Pulmonology additional (Seth's Additional info) (12%)

Question 1

Leading cause of infant hospitalization

Answer 1

Bronchiolitis

2 months - 2 years

Question 2

MCC of acute bronchilolitis

Answer 2

RSV

Respiratory Syncytial Virus

in the winter, spring, and sorta fall

Question 3

what is acute bronchilitis inflammation of?

Answer 3

Bronchioles

smallest air passages

Defined as a clinical syndrome of respiratory distress in children under 2 years of age

Question 4

MC age of acute bronchilits

Answer 4

2 months - 2 years

Question 5

desribed the symptom evolution of bronchiolitis

Answer 5

upper respiratory symptoms, followed by the acute onset of wheezing, crackles, hyperinflation, and tachypnea

Resulting in acute inflammation of airways

Question 6

PE of bronchiloitis
RR ()
Prolonged ()
Cough
() wheeze
otitis media

Answer 6

RR increased
Prolonged expiration
Cough
expiratory wheeze
otitis media

Question 7

t/f first line dx of bronchilitis is imaging showing inflammed airways

Answer 7

FALSE

clinically typically, xray only sometimes

Question 8

Treatment of acute bronchilitis

Answer 8

Supportive and hydration

f/u patient in 2 days if outpatient

if hypoxia/apnea/ect consider hospitalization

Question 9

which (rarely used) antiviral has a good treatment response for bronchilitis

Answer 9

Ribavirin

Question 10

what pulm medications should be AVOIDED with bronchilitis?

Answer 10

Bronchodilators (albuterol)
Systemic glucocorticoids

Question 11

MC lethal genetic disease in the US

Answer 11

Cystic fibrosis :(

Median survival 47 years

Question 12

inheritance pattern of CF

Answer 12

Autosomal recessive

Spells CAR

Seen in caucasians mostly

Question 13

Overview of CF
(obstructive/restrictive) disease that leads to progressive respiratory failure and death

Answer 13

Obstructive

secrections get in the way

Question 14

Chromsome # that contains CF gene and is defected in CF

Answer 14

Chromosome 7

Cystic Fibrosis averages 7 letters each

Question 15

What does the CF gene on chromosome 7 typically code for

Answer 15

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

Question 16

Early symptoms that key you into CF shortly after birth

Answer 16

Meconium ileus
Respirtory symptoms
FTT

if meconium ileus assume CF until confirmed with sweat tests and genotyping

Question 17

Meconium ileus is obstruction of bowel by meconium in newborn infant that occurs at this anatomic site ().

virtually diagnostic of CF

Answer 17

terminal ileum

in the name!

think crohn’s I guess

Question 18

What age do kiddos typically get diagnosed with CF?

Answer 18

Upon heel prick while in hospital

early diagnoses

Question 19

what is the overview of upper respiratory, lower respiratory, GI, and pancreas symptoms

for CF

Answer 19

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

Question 20

Electrolyte abn sometimes seen in CF and why

Answer 20

metabolic alkalosis

d/t losing electrolytes

Question 21

Although typically initially dx with a heel stick, what is the gs dx of CF?

Answer 21

Sweat chloride test

Collection of sweat with pilocarpine iontophoresis

Question 22

what is a borderline sweat-chloride test for CF?

above = dx
below = normal

Answer 22

40-60 mmol/L

50 +/- 10
think of sweat being 5 letters (so 50)

Question 23

What do you do after you get 60+ sweat chloride test?

Positive test for CF

Answer 23

Genetic testing + therapy

can also get fecal elastase, pancreatic elastase-1 absent in 80% with CF

Question 24

Tx of CF respiratory

Answer 24

1. Follow with CF foundation
2. Every 3 months
3. Pulmozyme (mucolytic to decrease viscosity of purulent CF sputum)
4. Hypertonic saline
5. Bronchodilators
6. Chest phsyio
7. ABX for infections
8. CFTR modulators
9. Vaccines

Question 25

Tx of CF GI

Answer 25

1. Pancreatic enzyme supplementation combined with high calorie, high protein, high fat diet 2. Daily vitamins 3. Caloric supplements 4. G-tube placement and supplemental feedings in FTT

Question 26

Tx of acute exacerbation of CF ## Footnote increased sputum, increased cough, DOE, fatigue, decreased apetite, fever, increased nasal congestion

Answer 26

1. systemic ABX 2. Sputum cultures 3. **1 abx to target microbe grown** on culture and **2 for pseodomonas**

Question 27

What is hyaline membrane disease AKA?

Answer 27

Infant respiratory distress syndrome

Question 28

#1 RF associated with hyaline membrane disease

Answer 28

Preterm | DM moms with term babies sometimes as well, but not nearly as common ## Footnote Approximately 50% of infants born between 26 and 28 weeks gestation develop RDS, drops to 20 - 30% at 30 - 32 weeks

Question 29

Pathophys of hyaline membrane disease

Answer 29

1. Deficiency in **pulmonary surfactant** d/t prematurity 2. Leads to noncompliant, stiff lungs 3. Amount of pressure needed to open alveoli is increased, leading to atelectasis at end expiration 4. Leads to a ventilation/perfusion mismatch, hypoxemia, hypercarbia, and persistent HTN

Question 30

When do the manifestations of hyaline membrane disease (IRDS) typically present by?

Answer 30

min-hours after birth

Question 31

s/s of hyaline membrane disease (IRDS)

Answer 31

1. Premature infant 2. Tachypnea 3. Intercostal retractions 4. Expiratory grunting 5. Diminished breath sounds 6. Cyanosis 7. *Progressively worsening*

Question 32

Dx and classic CXR finding of hyaline membrane disease (IRDS)

Answer 32

Clinically + cxr, pulse ox, ABG **diffuse ground-glass appearance**

Question 33

Treatment of hyaline membrane disease (what O2 delivery is used?)

Answer 33

**Multidisciplanary** + **Nasal CPAP** (initial preferred intervention) and **surfactant replacement**

Question 34

What might you give to prevent hyaline membrane disease (IRDS) and when?

Answer 34

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**

Question 35

Asthma is a reversible (obstructive/restrictive) disease

Answer 35

obstructive

Question 36

The pathogenesis of asthma involves Inflammatory cell infiltration with ___ ____ hyperplasia Plugging of ___ airways with thick mucus Hypertrophy of ____ muscle Airway _____ ___ cell activation

Answer 36

Inflammatory cell infiltration with **eosonophils** **Goblet cell hyperplasia** **Plugging of small airways** with thick mucus **Hypertrophy of smooth muscle** **Airway edema** **Mast cell activation**

Question 37

strongest RF for asthma

Answer 37

atopy ## Footnote but lots of others as well

Question 38

MC age range that marks the beginning of asthma

Answer 38

< 5 yo ## Footnote 77% of asthma begins in children <5 years old

Question 39

What is the difference between extrinsic and intrinsic asthma and which is most common?

Answer 39

**Extrinisic = allergic** (MC) Intrinsic = anything other than allergies

Question 40

Overall common s/s of asthma

Answer 40

1. Cough 2. Chest tightness 3. SOB/dyspnea 4. difficulty breathing 5. **Episodic wheezing** with expiration, hyperexpansion of thorax, use of accessory muscles. 6. Decreased tactile fremitus (sometimes) 7. Increased nasal secretions 8. Atopy 9. Hunched shoulders to breathe 10. Percusion is normal to hyperresonant

Question 41

Other than clinical suspicion, what is the main diagnostic tool for asthma and what does it show (in general).

Answer 41

Spirometry | Shows reversibility with bronchodilator + obstruction ## Footnote Reduced FEV1/FVC and increased FEV1 after bronchodilator therapy

Question 42

Explain the steps to diagnosing asthma for patients 5-18 yo with a obstructive pattern

Answer 42

1. **FEV1/FVC is < 85% of predicted** 2. if **FVC < 80% predicted = obstructive** (A); if FVC > 80% predicted = mixed (B). 3. (A) For obstructive **administer brochodilater**, which **shows increase in FEV1 of > 12% = reversible condition = asthma** (if not increased by 12% consider alternative diagnosis) 4. (B) For mixed, adminster bronchodilator, which shows FVC > 80% = likely COPD ## Footnote obstrutive reversible is needed for dx

Question 43

If spirometry is nondiagnostic, but you still are highly sus of asthma, what can you do? ## Footnote what is a positive result?

Answer 43

**Bronchoprovocation** testing with **inhaled** **methacholine**, histamine, or mannitol | worsens breathing d/t causing contraction/narrowing if hyperresponive ## Footnote 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

Question 44

what testing can you use for exercise and cold-induced asthma?

Answer 44

Provocative testing ## Footnote In these tests, your doctor measures your airway obstruction before and after you perform vigorous physical activity or take several breaths of cold air

Question 45

ABG findings of asthma commonly show (2)

Answer 45

1. Hypoxemia 2. Hypercarbia with decompensation

Question 46

Sputum sample of asthma sometimes shows: () of small airways Thick, mucoid sputum and what other 2 classic findings?

Answer 46

**casts** of small airways Thick, mucoid sputum **Curschmann's spirals** (from shed epithelium) **Charcot-Leyden crystals** (crystalloids with galectin-10)

Question 47

What is mild intermittent asthma? _ days a week _ night awakenings _ FEV1/FVC () exacerbations requiring glucocortidoids per year

Answer 47

**<= 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

Question 48

# [](http://) how often does some1 with moderate persistent asthma need a SABA?

Answer 48

Daily ## Footnote FEV1 between 60-80% of predicted and FEV1/FVC below normal

Question 49

FEV1 of severe asthma

Answer 49

60% or less ## Footnote FEV1/FVC below normal

Question 50

6 steps of asthma treatment

Answer 50

1. **SABA** + low dose ICS when symptomatic **OR low dose ICS daily** 2. SABA + **low dose ICS** 3. SABA + low dose ICS + **LABA ** **OR** **medium dose ICS alone** 4. SABA + **medium dose ICS AND LABA** 5. SABA + **high dose ICS** + LABA (or montelukast) 6. SABA + high dose ICS + **oral steroids** + LABA (or montelukast); consider monoclonal antibody

Question 51

How often should patients with asthma f/u?

Answer 51

every 1-**6 months** depending on severity

Question 52

when might you consider step down therapy for asthma?

Answer 52

if stable for 3 months

Question 53

Your patient is dx with asthma - they can use this assessment tool at home to keep an "asthma diary" of how they are doing

Answer 53

Peak flow meter

Question 54

t/f Peak flower meters consider height, weight, and age to measure normal values

Answer 54

FALSE ## Footnote NOT weight, but height and age are a factor

Question 55

What are the 4 factors used to predict normal values of peak flow monitors?

Answer 55

1. Height 2. Age 3. Sex 4. Ethnicity sorta (AA and hispanic americans are approx 10% lower)

Question 56

What are the different colors of a peak flow monitor and what is the "caution" zone color and range?

Answer 56

Green, **yellow**, red | yellow = caution (**50-80% predicted**) follow treatment plan ## Footnote below this = Bronchodilator therapy should be started immediately and clinician should be contacted

Question 57

When to refer a pt with asthma to a pulmonologist or allergist

Answer 57

1. Experienced a life threatening attack 2. Hospitalized for attack 3. > 2 rounds of oral corticosteroids needed 4. Over 5 yo requiring step 4 care or higher 5. Under 5 yo and requiring step 3 care or higher 6. Unresponsive to treatment after 3-6 months 7. Candidate for allergen immunotherapy

Question 58

When would you take a SABA for exercise induced asthma/bronchospasm?

Answer 58

15-30 min prior to exercise

Question 59

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 ()

Answer 59

Cough lasting (**> 3 weeks**) Cough is (**nonproductive**) Cough typically occurs at this hour (**night**)