Pulmonology

Question 1

what are common etiologies of bronchiolitis?

Answer 1

viral - RSV, influenza, parainfluenza, metapneumovirus

Question 2

what is the presentation of bronchiolitis?

Answer 2

apnea (esp. in 4 months of age -RSV)

copious rhinorrhea

cough/wheeze

fever

Question 3

how do you diagnose bronchiolitis?

Answer 3

PE findings and history

x-ray unecessary

specific cause can be confirmed by antigen testing or PCR?

Question 4

what’s the most common cause of bronchiolitis?

Answer 4

RSV

Question 5

how do you manage bronchiolitis?

Answer 5

supportive care - nasal suction, hydration, supplemental O2 if sats<90% on room air

meds - trial of beta 2 agonist or racemic epinephrine (works, keep it up), nebulized 3% hypertonic saline

no benefit to chest PT

screen for RSV to avoid abx and isolate infants in hospitals

Question 6

what are the sequelae of bronchiolitis?

Answer 6

obstruction of the u and l respiratory tract that can lead to respiratory failure

• highest risk in premies and those with lung disease
• give these babies Synagis

Question 7

What is Synagis?

Answer 7

Palivizumab

IgG monoclonal Ab

<29 weeks gestation, younger than a year at onset of RSV season

chronic lung dz less than 24 years

*consider in immunocompromised, CV disease, neuromuscular disease

Question 8

what are the causes of respiratory failure in infants?

Answer 8

upper airway ob

lower airway ob

sepsis

hypotonia

Question 9

what presentations in infants is concerning for impending respiratory failure?

Answer 9

inreased accessory muscle use

inability to coordinate feeding (poop out)

decreased arousability

hypoxemia/hypercarbia

*normal PCO2 with marked tachypnea very poor sign

Question 10

what are the three phases of pertussis and the clinical features of each?

Answer 10

1. catarrhal: cough and rhinorrhea (1-2 weeks)
2. paroxysmal: fits of coughing, inspiratory whoop, post-tussive emesis (2-8 weeks)
3. convalescent - gradual waning of symptoms (weeks to months)

Generally, NO FEVER

Question 11

what is the incubation period for pertussis?

Answer 11

7-10 days

Question 12

how is diagnosis of pertussis made?

Answer 12

clinical - paroxysmal cough, whoop, post-tussive emesis

lymphocytosis is a clue

PCR and culture

Question 13

what is the treatment for pertussis?

Answer 13

macrolides

azithromycin (5 days)

preferred in young, pregnant women

alternatives: erythromycin (14 days), clarithromycin (7 days), TMP-SMX (14 days)

*prevents spread and limits cough in catrarrhal

Question 14

what are the complications of pertussis?

Answer 14

abx don’t do much

hospitalization

apnea

2ndary pneumonia

seizure

death

Question 15

what is the most common source in infant pertussis?

Answer 15

family members

one of the reasons we have been moving to immunizing mother during pregnancy

Question 16

what are the clinical manifestations of pneumonia by age?

Answer 16

neonates - fever or hypoxia only

young infants - apnea may be first sign

children - fever, chills, tachypnea, cough, malaise, retractions, apprehension

Question 17

which type of pneumonia usually presents with high fever, chills, and focal findings?

Answer 17

bacterial

Question 18

what type of pneumonia presents with diffuse crackles?

Answer 18

atypical

Question 19

what are the most common causative organisms for pneumonia by age?

Answer 19

Question 20

in longstanding asthma, what may occur?

Answer 20

remodeling of the airway that can lead to incomplete reversability

Question 21

what’s a common clinical sign of childhood asthma?

Answer 21

post-tussive emesis (night or early morning)

Question 22

when do peds usually diagnose with asthma?

Answer 22

after recurrent episodes

usually 4

partially reversible measured by spirometry increase of FEV 1 > 200 mL AND 12% from baseline after SABA admin.

Question 23

using metered dose inhaler without a spacer can cause loss of up to how much of the medicine?

Answer 23

60%

Question 24

how often should children have spirometry once the asthma is under control?

Answer 24

every 1-2 years

Question 25

what’s an unusual asthma trigger?

Answer 25

essential oil infusers

Question 26

what percentage of children with asthma have an allergic phenotype?

Answer 26

60-80%

Question 27

what happens during exercise induced bronchospasm?

Answer 27

airway dries out, and bronchospasm ensues from inflammation

Question 28

what do you need to know to determine asthma severity?

Answer 28

symptoms

nighttime awakenings

SABA use for rescue

interference with normal activities

PFTs

Question 29

what is the preferred approach to initiate controller therapy in pediatric asthma?

Answer 29

inhaled cortiocosteroids if already on SABA

add LABA to ICS if not well controlled

leukotriene alternative (good for allergic)

Question 30

what are the components of an asthma action plan?

Answer 30

green - daily regimen

yellow - acute loss of asthma control (nip exacerbation in the bud)

red - ER

Question 31

what are the highest risks for severe asthma exacerbations?

Answer 31

poor asthma control

higher disease severity

prior hospitalizations/intubations

non-adherence to therapy

Question 32

what is status asthmaticus?

Answer 32

no response to reptitive or continuous administration of SABA

Question 33

what are third tier therapies for asthma?

Answer 33

IV ketamine

inhaled anesthetics

ECMO

Question 34

what are 2nd tier asthma exacterbation treatments?

Answer 34

IV magnesium

aminophylline

salbutamol

non-invasive ventilation

heliox

Question 35

what are 1st tier asthma exacerbation treatments?

Answer 35

inhaled Beta agonists

inhaled anti-cholinergics

systemic corticosteroids