Resp/Cardio Flashcards
What is the cardiac lesion represented in this CXR?
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TAPVD
What is the cardiac lesion represented in this cxr?
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Tetralogy of fallot
What are the characteristics of Marfan syndrome?
Fibrillin gene defect
AUTOSOMINAL DOMINANT
Sx: thumb sign, pectus excavatum, scoliosis, long arms
Dilatation of the ascending Ao and MVP (mid systolic click)
What does an ASD murmur sound like?
Low pitched systolic ehection murmur at base
Fixed split S2
What does an AS murmur sound like?
SEM radiating to neck
What are the characteristics of cardiac syncope?
- Little or no prodrome
- Prolonged LOC
- Exercise induced
- Fright/startle induced
- Associated chest apin or palpitations
- History of cardiac disease: AS, PHTN
- FHx for: Long QTc, arrhythmia syndromes, devices, sudden death, cardiomyopathy
When does Torsades des Pointes occur?
Long QT and hypomagnesemia
What are the clues on history to long QT syndrome?
Unusual sz, palpitations while swimming
Deafness
FHx of sudden death, unexplained MVA, drownings, deafness
What are the causes of long QT interval?
Low Ca
Low Mg
Low K
Drugs (TCAs)
What is WPW?
Wolff Parkinson White
Accessory AV pathway allows for “early” depolarization of ventricles
Ass with ebsteins and CCTGA
Can cause SVT and sudden death
What is the first step of the SV palliation?
Glenn or BT shunt at 4-6 months
- SVC to RPA
- Expected sats 75-85%
Fontan at 2-y4 years
- IVC to RPA
- Expected sats usually >90%
What are the recommendations for antiplatelet therapy in Kawasaki disease?
If no aneurysms or ectasia or resolve within 6-8 weeks, discontinued in 6-8 weeks
If 1 large coronary artery aneurysm or complex aneurysms, long term antiplatelet therapy is recommended
What are the general guidelines for SBE PPx?
High risk lesion + high risk procedure
What qualifies as a high risk lesion?
- Cyanotic CHD, not repairs, shunts
- CHD repaired with prosthetic material
- CHD with residual defects
What is considered a high risk procedure?
Dental procedure where the gums or lining of mouth likely to be injured
Gut or GU surgery through infected area
Things that do not need antibiotics
Injections of anaesthetic to mouth
Loss of baby teeth
Accidental injury to lips/gums
Nosebleeds
Routine placements or adjustment of braces
Deliveries
Most surgeries and procedures
What are the cynaotic CHD lesions?
6Ts: TGA, TOF, TA, TAPVR, TA, “TINGLE” ventricle
2As: PA, Ebsteins anomaly
What are the lesions that cause CHF in the first weeks of life?
OBSTRUCTION
- HLHS
- Severe AS
- Coarctation
- Asphyxia
- Severe MR, TR
- Uncontrolled tachycardias
What are the lesions that cause CHF in weeks 2-6?
Left to right shunts:
VSD
AVSD
PDA
What are the lesions that cause CHF inolder children?
Pump failure
Dilated cardiomyopathy
Myocarditis
Tachycardias
What are the three cardinal signs of CHF in infants?
Tachycardia
Tachypnea
Hepatomegaly
What are the signs of infective endocarditis?
Janeway lesion
Embolus
Splinter hemorrhages
Oslers node: PAINFUL
What is rheumatic fever?
Occurs after GAS infection
Pancarditis: aschoff bodies (collection of immunological cells and fibrinoid material around a central necrosis)
What are the diagnostic criteria for rheumatic fever?
Major: (2)
- Carditis
- Polyarthritis
- Chorea
- Subcutaneous nodules
- EM
Minor:
- Fever
- Arthralgia
- Prolonged PR
- Elevated ESR, CRP
What are the complications of foreign body?
Recurrent pneumonia
Bronchiectasis
Cardiac arrest and death
In what findings MUST you r/o cystic fibrosis?
Meconium ileus
HypoNa, hypoCl metabolic alkalosis
Recurrent rectal prolapse
Clubbing
Bronciectasis
Nasal polyps
Pseudomonas colonization
What is the test positive in a sweat chloride?
>60 meQ/L
What are the prognostic factors in CF?
Male?female
Lung disease:FEV1, Burkohderia, PTX
Nutritional status: Wt/Ht, DM
How does primary ciliary dyskinesia?
Year round daily wet cough
Year round nasal congestion
Recurrent otitis media
Neonatal respiratory distress
Laterality defects
What qualifies as asthma control?
Daytime Sx < 4 days/week
Nighttime Sx <1 night/week
Physical activity normal
Exacerbation: mild, infrequency
Absence: none
SABA use < 4 dose/week
FEV1 >90% personal best
How do you diagnose asthma?
Clinical symptoms
+
Objective evidence: spirometry, peakflow, methacholine challenge
What are the sequalae of OSA?
Neurocognitive: behavioural, attention, schoolperformance, developement
Cardiovascular: HTN, cor pulmonale
FTT
Inflammatory
Qualityof life
How do diagnose OSA?
Polysomnography
What are the treatment modalities for OSA?
Non-pharmacologic: Nasal and sleep hygiene
Pharmacologic: intranasal corticosteriods, montelukast
Surgical: T&A
Weight loss
CPAP
What is the most common CHD?
VSD 25-30%, ASD +PDA 6-8%
What is the hyperoxia test?
If PaO2 rise above 150 mm during 100% O2 administration then a shunt lesion is excluded
What % of small VSD will close?
75% in the first 2 years of life
What are the potential complications of a VSD?
Endocarditis
Aortic regurg
Subaortic stenosis
RVOTO
LV TO RA shunting: Gerbode defect
What are the indications for surgery with a VSD?
< 6 months with uncontrolled CHF despite max medical RX
Children with significatn shunt and increased PA pressures
Children with significant shunt and N pressures
Subpulmonic and membranous defects
What are the three types of ASD?
Primum (15%)
Secundum (75%)
Sinus venosus (10%)
What are the features of an ASD?
Grade 3 SEM at ULSB with widely split S2
Age 3-4 years
What are the four features of tetralogy of fallot?
PS
Overriding aorta
RVH
VSD
What syndromes are associated with TOF?
T21, DiGeorge, Alagille
If you find long Qt, what should you check
Ca, Mg, K, Drugs (TCAs)
How do you approach SVT?
Stable: Vagal, Adenosine
Unstable: Syn cardio 0.5-1 J/kg
What is the description of a stills murmur?
VIbratory LLSB SEM, changes with position
DDx: SubAo stenosis, Small VSD
What is the description of a venous hum?
Infraclavicular hum, continuous R>L
DDx: PDA
What is the differential for a widely split S2?
AS, PS, Ebstein, TAPVR, RBBB
DDX for a wide pulse pressure?
PDA
Ao insuff
AVM
Vasodilation
What defect is associated with alpha 1 AT deficiency?
PiZZ
Will present as liver disease in children
What are the characteristics of CCAM?
Cystic adenomatoid malformation CCAM
Hamartomatous or dysplastic lung tissue mixed with normal lung
Presents in infancy
What are the characteristics of congenital lobar emphysema?
Presents at 6 months: resp distress
HYperinflation of affect lobe with atelectasis of other
What is the acronym to remember the compotents of CF?
CF PANCREAS
Chronic cough and wheezing
FTT
Pancreatic insufficiency
Alkalosis and HypoNa
Neonatal intestinal obstruction Nasal polyps
Clubbing
Rectal prolapse
Electrolytes elevation in sweat
Absence vas derens
Sputum with stap a or pseud
What is the progression of bugs in CF?
S aureus, H flu, pseudo aeroginosa, B cepacia
What are compotents of routine care for CF?
Chest physio + bronchodilatory BID
Balanced high calorie diet
Pancreatic supplemnts
ADEK replacement
Osteoporos monitoring
GERD monitoring
Whatis kartagener syndrome?
- Situs inversus (25% will have PCD)
- Chronic sinusitis and otitis
- Airway d/po leading to bronchiectasis
What is the most common cause of chest pain?
MSK
Cardiac <1%
What are the common MSK causes of CP?
Strained msucles
Costochondritis
Tietze syndrome
Precordial catch syndrome
What is tietze syndrome?
Localized form of costochondritis usually involving junst one costochondral junction, tender swollen mass palpable at the site
Costochrondritis is usually multiple sites without swelling
What is precordial catch syndrome?
Texidor twinge
Sudden onset CP in children, very localized, occurs most commonly over the left sternal border
At rest without trigger
Usuallys 30s to 3 minutes
What is the difference between a vascular ring and sling?
Ring: trachea and/or esophagus is encircled by aberrant vascular strctures
Sling: compressions by nonencircling vessels
What are the two types of complete vascular rings?
- Double Ao arch
- Right Ao arch with left ligamentum arteriosum
What are the cardiac causes of sudden death?
- HOCM
- Anomalies of cornoary arteries
- Margan
- Arrhythmogenic right ventricular dysplasia (ARVD)
- Brugada
- Prolonged QTC
What is commotio cordis?
Arrhythmia as a result of blunt, nonpenetrating direct blow to the chest
VF occurs during vulnerable phase of repolarization
CPR +Defib
What are the signs of a Coarct in an older children?
Differential BP
Systolic murmur in the back
SystolicHTN in the upper extremities
Diminished femorals
What are two neuromuscular conditions in which cardio consult is recommended?
DMD (Dystrophin)-Cardiomyopathy
Friedrich ataxia (Frataxin)-Cardiomyopathy, A fib/fliutter
What CHD gives you decreased lung markings?
TOF
Pulmonary Atresia
Tricuspid atresia
Ebstein
What lesions given with increased pulmonary markings?
Transposition
TAPVR
Truncus arteriosis
What are the classic chest xray findings in CHD?
Boot: TOF
Egg: TGA
Snowman: TAPVR
Rib notching: Coarctation
In what two conditions is a diminished murmur bad?
TOF: worsening RVOTO
VSD: eisenmenger syndrome
At what age do you need to investigate an PPS mrumur?
6 months or older
What is unique about a baby ECG?
RV dominance
T waves upright in chest leads, invert at 7 days until 12-13 years
What are the two most common mechanisms of SVT?
- WPW
- AV nodal reentry
When should you suspect myocarditis?
Unexplained CHF
Tachycardia out of proportion to fever, tachypnea, quiet precordium, muffled HS, gallop rhythm without murmur, HM
What are the clinical signs of pericarditis?
CP, fever, cough, palpitations
Friction rub, pallor, pulsus paradoxus
Pt sitting up and leaning forward
What are the side effects of indomethacin in the neonate?
- Decreased renal function
- Hyponatremia
- Platelet dysfunction
- GI blood loss
What are the side effects of PGE?
Apnea, fever, cutaneous flushing, seizures, hypotension, bradycardia
What do alpha receptors do?
Vascular smooth muscle, vasoconstriction
What do beta 1 receptors do?
Myocardial smooth msucle, increase myocardial contractility (inotropic), cardiac rate (chronotrophic) and AV conduction (dromotophic)
What do B2 receptors do?
Vascular smooth muscle, vasodilation
What do doapminergic receptors do?
Renal and mesenteric vascular smooth muscle
Vasodilation
What is the effect of sitting up on common innocent murmurs?
Venous hum= increased
Vinratory=decreases
What is a BT shunt?
Anastomosis between subclavian artery and pulmonary artery
What are the common rhythm issues post Fontan?
Loss of sinus
INtra-atrial reentrant tachycardia
Which lesion does protein losing enteropathy occur after correction?
Fontan
Abnormal flow to mesenteric vasculature
How common is allergic rhinitis?
40% of children experience
If both parents are asthma, what is the risk that their child will have asthma?
60%
What is the most common cause of infantile stridor?
Laryngomalacia
What is the basic defect in CF?
Defect in the CF transmembrane conductance regulator (CFTR) protein
Regulates chloride and sodium transfer across the apical membrane of the epithetial cells
What are Kussmaul respirations?
Deep, slow resps with prolonged exhalation
What are Cheyne-stokes resps?
Crescendo-descendo respira with alternating apnea
What are biot resps?
AKA ataxic breathing
Unpredictable irregularity in respirations
Most common CHD?
VSD
What is the medical management of a VSD prior to surgery?
- Nutrition
- Diuretics
- ACEi
What is the most common type of ASD?
Secundum 75%
What are the risks of non closure of an ASD?
- Right heart failure
- Embolism
- Arrhythmia
- PVD
What is the consequence of outflow tract obstruction?
Concentric ventricular hypertrophy from pressure overload
Initially adapative to maintain CO however becomes maladaptive increasing the stiffness of the chambers and resulting in diastolic dysfunction
What is william syndrome?
Hypercalcemia
Elfin features
Supravalvular AS
PA Branch stenosis
MR
What is situs solitus?
Normal viscera, lungs and atrial position
What is situs inversus
Abdo, atria and lungs and reversed
When does perfusion of the coronary arteries occur?
DIASTOLE
What are the strategies to maximize CO in CHF?
- Afterload reduction
- Preload reudction
- Sympathetic inhibition
- Cardiac remodelling prevention
- Inotrophy
What are the common viruses that cause percarditis?
Coxsackie
Echovirus
Adenovirus
EBV
Influenza
HIV
What is the benefit of FRC?
Functional residual capacity
Volume of air left in the lungs after tidal expiration
Buffer, minimizing PaO2 and PaCO2 changes during inspiration and expiration
Improved with PEEP
What is the major determinant of FRC?
Chest wall compliance
FRC= Outward elastic recoil= inward lung recoil
Infants, more compliant chest wall therefore lower FRC
Why are infants at a disadvantage?
- CNS depression =chest wall retraction
- Poor lung compliance= lung recoil, loss of FRC
- Compliant chest wall= loss of FRC
What is elastance?
Property of a substance to oppose deformation or stretching
Change in pressure over change in volume
Enbales return to original state
What is compliance
repicrocal of elastance
Distensibility
Change in volume/change in pressure
What is resistance?
Amount of pressure required to generate flow of gas across airways
R= 8 x length x viscosity/R4
How do you classify size of pleural effusions on CXR?
1/2 height if hemithorax = large
What are the signs of a pulmonary exacerbation in CF?
- Increased cough/sputum
- Hemoptysis
- Anorexia and weight loss
How do you interpret a PFT?
- Look at flow-volume curve: is it reproducible (aka straight exp line vs squiggly)?
- Look at effort curve: kids 12 should exhale for at least 10 seconds
- Look at FEV1: mild (70-79), moderate (60-69), severe (50-59), very severe (12% change is significant, CHEO uses > 10%)
- Compare FEV1 to last PFT: has it changed?
What are complications of Cystic Fibrosis from head to toe?
- Nasal polyps
- Chronic sinusitis
- Chronic cough
- Bronchiectasis
- Chronic colonization with staph, hemophilus, pseudomonas, burkholderia seppacia
- GERD secondary to obstructive lung disease, hyperinflation and diaphragms pushing on stomach
- Meconium ileus
- Failure to thrive
- Pancreatic insufficiency (with delta F508 mutation) –> Fat soluble vitamin deficiency, steatorrhea, eventual diabetes
- Liver cirrhosis - from thickened bile
- Congenital absence of vas deferens in males
- Infertility in both males and females - in females, thick cervical secretions or secondary amenorrhea from malnutrition
- Rectal prolapse - from chronic diarrhea, malnutrition and weak musculature
- Clubbing
- Cor pulmonary from pulmonary hypertension
What is the pattern of colonization/chronic infection in CF patients?
Babies - staph aureus
Toddlers - hemophilus b influenza
School age children - pseudomonas
Teenagers - Burkholderia seppacia, stenotrophomonas maltophilia
This is prognosticator important: if a baby is already infected with pseudomonas, this means their CF is advanced; if a teenager is only colonized with h.flu, doing well
What is the differential diagnosis of wheeze? (10)
- Asthma
- Aspiration penumonitis: ask about coughing/choking with feeds, reflux symptoms, rule out TEF
- BPD
- Bronchiolitis obliterans: chronic wheezing after adenovirus infection
- Congenital cardiac lesion: left to right shunts causing increased pulmonary blood flow
- Cystic fibrosis: ask about recurrent diarrhea, failure to thrive
- Foreign body aspiration
- Vascular rings/slings
- Airway malformations: tracheomalacia, lung cysts, mediastinal mass
- Primary ciliary dyskinesia: ask about recurrent sinusitis, ear infections
What are the classic ECG findings in a patient with pulmonary embolism?
Most common: sinus tachycardia
Most characteristic: S1-Q3-T3
-large S wave in lead 1, large Q wave in lead 3, inverted T wave in lead 3
Also can have RBBB and right axis deviation since right heart is pumping heart against a blocked PA
What is the most important cause of a false negative on a sweat chloride test?
Edema! (ie. hypoalbuminemia)
-other causes: malnutrition, hyponatremia (not enough sweat to collect)
What is ABPA?
- diagnosis?
- treatment?
Allergic bronchopulmonary aspergillosis: allergic hypersensitivity reaction to aspergillus in lungs
- occurs most commonly in CF pts, NOT responsive to antibiotics
- diagnosis: PERIPHERAL EOSINOPHILIA, sputum culture with branching hyphae, RUST-COLORED SPUTUM, proximal bronchiectasis on CXR
- Treatment: steroids and anti-fungals (voriconazole) x 6 wks
What is the inheritance pattern of cystic fibrosis?
Autosomal recessive
Which chromosome has the gene for cystic fibrosis?
-most common mutation?
Chromosome 7 (encodes CFTR protein) = deltaF508 mutation
- chloride channel on surface of epithelial cells responsible for movement of salt and water across cell membranes
- essentially have overactive sodium pumps and impermeable chloride channels = thus, Na can get out of tubule structures and draw water out with it, leaving thick secretions left behind
- most common mutation delta F508 mutation
What is considered a positive sweat chloride test?
CF test positive if > 60 mEQ/L
-negative if
What are the 3 most important interventions in CF that affects prognosis?
- Nutrition
- Chest physiotherapy
- Antibiotics
What are the 6 causes of hypoxia?
- V/Q mismatch
- Shunt
- Hypoventilation
- Low FiO2
- Diffusion barrier
- Abnormal Hgb saturation curve
What are 3 complications of bronchiectasis?
- Increased risk of infection secondary to trapping of secretions
- Increased risk of pneumothorax
- Increased risk of pulmonary hemorrhage (and thus hemoptysis)
What is the differential for:
- diffuse wheezing
- localized wheezing
Diffuse wheezing:
- CF
- Asthma
- Bronchiolitis
- Anaphylaxis with resp involvement
- GERD
Localized wheezing:
- Foreign body
- Extrinsic compression by mass
- Bronchomalacia
What are the complications of chronic recurrent aspiration? (3)
- Granuloma formation
- Interstitial fibrosis
- Lipoid pneumonia = through oral or nasal administration of animal or vegetable oils to treat childhood illnesses as a folk remedy
What is the most common underlying problem associated with recurrent pneumonias in hospitalized children?
-defn of recurrent pneumonia?
Oropharyngal incoordination/dysphagia leading to chronic recurrent aspiration
- 2nd most common is probably GERD
- defn of recurrent pneumonia: 2 or more pneumonias in 1 year OR 3 or more in a lifetime
What are the differences between a barium swallow, swallowing study with video fluoroscopy, and a gastroesophageal scintigraphy (milk scan)?
***All look for causes of recurrent aspiration
Barium swallow: Pt drinks barium and you take xrays to look at ANATOMIC ABNORMALITIES (vascular ring, stricture, hiatal hernia, TEF). Short viewing time so insensitive and nonspecific for GERD
-Swallowing study with video fluoroscopy: conducted with OT feeding different consistencies and is the gold standard for evaluating swallowing mechanism. More sensitive for demonstrating aspiration.
-Milk scan: pt swallows milk with radiolabel and multiple xrays are taken up to 60 minutes later to check gastric emptying
What are the early childhood risk factors for persistent asthma? (10)
- Parental asthma
- Atopy
- Reduced lung function at birth
- Possible use of acetaminophen
- Exposure to chlorinated swimming pools
- Severe lower resp tract infection (pneumonia, bronchiolitis requiring hospitalization)
- Male gender
- Wheezing apart from colds
- Environmental tobacco smoke exposure
- Low birthweight
What are the 2 main types of childhood asthma?
- Recurrent wheezing in early childhood (ie. transient early wheezing): triggered by viruses, tends to resolve during preschool years without increased risk for asthma in later life
- Chronic asthma (persistent atopy-associated asthma): associated with allergy (usually persists into later childhood and often adulthood)
What is the treatment for acute vocal cord dysfunction exacerbations?
- Relaxation breathing techniques
- Inhalation of heliox to relieve vocal cord spasm
What are the abnormalities seen on spirometry in asthma?
- Airflow limitation
- low FEV1
- FEV1/FVC ratio 12% - Exercise challenge: worsening in FEV1 > 15%
What is the broad differential for bronchiectasis?
- Cystic fibrosis
- Aspergillus (proximal bronchiectasis)
- Ciliary dyskinesia
- Immunodeficiencies
What are the criteria for determining if a patient’s asthma is well-controlled? (7)
Daytime
Night
What is the gene involved in congenital central hypoventilation syndrome?
PHOX2B gene: essential to embryologic development of the autonomic nervous system from the neural crest
- 90-95% are de novo mutations and the rest inherit the mutation from asymptomatic mosaic parent (autosomal dominant)
- an individual with CCHS has 50% chance of passing on the mutation to their children
In a child with congenital central hypoventilation syndrome presenting with constipation, what condition should be ruled out?
Hirschsprung disease: 20% of CCHS children
-should undergo rectal biopsy to screen for absence of ganglion cells
What are the clinical features of congenital central hypoventilation syndrome?
Deficient hypercarbia and hypoxia sensitivity during wakefulness and sleep and thus do not respond with increased ventilation or arousal during sleep (or awake for some)
- shallow respirations and apneas presenting in first few hours after birth
- can also present with autonomic nervous system abnormalities: cardiac asystole, tumors of neural crest origin, Hirschsprung disease
What investigations should be ordered for a baby suspected to have central sleep apnea?
- Congenital central hypoventilation: PHOX2B genetic testing
- Airway obstruction: consider bronchoscopy/CT chest
- Diaphragm dysfunction: diaphragm fluoroscopy
- Congenital cardiac disease: consider ECHO
- Structural hindbrain or brainstem abnormality: MRI head
- Metabolic disorders
What are the long term complications of obstructive sleep apnea?
- Metabolic: insulin resistance, dyslipidemia
- Cardiovascular disease
- Pulmonary hypertension with cor pulmonale
- Neurocognitive disturbances
What are the long term complications of obstructive sleep apnea?
- Metabolic: insulin resistance, dyslipidemia
- Cardiovascular disease
- Pulmonary hypertension with cor pulmonale
- Neurocognitive disturbances
What are the clinical manifestations of OSA?
-daytime vs nighttime
Daytime: mouth breathing and dry mouth, chronic nasal congestion, hyponasal speech, morning headaches, difficulty swallowing, poor appetite/FTT, secondary enuresis (due to disruption of normal nocturnal pattern of ADH), mood/behaviour/learning difficulties, daytime sleepiness, frequent napping
Nighttime: snoring, breathing pauses, choking or gasping arousals, restless sleep, adopt unusual sleeping positions to keep their necks hyperextended to open up airway
How well did you know this?
What is the gold standard diagnostic test for obstructive sleep apnea?
- What is the first line treatment for obstructive sleep apnea?
- 2nd line?
Gold standard test: polysomnography (sleep study)
- 1st line treatment: Adenotonsillectomy
- 2nd line: CPAP if surgery fails or pts who are not candidates for surgery
What is the polysomnographic parameter most commonly used in evaluating sleep disordered breathing?
-normal values for children 12 yo?
Apnea/Hyponea index (AHI): tells us number of apneic and hypopneic events per hr of sleep
-Normal cutoff AHI value for OSA in kids 1.5
-normal cutoff AHI value for OSA in kids > 12: >5
***consensus is that any child with an apnea index > 5 should be treated
What is the treatment of a pneumothorax that is small
No treatment needed: will self-resolve usually in 1 wk
-recurrent pneumothoraces: may need to induce formation of strong adhesions between the lung and chest wall (sclerosing procedure with talc or iodopovidone into pleural space, VATS with stripping of the pleura to leave inflamed pleura to heal with sealing adhesions)
What is the mechanism of action of theophylline?
- why is it not a first-line agent for young children?
- adverse effects?
Bronchodilation and anti-inflammatory properties (phosphodiesterase inhibitor)
- not first line agent because of differences in absorption and metabolism of theophylline in different patients –> narrow therapeutic window and need to closely monitor serum theophylline levels
- adverse effects with overdose: headaches, vomiting, cardiac arrhythmias, seizures and death
What are the biologic risk factors for asthma morbidity and mortality? (8)
- Previous hx of ICU admission or intubation due to severe asthma exacerbation
- Sudden respiratory failure or arrest
- Two or more hospitalizations for asthma in past year
- 3 or more ED visits for asthma in past year
- Use of > 2 cannisters of SABA per month
- Poor response to systemic corticosteroid therapy
- Low birthweight
- Nonwhite ethnicity
What are the 3 stages of symptoms from aspiration of an object into the airway?
- Initial event: Violent paroxysms of coughing, choking, gagging, and airway obstruction
- Asymptomatic interval: The foreign body becomes lodged, reflexes fatigue, and the immediate irritating symptoms subside. This stage is most treacherous and accounts for a large percentage of delayed diagnoses and overlooked foreign bodies. It is during this 2nd stage, when the child is first seen, that the possibility of a foreign body aspiration is minimized, the physician being reassured by the absence of symptoms that no foreign body is present.
- Complications: Obstruction, erosion, or infection develops to direct attention again to the presence of a foreign body. In this 3rd stage, complications include fever, cough, hemoptysis, pneumonia, and atelectasis.
What is the difference between a primary and secondary lung abscess?
Primary: occurs in previously healthy patient with no underlying medical conditions
-more commonly found on right side
Secondary: occurs in patient with underlying medical conditions
-more commonly on the left side
Which conditions predispose children to the development of pulmonary abscesses? (6)
- Aspiration pneumonia
- Cystic fibrosis
- GERD
- TEF
- Immunodeficiencies
- Neurological conditions
**anything that can lead to aspiration of infected materials with oral organisms
**can also occur secondary to a pneumonia
What is the classic finding on CXR for a lung abscess?
Parenchymal inflammation with a cavity containing an air fluid level
What is the treatment for a pulmonary abscess?
- empiric abx
- treatment duration
- option for patient who does not improve with IV abx
2-3 wk course of IV abx followed by PO abx to complete 4-6 wk course
- choice of abx should be guided by results of gram stain and culture but should initially include agents with both aerobic and anaerobic coverage
- Ceftriaxone + clindamycin, add aminoglycoside if gram negative bacteria are isolated
- for severely ill patients who do not improve after 7-10 d IV abx, consider surgical intervention (CT guided percutaneous drainage or thoractomy)
What is the most common cause of recurrent or persistent cough in children?
Asthma
What is the characteristic features of a habit (tic) cough?
-treatment?
- Cough occurs only during the day and never during sleep
- Cough is absent if physician listens outside the exam room but appears immediatly on direct attention to the child and the symptom
Treatment: reassurance that pathologic lung condition is absent, recommend that child resume school immediately, speech therapy to allow child to increase awareness of the sensations that trigger cough, self hypnosis
A child presents to your clinic with a cough that has persisted for > 6 weeks. What is your next step in management?
Test for cystic fibrosis regardless of race or ethnicity
What is the most common foreign body aspirated by children?
Nuts!
-must ask parents specifically about nuts; if there is any history of eating nuts, bronchoscopy should be carried out immediately
What percentage of foreign bodies lodge in the right main bronchus in children?
-what is the most important factor in determining the need for bronchoscopy in possible foreign body aspiration?
60%
-most important factor: history! (imaging may be negative in up to 30% of cases)
What is the first step in evaluation for foreign body aspiration?
-what might you see if there is a foreign body obstructing a bronchus?
CXR! Expiratory PA chest film is most helpful
-will see obstructive emphysema and air trapping with persistent inflation of the obstructed lung and shift of the mediastium towards the opposite side during expiration
What is the treatment for ARDS?
Overall: supportive management
- Nitric oxide
- Oxygen
- Prone position (improves V/Q mismatch)
- Surfactant (does not change mortality however)
- Sedation (decrease pulm htn)
- Limit tidal volumes to 6-8 ml/kg)
- HFO (gentle ventilation)
- Neuromuscular blockade
- Permissive hypercapnea
- Steroids (start within 72 hrs, can be used up to 30 d)
***If all else fails, ECMO
What are the causes of ARDS?
-two broad categories
Direct lung injury
- Pneumonia (most common)
- Aspiration
- Pulmonary contusion
- Submersion injury
- Inhalational injury
Indirect lung injury:
- Sepsis
- Shock
- Burns
- Transfusion related
- Trauma
What are the 3 phases of ARDS?
- Exudative phase: decreased pulmonary compliance, increased hypoxia, increased tachypnea
- see inflammation, diffuse alveolar infiltrates, pulmonary edema - Fibroproliferative phase: increased alveolar dead space, pulmonary hypertension
- scarring of lung, epithelial damage, surfactant deactivation - Recovery phase: restoration of pulmonary epithelial barrier
What is the definition of ARDS? (4)
- Acute onset
- PaO2/FiO2
What are the benefits of using a spacer with an MDI? (4)
-optimal technique for MDI + spacer?
- Decreases the coordination required to use MDIs
- Improves delivery of drug to lower airways
- Minimizes risk of thrush
- Decreases risk of oral deposition of medicine
**Optimal technique: for each puff, take 5 sec inhalation with 5-10 sec breath hold
-for young children, use spacer and mask and after each puff, hold mask on face for 5-10 breaths (or 30 seconds)
How does the presentation of alpha-1-antitrypsin deficiency differ between children and adults?
In children: has little or no detectable pulmonary disease during childhood; instead, causes liver disease
In adults: causes early-onset pulmonary emphysema in 30s and 40s
-alpha-1-antitrypsin is a protein that deactivates proteolytic enzymes released from dead bacteria or leukocytes in the lung: without this protein, the enyzmes destroy the pulmonary tissue and cause emphysema
What is the treatment for alpha-1-antitrypsin deficiency?
IV enzyme replacement from pooled human plasma
What are common risk factors for thromboembolic disease in children? (7)
-what thrombophilia disorders cause hypercoagulability? (5)
- Malignancy (solid tumors > non solid)
- Presence of a central venous catheter (induces endothelial damage)
- Thrombophilia (deficiency of antithrombin 3, protein C or S; factor 5 leiden, hyperhomocysteinemia, antiphospholipid antibodies)
- Recent surgery/immobilization
- Nephrotic syndrome (losing protein C & S)
- SLE (systemic inflammation)
- OCP
***Remember virschow’s triad: hypercoagulability, endothelial injury, stasis
What is the gold standard for diagnosis of PE?
- what is the diagnostic test of choice?
- what is the utility of a V/Q scan?
Gold standard: pulmonary angiography
- not necessary except in unusual cases since spiral CT is almost always available
- diagnostic test of choice: spiral CT with IV contrast (specificity 90%)
- V/Q scans are noninvasive and sensitive: use if pre-test probability is low
What is the treatment for a PE?
-what is the mortality rate in children from PE?
Heparin infusion (aim for aPTT to be 1.5-2x normal) x several days, then begin PO warfarin x 3-6 mo
- LMWH can also be used
- thrombolytic agents should only be used in combo with anticoagulants in the sickest patients
- mortality rate: 2.2%
In children with prolonged or high inhaled corticosteroid therapy, what are two things you should monitor for?
-does the use of inhaled corticosteroids affect adult height?
- Height velocity
- Cataracts
***Does not affect adult height
What are the two most common adverse effects of inhaled corticosteroids?
- Thrush
- Hoarse voice (dysphonia)
What population do you most commonly see idiopathic pneumothorax in?
Tall, thin male with subpleural bleb
What recreational drug is associated with pneumothorax?
Ecstasy!
What are the 5 Ts of anterior mediastinal mass?
- Thymoma
- T cell leukemia
- Terrible lymphoma
- Thyroid tumors
- Teratoma
What is the differential diagnosis for middle mediastinal mass?
A+B
- Adenopathy: infectious (histoplasmosis most common), neoplastic, metastatic, sarcoidosis
- Bronchogenic cyst
What is the differential diagnosis for posterior mediastinal mass?
The Ns
- Neurogenic tumor: neuroblastoma, benign ganglioneuroma, ganglioneuroblastoma
- Neurofibroma
- Esophageal duplication cysts
- Pulmonary sequestration