Pulmonology

Question 1

Identify the age specific upper airway factors that may lead to respiratory distress.

Answer 1

Small nasal passages, obligate nasal breathers, small and narrow pharynx, inability to coordinate secretions/swallowing/feeding

Question 2

Clinical and laboratory evaluation of croup

Answer 2

Fever, barking cough due to subglottic narrowing, steeple sign on X-ray, WBC may be normal, elevated or low

Question 3

Appropriate management of croup

Answer 3

Children with biphasic stridor at rest should receive racemic epinephrine nebulizer. Dexamethasone 0.6 mg/kg. Might need respiratory support depending on severity.

Question 4

Clinical and laboratory evaluation of epiglottitis

Answer 4

Sudden onset fever, sore throat, hot potato/muffled voice, drooling, tripod/sniffing position. Assess immunization status. If epiglottitis is suspected, avoid examination of the throat until controlled airway is available. Will see thumb print sign/enlarged epiglottis on lateral neck X-ray.

Question 5

Plan for epiglottitis

Answer 5

Airway management is the most important and may require intubation. Afterwards, antimicrobial therapy with a 3rd generation cephalosporin and vancomycin +/- steroids.

Question 6

What are the various etiologies of tracheomalacia?

Answer 6

Congenital disorders that are associated with tracheomalacia include anything leading to in-utero tracheal compression (eg congenital heart disease with cardiomegaly or intrathoracic masses), craniofacial anomalies, and other genetic syndrome, mucopolysaccharidoses, connective tissue disease, and others.

Acquired causes include those related to chronic barotrauma (from Pos Pressure ventilation), infection, or inflammation.

Question 7

What are the various etiologies of laryngomalacia?

Answer 7

May be isolated or may be seen in conjunction with congenital syndromes or other non airway anomalies.

Question 8

What are the clinical finding associated with tracheomalacia?

Answer 8

Presents around 4-6 weeks and may be worse when supine. Usually have an expiratory stridor or wheeze, located in the trachea. Can sometimes have inspiratory stridor.

Question 9

What are the clinical finding associated with laryngomalacia?

Answer 9

Soft, floppy immature cartilage of the larynx collapsing and causing airway obstruction. MCC of stridor in infants. Inspiratory stridor. Stridor prominent around 4-6 weeks. Worse when supine or agitated.

Question 10

Recognize the clinical findings, including disease course, associated with tracheitis

Answer 10

Fever, cough, stridor, respiratory distress. Endoscopy typically demonstrates a normal epiglottis with subglottic narrowing (edema, endoscopy typically demonstrates a normal epiglottis with subglottic narrowing (edema, erythema) and thick purulent secretions in the trachea. Can be either sudden onset or progressive toxic appearance after a seemingly normal sinusitis or predisposing virus.

Question 11

Appropriate management of tracheitis

Answer 11

Airway management, fluid resuscitation, +/- endoscopy, +/- racemic epi, broad spectrum abx

Question 12

Identify the pathogens most likely associated with tracheitis

Answer 12

most pathogens are those that are colonized in the respiratory tract. Staphylococcus aureus, Streptococcus pneumoniae, gram neg enteric bacteria, pseudomonas aeruginosa.

They can also be associated with predisposing virus. Viruses that have been isolated in children with bacterial tracheitis include: influenza A & B, RSV, Parainfluenza virus, measles, and enterovirus. Influenza A appears to be the most commonly associated viral infection. HSV may predispose and cause tracheitis, esp in immunocompromised individuals.

Question 13

Clinical and laboratory evaluation of vascular anomalies that affect the airway

Answer 13

Common presenting symptoms are respiratory and associated with tracheobronchial compression. Stridor, cough, respiratory distress. Initial evaluation with A/P and lateral CXR.

Anterior bowing of the trachea in the lateral view is associated with vascular ring. Can also do CT, MRA, Bronchoscopy, Barium swallow, echo.

Question 14

Recognize the clinical findings associated with congenital malformations of the lower airway.

Answer 14

Can be associated with recurrent unilateral pneumonia- congenital pulmonary malformations like CCAM, pulmonary sequestration, congenital lobar emphysema, congenital bronchogenic cysts.

Question 15

What are the clinical findings associated with bronchiolitis?

Answer 15

Kids <2 yo presenting with fever, cough, and respiratory distress, apnea, hypoxemia. Worsened by risk factors like prematurity, age <12, low weight, other comorbidites.

Often preceded by 2-3 days of viral URI symptoms.

Question 16

Management of bronchiolitis.

Answer 16

Supportive care including hydration and oxygen. Occasionally a trial of bronchodilators or nebulizer hypertonic saline may be appropriate.

Its important to monitor for secondary bacterial infections.

Question 17

Recognize the historical, clinical, and laboratory findings associated with foreign body aspiration.

Answer 17

Often in kids <3yo. Male predominance.

Clinically can present with a range of findings. the most severe being cyanosis, AMS. More commonly cough, tachyonea, stridor, monofocal wheezing, decreased air entry into one lung.

Foreign body in the lower airway can present with little symptoms. May be able to see radiopaque objects on XR.

Question 18

Evaluation of suspected foreign body aspiration and management.

Answer 18

Obtain CXR 1st for possible clues including the object or hyper inflated lung, atelectasis, mediastinal shift, pneumonia.

May also need to do a neck XR, bronchoscopy, or CT depending on level of suspicion

Management includes removal of the foreign body including flexed or rigid bronchoscopy.

In rare cases a thoracotomy is required.

Question 19

Long term complications associated with foreign body aspiration.

Answer 19

MC are atelectasis or post obstructive pneumonia. It is important to treat pneumonia afterwards or it can lead to bronchiectasis.

Question 20

What is bronchiectasis?

Answer 20

A structural abnormality characterized by abnormal dilation and distortion of the bronchial tree resulting in COPD.

The condition is typically the end result of a variety of pathophysiologic processes that render the bronchial walls weakened, easily collapsible, chronically inflamed and plugged with mucus secretion.s

Associated findings include atelectasis, emphysema, fibrosis, and hypertrophy of the bronchial vasculature.

Question 21

Differential diagnosis of bronchiectasis.

Answer 21

Asthma, GERD, chronic cough, emphysema, tracheal ring/sling, recurrent pneumonia, chronic sinusitis, allergic rhinitis, immune deficiency, CF

Question 22

Diagnosis evaluation of suspected bronchiectasis

Answer 22

CXR can show linear atelectasis, dilated and thickened airways.

High resolution CT is the gold standard- internal diameter of the airway is larger than the diameter of the adjacent artery.

Labs can be helpful to look for the etiology of the bronchiectasis

Question 23

Clinical findings associated with hemosiderosis.

Answer 23

Initially kids present with cough that progresses to hemoptysis and can develop into anemia.

20% have an enlarged liver or spleen.

May have crackles on lung exam.

Question 24

Identify risk factors associated with hemosiderosis

Answer 24

Kids with ANCA + vasculitides, fmhx of autoimmune disease, other collagen vascular disorders.

Question 25

Understand the epidemiology of asthma

Answer 25

1. Boys>girls pre-puberty, Girls>boys after puberty
2. African Americans, Puerto Ricans, Caucasians, Mexican Americans (in decreasing order)
3. More prevalent in family income below the poverty level
4. Urban>rural. NE and S> other US areas.

Question 26

Understand the natural history of asthma and factors that affect it.

Answer 26

1. Many infants wheeze early in life, but 3/4 outgrow it by adulthood
2. The majority of chronic asthma begins in the first 6 years of life.
3. One group has intermittent symptoms usually in relation to viral illness and outgrow these. The other group has later onset and is more persistent.

More likely to be persistent in those with pos fmhx and characterized by atopy. Risk factors for this group include frequent symptoms in the first year of life, eczema, elevated IgE levels, maternal hx of asthma, maternal smoking.