7-8 ml./kg) and higher PEEP (to keep Fio2 <0.6) should be considered in the plan of care.

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7
Q

Despite optimization of mechanical ventilation settings in the management of the child with ARDS, it is decided to transition to high-frequency oscillatory ventilation for which of the following primary reasons?
a. Need for higher tidal volumes
b. Limiting peak inspiratory pressures
C. Ability to provide lower mean airway pressure
d. Lowering oxygenation requirements

3.7

A

Answer: B
High-frequency oscillatory ventilation assists in limiting peak inspiratory pressures for the purpose of protecting the lungs and offering a constant distending pressure (MAP), while avoiding overdistention of alveoli.

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8
Q

What dose of dexamethasone is indicated for a child with rhinorrhea, stridor, and a barky cough?

3.8

A

0.6 mg/kg

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9
Q

Percentage of CF population with nontuberculous mycobacterium (NTM)

A

5-20%

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10
Q

Percentage of population between ages of 6-10 years with Pseudomonas aeruginosa

A

35-40%

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11
Q

Percentage of CF population with Burkholderia cepacia complex (Bcc)

A

2.5%

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12
Q

Cessation of airflow through the respiratory tract for 20 seconds or longer or shorter respiratory pause associated with bradycardia or cyanosis significant enough to cause arterial hypoxemia and hypercapnia

A

Apnea

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13
Q
  • Disruption of afferent (cessation of output) or efferent (inability of peripheral nerves or respiratory muscles to receive input) signals of the central respiratory center
  • Inappropriate response to hypercapnia and hypoxemia
  • Immaturity of the respiratory center (premature infants), head trauma, toxin-mediated
A

Central Apnea

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14
Q
  • Reduced airway patency secondary to some form of obstruction causing poor or no air movement through passage
  • Usually results in significant respiratory effort that is ineffective
A

Obstructive Apnea

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15
Q

Diagnostic evaluation for sleep apnea

A
  • Polysomnography (sleep study)
  • Echocardiography and/or electrocardiography (EKG) to evaluate for cardiac sequelae
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16
Q

Pearl of apnea

A

Always consider an acute life-threatening event in a young infant presenting with apnea

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17
Q

Result of lung injury, specifically to the alveolar capillary barrier (alveolar epithelium, capillary endothelium), which is vital in maintaining lung fluid balance

A

Acute respiratory distress syndrome (ARDS)

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18
Q

Diagnostic criteria for ARDS

A
  • Acute onset
  • Bilateral infiltrates on chest radiograph
  • PaO2/FiO2 ratio of <200
  • Noncardiogenic origin: pulmonary artery wedge pressure <18 mmHg or absence of clinical evidence of left atrial hypertension
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19
Q

Oxygen index calculation

A

([FiO2*MAP]/PaO2)

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20
Q

PaO2:SpO2
100:____
70:____
40:____
26:____
0:____

A

100:98
70:94
40:75
26:50
0:0

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21
Q

If Oxygen index >20 consider…

A

high-frequency oscillatory ventilation

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22
Q

If Oxygen index >40 consider…

A

extracorporeal membrane oxygenation (ECMO)

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23
Q

Management of ARDS

A
  • High positive end-expiratory pressure (PEEP) to achieve FiO2<0.5-0.6
  • Low tidal volume (7-8mL/kg)
  • Avoid peak inspiratory pressure (PIP) >30
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24
Q

When is permissive hypercapnia indicated?

A

managing acute respiratory distress syndrome (ARDS)

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25
Q

Significance of high frequency oscillatory ventilation (HFVO)

A
  • small tidal volumes
  • high mean airway pressures
  • limited PIPs
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26
Q

ARDS Pearls

A
  • ARDS is a clinical syndrome with multiple etiologies
  • Management focuses on lung-protective strategies
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27
Q

Tension pneumothorax clinical presentation

A
  • tracheal deviation (contralateral)
  • hypotension
  • tachycardia
  • cyanosis
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28
Q

Chest pain, dyspnea, neck pain, subcutaneous emphysema, Hamman’s sing

A

pneumomediastinum clinical presentation

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29
Q

Halo sign on x-ray may indicate what?

A

pneumopericardium

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30
Q

Air leak Pearls

A
  • Pneumomediastinum may be associated with subcutaneous emphysema on examination
  • Pneumomediastinum and pneumopericardium typically do not require intervention unless associated with marked cardiopulmonary compromise
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31
Q

Abnormal collection of air between the visceral and parietal pleura in the thoracic cage

A

Pneumothorax

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32
Q

Spontaneous pneumothorax triggered by menstruation and thought to be associated with thoracic endometriosis

A

Catamenial pneumothorax

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33
Q

Symptoms of a pneumothorax

A
  • may be asymptomatic
  • pleuritic chest pain (sharp and worse with inspiration) and dyspnea
  • Chest pain usually resolves or changes to a dull pain within 1-3 days despite the persistence of the pneumothorax
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34
Q

s/s of a pneumothorax in ventilated patients

A

increased PIP or decreased expired tidal volume on mechanical ventilator

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35
Q

Management of Pneumothorax: observation

A
  • pulse oximetry and cardiorespiratory monitoring in stable patients
  • 100% oxygen delivered via face mask to “wash out” nitrogen from pleural space
36
Q

Where is the needle inserted during needle aspiration in a pneumothorax?

A

at the second intercostal space at the midclavicular line

37
Q

Where is the thoracostomy tube placed in the pleural space?

A

in the pleural space at the fourth, fifth, or sixth intercostal space at the mid-axillary line

38
Q

Pneumothorax Pearls

A
  • Conservative and noninvasive treatment options should be considered first in the clinically stable patient
  • Tension pneumothorax is diagnosed by clinical findings and is considered a medical emergency
39
Q

Intermittent asthma

A
  • occur fewer than 2 days per week
  • do not interfere with normal activities
  • nighttime symptoms occur fewer than 2 days per month
40
Q

Mild persistent asthma

A
  • symptoms occur more than 2 days a week, but do not occur every day; they interfere with daily activities
  • nighttime symptoms occur 3-4 times per month
  • lung function tests are normal when there are no symptoms
  • lung function tests are >80% of expected value and may vary slightly
41
Q

Moderate persistent asthma

A
  • symptoms occur daily and interfere with daily activities - inhaled short-acting asthma medication is used daily
  • nighttime symptoms occure more than 1 time per week, but do not happen daily
  • lung function tests are abnormal (>60% and <80%)
42
Q

Severe persistent asthma

A
  • Symptoms occur every day and severely limit daily physical activities
  • nighttime symptoms occur often, sometimes every night
  • lung function tests are abnormal (<60%)
43
Q

What are common findings on chest radiography in asthma?

A
  • hyperinflation with flattened diaphragms
  • peribronchial thickening
  • narrowed cardiac silhouette
44
Q

Acute Management of Asthma

A
  • Oxygen (first priority)
  • B-agonists (bronchial smooth muscle relaxation)
  • Corticosteroids (target underlying airway inflammation)
  • Anticholinergics (ipratropium bromide or Atrovent - promotes bronchodilation without affecting mucociliary clearance)
45
Q

Typical pathogens found to cause bronchiolitis

A

Respiratory syncytial virus (RSV), adenovirus, influenza, parainfluenza, and human metapneumovirus

46
Q

Physical examination findings of bronchiolitis

A

hypoxia, respiratory distress, diffuse crackles/rhonchi, expiratory wheeze, prolonged expiratory phase, irritability

47
Q
  • A form of chronic lung disease occurring in premature infants
  • Result of acute respiratory disease that originates in the neonatal period
A

bronchopulmonary dysplasia

48
Q

congenital central hypoventilation syndrome

A

inadequate respiratory drive as a result of genetic defect in the autonomic nervous system’s control of breathing

49
Q

What gene causes congenital central hypoventilation syndrome?

A

PHOX2B gene

50
Q

Congenital defect of diaphragm resulting in herniation of gastrointestinal contents into thoracic cavity

A

Congenital diaphragmatic hernia

51
Q

Which side of the chest does CDH typically occur on?

A

Left side

52
Q

Retractions, tachypnea, grunting, cyanosis, absent breaths, increased chest diameter, sounds on ipsilateral side, heart sounds shifted to contralateral side, scaphoid abdomen, presence of bowel sounds in thorax all can be physical exam findings of?

A

congenital diaphragmatic hernia

53
Q

What should be avoided in newborns with CDH that will introduce air into gastrointestinal tract, worsening lung compression?

A

bag-mask ventilation

54
Q

Croup is caused by most commonly by which virus?

A

Parainfluenza types 1&2

55
Q

What is the common finding on chest radiography in children with croup?

A
  • narrowing of the subglottic area, aka steeple sign
56
Q

Croup Pearls

A
  • symptoms typically more prominent at night, peak in 48 hours and can last up to 1 week
  • accounts for up to 90% of infectious airway obstruction
57
Q

Pathophysiology of cystic fibrosis

A

impaired movement of salt and water across the epithelial cell wall in the exocrine glands, leading to thick sticky secretions

58
Q

What leads to malabsorption and malnutrition in children with cystic fibrosis?

A

sticky mucus blocks pancreatic ducts, impairing excretion of pancreatic enzymes and bicarbonate, both of which are necessary for digestion of nutrients

59
Q

In patients with CF, RLQ pain may mimic appendicitis; however, it is usually caused by what?

A

distal intestinal obstruction syndrome (DIOS)

60
Q

Cystic Fibrosis Pearls

A
  • Consider the diagnosis of CF in any patient with poor growth and frequent respiratory infections
  • Newborn screening is not a diagnostic procedure and may not detect all individuals with CF
  • If airway culture results are unknown or patient quite ill, treat for pseudomonas initially while waiting for culture results
  • Cepacia syndrome, which occurs in patients who culture Burkholderia cepacia complex, is life-threatening. Syndrome involves rapid decline, fever, bacteremia, and necrotizing pneumonia
  • Appendix is often enlarged in CF, even without appendicitis. An abdominal CT may show this enlargement, but patient may not require surgical intervention
  • A child who presents with hyponatremia and hypochloremia should always be suspected of having CF
61
Q

Obstructive sleep apnea Pearls

A
  • not all snoring results in OSA
  • history and physical examination alone are not reliable in distinguishing primary snoring from OSA
  • OSA should be considered in children evaluated for ADD
  • Long-term, untreated OSA has been associated with neurocognitive impairment, behavior problems, and cor pulmonale
62
Q

Antibiotics of choice for pertussis

A

Macrolides - azithromycin (in young infants) and erythromycin

63
Q

Pertussis Pearls

A
  • AAP recommends antimicrobial prophylaxis for all exposed close contacts regardless of their immunization status
  • Suspect pertussis in infants <4 months of age if paroxysmal cough is present
64
Q

Serous, acellular fluid collection due to increased hydrostatic pressure across the vascular membrane

A

Transudative pleural effusion

65
Q

Due to leakage of protein and inflammatory cells, secondary to inflammatory cascade

A

Exudative pleural effusion

66
Q

Often associated with congestive heart failure, pericarditis, hypoalbuminemia, nephrotic syndrome, peritoneal dialysis. Transudative or Exudative?

A

Transudative

67
Q

Often associated with infectious process, chylothorax, neoplasm, connective tissue disease, immunodeficiency. Transudative or Exudative?

A

Exudative

68
Q

Findings in chest radiography with pleural effusions

A

blunted costophrenic angle

69
Q

Pulmonary Contusion Pearls

A
  • Most common thoracic injury in pediatric trauma patients and frequently seen with other injuries to the chest wall and to other organ systems
  • primary goal is to identify other life-threatening injuries
  • severe pulmonary hemorrhage may be associated with diffuse hemorrhage-related liver damage and massive hilar contusions
  • increased morbidity for trauma patients with pulmonary contusions
70
Q

Smoke Inhalation Pearls

A
  • direct bronchoscopy is the diagnostic study of choice
  • most children with smoke inhalation injuries do not suffer long-term respiratory sequelae
71
Q

thought to be the most important cause of ventilator-induced lung injury, due to the use of high inspiratory pressure during mechanical ventilation

A

barotrauma

72
Q

causative factor which leads to alveolar rupture and trapping of air along the interstitium, causing pneumothorax, pneumomediastinum and subcutaneous emphysema

A

volutrauma

73
Q

trauma due to repeated opening and collapse of alveolus at low lung volumes

A

atelectrauma

74
Q

Management in ventilator associated lung injury

A
  • keep alveoli open during all stages of ventilation with appropriate PEEP
  • reduce FiO2 to less than 0.6
  • low tidal volumes of 5-6 ml/kg
75
Q

Acidosis with high pCO2

A

primary respiratory acidosis

76
Q

Acidosis with low pCO2

A

compensation for a primary metabolic acidosis

77
Q

Acidosis with normal CO2

A

either uncompensated or partially compensated metabolic acidosis

78
Q

Acidosis with high HCO3

A

compensation for a respiratory acidosis

79
Q

Acidosis with normal HCO3

A

partial or uncompensated respiratory acidosis

80
Q

Acidosis with low HCO3

A

primary metabolic acidosis

81
Q

Alkalosis with high HCO3

A

primary metabolic acidosis

82
Q

Alkalosis with low HCO3

A

compensation for a respiratory alkalosis

83
Q

Alkalosis with normal HCO3

A

partial or uncompensated respiratory alkalosis

84
Q

Alkalosis with high pCO2

A

compensation for primary metabolic alkalosis

85
Q

Alkalosis with low pCO2

A

primary respiratory alkalosis

Pediatric ACNP (4 decks)

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