Respiratory Flashcards
Asthma Etiology
Genetic predisposition of IgE mediated response to allergens (atopy) is strongest risk factor. common triggers: URI, environmental allergens, change in weather, stress, emotional expression, exercise, comorbidities.
Asthma s/s
mild: wheezing at end of expiration/no wheezing, no retractions, slight prolonged expiratory phase, normal aeration in lung fields. moderate: wheezing through expiration, intercostal retractions, prolonged exp. phase, decreased base breath sounds. Severe: accessory muscles, nasal flaring, inspiratory/expiratory wheezing or tight, suprasternal retractions, decreased base breath sounds. Impending arrest: diminished everywhere, tiring, severely prolonged expiration, drowsy, confused.
Asthma differentials
bronchiolitis, laryngotracheobronchitis, bronchopneumonia, pneumothorax, inhaled foreign body, congenital heart/lung defects, BPD, CF, ciliary dyskinesia, vascular aortic ring, chronic lower RTI, GERD, vocal cord dysfunction, anaphylaxis.
Asthma characteristics
cough/wheezing at night and early morning or SOB with exercise/exertion. lower airway obstruction that is partially/fully reversible with bronchodilator or anti-inflammatory treatments or spontaneously, the presence of lower airway inflammation, and increased lower airway responsiveness (hyperreactivity). Mucosal edema, increased mucus, smooth muscle contraction > inflammation, hyperreactivity, bronchoconstriction > reversible obstruction.
Asthma diagnostic criteria
do spirometry q1-2 years (usually >5 years old). peak expiratory flow function (max flow rate during forced expiration with fully inflated lungs). airway hyper responsiveness assessed with bronchial provocation test with methacholine or exercise. 20% reduction in FEV1 with methacholine or 10% reduction with exercise is +. consider sweat test. PFTs is gold standard for diagnosing. Reversibility with bronchodilator is increase in FEV1 of 12% or 100ml from baseline. Highest PEF in 2-week period under good asthma control is personal best value. check bid and 15-20 min after SABA.
Asthma management
avoid allergens/irritants, use a/c, close windows/doors stay indoors during high pollen season. fever can be managed with tylenol/motrin. consider allergen immunotherapy. treat rhinitis, sinusitis, GERD. consider: anticholinergics, cromolyn, LTRA, omalizumab. EIA: warm up 5-10min prior to exercise and use SABA 5-20 minutes prior. can add cromolyn. can use epi, ketamine, helix.
how to calculate peak flow
have the child take in a breath and breath it all out as fast as possible, take the highest of three recordings and that’s the child’s best. then compare what they can get to their best to get the percentage
Stepwise approach to treat asthma
Intermittent: consider consult at step 3. Step 1: SABA prn. 2: low-dose ICS or cromolyn, LTRA, theophylline. step 3: low dose ICS + LABA or medium dose ICS. alternative: low dose ICS + LTRA, theophylline, or zileuton. 4: medium ICS + LABA or medium ICS + LTRA/theophylline/zileuton. 5: high dose ICS + LABA, consider omalizumab. 6: high dose ICS + LABA + PO steroids and consider omalizumab. step down if well controlled >3months. SABA prn for all, but if using >2 days a week for symptoms need a step up. in <4 years, Singulair as alternative with LABA.
Common Cold
URI. average 2-10 a year (14 daycare). low grade fever, sore throat > rhinorrhea, cough, congestion. lasts 7-9 days. most contagious day 3 but up to 2 weeks. s/s: congestion, cough, sneezing, rhinorrhea, fever, hoarseness, pharyngitis. if viral, mild conjunctival irritation, lymphadenopathy, chest clear. dx: if sore throat rather than rhinitis do RADT or rapid strep. Diff: allergic rhinitis, rhino sinusitis, adenoiditis. Tx: supportive care. fluids.
Pharyngitis
throat infection, often viral. hoarseness, cough, coryza, conjunctivitis, diarrhea, sore throat. most common bacterial cause is GABHS. 5-13 year olds. abrupt onset, tender lymph nodes, myalgia, headache, high fever, n/v, winter time. do RADT. if +, within 9 days start abx like penicillin V potassium, amoxicillin, penicillin G, or cephalexin, cefadroxil, clindamycin, azithromycin, clarithromycin and supportive care. can go to school when afebrile and on meds for 24 hours.
Rhinosinusitis
inflamed mucosal lining of the nasal passages. onset of severe URI, persistent symptoms, then double sickening. chronic must last 12 weeks or longer. d/t Strep pneumonia, H. Flu, moraxella catararhalis. rarely staph aureus. persistent swelling of sinonasal mucosa impairs drainage. adenoidectomy sometimes helps. no dx just clinical. diff: viral URI, allergic rhinitis, nasal polyps, nasal tumors, tension, migraine, cluster headache. ethmoid can occur after 6months, and frontal after 10 year. tx: chronic may need referral. tx: uri with persistent discharge >10 days no improvement, new onset fever, high fever, severe and worsening needs antibiotics. treatment 10-28 days with amoxicillin/augmentin. may need drainage, intranasal steroids, saline irrigation,
Croup
inflammation/edemae of pharynx, upper airways, maximal narrowing immediate subglottic region. usually d/t viral causes. October-April. 6months-3year olds. s/s: mild URI 1-5 days then abrupt change often at night to croupy Barry cough, hoarseness, fever, inspiratory stridor lasting average 3 days. possible wheezing. defer oral examination in severe cases until secure airway. tx: humidification > racemic Epi with inpatient observation > steroids > airway stabilization.
Epiglottitis
upper airway obstruction, often d/t H. flu. peak age 1-7 years old. onset sudden with rapid progression, present within 12 Hours of first appearance. high fever, quiet stridor, severe throat pain with dysphagia/drooling, dyspnea, anxiety, toxic anxious, still, sitting upright with extended neck, retractions. do not move parents or child or force inspection/be invasive, immediate airway stabilization needed.
Pertussis
d/t Bordetella pertussis. whooping cough d/t high pitched inspiratory whoop following spasms of coughing (attempt to dislodge plugs of necrotic bronchial epithelial tissue and thick mucus followed by whoop to draw in O2). Incubation 7-10 days but can last 28 days, most contagious during catarrhal stage. highest incidence 6 Months. s/s: apnea, seizures, cough, poor feeding, leukocytosis. reinfections are common. dx: PCRculture is gold standard (NP within 2 weeks of onset).
Bronchiolitis
most common respiratory infection in infancy, causing cell death/necrosis of epithelial cells lining the airways. URI, decreased feeds, mild fever, apnea. wheezing, course crackles with tachypnea/retractions. often <2 years of age. peak age 6 months. Commonly d/t RSV.may order CXR. Diff: asthma, FB aspiration, HF, GERD, pneumonia, allergic pneumonitis, vascular rings. Tx: supportive. may cough 2-3 weeks. smaller frequent feeds. hospital: apnea, low O2, poor PO, respiratory distress.
