Pulmonology Flashcards

Question

Influenza HPI/PE

Answer 1

HPI: Sudden onset of high fever (102-106F) Headache, chills, cough, sore throat, body ache Coryza (inflammation of nasal mucous membrane) Severe - may see chest pain, croup like symptoms, lung infiltrates and children may be ill appearing PE: Ill appearing, weakness Rhinorrhea Conjunctival injections Clear TMs Pharyngeal injection Respiratory- clear or atelectasis (if they are starting to develop inflammation to lower respiratory tract) Cardiac- tachycardia if febrile; concern of myocarditis if complaint of chest pain Abdominal exam benign in most cases (flu B may have some GI symptoms)

Answer 2

Differentials: Other viral URI (covid, parainfluenza, rhinovirus) Croup Pneumonia Epiglottitis Diagnostics: Rapid antigen testing (if family member has flu and child is brought in w/ symptoms but rapid is negative, can clinically diagnosis) PCR viral panels Viral culture (within 72 hrs of symptoms onset) CBC- leukopenia

Answer 3

Supportive: Fluid, rest, OTC fever reducer (APAP, ibuprofen) No ASA containing products- risk of Reye syndrome- encephalopathy from reaction b/w ASA and influenza virus Isolation / social distancing Good handwashing Antiviral (Tx and post exposure prophylaxis) - should be taken within 48 hrs of symptoms starting -Oseltamivir -Zanamivir -avoid in asthmatics - risk of bronchospasm

Answer 4

Viral infection caused by SARS COV-2 **HPI**: Loss of taste or smell Fever, myalgia, headache Cough, sore throat GI: nausea, vomiting, diarrhea (50% of children can be asymptomatic) **PE:** Mild or ill appearing Congestion, rhinorrhea, erythematous posterior oropharynx Ears- usually not involved, pearly TMs Respiratory - WNL besides cough, usually no wheezing unless child has underlying asthma or pulmonary disease Cardio- WNL, unless signs of myocarditis (chest pain, tachycardia) Differntial: other URI (influenza, parainfluenza, human metapneumovirus, RSV) Treatment: Supportive care Antiviral -12-18 yr emergency use authorization: Nirmatrelvir and Ritonavir w/i 5 days of symtpom onset and positive covid 19 test side effects: diarrhea, nausea, vomiting, loss of taste or smell, metallic taste in mouth, blood pressure changes, myalgia risk for drug drug interaction

Answer 5

2-6 weeks post covid infection 1-2% mortality rate Consider in child who has had recent covid, and starts developing new fever Confirm w/ PCR testing when possible s/s: - Fever >100.4 - Elevated CRP (> 3.0) Organ involvement - Cardiac, mucocutaneous, GI or hematologic - Redness of eyes, chest pain, beefy red mucous membranes, stomach ache

Answer 6

Defined as brief, **resolved** unexplainable event including 1 or more of the following: Cyanosis or pallor Change in respiration- apnea (cessation of breathing), decreased RR or irregular rate Change in muscle tone Change in responsiveness (diagnosis of exlclusion) risk factors contributing to alternative diagnoses or further eval: GER Neurologic problems Some respiratory infections Toxic ingestion Child abuse Cardiac disease Upper airway obstruction

Answer 7

Full PE including vitals Observation for 1-4 hrs (typically done in higher acuity setting but can be observed in clinic setting as well) Educate parents about BRUE- often time it is one time occurrence, but if it repetitive, then bigger workup will be necessary d/c home if stable; close followup within 24 hrs If parents are uncomfortable or cannot provide care- consider observation in hospital setting Consider EKG Pertussis test- infants <6mts can have apneic episodes from coughing

Answer 8

5 yrs and up Best of 3 attempts in asthma: establish diagnosis, follow progression of dx, establish need to step up or down on maintenance meds Intepretation: Prebronchodilator and post bronchodilator measurement Lung function measured before and after albuterol administration To diagnose asthma, there should be increase in lung function after albuterol administration - at least a **12% difference** should be seen to diagnose % predicted - values are based on sex, height, age

Answer 9

total volume of air that can be exhaled during a maximal forced exhalation effort

Answer 10

the volume of air exhaled in the first second under force after a maximal inhalation

Answer 11

the percentage of the FVC that is expired in 1 second

Answer 12

average flow after 25% of the FVC has been exhaled to the point at which 75% of the FVC has been exhaled

Answer 13

Autosomal recessive CF transmembrane conductance regulator (CFTR) defect - involved in the transport of **sodium** and **chloride** ions across the apical membrane of epithelial cells - abnormal CFTR protein **traps** choride and water **inside** the cell → **mucus** outside **thicker** and stickier Lung transplant extends life, but is not a cure

Answer 14

sweat chloride test >60 mmol/L x2 **0-6mts** 0-29 CF unlikely 30-59 intermediate >/= 60 indicative of CF >6mts, children, adults 0-39 CF unlikely 40-59 intermediate >/= 60 indicative of CF

Answer 15

- recurrent sinus or pulmonary infections - steatorrhea - growth failure - meconium plug (15-20% of infants w/ CF) - meconium ileus & bowel obstruction - rectal prolapse Less common: prolonged neonatal jaundice, hypoproteinemia enteropathy, hemorrhaic disease of the newborn Older children: - nasal polyps - bronchiectasis - digital clubbing - growth failure - distal intestinal obstruction syndrome - liver disease - pancreatitis

Answer 16

CPT Devices Huff cough- begin teaching as toddler, helps more effectively mobilize mucus from deeper in lungs Aerobic exercise Postural drainage- < 2yrs old, rotate child to promote drainage through gravity

Answer 17

- malabsorption of fats and proteins - fat soluble vitamin (ADEK) deficiency - malnutrition and FTT - 120-125% of RDA of calories - 80-85% are pancreatic insufficient Pancreatic Enzyme Replacement Therapy - indicated in 85% of CF pts - Creon most commonly used - Usual dose 2000-2500 units/kg of lipase per meal (max 10K units/day) - If enteral (tube) nutrition needed, special cartridges automatically add the enzymes based on the volume (Relizorb)

Answer 18

s/s: - increased cough, sputum - new crackles - new radiographic findings - weight loss, decreased appetite - decreased PFT and O2 sat - decreased exercise tolerance, fatigue - often triggered by viral infection management: - abx therapy improve pulmonary function, exercise tolerance and quality of life - may include anti inflammatory meds (azitrhomycin- has anti inflammatory properties, or ibuprofen) - mild exacerbation- oral and or inhaled abx based on culture sensitivity **- P. aeruginosa, S. aureus common **- 14 day or longer course until clinical improvement is achieved - send sputum sample when able

Answer 19

**Pulmonary** asthma hemoptysis pneumothorax chronic sinusitis **GI/Hepatobiliary** distal intestinal obstruction syndrome (DIOS) gall stones CF liver disease GERD **Endrocrine** CF related diabetes - annual screening oral glucose tolerance test starting at 10 yrs **Mental Health** Anxiety/depression **Other** Arthritis Osteopenia/porosis

Answer 20

caused by Mycobacterium tuberculosis complex air borne tradmission, not spread by contact

Answer 21

previously called latent TB infection Criteria- infection in person who: -has no symptoms or signs of disease and - has normal chest x ray findings and - has positive test result indicating infection

Answer 22

person with infection in whom symptoms, signs, and radiographic manifestations are apparent, dx can be pulmonary or extrapulmonary s/s (appear 1 month- 2 yrs after infection) - fever - weight loss or poor weight gain - cough - night sweats - chills - radiological findings vary

Answer 23

**Tuberculin skin testing**- tuberculin units injected intradermally creating a palpable wheal 6-10mm in diameter - preferred method for < 2 yrs old - interpret 48-72 hrs after injection - BCG (Tb vaccine overseas) can produce false positive **Interferon gamma release assay (IGRA)**- measure ex vivo interferon gamma production from T lymphocytes in response to stimulation w/ antigens specific to M. Tuberculosis complex performs reliably in children >2 yrs, very unreliable <3 mts positive test indicates infection, not disease If positive- ask about sx of dx, exposure to tb pts, perform PE for signs of dx, obtain CXR If CXR positive- obtain sputum or gastric aspitate sampling <12 mts consider lumbar puncture if any neuro s/s- higher risk for neurological impact from dx

Answer 24

**Induration >/= 5 mm** - considered positive in: - Children in close contact w/ known or suspected contagious people w/ TB disease - Children suspected to have TB disease: - Findings on chest radiograph consistent w/ active or previous TB disease - Clinical evidence of TB disease - Children receiving immunosuppressive therapy or w/ immunosuppressive conditions, including HIV **Induration >/= 10 mm** Children with increased risk for disseminated TB disease: - Children younger than 4 yrs - Children with other medical conditions, including Hodgkin disease, lymphoma, diabetes mellitus, chronic renal failure, or malnutrition - Children born in high prevalence regions of the world - Children with significant travel to high prevalence regions of the world - Children frequently exposed to adults who are living with HIV, experiencing homelessness, or incarcerated or to people who inject or use drugs or have alcohol use disorder **Induration >/= 15 mm** Children w/o any risk factors

Answer 25

Regimens: 12-week course of once-weekly dosing of isoniazid and rifapentine (treatment for those 2 years and older) 4-month course of rifampin daily (preferred regimen when isoniazid resistance is likely) 3 months of daily isoniazid and rifampin (no age restriction) 9-month course of isoniazid monotherapy daily (most widely recommended and used treatment for pediatric tuberculosis infection)

Answer 26

**Direct observation therapy**- intervention by which medications are taken by patient while a healthcare professional or trained third party observes and documents ingestion of each dose and assesses for adverse drug effects **6 mts, 4 drug regimen** Rifampin, Isoniazid, Pyrazinamide, and Ethambutol (RIPE) for the first **2 mts** (daily for at least 5 days/wk) Isoniazid and Rifampin for the remaining **4 mts** (3 times/wk) Other regimens recommended when drug resistance is likely Evaluation/Monitoring: CXR after 2 mts of therapy DOT to monitor for adherence and side effects Regular check ins with ID team to assess adherence and side effects Possible side effects can include** severe hepatitis** -should call for signs of **hepatotoxicity** - N/V, abdominal pain, jaundice

Answer 27

caused by collapse on inspiration of the soft, immature cartilages of the larynx structural weakness of tissues of the larynx (especially in supraglottic area) → tissue collapses inward during inspiration → obstruction Clinical Manifestations: - noisy breathing that worsens w/ feeds or when supine (positional) - on exam may note stridor when feeding or w/ excitement Varying degrees of severity -mild - just noisy breathing w/o airway compromise or growth issues -as severity increases, increased likelihood of airway compromise and FTT d/t increased caloric demands

Answer 28

**Unilateral or bilateral vocal cord paralysis** - 1 or both vocal cords do not open or close properly - can be congenital or associated w/ medical conditions or surgeries - *usually presents w/ inspiratory and expiratory stridor* **Laryngeal papillomatosis** - Associated w/ HPV infection that has settled in airways - Can be d/t maternal infection in infants - Small tumors form inside of larynx **Subglottic hemangioma** - Form a mass below vocal cords - Grow rapidly for 12-18 mts then atrophy **Subglottic stenosis** - Congenital or acquired (prolonged intubation) narrowing of the airway in the subglottic region *- Stridor is not positional* **Tracheomalacia** - Structural abnormality of the tracheal cartilage inducing collapsibility of the trachea - Kids can be severely affected and require trach - Can co-occur w/ laryngomalacia - *Expiratory sounds are usually present* **Vascular ring** - Aortic arch or its branches form a ring around the trachea or esophagus or both

Answer 29

**History** Birth history: procedures, intubations, NICU Breathing history at home Feeding habits Sleeping habits Medical history: GERD, recurrent PNA. FTT **Physical Exam** Oral cavity Clefts Micrognathia (mandibular hypoplasia), glossoptosis (downward displacement of tongue), upper airway obstruction associated with Pierre Robin Syndrome Nose - patency and choanal atresia (partial or full occlusion of nasal passage) Neck - retractions and masses or vascular lesions Chest- auscultation and inspection for retractions Beardlike distribution of hemangiomas associated w/ airway hemangioma

Answer 30

Flexible laryngoscopy - is mainstay for diagnostic evaluation of the infant with stridor - *Gold standard* for diagnosing laryngomalacia- not always done Modified barium swallow with speech therapist - Assess for feeding problems - Live fluoro study with mixed contrast and have baby drink it- evaluate how it goes down from esophagus into stomach and move into bowels - Speech therapist will watch for signs of reflux or contrast going down wrong tube Polysomnogram - Is child is having sleep concerns - Assess for apneic episodes Treatment: Refer to pediatric pulmonology Mild to moderate stridor without feeding difficulties → observation: - Continue to monitor weight gain and development of severe symptoms - Feed upright - Antireflux medications if indicated If feeding difficulties are present- thickening feeds Surgical intervention for those severely affected (10-20%) Resolution occurs in majority of patients by 12-18 mts

Answer 31

Radiolucent- allows crays to pass through, appears dark on film (air) Radiopaque- impenetrable to x-rays, appears light on film (bone) Density- composition of structures - Air-black, not dense - Fluid/soft tissues- gray, variable density - bones - white, dense - lead- pure white, most radiopaque

Answer 32

**Pneumothorax** - pulmonary markings replaced by *dark edge* (air leaked into pleural space), trachea may deviate away from PTX **Pneumomediastinum**- mediastinum *encircled by a dark line* (ring of air around mediastinum) **Atelectasis **(collapsed alveoli)- density of lung appears *more opaque* (white-collapsed alveoli → *lost air *→ less dense, so will appear grey or white), may be difficult to differentiate heart border **Infiltrates**- increased *haziness* d/t loss of air from alveoli being *consolidated* with pulmonary edema, pna, purulent fluids (Causes: dema, hemorrhage, pulmonary venous congestion, infectious pneumonia, aspiration)

Answer 33

Check for right patient, date and time Step 1: Tube placements - ETT- usually 2nd-3rd rib, at least 1 cm above carina - NG- well into stomach, below diaphragm - ND (nasoduodenal)- into stomach, curved and back right, past the spine (in stomach, through pylorus and curved back across into small intestine) Step 2: Evaluate lung fields - changes may be symmetric and diffuse, or lobar Step 3: Evaluate cardiac structures - Cardiac silhouette - **Normal size is no more than ½ of the chest width** - Central line placement in RA, IVC or SVC (not RV) - PA catheter- catheter extends down through RA, RV and up into PA Step 4: Evaluate bone structures Step 5: Evaluate abdomen