Pulmonology Flashcards
A septum separating the nasal cavity from the pharynx
Newborns are nose breathers - cyanosis with bilateral obstruction, relieved by crying
Dx: inability to pass an NGT through the nostril; fiber optic rhinoscopy
Tx: airway first then surgical correction
CHOANAL ATRESIA
Organisms: RHINOVIRUS, PARAINFLUENZA VIRUS, RSV, CORONAVIRUS (children are reservoirs)
Incubation period: 2-5 days, resolved 5-7 days
SSX: sore throat, sneezing, rhinorrhea, nasal congestion, pharyngitis
Tx: supportive
Complications: otitis media, sinusitis, pneumonia
COMMON COLDS/RHINITIS
Organisms: S. PNEUMONIAE, H. INFLUENZAE TYPE B, M. CATARRHALIS (acute), anaerobes (chronic)
Anything that impairs mucociliary transport or causes nasal obstruction predisposes to sinusitis
SSX: cold symptoms > 7-10 days, purple not nasal discharge, headache, tenderness over the sinuses
X-ray: air-fluid levels, opacification of the sinuses
Tx: antibiotics x 14 days (CO-AMOXICLAV)
Complications: abscess, meningitis
SINUSITIS
Gradual onset
Moderate throat pain
Symptoms of viral URTI
Contacts with cold symptoms
Vesicles and ulcers (HSV)
Conjunctivitis (adenovirus)
Tx: symptomatic
Acute pharyngitis (VIRAL)
Headache, vomiting, abdominal pain
No URTI symptoms
Palatial petechiae and diffuse erythema of tonsils and pillars
Sandpaper rash on inguinal and antecubital areas
Dx: rapid strep Ag test, throat culture
Tx: penicillin or amoxicillin x 10 days
Complications:
- rheumatic fever
- post-streptococcal glomerulonephritis
- peritonsillar/retropharyngeal abscess
GABHS (GROUP A BETA HEMOLYTIC STREPTOCOCCI)
Bacterial invasion through the capsule of the tonsils
Adolescents
Group A streptococcus and anaerobes
Fever, sore throat, dysphagia, trismus
PE: tonsils may be markedly red with swelling and uvula is displaced
CT scan: ideally
Surgical drainage and antibiotics
PERITONSILLAR ABSCESS
3-4 years old
Retropharyngeal space located between the pharynx and the cervical vertebrae and extending down into the superior mediastinum
Can result from penetrating trauma to the oropharynx, dental infection and vertebral osteomyelitis
Manifestations:
- GROUP A streptococcus, anaerobes, Staphylococcus aureus
- fever, progressive dysphagia
- PE: drooling, neck held in hyperextension, bulge seen behind the posterior pharyngeal wall, neck pain, muffled voice, respiratory distress
RETROPHARYNGEAL ABSCESS
Also called viral croup
Acute inflammatory disease of the larynx (within the subglottic space)
Most common etiology: PARAINFLUENZA VIRUS
SSX: prodromal URTI symptoms, low-grade fever, inspiratory stridor, hoarse voice, barking cough
Neck X-ray: subglottic narrowing - “steeple sign”
Tx:
- mild (at home): oral fluids, cool mist or steam therapy
- moderate: oral steroids
- severe (admit to hospital): nebulized racemic epinephrine
- parenteral steroids
LARYNGOTRACHEOBRONCHITIS
Serious and rapidly progressive infection of supra glottic structures
Most common etiology is H. Influenzae B
SSX: acute onset of high fever, dysphagia, drooling, muffled voice, “sniffing dog” position
Dx: examine the throat only under double set-up
X-ray: “thumbprint” or “leaf” sign
Fiberoptic laryngoscopy: direct visualization of inflamed epiglottis
Tx: secure airway (intubation or tracheostomy); under double set-up, IV antibiotics (3rd gen cephalosporin or Ampicillin-Sulbactam)
ACUTE EPIGLOTTITIS
AGE GROUP: 3 months to 3 years
STRIDOR: 88%
PATHOGEN: parainfluenza virus
ONSET: prodrome (1-7 days)
FEVER SEVERITY: low grade
ASSOCIATED SX: barking cough, hoarseness
RESPONSE TO RACEMIC EPINEPHRINE: stridor improves
CXR: “steeple sign”
VIRAL CROUP
AGE GROUP: 3-7 years
STRIDOR: 8%
PATHOGEN: H. Influenzae type B
ONSET: rapid (4-12 hours)
FEVER SEVERITY: high grade
ASSOCIATED SX: muffled voice, drooling
RESPONSE TO RACEMIC EPINEPHRINE: none
CXR: “thumbprint/leaf sign”
EPIGLOTTITIS
Aspirated FBs may lodge in the larynx, trachea or bronchi
- larynx (1 yr)
Most commonly aspirated food: peanut
Most common cause of death in food aspiration: hotdogs and bread
SSX: sudden onset of respiratory distress, cough, hoarseness, cyanosis, localized wheezing, localized absence of breath sounds
CXR: lung remains overgerated on expiratory film (ball-valve mechanism)
Rigid bronchoscopy diagnostic and therapeutic
May be mistakenly diagnosed as asthma or pneumonia
FOREIGN BODY ASPIRATION
Acute inflammation of the small airways in children
BRONCHIOLITIS
Classification according to location:
- pneumonitis - inflammation of the interstitium
- lobar pneumonia - with consolidation of one or more lobes
- bronchopneumonia - inflammation of the bronchioles with mucopurulent exudate
Most commonly viral in childhood
SSX: clinical triad - fever, cough & tachypnea
Etiologies in young infant:
- 0-28 days: GBS, E. Coli, Listeria S. Pneumoniae
- 3 weeks-3 months: RSV, Parainfluenza
- Chlamydia, Mycoplasma, S. pneumoniae, S. Aureus
Etiologies in older infants and children:
- 4 months-4 years: viruses, S. Pneumoniae, H. Influenzae type b, Mycoplasma
- 5-15 years: Mycoplasma, S. Pneumoniae
PNEUMONIA
SSX: cough, wheezing, stridor
CXR, CBC: diffuse streaky infiltrates; lymphocytosis
Tx: supportive
Viral Pneumonia
SSX: cough, high fevers, dyspnea, dullness to percussion
CXR, CBC: lobar consolidation; neurophilia
Tx:
- (0-2mo) AMPICILLIN + AMINOGLYCOSIDE
- (2mos-5yrs) CEFTRIAXONE or CEFUROXIME or CEFUROXIME + AMPICILLIN or AMOCLAV
Bacterial Pneumonia
SSX: less ill-looking, non-productive cough
CXR, CBC: interstitial pattern, usually lower lobes
Tx: (>5 yrs) ERYTHROMYCIN, CLARITHROMYCIN, or AZITHROMYCIN
Mycoplasma “walking pneumonia”
SSX: 6 weeks to 6 months, “staccato”, cough, maternal he of infection
CXR, CBC: hyperinflation, “ground-glass” appearance, eosinophilia
Tx: erythromycin PO x 14 days
Chlamydia (pneumonia)
Mycobacterium tuberculosis
Most specific confirmation is isolation of the organism
Sputum specimens for culture for those who can expectorate
Induce sputum with a jet nebulizer and chest percussion followed by nasopharyngeal suctioning: for culture and smear staining
Gastric aspirates: AFB culture
Young children: early AM gastric acid obtained before the child has arisen & peristalsis has emptied the stomach of the pooled secretions
3 consecutive AM gastric aspirates yield the organism in
Pulmonary tuberculosis
Primary complex (Ghon complex)
- Primary pulmonary focus
- Regional lymph nodes
- Peritracheal lymph nodes
- Localized pleurisy between the middle & lower lobes
Diagnostic criteria for PTB
Exposure to TB sputum (+) adults
(+) PPD test
Signs and symptoms (any 2 or more)
Chet x Ray findings
Isolation of the organism
Sign and symptoms of PTB
(Any 2 or more)
Cough with or without wheezing for >2 weeks
Unexplained fever for >2 weeks
Failure to gain weight: weight loss
Unexplained poor appetite
Painless cervical lymphadenopathy
Failure to respond to 2 weeks appropriate antibiotic therapy for LRTI
Classification of PTB
Class I
TB exposure: (+) exposure to and adult/adolescent with active disease, (-) PPD, no signs/symptoms, negative chest X Ray findings
Class II
TB exposure: +/- exposure, (+)PPD, no signs/symptoms, negative chest X ray findings
Class III TB disease: 3 or more of the ff criteria - exposure to an adult/adolescent with active TB disease - signs/symptoms suggestive of TB - abnormal chest x ray findings - laboratory findings
Class IV TB inactive: - with or without history of previous TB - with or without previous chemotherapy - has radiologic evidence of healed/calcified TB - (+) PPD - no signs and symptoms - (-) smear or culture for TB
PPD interpretation
Equal or >10mm is (+)
Equal or >5mm is (+) in the presence of any or all of the ff:
- history of close contact with a known or suspected case of TB
- clinical findings suggestive of TB
- chest x ray findings suggestive of TB
- immunocompromised condition
