Pulmonary & Orofacial Disorders Flashcards
What are the goals of care for ED treatment of ENT concerns?
Rapid recognition of rare surgical and infectious emergencies; obtaining thorough evaluation
What are intracranial complications of sinusitis?
Fever, headache, vomiting, change in mental status
What is the diagnostic test of choice to diagnose retropharyngeal abscess?
CT scans
What is the priority for otalgia patients?
Symptomatic relief
What should facial nerve palsies prompt an evaluation of?
Middle ear
What are young children with cochlear implants at significant risk for?
Pneumococcal meningitis secondary to acute otitis media
The most common head and neck infection and children and the second most common diagnosis made in ED
Acute otitis media
What are risk factors for AOM?
Otitis media with effusion/serous otitis media
daycare attendance
exposure to secondhand smoke
immunodeficiency state
What are the most common organisms causing acute otitis?
Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis
Diagnosis of AOM must have any one of the following three criteria:
Moderate to severe bulging of TM
Acute onset otorrhea not due to otitis external
Mild bulging and >48 hours of ear pain or intense erythema of TM
Any child how is irritable or lethargic, low-grade fever, and localized pain in the ear
Suspect AOM
What is the strongest predictor of AOM?
Presence of bulging TM that obliterates normal landmarks
When visualizing directly in the ear canal, how do you pull the pinna?
Posteriorly and superiorly
Do not perform irrigation of canal if…
Ventilating tube is in place or perforation of TM is suspected
How long can amniotic fluid be present in the middle ear?
Days to weeks after birth
How should otherwise healthy patients with AOM be treated?
With observation
Very young children; immune, genetic, or craniofacial anomalies, or recent AOM in previous 30 days
Should be treated with antibiotics
If the patient is younger than 6 months old with AOM , should they be treated or not treated with antibiotics?
Treated with antibiotics
Which children should be referred to an otolaryngologist for evaluation for possible myringotomy and tube placement?
- Multiple episodes of AOM over a period of months
- OME lasting more than 6 to 8 weeks
- Complications of middle ear disease
- Associated hearing or speech concerns
What is the initial therapy for uncomplicated AOM in patients with type 1 hypersensitivity (anaphylaxis or history of hives) to penicillin?
Cephalosporin
What is the initial therapy for uncomplicated AOM in patients with type 1 hypersensitivity (anaphylaxis or history of hives) to penicillin and cephalosporins?
Macrolide
OR
Clindamycin
What is not recommended for AOM treatment?
Antihistamines
Decongestants
Corticosteroids
Myringoscleoriss
Calcium deposits within TM resulting in the appearance of white patches
Tympanoscleorsis
White deposits in middle ear
How to treat facial nerve paralysis with AOM?
Can be partial or complete
Recovers completely if appropriate systemic antibiotic and corticosteroid therapy is given
Myringotomy with or without tube placement should be carried out as soon as possible
What can bacterial invasion of the inner ear cause?
Severe sensorineural hearing loss and severe vertigo associated with nausea and vomiting
What season does pertussis normally occur?
Late summer and early fall
What bacteria casues pertussis?
Bordetella pertussis
Pertussis is endemic every ____ years?
3-5 years
What are the three stages of pertussis?
Catarrhal, paroxysmal, convalescent
In what stage are people most contagious with pertussis?
Catarrhal stage
Describe the catarrhal stage
Occasionally short or absent
Symptoms similar to upper respiratory infection (sneezing, mild cough, rhinorrhea, injected conjunctiva, low-grade fever, malaise, anorexia)
Describe the paroxysmal stage
Increase in disease severity and frequency of cough with characteristic “whoop” following cough
Copious viscid mucus and post-tussive vomiting
Choking spells can occur in infants instead of whoop
Chest/abdominal pain, rib fractures, and even air leak syndromes can occur in older children
Describe the convalescent phase
Symptoms slowly diminish
Cough recurs easily with triggers such as cigarettes, reactive airway exacerbations, or URIs
How does pertussis present in vaccinated children?
Persistent paroxysmal cough often with post-tussive emesis that is worst at night and may last as long as 4-6 weeks
What are differential diagnoses for pertussis?
Infectious diseases
GI concerns
Neurological disorders
Who qualifies for admission for pertussis?
Young infants
Any age with moderate to severe respiratory distress
Dehydration
Evidence of encephalopathy
What precautions should be used for pertussis?
Standard and droplet precautions
When should patients suspected with pertussis begin treatment?
Upon presentation
Why should erythromycin not be given to neonates?
Associated with infantile hypertrophic pyloric stenosis
How long should infants be excluded from school with pertussis?
Excluded until completion of 5 days of effective therapy or a minimum of 21 days after onset of cough
Who is recommended for chemoprophylaxis after exposure to pertussis?
All close contacts, even vaccinated, within first 3 weeks of exposure
Infection and inflammation of lower respiratory tract in association with detectable radiographic changes of lung parenchyma
Pneumonia
What is the leading cause of mortality in children younger than 5 years worldwide?
Childhood pneumonia
Who are at risk for developing pneumonia?
Premature infants Musculoskeletal abnormalities (severe scoliosis) Malnourished patients Chronic lung disease Those living with caregivers who smoke
What is the most common pathogen outside of the neonatal period for pneumonia?
S. pneumoniae
What are the most common pathogens in community-acquired pneumonia in school-aged children?
Mycoplasma pneumoniae and Chlamydia pneumonia
What is the common presentation for community-acquired pneumonia?
Fever, tachypnea, cough, nasal flaring, retractions, crackles, and focal findings
In infants younger than 2 years who present with tachypnea and fever higher than 28C
Bacterial pneumonia
What are the best radiographs for pneumonia?
Posterior/anterior and lateral
What is the treatment for older infants with mild cases of pneumonia?
Enteral amoxicillin
What is the treatment for older children with mild community-acquired pneumonia?
Macrolide is first-line
What is the treatment for small effusions?
Antibiotic therapy alone
What is the treatment for large pleural effusion?
Refer to pediatric surgery for consideration of VATS procedure or thoracostomy tube placement
What causes pulmonary edema?
Any disruption in the Starling forces favoring increased filtration or decreased absorption of fluid in pulmonary capillaries
What causes cardiogenic pulmonary edema?
Most commonly by left-sided heart failure due to any mechanism that leads to depressed left ventricular function damage to myocytes from infectious processes or cardiomyopathies
What causes noncardiogenic pulmonary edema?
Pulmonary (intrinsic) –infectious process
Neurogenic–any type of CNS insult (surgery, trauma, seizures)
Other causes–medication ingestion (salicylates, narcotics), exaggerated immune responses, administration of some chemotherapeutic agents
What are the physical symptoms of pulmonary edema?
Shortness of breath, tachypnea, tachycardia, hypoxia, weakness, cough with frothy sputum, diaphoresis, orthopnea, or paroxysmal nocturnal dyspnea
What will the exam show for pulmonary edema?
Dyspnea, cyanosis, hypoxemia, subcostal retractions, and crackles on auscultation of lungs
What will a chest x-ray show for pulmonary edema?
Peribronchial cuffing and perihilar haziness and the sometimes enlarged cardiac silhouette
What is the primary therapy for pulmonary edema?
Supplemental oxygen and diuretics
What kind of oxygen levels do patients with pulmonary edema require?
Higher levels of PEEP and oxygen to maintain adequate saturation levels
Result of edema, de-epithelialization of tracheobronchial region, airway obstruction, and decreased pulmonary compliance
Lung injury from smoke inhalation
What occurs when nitric oxide is formed in the lungs?
Leads to loss of hypoxic vasoconstriction (HPV) which shunts blood from nonventilated alveoli to ventilated alveoli
What are some causes of smoke inhalation?
Overused electrical outlets, inappropriately used paced heaters, unattended candles, cigarette smoking, and children playing with fire materials
What is the common presentation for smoke inhalation?
Signs of respiratory distress, hypoxemia, upper airway edema, and wheezing/rhonchi
What are diagnostic studies for smoke inhalation?
Pulse oximetry, CXR, carbon monoxide and cyanide levels, and direct bronchoscopy
What are the signs and symptoms of mild intoxication of carbon monoxide poisoning?
Headache and mild respiratory distress
What are the signs and symptoms of moderate (>40%) of carbon monoxide poisoning?
Irritability, nausea, fatigue, decreased vision, and altered mental status
Characterized by obvious use of compensatory mechanisms in attempt to maintain adequate gas exchange
Respiratory distress
Signs of respiratory distress
tachypnea, increased work of breathing (retractions, accessory muscle, grunting, nasal flaring)
Progression of signs and symptoms of respiratory distress or respiratory depression accompanied by arterial blood gas values with PaO2 less than 60 and/or PaCO2 more than 50
Respiratory failure
Result of lung disease, cardiac dysfunction, neurologic abnormalities, or multiple organ dysfunction
Failure to adequate oxygenation
What are examples of inadequate oxygenation triggers?
Pneumonia, inhalation injury, chest trauma, submersion injury, hydrocarbon aspiration, pulmonary hemorrhage, chronic lung disease, BPD, chemotherapy-induced pulmonary fibrosis, asthma
Total amount of air in lungs after maximal inspiration
Total lung capacity (TLC)
Maximum amount of air that a patient can exhale after maximal inhalation
Vital capacity (VC)
Volume of air left in lungs after maximal exhalation
Residual volume (RV)
Sum of VC and RV equal ____
total lung capacity
Representing the resting volume of air in the lungs after a spontaneous breath
Functional residual capacity
Ability of lungs to stretch and change in volume relative to change in pressure
Lung compliance
What does low compliance mean?
“Stiff” lung meaning circumstance extra work needed to transport normal volume of air
Sedation or neuromuscular blockade can cause ____?
Used to increase total respiratory compliance by limiting contribution of chest wall rigidity or muscle tone on lung expansion for a given inspiratory pressure
What does mean airway pressure (MAP) measure?
Average pressure that distends the alveolus and chest wall that correlates with alveolar size and recruitment as well as intrapleural pressure
Ventilation that delivers a set tidal volume to patient during preset inspiratory time
Volume-regulated
What are advantages of volume-regulated ventilation?
Reduced risk of volutrauma due to preset tidal volume and better control over minute ventilation and carbon dioxide clearance
What are disadvantages of volume-regulated ventilation?
Need to delivery high peak pressures to achieve goal tidal volume or minute ventilation; risk of not meeting patient demands for oxygenation
Ventilation that delivers pressure-limited breath during predetermined inspiratory time in conjunction with preset ventilation rate
Pressu-regulated
What are advantages of pressure-regulated ventilation?
Better ventilation for stiff lungs, overall lower peak pressure needed for same tidal volume, and even distribution of gas flow
What are disadvantages of pressure-regulated ventilation?
Varying tidal volume delivery and lack of guaranteed minute ventilation
Supports spontaneous respirations with set pressure that is delivered during inspiratory phase
Pressure support
Amount of pressure that is delivered to pediatric patient during exhalation and in between respiration
PEEP
When can pressure support ventilation be used?
To promote respiratory muscle training and compensate for high resistance of endotracheal tube during spontaneous respiration
When can volume support ventilation be useful?
To promote respiratory muscle retraining and compensation for high resistance of endotracheal tube during spontaneous respiration
Technique of delivering positive pressure via noninvasive interface such as a full face mask, nasal mask, nasal pillows, or helmet
Noninvasive ventilation
What are contraindications for noninvasive ventilation?
Impaired airway protective reflexes; reduced respiratory drive; respiratory failure
What is the risk of chronic noninvasive ventilation?
Midface hypoplasia
Provides one set level of positive pressure through respiratory cycle
Continuous positive airway pressure (CPAP)
Provides two levels of pressure during respiratory cycle (inspiratory positive pressure airway pressure and expiratory positive airway pressure)
Bilevel positive airway pressure (BiPAP)
