Pulmonology additional (Seth's Additional info) (12%) Flashcards
Leading cause of infant hospitalization
Bronchiolitis
2 months - 2 years
MCC of acute bronchilolitis
RSV
Respiratory Syncytial Virus
in the winter, spring, and sorta fall
what is acute bronchilitis inflammation of?
Bronchioles
smallest air passages
Defined as a clinical syndrome of respiratory distress in children under 2 years of age
MC age of acute bronchilits
2 months - 2 years
desribed the symptom evolution of bronchiolitis
upper respiratory symptoms, followed by the acute onset of wheezing, crackles, hyperinflation, and tachypnea
Resulting in acute inflammation of airways
PE of bronchiloitis
RR ()
Prolonged ()
Cough
() wheeze
otitis media
RR increased
Prolonged expiration
Cough
expiratory wheeze
otitis media
t/f first line dx of bronchilitis is imaging showing inflammed airways
FALSE
clinically typically, xray only sometimes
Treatment of acute bronchilitis
Supportive and hydration
f/u patient in 2 days if outpatient
if hypoxia/apnea/ect consider hospitalization
which (rarely used) antiviral has a good treatment response for bronchilitis
Ribavirin
what pulm medications should be AVOIDED with bronchilitis?
Bronchodilators (albuterol)
Systemic glucocorticoids
MC lethal genetic disease in the US
Cystic fibrosis :(
Median survival 47 years
inheritance pattern of CF
Autosomal recessive
Spells CAR
Seen in caucasians mostly
Overview of CF
(obstructive/restrictive) disease that leads to progressive respiratory failure and death
Obstructive
secrections get in the way
Chromsome # that contains CF gene and is defected in CF
Chromosome 7
Cystic Fibrosis averages 7 letters each
What does the CF gene on chromosome 7 typically code for
epithelial chloride channel (CF transmembrane conductance regulator protein)—(CFTR)
found on MANY organs
This in turn leads to problems in salt and water movement across cell membranes resulting in abnormally thick secretions in various organs
Early symptoms that key you into CF shortly after birth
Meconium ileus
Respirtory symptoms
FTT
if meconium ileus assume CF until confirmed with sweat tests and genotyping
Meconium ileus is obstruction of bowel by meconium in newborn infant that occurs at this anatomic site ().
virtually diagnostic of CF
terminal ileum
in the name!
think crohn’s I guess
What age do kiddos typically get diagnosed with CF?
Upon heel prick while in hospital
early diagnoses
what is the overview of upper respiratory, lower respiratory, GI, and pancreas symptoms
for CF
GI: volvulus, poor hydration, rectal prolapse
UR: Chronic sinusitis, nasal polyps, persistent cough
LR: infections, pneomothrax, right-sided heart failure (from pulm congestion)
Pancreas = abnormal electrolyte secretions, destruction of acini cells (leading to decreased pancreatic enzymes and pancreatic insuffiency in 85%+ of CF patients), DM, pancreatitis, malabsorbtion of fat soluble vit (DAKE), FTT
Electrolyte abn sometimes seen in CF and why
metabolic alkalosis
d/t losing electrolytes
Although typically initially dx with a heel stick, what is the gs dx of CF?
Sweat chloride test
Collection of sweat with pilocarpine iontophoresis
what is a borderline sweat-chloride test for CF?
above = dx
below = normal
40-60 mmol/L
50 +/- 10
think of sweat being 5 letters (so 50)
What do you do after you get 60+ sweat chloride test?
Positive test for CF
Genetic testing + therapy
can also get fecal elastase, pancreatic elastase-1 absent in 80% with CF
Tx of CF respiratory
- Follow with CF foundation
- Every 3 months
- Pulmozyme (mucolytic to decrease viscosity of purulent CF sputum)
- Hypertonic saline
- Bronchodilators
- Chest phsyio
- ABX for infections
- CFTR modulators
- Vaccines
Tx of CF GI
- Pancreatic enzyme supplementation combined with high calorie, high protein, high fat diet
- Daily vitamins
- Caloric supplements
- G-tube placement and supplemental feedings in FTT
Tx of acute exacerbation of CF
increased sputum, increased cough, DOE, fatigue, decreased apetite, fever, increased nasal congestion
- systemic ABX
- Sputum cultures
- 1 abx to target microbe grown on culture and 2 for pseodomonas
What is hyaline membrane disease AKA?
Infant respiratory distress syndrome
1 RF associated with hyaline membrane disease
Preterm
DM moms with term babies sometimes as well, but not nearly as common
Approximately 50% of infants born between 26 and 28 weeks gestation develop RDS, drops to 20 - 30% at 30 - 32 weeks
Pathophys of hyaline membrane disease
- Deficiency in pulmonary surfactant d/t prematurity
- Leads to noncompliant, stiff lungs
- Amount of pressure needed to open alveoli is increased, leading to atelectasis at end expiration
- Leads to a ventilation/perfusion mismatch, hypoxemia, hypercarbia, and persistent HTN
When do the manifestations of hyaline membrane disease (IRDS) typically present by?
min-hours after birth
s/s of hyaline membrane disease (IRDS)
- Premature infant
- Tachypnea
- Intercostal retractions
- Expiratory grunting
- Diminished breath sounds
- Cyanosis
- Progressively worsening
Dx and classic CXR finding of hyaline membrane disease (IRDS)
Clinically + cxr, pulse ox, ABG
diffuse ground-glass appearance
Treatment of hyaline membrane disease
(what O2 delivery is used?)
Multidisciplanary + Nasal CPAP (initial preferred intervention) and surfactant replacement
What might you give to prevent hyaline membrane disease (IRDS) and when?
Prenatal administration of a single course of steroids to women in preterm labor or at risk of delivery within the next 7 days between 24 - 34 weeks gestation
Asthma is a reversible (obstructive/restrictive) disease
obstructive
The pathogenesis of asthma involves
Inflammatory cell infiltration with ___
____ hyperplasia
Plugging of ___ airways with thick mucus
Hypertrophy of ____ muscle
Airway _____
___ cell activation
Inflammatory cell infiltration with eosonophils
Goblet cell hyperplasia
Plugging of small airways with thick mucus
Hypertrophy of smooth muscle
Airway edema
Mast cell activation
strongest RF for asthma
atopy
but lots of others as well
MC age range that marks the beginning of asthma
< 5 yo
77% of asthma begins in children <5 years old
What is the difference between extrinsic and intrinsic asthma and which is most common?
Extrinisic = allergic (MC)
Intrinsic = anything other than allergies
Overall common s/s of asthma
- Cough
- Chest tightness
- SOB/dyspnea
- difficulty breathing
- Episodic wheezing with expiration, hyperexpansion of thorax, use of accessory muscles.
- Decreased tactile fremitus (sometimes)
- Increased nasal secretions
- Atopy
- Hunched shoulders to breathe
- Percusion is normal to hyperresonant
Other than clinical suspicion, what is the main diagnostic tool for asthma and what does it show (in general).
Spirometry
Shows reversibility with bronchodilator + obstruction
Reduced FEV1/FVC and increased FEV1 after bronchodilator therapy
Explain the steps to diagnosing asthma for patients 5-18 yo with a obstructive pattern
- FEV1/FVC is < 85% of predicted
- if FVC < 80% predicted = obstructive (A); if FVC > 80% predicted = mixed (B).
- (A) For obstructive administer brochodilater, which shows increase in FEV1 of > 12% = reversible condition = asthma (if not increased by 12% consider alternative diagnosis)
- (B) For mixed, adminster bronchodilator, which shows FVC > 80% = likely COPD
obstrutive reversible is needed for dx
If spirometry is nondiagnostic, but you still are highly sus of asthma, what can you do?
what is a positive result?
Bronchoprovocation testing with inhaled methacholine, histamine, or mannitol
worsens breathing d/t causing contraction/narrowing if hyperresponive
Patients breathe in increasing amounts of methacholine and perform spirometry after each dose
Increased airway hyperresponsiveness with a ≥ 20% decrease in FEV1 up to 16 mg/mL max dose
others include exercise challenge, peal flow meters, chest xray (especially with status asthmaticus to r/o other dx), skin testing, sputum for eosinophils
what testing can you use for exercise and cold-induced asthma?
Provocative testing
In these tests, your doctor measures your airway obstruction before and after you perform vigorous physical activity or take several breaths of cold air
ABG findings of asthma commonly show (2)
- Hypoxemia
- Hypercarbia with decompensation
Sputum sample of asthma sometimes shows:
() of small airways
Thick, mucoid sputum
and what other 2 classic findings?
casts of small airways
Thick, mucoid sputum
Curschmann’s spirals (from shed epithelium)
Charcot-Leyden crystals (crystalloids with galectin-10)
What is mild intermittent asthma?
_ days a week
_ night awakenings
_ FEV1/FVC
() exacerbations requiring glucocortidoids per year
<= 2 days a week
<= 2 night awakenings per month
< 2 SABAs per week
No interfence with normal activites
Normal FEV1/FVC
0-1 exacerbations (< 2 basically)
Rule of 2s
Daily
FEV1 between 60-80% of predicted and FEV1/FVC below normal
FEV1 of severe asthma
60% or less
FEV1/FVC below normal
6 steps of asthma treatment
- SABA + low dose ICS when symptomatic OR low dose ICS daily
- SABA + low dose ICS
- SABA + low dose ICS + **LABA ** OR medium dose ICS alone
- SABA + medium dose ICS AND LABA
- SABA + high dose ICS + LABA (or montelukast)
- SABA + high dose ICS + oral steroids + LABA (or montelukast); consider monoclonal antibody
How often should patients with asthma f/u?
every 1-6 months depending on severity
when might you consider step down therapy for asthma?
if stable for 3 months
Your patient is dx with asthma - they can use this assessment tool at home to keep an “asthma diary” of how they are doing
Peak flow meter
t/f Peak flower meters consider height, weight, and age to measure normal values
FALSE
NOT weight, but height and age are a factor
What are the 4 factors used to predict normal values of peak flow monitors?
- Height
- Age
- Sex
- Ethnicity sorta (AA and hispanic americans are approx 10% lower)
What are the different colors of a peak flow monitor and what is the “caution” zone color and range?
Green, yellow, red
yellow = caution (50-80% predicted) follow treatment plan
below this = Bronchodilator therapy should be started immediately and clinician should be contacted
When to refer a pt with asthma to a pulmonologist or allergist
- Experienced a life threatening attack
- Hospitalized for attack
- > 2 rounds of oral corticosteroids needed
- Over 5 yo requiring step 4 care or higher
- Under 5 yo and requiring step 3 care or higher
- Unresponsive to treatment after 3-6 months
- Candidate for allergen immunotherapy
When would you take a SABA for exercise induced asthma/bronchospasm?
15-30 min prior to exercise
Cough variant asthma is treated the same as other forms, but is characterized by:
Cough lasting ()
Cough is (productive/nonproductive)
Cough typically occurs at this hour ()
Cough lasting (> 3 weeks)
Cough is (nonproductive)
Cough typically occurs at this hour (night)
