Pulmonology #5 (Bronchiolitis, Epiglottitis, Croup, PNA #1)

Question 1

MCC of bronchiolitis

Answer 1

RSV

Question 2

Who is MC affected by bronchiolitis?

Answer 2

Infants 2 months to 2 years old

Question 3

However, other risk factors for bronchiolitis are…

Answer 3

-Exposure to cigarette smoking
-Lack of breastfeeding
-Prematurity
-Crowded conditions

Question 4

Symptoms of acute bronchiolitis

Answer 4

Viral prodrome for 1-2 days followed by respiratory distress (tachypnea, nasal flaring, retractions, cyanosis, rales)

Question 5

Although bronchiolitis is mainly a clinical diagnosis. However, what diagnostic is the best predictor of disease in children?

Answer 5

Pulse oximetry

Question 6

Treatment for bronchiolitis

Answer 6

Supportive measures (humidified oxygen, IVF, nebulizer saline, cool mist humidifier, antipyretics)

Question 7

What is given during the first year of life for children < 29 weeks, immunodeficiency, chronic lung disease, or congenital heart disease to prevent bronchiolitis?

Answer 7

Palivizumab

Question 8

Risk factors for epiglottitis/supraglottitis

Answer 8

Males
DM
3 months-6 years old

Question 9

Historically, _____ was the MCC of epiglottitis. However, with vaccinations, ______ should be suspected if the patient is immunized.

Answer 9

H. Influenzae B (Hib)

Streptococcal species (GABHS)

Question 10

Symptoms of Epiglottitis (3 D’s)

Answer 10

Dysphagia
Drooling
Distress

-Fever, inspiratory stridor, odynophagia, hot potato voice, tripoding

Question 11

What gives the definitive diagnosis of epiglottitis?

Answer 11

Laryngoscopy (cherry red epiglottis with swelling)

Question 12

However, on lateral cervical radiographs, what is seen?

Answer 12

Thumb or thumbprint sign: swollen enlarged epiglottis

Question 13

What should you NOT do in children that you suspect this diagnosis?

Answer 13

Try to visualize with a tongue depressor

Question 14

What is the MOST important step in management of a patient with epiglottitis?

Answer 14

maintain the airway

OR is the best setting for intubation

Question 15

What is given to all close contacts of epiglottitis?

Answer 15

Rifampin

Question 16

What ABX are options for epiglottitis?

Answer 16

Ceftriaxone or Cefotaxime

Question 17

MCC of Croup

Answer 17

Parainfluenza virus 1

Question 18

Symptoms of Croup

Answer 18

-Harsh, seal-like barking cough
-Inspiratory stridor
-Hoarseness (in older kids and adults)
-Dyspnea
-Fever
-URI: Coryza
-Symptoms worse at night

Question 19

Although croup is a clinical diagnosis, what is seen on frontal cervical radiographs?

Answer 19

Steeple sign: subglottic narrowing of the airway (rarely done, though)

Question 20

Treatment for Croup, based on severity

Answer 20

Mild (no stridor at rest): supportive. Dexamethasone provides rapid relief of symptoms. Discharge home.

Moderate (stridor at rest with retractions): Dexamethasone + Nebulizer Epinephrine. Observe for 3-4 hours.

Severe (marked retractions): Dexamethasone + Nebulized Epi + Hospitalization

Question 21

MCC of Pneumonia

Answer 21

Strep Pneumoniae

Question 22

What are the 3 Atypical causes of PNA?

Answer 22

Chlamydia PNA
Mycoplasma Pneumoniae
Legionella PNA

Question 23

Symptoms of TYPICAL PNA

Answer 23

-Fever
-Productive cough
-Rigors (Strep Pneumo)
-Pleuritic chest pain

Question 24

What is a common symptom of Strep Pneumo PNA?

Answer 24

Rigors

Question 25

Symptoms of ATYPICAL PNA

Answer 25

-Fever -Dry, nonproductive cough -Extrapulmonary symptoms (myalgias, malaise, nausea, vomiting, diarrhea)

Question 26

True or False: With atypical PNA, the pulmonary exam is often normal.

Answer 26

True, but may have crackles/rales

Question 27

What are some physical exam findings of a patient with typical PNA?

Answer 27

Signs of consolidation (Bronchial breath sounds, dullness to percussion, increased tactile fremitus, ego phony, crackles/rales)

Question 28

What are the common symptoms of a patient with Strep Pneumo PNA?

Answer 28

Rigors, chills, blood-tinged (rusty) sputum

Question 29

What is seen on a gram-stain for Strep Pneumo

Answer 29

Gram-positive diplococci

Question 30

The second MCC of CAP, _______, has increased risk in extremes of age, immunocompromised, underlying pulmonary disease (CF, COPD, Asthma), and alcoholism.

Answer 30

H. Influenzae

Question 31

Staph A, often associated with _________, or _______, shows as gram positive cocci in clusters on a gram stain.

Answer 31

Superimposed infection after a viral infection or hospital acquired PNA

Question 32

What does Staph Aureus show up as on CXR?

Answer 32

Bilateral, multi lobar infiltrates or abscesses (cavitary lesions)

Question 33

What type of PNA is seen in chronic alcoholism or sick patients with chronic diseases (DM, etc.)

Answer 33

Klebsiella Pneumoniae

Question 34

What symptoms does a patient with Klebsiella PNA have?

Answer 34

Purple-colored, currant jelly sputum

Question 35

What is seen on CXR in a patient with Klebsiella PNA?

Answer 35

Cavitary lesions or lobar consolidations

Question 36

Klebsiella PNA is seen as ______ on gram-stain

Answer 36

Gram-negative rods

Question 37

MCC of atypical PNA

Answer 37

Mycoplasma PNA

Question 38

Risk factors for mycoplasma PNA?

Answer 38

Young, healthy (college students, military recruits, school-aged kids)

Question 39

Symptoms of Mycoplasma PNA

Answer 39

-Extrapulmonary symptoms: pharyngitis and URI symptoms followed by dry, nonproductive cough -Bullous myringitis: fluid filled blisters on TM

Question 40

What are some complications of mycoplasma PNA?

Answer 40

-Cold autoimmune hemolytic anemia (IgM) -SJS, TEN -Erythema Multiforme

Question 41

What is the diagnostic of choice for mycoplasma PNA?

Answer 41

PCR (cold agglutinins) -Gram stain is not useful because it has no cell wall

Question 42

What is seen on CXR in Mycoplasma PNA?

Answer 42

reticulonodular pattern MC Diffuse, patchy infiltrates

Question 43

Treatment for Mycoplasma PNA

Answer 43

Macrolides (Azithromycin, Clarithromycin) or Doxycycline

Question 44

How is Legionella PNA transmitted?

Answer 44

Outbreaks related to contaminated water sources (air conditioners, portable water, cooling towers, etc.) No person to person transmission.

Question 45

Symptoms of Legionella PNA

Answer 45

Fever, chills, dyspnea, chest pain, myalgias, etc. Extrapulmonary symptoms: GI symptoms such as diarrhea, nausea, vomiting. Hyponatremia and increased LFT's. Neurologic symptoms: headache, confusion, AMS.

Question 46

How do you diagnose Legionella PNA?

Answer 46

Nucleic acid detection (PCR, urine antigen, culture)

Question 47

Treatment for Legionella PNA

Answer 47

Macrolides or respiratory Fluoroquinolones (Levofloxacin, Moxifloxacin, Gemifloxacin)