Respiratory Flashcards
PE of asthama?
labs?
Allergic: Eosinophilic inflammation - in blood work
Expiratory wheeze or rhonchi
Hx questions to ask pt with suspected asthma?
How frequent cough, wheezing, difficulty breathing Nighttime awakening Medication response Activity response Exacerbations required oral steroids
Med must know for tx asthma in pts 6 and older?
NO SABA alone (death in 6 and older), only under age of 5
Asthma differentials?
Allergic rhinitis/sinusitis Respiratory infection GERD Medication induced cough (ACE Inhibitors) COPD Heart Failure Vocal cord dysfunction
GINA Asthma Guidelines
- mild
- moderate
- severe
Mild:- well controlled with PRN alone or with low ICS (6 or older) -> STEP 1/2
Hard to diagnose under 5
Moderate- well controlled with low dose ICS.
-> LABA (STEP 3) SABA prn
Severe: high dose ICS/ LABA, -> remains uncontrolled (Step 4), saba prn
No ICS for kids under 6 y.o ,9
What age is treated as an adult for asthma
Over 6 years
<5 cant do spirometry
Pedi Asthma Differentials
VIral URI
Allergic rhinitis
Foreign body
How to treat pedi asthma? 1-11 years old
- Montelukast chewable
- Neb ICD until able to use inhaler
1-11 y/o
Neb with albuterol
Oral steroid burst : 60 mg/day
Liquid prednisone : 1-2mg/kg/day QAM for 3-10 days
Orapred 15mg/ml (has sorbitol- can make diarrhea worse)
For Rescue only
Not to be used alone, except for < 5 years of age.
Albuterol
Levalbuterol
Used in Combination therapy (long-acting, LABAs)
Salmeterol (Serevent)
Formoterol (Foradil)
Beta 2 Agonists
For Rescue only (short-acting, SABAs).
Acute infection of lower RR tract in infants and young children (common in infant hospitalization)
Agent: RSV, Rhino, adeno, corona
Bronchiolitis (self limiting, most mild)
Dehydration , feeding, lethargy → impending RR failure
Decrease UO
Bronchiolitis
How to manage/ tx bronchiolitis?
Improves itself, most mild and managed at home
Supportive- antipyretics, hydration, bulb syringe
TOXIC appearance
Otitis media, nasal congestion, tons secretions, tachypnea, increase WOB, wheezing, rhonchi, delayed cap refill, displaced spleen and liver d/t lung expansion
bronchiolitis
Inflammation of the trachea and bronchi/ lower tract by definition , caused by viruses or lung irritation
Risk Factors:
Occupational - exposure to irritants
Smoking
Bronchitis- URI
Cough-may or may not have sputum lasting longer than 7 days
Retrosternal pain- behind the sternum—> “chest cold”
Nasal discharge
Sore throat
Low grade fever
Reduction in FEV1
Bronchitis
What to consider in adult with hacking cough lasting > 2 weeks?
consider B. Pertussis
over Bronchitis
Cough and sputum on most days for 3 months of year, two consecutive years
Chronic Bronchitis
How to Tx/ manage Bronchitis?
Cough ____
What is the cause? Sx treatment- 80% improvement without
Cough: dextromethorphan/ benzonotate
Severe cough (bedtime: codine or hyd
Antipyretics
Cough suppressant is controversial- you want to be able to get the sputum out, not suppress it
Bronchodilator - doesn’t help w cough (unless has asthma)
NO ANTIBIOTIC- not likely bacterial - if it is, macrolides (first line)
Stop smoking
Illness of larynx, trachea and bronchi → stridor and barking, Inflammation of UR tract
Risk Factors:
18m-2 y.o
History of past infection - can cause recurrent spasmodic
Worse at night (runs course 3-5 days) Clinical Manifestations: Rhinorrhea Barking cough Fever Accessory muscle use
Croup
WestleyCroup scoring system
*Less than 3 - mild
3-6 -moderate
>6 - severe
PE:
Dyspnea
Tachypnea
Retractions
Stridor - (stridor at rest- foreign body)
Wheezing and rales may be heard if there is additional lower airway involvement.
Croup
Croup Differentials?
How to manage?
Differentials:
- FB aspiration (if stridor on rest)
- Epiglottitis (if drooling)
Management: Racemic epi (Causes vasoconstriction diminishing edema) Corticosteroids Humidifier in mild cases Antipyretic Oral hydration
the maximum rate that person can exhale in a short, maximal expiratory effort after a full inspiration
Peak Flow
Most common cause of Bronchiolitis
RSV
Well-controlled with as-needed reliever medication alone or with low-intensity controller treatment such as low-dose inhaled corticosteroids (ICSs), leukotriene receptor antagonists, or
chromones
Mild asthma
Well-controlled with low-dose ICS/long-acting beta2-agonists
LABA
Moderate Asthma
Requires high-dose ICS/LABA to prevent it from becoming
uncontrolled, or asthma that remains uncontrolled despite this
treatment
Severe asthma
GINA no longer recommends ______ for first-line use in asthma except in children
aged under 5 years (where evidence is lacking) and where a trial of ICS should be
used in those not responding to as-needed
SABAs
for as-needed relief of symptoms, GINA’s preferred choice of reliever is _____ for adults and adolescents over the age of 12 and _____ taken as needed together with a ____ in children aged 6–11 years
ICSs in combination with formoterol for adults and adolescents over the age of 12
ICS taken as needed together with a SABA in children aged 6–11 years
long-acting bronchodilator with rapid action
ICS-formoterol
For Rescue only (short-acting, SABAs).
• Not to be used alone, except for < 5 years of age.
Beta2 Agonists
• Albuterol
• Levalbuterol
Used in Combination asthma therapy (long-acting, LABAs)
Beta2 Agonists
• Salmeterol (Serevent)
• Formoterol (Foradil)
Exercised Induced Asthma tx
- Warm up
- Scarf over mouth in cold
- SABA 2 puffs 5 mins before exercise
- LABA
Acute Exacerbation Management for > 12 years
• Oral steroid burst 3-10 days • Prednisone up to 60mg AM • Methylprednisolone 40-60mg AM • Medrol dosepak 4mg tablets (84mg total divided over 6 days = inadequate dosing)
Acute Exacerbation Management for ages 6-11
• Chewable Montelukast (Singulair)
• Nebulizer for ICS until able to use inhaler
• Budesonide 0.25mg/2mL to 1mg/day; may
divide into BID
asthma exacerbation Ages 1-11
• Nebulizer with albuterol or albuterol syrup or inhaler • Oral steroid burst: maximum 60mg/day • Liquid prednisolone: 1-2mg/kg/day QAM x 3-10 days • Pediapred 5mg/5mL (contains sorbitol) • Orapred 15mg/5mL (contains sorbitol) • Prelone 15mg/5mL (contains 5% alcohol)
Bacteria infection of RR tract that this cause by strains of gram + c, humans are only reservoir
Diphtheria
Thick grey pseudomembrane. In nasopharyngeal, pharynx, trachea that bleeds when removed
Blood nasal discharge
Sore throat
Neck swelling with cervical Aden it is (bull neck)
Cutaneous lesions (non-healing ulcers with dirty grey membranes
Diphtheria
Diagnostics for Diphtheria
Culture from nose, throat or lesions
Diphtheria Differentials
Acute step pharyngitis
Mono
Nasal foreign body/ purulent rhino- nasal diphtheria, epiglottis, laryngeal diphtheria, viral croup
how to manage / tx diphtheria
Children: hospital for tracheostomy
Anti-serum - scratch test prior d/.t allergies + Abx
Erythromycin oral for 14 dats, PCN G 14 days IM or IV,
Supportive care
Droplet precautions until 2 - cultures
Immunization after recovery
Sudden swelling of the epiglottis, which worsens rapidly (w/i hours) → death
Airway obstruction, mucous plugging
Epiglottitis
Tripod Retractions, cyanosis (late sign) Abrupt onset of fever, irritability ***Muffled voice*** Severe sore throat , dysphagia ***Drooling*** Increased respiratory distress. cough and the hoarseness are generally absent… considered late symptoms
Epiglottitis
- Inspiratory stridor
- Drooling, muffled voice and high fever
- Respiratory obstruction
- Tripod position- Hyperflexion of the neck
Epiglottitis
- Do not examine the throat as it can cause spasms and worsen obstruction *
Diagnostics for Epiglottitis
History and observation- ICU and airway mgmt
CBC- increase WBC (left shift)
Blood cultures
Lateral neck radiograph before examining the patient. If positive it will show the “thumb sign”.
Following intubation, epiglottis culture is performed
management for Epiglottitis
Goal is to establish the airway and start appropriate antibiotics
Droplet isolation first 24 hours, upright until airway secure
Antibiotics to tx Epiglottitis
Antibiotic- Gram +. H fl (B) cephalosporins (cefotaxime or ceftriaxone), Amp/sub
Cephalosporin allergies: Amp/Sub, Levofloxacin
7-10days
Very transmissible. Susceptible children should take prophylaxis with Rifampin
Swallowed- where is it?
coughing, wheezing
Larynx
Swallowed- where is it?
Brassy cough, dyspnea, cyanosis
Trachea
Swallowed- where is it?
R lung aspiration
Bronchiole
Respiratory illness with PROLONGED coughing; children>adults, highly contagious
Risk Factors:
*unvaccinated infants
Pertussis
Adults- cough worse at night, gagging and vomiting, WHOOPING COUGH,
DEADLY TO NEWBORNS- Tdap for pregnant moms
1-2 weeks symptoms
Pertussis
phase of pertussis ?
low grade fever, rhinorrhea, mild cough, excessive lacrimation, and conjunctivitis (Highly spreadable ) 1-2 weeks of UR sx
Catarrhal phase of pertussis
phase of pertussis?
Increased mucous, paroxysmal cough, cyanosis vomiting, exhaustion (whoop)
Adults: 2-3 weeks cough * hallmark symptoms*
Paroxysmal
phase of pertussis?
Decease in cough, less persistent, slow recovery. Symptoms wane.
1-2 weeks or months
Convalescent
what sx is not seen in pertussis and thus if present means you should look for another reason
Fever
Diagnostics for pertussis
PCR Swab
Nasopharyngeal secretion culture (gold standard but can take too long)
Toxin IgG
CBC- 18k WBC, lymphocyte count (lymphocytosis in infants and children who are in the paroxysmal phase)
CXR- interstitial edema, atelectasis, perihilar infiltrates
pertussis Differentials
RSV, adenovirus, influenza, gastro-esophageal reflux, CF, aspiration pneumonia, asthma, FB aspiration
Treatment for pertussus
(hospital if severe)
Antibiotics( Macrolide-1st line- azithromycin ) TMP-SMX is alternative
Bactrim is alternative to macrolide if > 2 months old
Must give early in disease process for it to be effective
Erythromycin in < 1 month olds can cause pyloric stenosis
preferred for pertussis prophylaxis for babies < 1 month
Azithromycin
Increased amount of fluid in pleural space- IS IT WORSE WITH INSPIRATION?
Pleurisy(symptom)/Pleural Effusion
Inflammation in the pleural space: causes pain as layers rub together form swelling- viral most common; not a dx, but a symptom of numerous localized and systemic disease processes
Risk Factors:
Trauma
Systemic disease- SLE, sarcoidosis
Pleurisy ( symptom)/Pleural Effusion
Pain over affected chest area, usually lower portion of test
Painful with deep inhalation- sharp/ stabbing pain
coughing / sneezing- worse, toughing
R/O MI !!!!!!
They may lay on affected side to decrease lung expansion
Pleurisy
Guarded near area, palpation is tender, friction rub with auscultation
Fevers, chills, productive cough (PNA), joint pain/ rash (inflammatory issues or connective tissues disorder)
Tenderness to palpation - directly over site of inflammation
Percussion- dull if there is consolidation or pleural effusion
Pleurisy/ Pleural Effusion
diagnostics for Pleurisy/ Pleural Effusion
differentials?
tics
No dx but can help r/o
CXR
CBC- high leuk with shift to left; leukoPENIA= viral or SLE, CT or thora is severe , Thoracentesis
managing Pleurisy/ Pleural Effusion
Most are viral- sx mgmt Steroids- SLE helps with inflammation NSAIDS- pain Treat underlying - refer Severe- Refer
(most common in outpatient and inpatient ) - 8th leading cause of death , 1st among infection related death
CAP (community-acquired pneumonia)
what is the typical pathogen for pneumonia in 4m- 18 years
S pna (typical)
Sudden onset Chills common Cough Purulent sputum pleuritic pain focal crackles wheezes are rare air space-filling on CXR infiltrate commonly from S Pneumoniae
Typical Pneumonia
Slower onset (days) chills are rare prominent cough dry sputum musculoskeletal pain diffuse crackles occasional wheeze diffuse & interstitial CXR infiltrate commonly from M. pneumoniae
Atypical Pneumonia
Those at risk of Drug-resistant pneumococci
over 65, children in daycare, beta-lactam therapy in last 90 days, ETOH disorder, immunosuppression
Gold standard for pneumonia dx
CXR
What to give pt … No Abx in 3 months and outpatient CAP:
Non-ICU:
ICU:
Macrolide (p 509) or doxycycline
Non-ICU:L Fluroquinolone or B lactam
ICU: B lactam + azithromycin a fluoroquinolone
How to tx MRSA pt with CAP (community acquired pneumonia)?
amoxicillin/ doxycycline, or azithromycin
What to watch out for Macrolides (-mycin drugs) / fluoroquinolones (-floxacin drugs)?
AE: QT prolong
Fluro: tendonitis, rupture, peripheral neuropathy, AAA
Macrolide: rate >25% resistance then it NOT a good option - combo therapy
Comorbidities
Drug that can cause fetal demise (new)
Bacterial protein synthesis inhibitor (strep pneumoniae, MSSA, H influenzae, legionella, mycoplasma, and chlamydia pneumoniae)
QT prolongation* and can affect CYP drugs
Lefamulin
used to tx pneumonia
Fluoroquinolone- also works with gram negative pathogens
Risk of AAA, Tendonitis/ rupture
Delfoxacin
used to tx pneumonia
Caused by a virus. Causes common cold symptoms. More severe in infants and old adults. The infection starts at the nasopharynx and progresses towards the lower respiratory tract. It causes edema and necrosis of the epithelial cells which results in airway obstruction/trapping.
Risk Factors:
November-April
Prematurity, smoke exposure
RSV
Clinical Manifestations: Rinorrhea, otitis media with or without effusion, dehydration, conjunctivitis, respiratory distress (tahcy), barrel chest and displaced liver and spleen (lungs displacement)
PE: Nasal secretion, cough, fever and lower respiratory infection symptoms. More severe infection presents with apnea, severe cough with possible cyanotic episodes, and poor oral intake. (sx may last up to 3 weeks)
RSV
Dx for RSV
Viral testing not recommended (takes 5 days) unless severe case or patient is immunosuppressed. Rapid nasopharyngeal specimens can be used as diagnostic if indicated. Blood cultures not indicated as concurrent bacterial infection with RSV is not common
How to manage RSV?
what is not recommended?
Supportive, hydration, Pulse ox, CPAP in severe cases
NOT recommended: bronchodilators, antibiotics steroids, nebs (also for bronchiolitis)
Ribavirin (antiviral) not recommended unless immunocompromised with severe RSV
Infection of the trachea causing airway inflammation and obstruction- life-threatening
caused by epithelial damage from viral infection and/or mechanical trauma in the trachea at the level of the cricoid cartilage = damaged tissue that’s more susceptible to bacterial superinfections.
Tracheitis
mucosal damage is characterized by subglottic edema, purulent secretions, and a pseudomembrane
= airway obstruction or even toxic shock syndrome
hyperpyrexia, a brassy cough, noisy respirations, lethargy, dyspnea, rapid progression of airway occlusion, and the presence of upper airway infection or croup
Tracheitis
Toxic appearance, anxiety, agitation, lethargy, pallor, cyanosis, severe stridor, sx of pneumonia
Tracheitis
The gold standard for microbiologic diagnosis of Tracheitis?
Tracheal bacterial cultures
How to manage trachitis?
Airway! -> Emergency Transport
Antibiotic therapy is based on gram stain and culture results
how do foreign bodies in various locations of the respiratory tract present?
- larynx, trachea, bronchioles
started suddenly, was gagging or choking,
Larynx= unilateral wheeze
Trachea= brassy cough, echoing wheeze, cyanosis
Bronchioles= (usually on the right side)
Reduced in obstructive lung disease
FEV1
abnormality in ___ often indicates restrictive lung condition
FVC
represents the % of lung capacity one is able to exhale in 1 sec, if low/ abnormal = obstruction
what is abnormal for adults/ kids?
FV1/FVC Ratio
Adults = Gold critiera <70% is abnormal Kids= <85%
For Rescue only (short-acting, SABAs).
Not to be used alone, except for < 5 years of age.
Albuterol
Levalbuterol
Used in Combination therapy (long-acting, LABAs)
Salmeterol (Serevent)
Formoterol (Foradil)
Beta 2 Agonists
scratching sound/ loud creek- at the end of inspiration, stops when hold breath
Friction rub
