Pulmonology

Question 1

Congenital Lung Malformations

Answer 1

Pulmonary hypoplasia- a lung that does not develop properly

Sequestration- born w/ adherent lung tissue that doesn’t function like normal lung tissue

Congenital cystic adenomatoid malformation (CCAM)- cysts develop in lobes of the lung, considered benign but can develop into cancer when they are older

Congenital lobar emphysema- hyperinflation of the lobe, deficient development of bronchial cartilage leading to over inflation, surgical intervention once child is older

Lung agenesis- lung didn’t develop properly

Question 2

Pneumonia pathophysiology

Answer 2

Infectious pathogen invades lung tissues → activation of body’s defense mechanisms
- cytokines
- polymorphonuclear neutrophils (PMNs)
- macrophages
→ Edema and increased permeability allowing fluid into alveoli and surrounding tissues

Question 3

Pneumonia types

Answer 3

Bronchopneumonia- infection of bronchioles and alveoli

Lobar pneumonia- most common, consolidation

Interstitial pneumonia- walls of alveoli & bronchi infected, occurs most often in viral cases

Question 4

Pneumonia etiology

Answer 4

Viral- influenza, RSV, adenovirus
(lung defenses are deceased d/t increases secretions → disrupts normal flora and normal phagycytosis → lungs are more susceptible)

Bacterial- strep pneumoniae, mycoplasma, chlamydia, TB

Fungal

Age Variants

**Neonatal **
-viral: CMV
-bacterial: group b strep, gram negative enteric, Listeria, chlamydia

Infants
-viral (most common): RSV, parainfluenza, adenovirus, metapneumovirus
-bacterial: s. pnemoniae, haemophilus influenzae, mycoplasma pneumoniae, mycobacterium tuberculosis, bordetella pertussis

preschool
-viral (most common): RSV, parainfluenza, influenza, adenovirus, metapneumovirus
-bacterial: s. pnemoniae, h. influenzae, m. pneumoniae, m. tuberculosis, chlamydia

school age
-viral: RSV, parainfluenza, influenza, adenovirus, metapneumovirus
-bacterial: M. pneumoniae, C. pneumoniae, S. pneumonia, M. tuberculosis

Question 5

Pneumonia HPI/PE

Answer 5

HPI:
recent illness
cough
chest discomfort
fever
did they recently have virus and now have cough + fever?

s/s:
Cough, fever, poor feeding, retractions, nasal flaring, tachypnea, hypoxemia
ill appearing
pleural rub may not be appreciated in infants, but can be heard in older child (also rales, crackles)

PE:
Crackles, diminshed breath sounds, bronchial sounds, egophany
Wheezing associated w/ viral etiology
Dullness to percussion, pain, w/pleural friction rub think pleural effusion

Imaging not routinely recommended if stable. Consider if hospitlization, confirm diagnosis when other potential etiology cannot be determined; complicated/severe cases or recurrent PNA

Question 6

PNA differntials/treatment

Answer 6

Differentials:
FB
Asthma
Bronchiolitis
Heart failure
Sepsis

Treatment
(think about common etiology)
Amoxicillin 90mg/kg/day or Augmentin
PCN allergy: Cefdinir 14 mg/kg/day or clindamycin 30-40 mg/kg/day divided into 3-4x/day (5-7 days)
Azithromycin 10mg/kg/day x1, then 5 mg/kg/day for 4 more days

Pearls:
- in infants < 6 mts, consider c. trachomatis, treat w/ azithtomycin 20 mg/kg/day x 3 days
- consider other etiology if not responding to initial treatment

Question 7

Bronchiolitis

Answer 7

Inflammation & swelling of bronchioles (smaller airways)

Lower respiratory tract infection <2 yrs old

s/s: Acute wheezing, tachypnea, WOB, cough, rhinorrhea, congestion

Viral etiology: RSV, parainfluenza, human metapneumovirus

PE:
General appearance is irritable infant/ toddler, fever
HEENT: rhinorrhea, cough, nasal flaring
Lungs: tachypnea, crackles, wheezing, grunting, hyperresonance on percussion
Heart: tachycardia

Question 8

Bronchiolitis pathophysiology/clinical course

Answer 8

Typically a prodrome of mild illness → increased respiratory symptoms,peak around days 5-7, lasting up to 21 days

Pathophysiology:
virus infects epithelial cells in URT → sloughed to LRT → further edema, sloughing into airway, mucus → obstruction + air trapping

(day 0-6)
Upper respiratory: virus infects epithelial cells that are sloughed to lower respiratory tract. Lower respiratory is normal
(day 6-18)
Lower Respiratory: further epithelial infection w/ edema, sloughing of cells into airway, mucous production and edema associated with obstruction & air trapping
Ciliary function impaired
Polymorphonuclear cells and lymphocytes proliferate in an inflammatory response
(day 18-22)
Upper & lower respiratory: regeneration of epithelium

Question 9

Bronchiolitis Diagnosis

Answer 9

Baby or child with coryzal prodrome lasting 1-3 days followed by:
- persistant cough and
- tachypnea or retractions and
- wheezes or crackles on ausculatation

fever and poor feeding are common findings

Question 10

Bronchiolitis treatment

Answer 10

Mild-moderate w/ adequate oxygen saturation (90%)
Supportive care: Hydration, saline and nasal suctioning, monitoring closely

Anticipatory guidance regarding disease process- let parents know things may get worse before they get better

When to f/u or seek emergent care- not feeding well, vomiting, > 6 hrs w/o wet diaper
Increasing distress or severe disease process
ED evaluation, oxygen support, support for hydration

Question 11

Bronchiolitis differentials

Answer 11

PNA
Pertussis
Recurrent wheezing
Chronic pulmonary disease
FB
Congenital heart disease

Question 12

RSV s/s

Answer 12

spread by respiratory droplets

gradual onset, may have 3-7 days of prodromal symptoms

s/s: fever, profuse rhinorrhea, cough, wheezing, respiratory distress

Question 13

RSV treatment

Answer 13

Supportive care:
Nasal suctioning (carefully, PRN), saline, humidified air
Monitor closely for respiratory compromise

Hospitalization if:
Desaturation despite airway suctioning
Poor feeding
Vomiting

Treatment:
oxygen if needed
suctioning
treat secondary infection (pna. aom)
IV fluids if needed
PICU for progressing respiratory failure

Question 14

RSV Prophylaxis

Answer 14

Nirsevimab (one dose)
Infants 0-8mts born during or entering first RSV season
8-19 mts who are at increased risk for severe RSV disease and entering their second RSV season

Palivizumab (synergis) (monoclonal antibiody)
Born </= 35 weeks gestation and <6 mts old at beginning of RSV season

<24 mts in 2nd RSV season with high-risk conditions (BPD, CHD) - given once a month during RSV season

(High risk= premature birth, <29 week gestation, chronic lung disease of prematurity, hemodynamically significant congenital heart disease, severe immunocompromise, severe cystic fibrosis)

Adult vaccines
Arexvy (nirsevimab) - 60 yrs + (late summer- early fall, before RSV starts to spread)
Abrysvo- maternal vaccine administered 32-36 weeks gestation, september-january

Question 15

Bronchitis

Answer 15

Nonspecific Inflammation & swelling of bronchi (larger airway) secondary to viral infection (inflammatory response to prior infection)

Pathophysiology:
Epithelium of bronchi affected → inflammatory cells & cytokines released → inflammation of epithelium w/ mucus production

Question 16

Bronchitis HPI/PE

Answer 16

HPI:
May report viral symptoms - rhinorrhea, nasal congestion, fever, sore throat
Cough develops, dry hacky then productive
Chest pain in older children

PE:
Afebrile or low-grade temp
Rhinitis, nasopharyngitis, conjunctivitis, may see petechiae around periorbital region from cough
Lungs
-Early- normal exam
-Late phase- may hear coarse sounds, crackles or wheezing

Question 17

Bronchitis differentials/treatment

Answer 17

Differentials:
Pertussis
Asthma
Bronchiolitis
Wheezing
Pneumonia

Treatment:
Supportive- lots of fluid, rest, lay on extra pillow
Caution w/ OTC cough suppressants in ages 4-11, contraindicated < 4 y/o
Antibiotics not necessary

Question 18

Pertussis

Answer 18

“whooping cough”
caused most often by Bordatella Pertussis- gram negative coccobacillus
spread via respiratory droplets
incubation period 7-10 days

classic presentation: paroxysms of coughing, inspiratory whoop and post tussive vomiting

Question 19

Pertussis Phases

Answer 19

Catarrhal phase:
- mild, nonspecific symptoms- clear rhinorrhea, cough, congesstion, afebrile or low grafr

Paroxymal phase:
- intermittent dry, hacking cough (prolonged and can see gagging, cyanosis or classic whoop in older chidlren
- post-tussive emesis in <12 mts old
- in babies may see apnea spells or color changes d/t intensity of coughing

Convalescent stage:
- decreased cough severity and frequency

Question 20

Pertussis PE

Answer 20

HEENT- petechial hemorrhage (from intensity of coughing), in catarrhal phase- rhinorrhea, nasal congestion
Skin- petechial rash

Infant exceptions:
May lack cararrhal phase
Gaggings, gasping, eye bulging w/ coughing in < 6 mts
Apnea, respiratory distress, seizures, shock, poor weight gain

Question 21

Pertussis diagnostics

Answer 21

CBC if febrile- unimmunized may have leukocytosis

Chest radiograph- normal in most cases, may see pneumomediastinum, pneumothorax, perihilar infiltrates

Pertussis specific (ideal to conduct early, within 3 weeks of symptoms)
- Culture- highest specificity, low sensitivity (ability to identify absence of dx, true negative)
- PCR- more sensitive test (ability to identify presence of dx, true positive)
- Serum- variable sensitivity/specificity

Question 22

Pertussis differentials

Answer 22

URI, adenovirus
RSV
Pneumonia
Other bordetella infection

Question 23

Pertussis Treatment

Answer 23

Guidelines:
If clinical picture leads you to suspect Pertussis- treat if < 21 days of symptoms onset
If culture is positive- treat
Infants treat within 6 weeks of onset
Older children and adolescents treat within 3 weeks of symptom onset

Treatment= macrolide abx
< 1 month: Azithromycin 10 mg/kg/day
**1-5 mts: **
Azithromycin 10 mg/kg/day
Erythromycin 40 mg/kg/day QID x 14 days
Clarithromycin 15 mg/kg/day BID x 7 days
TMP-SMX if allergic to macrolides (>2mts)
6mts+:
Azithromycin 10 mg/kg/day x1 day, 5 mg/kg/day x 4 days
Erythromycin 40 mg/kg/day QID x 7-14 days (maximum 2 g/day)
Clarithromycin 15 mg/kg/day BID x 7 days (max 1 g/day)

household contacts should receive macrolide abx as well

Question 24

Influenza

Answer 24

Viral infection
Antigenic types include A, B & C
Type A has surface proteins which allow for further subtyping- Hemagglutinin (H) & Neuraminidase (N)

Children shed virus for about 10 days
Easily spread
Incubation 1-4 days, contagious 24 hrs prior to symptom onset

High risk of hospitalization:
< 2 y/o and adults >65 yrs
Underlying immune compromising disease
Risk of death
unimmunized children
<5 yrs w/ high risk conditions

Question 25

Influenza HPI/PE

Answer 25

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)

Question 26

Influenza differentials/diagnostics

Answer 26

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

Question 27

Influenza Treatment

Answer 27

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

Question 28

COVID 19

Answer 28

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

Question 29

Multisystem Inflammatory Syndrome of childhood (MIS-C)

Answer 29

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

Question 30

Brief Resolved Unexplained Event (BRUE)

Answer 30

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

Question 31

BRUE management

Answer 31

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

Question 32

Spirometry

Answer 32

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

Question 33

FVC (forced vital capacity)

Answer 33

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

Question 34

FEV1 (forced expiratory volume in 1 second)

Answer 34

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

Question 35

FEV1/FVC ratio

Answer 35

the percentage of the FVC that is expired in 1 second

Question 36

FEF 25-75% (forced expiratory flow over the middle one half of the FVC)

Answer 36

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

Question 37

Cystic Fibrosis

Answer 37

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

Question 38

CF diagnosis

Answer 38

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

Question 39

CF clinical presentation

Answer 39

• 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

Question 40

CF airway clearance strategies

Answer 40

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

Question 41

CF nutritional defecits

Answer 41

• 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)

Question 42

CF Pulmonary Exacerbation

Answer 42

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

Question 43

CF complications

Answer 43

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

Question 45

Tuberculosis

Answer 45

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

Question 46

TB Infection

Answer 46

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

Question 47

TB disease

Answer 47

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

Question 48

TB testing

Answer 48

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

Question 49

Tuberculin skin testing interpretation

Answer 49

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

Question 50

TB Infection treatment

Answer 50

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)

Question 51

TB Disease treatment/management

Answer 51

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

Question 52

Laryngomalacia

Answer 52

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

Question 53

Laryngomalacia differential diagnoses

Answer 53

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

Question 54

Laryngomalacia H&P

Answer 54

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

Question 55

Laryngomalacia diagnostics/treatment

Answer 55

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

Question 56

X-Ray Terminology

Answer 56

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

Question 57

Evaluating lung fields on xray

Answer 57

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)

Question 58

CXR Systematic Approach

Answer 58

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