Resp Flashcards
A 3 year old girl is on 50ucg of fluoxetine (assuming this is fluticasone) INH BID for asthma. She has 2 nightly exacerbations per week and has missed a few days of daycare. On exam, she is breathing comfortably and has no wheeze; however, she does have a prolonged expiratory phase. How do you change your management?
a) Add a LABA
b) Add a Leukotriene inhibitor
c) Start oral prednisone
d) Increase dose of fluoxetine to 100ucg BID (medium dose) -
Increase dose of fluoxetine to 100ucg BID (medium dose) -
Add a LABA (based on CTS 2012 guidelines not approved for PRESCHOOL, must be over 6yo)
b) Add a Leukotriene inhibitor based on CTS 2012 guidelines not approved for PRESCHOOL, must be over 6yo)
c) Start oral prednisone (not recommended by CTS for part of control management )
d) Increase dose of fluoxetine to 100ucg BID (medium dose) - based on CPS recommend medium dose then titrate down to lowest level tolerable. She is on low dose now
Patient with description of pneumonia, and LLL opacity on chest x-ray. Emesis and fever for the past 2 days, crackles on exam. What do you treat with?
- Azithromycin
- Ampicillin
- Ceftriaxone
- Cefurixime
amp
2 month old child is found to have respiratory distress and focal right-sided crackles on exam. A CXR was done showing a defect of the right diaphragm, CDH vs evantration. What is the next test?
- Diaphragm Fluroscopy
- MRI chest
- CT chest
- Exploratory laparoscopy
diaphram fluorscopy
Diaphragmatic Eventration - Abnormal elevation, consisting of a thinned diaphragmatic muscle, that causes elevation of the entire hemidiaphragm, or more commonly, part of the anterior aspect. Most are asymptomatic and do not need repair. Can see on lateral that diaphragm attach in the right places, anteriorly and posteriorly. Sometimes see the gut in the chest, but still separated by diaphragm.
In CDH there is an defect in the diaphragm. Diaphragm fluoro is the first line step b/c in CDH diaphragm won’t move
Fluro aka sniff test- determines if there is PARALYSIS of the diaphram, which you have in CDH but not in eventration
Patient with CF, description of pulmonary exacerbation with a decrease in FEV1 and decrease in weight, increase cough with increased sputum. What is the likely pathogen?
- Burkholderia cepatia
- Pseudomonas aeruginosa
- Stenotrophomonas
- Aspergillus
Pseudomonas aeruginosa
Staphylococcus aureus and Pseudomonas aeruginosa are the most prevalent pathogens in most age groups and are associated with accelerated loss of pulmonary function
Common organisms, include S. aureus, nontypable Haemophilus influenzae, P. aeruginosa; B. cepacia and other gram-negative rods
-The standard of practice has been to treat pulmonary exacerbations in patients with P. aeruginosa with two antipseudomonal antibiotics
Father brings his overweight son to your office because he becomes short of breath when playing with peers. PFTs completed and FEV1 82% and FVC 80% pre-bronchodilator and increase to 87% and 85% respectively afterwards. Father has allergic rhinitis and boy has history of eczema. What do you recommend?
1) ICS and salbutamol
2) Salbutamol before exercisee
3) Conditioning program
conditioning program
ASTHMA diagnostics:
fev1/fvc = 82/80 = 1.02
FEV1 NOT increased by 12% post bronchodialato
6 year old girl with otitis media and sinusitis, found to have bilateral wheezes and crackles on exam as well as clubbing. She also has cobblestoning of the posterior oropharynx. Sweat chloride is negative. Which of the following tests would reveal the diagnosis?
a. CT sinuses
b. Electron microscopy of respiratory mucosa
c. Immunoglobulins
d. Alpha 1 anti-trypsin levels (serum)
EM
This is ciliary dyskinesia- aka Kartagener syndrome- CHAPTER 392 nelson
Diagnosis – EM of nasal epithelium or bronchial brushing– assess ultrastructural defects within the cilium
most often see shortening or absence of dynein arms
Imaging studies are helpful – can see paranasal involvement. CXR shows bilateral lung overinflation, peribronchial infiltrates, and lobar atelectasis and CT of the chest often reveals bronchiectasis. Can also have reduced nasal NO levels
Management is supportive - with chest PT and antibiotics
Primary Ciliary Dyskinesia – inherited disorder with impaired ciliary function
4 main features: -
chronic sinopulmonary disease
persistent middle ear effusions
laterality defects
infertility
Clubbing is a sign of long-standing pulmonary involvement
In empyema, fluid is most likely to show:
a. LDH 300
b. Fluid protein to serum protein > 0.5
c. Glucose 4.8 mmol/L
Fluid protein to serum protein > 0.5
Light’s Criteria Rule – if you have at least one of the following then the fluid is defined as exudate:
Pleural fluid protein/serum protein ratio greater than 0.5, or
Pleural fluid LDH/serum LDH ratio greater than 0.6, or
Pleural fluid LDH greater than two-thirds the upper limits of the laboratory’s normal serum LDH
A child is known to have congenital central hypoventilation syndrome (CCHS). He also had Hirschsprung disease. What test is required for annual screening for another associated condition?
a. Hearing test
b. Holter
c. MRI head
holter
CCHS- symptoms manifest after 1m of age and often into childhood and adulthood. Hypoventilation typically during sleep only. (Nelson’s pg 1520 -chapter 412).
Do not appropriately respond to hypercarbia + hypoexemia +/- anatomic autonomic nervous dysregulation
Genetics- PHOX2b, mostly de novo, can be AD
what are the surveillance needs for patient with PHOX2b mutations?
at baseline near MRI to exclude structure, cardiac eval, neuromusc, inborn errors of metabolism, r/o hirrshprung and neural crest tumor
this is cchs - congenital hypoventilation syndrome
1) polyomnography - q6 month for 1st 3yo, then q6month
2) echo - as above for co pulmonale
3) CBC and gas yearly
72 hour holter - for asysstole, annually
4) neural crst- neurpblastoma, chest AUS and urine catecholaemine q3month till 2yo then q6month till 7yo
5) neurocogn fuxn
A 7 year old boy with asthma is using ventolin. On your follow up visit, you find out that he uses his ventolin 2 puffs, 3-4 times per week, and has had 2 courses of systemic steroids in the last year. What should be your next course of action?
a. Increase ventolin dose to 4 puffs as needed
b. Add inhaled corticosteroid
c. Add oral prednisone
Add inhaled corticosteroid
poor control with day time sx and exacerbation needing oral steroids
A 6 year old Greek girl presents with a high fever, tachypnea, and RUQ pain. On exam, there is no guarding in the abdomen. What is the most likely diagnosis?
a. Bacterial pneumonia -
b. Pleurodynia -
c. FMF -
bacterial pneumonia
Pleurodynia - but no h/a and malaise reported here, more common in adolescent and also colic pain
caused most frequently by coxsackie B viruses 3, 5, 1, and 2 and echoviruses 1 and 6, is an epidemic or sporadic illness characterized by paroxysmal thoracic pain, due to myositis involving chest and abdominal wall muscles.
A child comes in with wheezing for the last few weeks. It started after playing at a friend’s house. She has not responded to corticosteroids or antibiotics. Her CXR is normal and she is not in respiratory distress. What is the next best management.
a. bronchoscopy
b. racemic epinephrine
c. ventolin and steroids
d. chest CT
e. Neck X-ray
bronchoscopy
Need to rule out foreign body (even though CXR is normal) - need INSP and EXP view
Most foreign bodies lodge in right bronchus
Can also be in the larynx or trachea
Can be asymptomatic and CXR is normal in 15-30% of cases.
If there is a high index of suspicion, bronchoscopy should be performed, despite negative imaging
Want PA, lateral films, and expiratory PA film is most helpful because during expiration the bronchial foreign body obstructs exit of air from obstructed lung, get emphysema, air trapping, with persistent inflation.
Severe asthmatic, tried multiple doses beta agonist and IV steroids with no response what should you do next?
a) one dose of MgSO4
b) INH heliox
c) Aminophylline infusion
one dose MgS04
CPS - asthma exacerbation statement
In severe exacerbation, therapies to consider include: oxygen, ventolin, atrovent, PO or IV steroids, continuous ventolin nebs, IV MgSO4
Give IV MgSO4 if not responding to ventolin/atrovent and steroids. Should consider this in the first 1 to 2 hr, if they are not fully responding to treatments.
SIDE EFFECT: hypotension and bradycardia as side effects,
Bronchiectasis-5 yo with productive cough day and night, wheeze, crackles, clubbing, how will you get the diagnosis
a) Immunoglobulins
b) A1AT - this is from Pizz defect, causes emphysema, rarely sx in children (nelson chapter 385) but can cause clubbing
c) Biopsy and microscopy
d) CT sinuses
bx and microscopy
Ddx - primary ciliary dyskinesia vs CF
Testing for CF here not an option (sweat chloride)
Hence test for PCD - nasal scraping/biopsy under EM (as above questio
Baby with inspiratory stridor, soft voice, vocals abduct in inspiration, what is the diagnosis? (unsure - picked through process of elimination)
a) Laryngomalacia
b) Tracheomalasia
c) Vocal cord palsy
laryncogmalacia
Abduction with inspiration is normal - if it said ADDUCTION or incomplete abduction/asymmetrical with inspiration, would choose vocal cord palsy
Kid has eczema and has cough with exercise relieved an hour later. Normal FEV. Normal PFT. What do you do to get the diagnosis?
a) Methalcholine challenge
b) Exercise with spirometry
MET challenge >16 is normal
CTS 2012 asthma guidelines
Do methacholine challenge when patients fail traditional PFT testing, but symptoms are highly suggestive of asthma. Test causes bronchoconstriction.
Can make diagnose when you give a dose of methacholine <4mg/ml, and this causes a decrease in FEV1
If the FEV, does not fall by at least 20% after the highest concentration (e.g., 16 mg/ml) then the PC20 should be reported as “> 16 mg/ml”
A child has CF. Family wants to use alternative medicine. Homeopathy has been proven effective for which condition:
a) Diarrhea
b) ADHD
c) Allergies
only one with “well designed studies and positive effect for homeopathy”
is DIARRHEA
16 year old competitive hockey player who had a history of asthma that was asymptomatic for 7 years. Has been having exercise induced symptoms and he’s using ventolin 6x/week before and during games. PFTs show normal FEV1 and FEV1/FVC but he has a positive methacholine challenge. What do you recommend?
Low dose inhaled corticosteroids
Stop playing high level hockey
5 day course of oral corticosteroids
LABA in the morning on the days of the games
Low dose inhaled corticosteroids
As per CTS 2012 guidelines, if physical activity affected, then add low dose steroid controller. See above
Next step: Since he is >12yo, once at medium ICS levels, can add LTRA or LABA as adjunct
What is the most likely side effect of inhaled steroids? Decreased linear growth. Immunosuppression Moon facies Hypertension
dec linear growth
oral candidiasis, bronchospasm
growth suppression
HPA axis supp
7 year old girl with persistent cough, wheeze, nighttime cough, worse with activity. FEV1/FVC is 75%, bronchodilator increases her FEV1 by 15%. What do you recommend?
(**NOTE THERE WERE NO FURTHER OPTIONS in 2016 exam- must check other exams)
Inhaled corticosteroid with SABA PRN
Avoid the activities that trigger the symptoms
Inhaled corticosteroid with SABA PRN
4 year old with CF, most likely deficiency:
a. Iron
b. Calcium
c. Vitamin D
d. Zinc
Vitamin D
85% of CF patients have pancreatic insufficiency, so can’t absorb fat or protein , and can’t absorb fat soluble vitamins - ADEK!
Teen with cystic fibrosis has worsened cough, sputum, drop in PFT. What is the most appropriate antibiotics to start? Ceftaz + tobra Clox and tobra Clox and ceftaz PO cipro
ceftaz and tobra
P. aeruginosa combine tobramycin with an antipseudomonal semisynthetic penicillin (eg, piperacillin-tazobactam), an extended third-generation cephalosporin (eg, ceftazidime, cefepime), a carbapenem (eg, imipenem-cilastatin or meropenem, but not ertapenem, which has less activity against P. aeruginosa), or less frequently a monobactam aztreonam.
CF kid w green sputum, what do you tx w?
a. Ceftaz and tobra IV
b. Ceftaz and clox
c. Clox and tobra IV
d. Vancomycin
a. Ceftaz and tobra IV
Kid w viral wheezing, worse w URTI
a. Give steroids & ventolin in winter & fall time
giver steroids and ventolin during witner fall time
. Kid with coughing fits during the day but none at night, what is it?
a. Habit cough
habit cough
. Kid with central apnea, what to do next?
a. MRI head
MRI head
Brain imaging – Neuroimaging, ideally with magnetic resonance imaging (MRI), is performed to exclude brainstem malformations that might impair ventilatory control, including Chiari malformations.
Child with FTT and diarrhea, suspected of having CF. His CF sweat test was negative. Which of the following can cause a false negative sweat test?
a. Hypoalbuminemia
b. Hypothyroidism
hypoalbuminemia
hypothyroid - causes false POSITIVE
-Sweat chloride test - pilocarpine iontophoresis to collect sweat, measure Cl, >60 mEq/L diagnostic, Usu wait 48 hours of life but can be low sweat 1-2w of life
Teenager with exercise induced wheezing. Spirometry normal. What is next step?
a. Methacholine challenge
b. Spirometry during exercise
methacholin echallenge
Child with wheezing during exercise. No significant reversibility (80 to 85%) PFTs given. How to further investigate?
a. exercise challenge
b. Methacholine test
Methacholine test
Teenager with asthma. Using lots of ventolin. What to do next?
a. Verify technique
verfiy technique
Recurrent wheezing with urti, how to treat? (More details in future questions)
a. fluticasone
b. salbutamol
salbutomol
14 year old girl with symptoms of obstructive sleep apnea and BMI > 95th percentile. Which of the following tests is MOST likely to reveal an underlying sequela of her disease?
a. Echocardiography
b. Electrocardiogram
c. Creatinine
d. Fundoscopy
a. Echocardiography
In very severe cases, there may be evidence of pulmonary hypertension, right-sided heart failure, and cor pulmonale; systemic hypertension may occur, especially in obese children.
Young child with 2 episodes of rectal prolapsed.
a. manometry
b. rectal bx
c. sweat chloride
d. barium enema
sweat chloride
Rectal prolapse x 2 that is easily managed in the ER. What test do you do now?
a. sweat chloride
b. Reassure
sweat chloride
It is also responsible for many cases of hyponatremic salt depletion, nasal polyposis, pansinusitis, rectal prolapse, pancreatitis, cholelithiasis, and nonautoimmune insulin-dependent hyperglycemia.
15 yo boy with poorly controlled chronic asthma. Fluticasone 125 mcg bid, on leukotriene antagonist, and still requires 2 ventolin puffs a day. What management should we do now?
a. fluticasone and salmeterol
b. Budesonide and formoterol
c. ciclesonide and salbuterol
d. budesonide + ipatropium bromide + salmeterol
b. Budesonide and formoterol (ICS + LABA)
12 years of age and over with moderate asthma and poor asthma control on ICS/LABA combination maintenance therapy.
2 yo child with recurrent viral wheezing. What is proven therapy?
a. ventolin PRN
b. prednisone 5 days
c. fluticasone 3 weeks
a. ventolin PRN
In children with frequent symptoms (≥2 days/week [3] or ≥8 days/month) or ≥1 moderate or severe asthma-like exacerbation (ie, treated with oral corticosteroids or a hospital admission), a therapeutic trial with a medium (200 µg to 250 µg) daily dose of ICS and as-needed SABA, administered by metered-dose inhaler, is suggested
Kid with whiteout hemithorax. Next test?
a. U/S
b. Dx thoracentesis
c. Lateral X-ray
u/s
A chest radiograph (CXR) should always be the initial imaging modality. Ultrasound provides a noninvasive, radiation-free modality to confirm the presence of a pleural effusion suspected on CXR. As well, ultrasound can estimate the size of the effusion, and differentiate free-flowing effusions from those that are loculated
What is the best measure to decrease the likelihood of asthma in child?
a. breastfeeding
b. avoid second hand smoke
c. elimination of environmental allergens
avoid second hand smoke
avoidance of environmental tobacco smoke (beginning prenatally), prolonged breastfeeding (>4 mo), an active lifestyle, and a healthy diet—might reduce the likelihood of asthma development
Adolescent female receives inhaler fluticasone BID and ventolin via MDI spacer TID. Her PFT shows FEV1 65% and improves by 20% with bronchodilators. What should be done now?
a. check technique and compliance
b. increase inhaled corticosteroid dose
a. check technique and compliance
Child with daytime sleepiness, snores at night. Weight 95th percentile. Best first line management option
a. T&A
b. CPAP
?weight managgement
T&A
T+A - first line if significant adenotonsillar hypertrophy, including if multifactorial (including obesity), generally results in complete resolution in uncomplicated cases
CPAP/BiPAP - indicated if T+A not indicated, if residual disease after T+A, or major risk factors not amenable to surgical therapy, patient’s preference for no surgery
In obese patients - recommend weight loss
Also treat additional risk factors (asthma, seasonal allergies, GERD)
6 yo child with persistent non-productive cough in the daytime, which settles at night. In your office, she has a hacking cough. What is your diagnosis?
a. psychogenic cough
b. habit cough
c. post-nasal drip cough
habitual cough - treat with assurance
cough is abrupt and loud and has a harsh, honking, or “barking” quality. A disassociation between the intensity of the cough and the child’s affect is typically striking. This cough may be absent if the physician listens outside the examination room, but it will reliably appear immediately on direct attention to the child and the symptom. It typically begins with an upper respiratory infection but then lingers.
Child with cerebral palsy has history of choking with feeds now comes in respiratory distress, drooling, febrile. Chest Xray reveals opacity in LLL with air bubbles. Most likely diagnosis is:
a. Pulmonary abscess
b. Pulmonary sequestration -
c. CCAM -
d. Empyema
pulm abscess
b. Pulmonary sequestration - mass on CXR, no air bubbles, often in lower lobes
c. CCAM - now known as CPAM, CXR should demonstrate a mass
Classically, the chest radiograph shows a parenchymal inflammation with a cavity containing an air–fluid level (Fig. 402-1). A chest CT scan can provide better anatomic definition of an abscess, including location and size
Child comes in febrile, coughing, tachypneic, tachycardic and lethargy for few days. O2 sat is 91% room air. CXR shows white out of right lung. Next step is: [repeat]
a. Diagnostic Thoracentesis
b. Ultrasound chest
c. CT chest
d. Lateral decubitus film
- ————–
u/s
What would cause false negative sweat chloride test?
a. Atopic dermatitis
b. Low albumin
c. Adrenal insufficiency
d. Hypothyroidism
low albumin OTHER FALSE NEG: Dilution Malnutrition Edema Insufficient sweat quantity Hyponatremia Cystic fibrosis transmembrane conductance regulator mutations with preserved sweat duct function
Greek 6 y/o girl with fever to 40 degrees. WBC 38. Tachnypeic. Pain in the right hypochondrium. Tender in right hypogastrium but no guarding or rebound. What is the diagnosis:
a. Pleurodynia
b. Bacterial pneumonia
c. First presentation of Familial Mediterranean Fever
d. Cholecystitis
bacterial pneumonia
A 2 month old child is seen with a 3-4 day history of viral URTI symptoms. Now, has progressively increasing work of breathing. RR is 65, O2 sat is 91% on room air. On auscultation there is diffuse wheezing. Of the following treatment modalities, which has been proven effective in this disorder?
a. oxygen plus nebulized ventolin
b. oxygen plus nebulized epinephrine
c. oxygen plus corticosteroids
d. humidified oxygen alone
oxygen
bronchiolitis
Wheezing toddler with URTI symptoms. Which is a proven therapy?
a. O2
b. racemic epi
c. iv steroids
d. Bronchodilators
oxygen
What will predict the persistence of asthma in adulthood?
a. Severe RSV pneumonia with intubation
b. Allergic rhinitis
allergic rhinitis
Which of the following is the most helpful measure to decrease risk of asthma?
a. dust mite covers
b. elimination of environmental smoke exposure
c. removing pets from the home
d. breastfeeding
eliminate from envt
breastfeeding can also improve
Child with BMI 25. Cough and shortness of breath with gym class. Dad had allergic rhinitis and boy has history of mild eczema. FVC 80%. With inhaler, FEV1 increases to 87% and FVC to 85%. Treatment?
a. salbutamol prior to exercise
b. steroid inhaler
c. needs conditioning
d. steroids po
conditioning
Patient presents with diffuse wheezing and crackles. He is well grown. He has had a negative sweat chloride. What test would help with his diagnosis?
a. CT chest
b. Ig
c. Bronchoscopy with tracheal mucosal biopsy
bronchoscopy
