Respiratory Flashcards
Where does the most resistance to airflow occur? Also where inhaled gas is warmed and humidified.
upper airway
Where does gas exchange occur?
lower airway
The pediatric airway is harder to intubate because they have a ___ tongue, ____ vocal cords, ____ epiglottis, and ___ larynx.
large, angled, floppy, funneled
The narrowest part of the pediatric airway if the?
cricoid cartilage
We do not overextend an infant’s airway due to its large?
occiput
Up to what age are infants obligate nose breathers?
6 months of age
Because infants are obligate nose breathers, they are at increased risk for difficulty breathing when _____ airway disease occurs.
upper
Anatomically, infants have a harder time compensating with lower airway disease due to their poorly developed _____ _____, ____ shaped chest, and e____ airway.
chest muscles, barrel, edematous
Prior to asystole or cardiac arrest, children begin with?
respiratory conditions or respiratory arrest
upper airway illness will lead to an increase in sn____ and no____ breathing.
snoring, noisy
Macroglossia, laryngomalacia, and an extrathoracic foreign body can lead to what respiratory problem?
inspiratory stridor
laryngitis, vocal cord paralysis, and papillomatosis may lead to what respiratory problem’s?
hoarse voice or stridor
Children with congenital syndrome Pierre-Robinson syndrome are harder to intubate due to their ____ chin and ___ tongue.
small, large
The obstruction of 1 or 2 nostrils is called?
choanal atresia
Children with asthma or a foreign body may present with an __ or ___ cough.
acute or chronic
Dehydration will lead to an elevation in __/__ and __
H/H and WBC
What type of chest x-ray is indicated to assess for effusions or pulmonary fluid level?
lateral decubitus
What test is used to assess for solid lung etiologies such as tumors?
pulmonary MRI
What diagnostic test is used to evaluate lung disease in the presence of asthma?
PFTs ( pulmonary function test)
Laryngotracheobronchitis also known as croup, is most common in kids less than ___ YOA, and often seen in what months?
6, October- march
What is the most common croup pathogen?
parainfluenza 1 & 2
Croup s/s are worse at ____, due to upper airway e____
night, edema
croup s/s include s____, a ____ cough, and h____
stridor, a barky cough, and hoarseness
Croup often begins ___ hours after a ____
48 hours after a URI
If croups s/s are severe, obtain a ____ ___ film x-ray.
lateral neck
The characteristic croup x-ray finding is known as the ____ sign.
steeple
Croup management includes ____. The dosing is ___mg/kg IV/IM x1
dexamethasone, 0.6 mg/kg
If a child with croup s/s does not improve with dexamethasone, obtain an __/__ neck ___ to r/o the presence of a foreign body.
a/p neck x-ray
Tracheitis is often bacterial in nature. The most common tracheitis pathogens include s____ and s___ ____
Staph and strep pneumonia
Key tracheitis characteristics include a ____ fever > ____ with ___ look
high fever, > 103 with a toxic look
What condition presents with high fever, toxic appearance, stridor, respiratory distress?
tracheitis
- May look like croup, doesn’t respond to racemic epi
What type of X-ray do you obtain for tracheitis?
lateral x-ray
Tracheitis x-ray findings include the ____ sign.
thumb
tracheitis management includes
C______ + na____ or ox____
Or
C_______ + c_______ if penecillin resistance exists
Or
V______ +- c_______ of patient toxic appearing with multi organ involvement
Ceftriaxone + naficillin/oxacillin
Ceftriaxone + clindamycin
Vancomycin + clindamycin
foreign body airway obstruction occurs in what age groups?
infants and toddlers
The most important history piece in a child with foreign body airway obstruction is that there is no?
illness prior to s/s development
Foreign body airway obstruction is an acute event of c___, c___, ____ breathing, and CHRONIC _____.
choking, coughing, difficulty breathing, and chronic stridor
When working up a child with a foreign body aspiration, what assesses for differences in lung sizes while the child is holding their breath?
An i_____ film
an inspiratory film
What diagnostic test, identifies where the foreign object is?
A Fl______ evaluation
a fluroscopic evaluation
What is the gold standard treatment for a foreign body aspiration?
a bronchoscopy in OR
Ensure to keep children with a foreign body aspiration ____ due to their high risk for complete ____. When agitation, foreign objects tend to?
calm, obstruction.
move further down the airway.
If the foreign object cannot be removed with bronchoscopy, prepare the child for a?
tracheotomy
What is the most common tracheal congenital anomaly?
tracheomalacia
Over time, tracheomalacia may?
improve on its own.
tracheomalacia is more common in premies and infants with a history of previous _____ as well as those with a history of pulmonary i____ or le____
intubation, lesions or injuries
tracheomalacia is associated with?
f____ problems
feeding problems
s/s of tracheomalacia include ___ and ___ which worsen with ____ or _____
stridor and cough. feeding or agitation
Due to a history of feeding difficulties, children with tracheomalacia may present as?
FTT
tracheomalacia is diagnosed with a fl______ br_____ during ______ respiration
flexible bronchoscopy, during spontaneous respiration
What radiology exam assesses for the presence of a vascular ring?
CT scan
What radiologic exam evaluates pulmonary anatomy?
fl______
fluoroscopy
what diagnostic test r/o laryngomalacia?
a laryngoscopy
Tracheomalacia management includes?
observation
Tracheomalacia typically resolves by what age
18 M.O.A
Severe cases of tracheomalacia may be treated with a T____+ ____
tracheostomy and CPAP
In severe cases of tracheomalacia, an aortopexy may be used to help decrease?
a____ c____
airway compression
What is acute severe epiglottis inflammation?
epiglottitis
epiglottitis is considered an airway _____
emergency
In epiglottitis, there is a sudden onset of breathing ____ without _____.
obstruction without fever
The most common organism of epiglottitis in children who aren’t vaccinated is?
Haemophilus influenza
The most common organism of epiglottitis in children who are vaccinated is?
1)
2)
1) strep
2) staph
What age group is most affected by epiglottitis?
1-5 YOA
The diagnostic test for epiglottitis is a?
lateral neck xray
What x-ray finding is characteristic of epiglottitis?
thumbprint sign
When evaluating a child with epiglottitis, a laryngoscopy will show a ___, ____, ___ epiglottis
beefy, red, swollen
Epiglottitis management includes keeping the child?
calm
- do not examine throat
- intubate, if intubation fails immediate tracheotomy
Treatment for a child with epiglottitis includes
R_____ and
D______
Rocephin
Dexamethasone
Warm humidified oxygen
Treatment for a child with epiglottitis resistant to MRSA and Penicillin includes r_______ + _____.
Rocephin + Vanco
What type of airway abscess is more common in older kids and teens
a peritonsillar abscess
A peritonsillar abscess typically begins as a L____ C____ that turns into a D___ N___ A___
Local cellulitis that turns into a deep neck abscess
Peritonsillar abscesses are typically polymicrobial. The most common 3 organisms in order of occurrence are?
strep, staph, H. flu
Peritonsillar abscess s/s include c/o of a ___ ____, decrease in ____ ____, ear ___, and a ____ voice (hot potato)
sore throat, oral intake, pain, muffled
Peritonsillar abscess outpatient treatment includes?
Augmentin
If a peritonsillar abscess does not improve with antibiotics treatment, consult with ENT who will?
lanse abscess
What is the most common reason for a TNA?
obstructive sleep apnea
The following clinical manifestations are characteristic of what?
snoring, obesity, daytime hyperactivity, and sleeping at school.
obstructive sleep apnea
Obstructive sleep apnea complications include ___ ___ and ___ ____
pulmonary hypertension and cor pulmonale
pulmonary hypertension can be diagnosed with an?
ECHO
What is the diagnostic exam for obstructive sleep apnea?
a polysomnography and/or sleep study
To rule out the presence of complications associated with OSA, obtain both an?
EKG and ECHO
True or False. After a TNA, obese kids may still have s/s?
true
After TNA, obese children may need extra respiratory support s/p surgery with a?
CPAP or BiPAP
What is the curative treatment for patients with severe obstructive sleep apnea?
a tracheotomy
What is the most common chronic illness in childhood?
asthma
Asthma is characterized by airway _____ leading to broncho ____
inflammation, constriction
Children that present with nighttime coughing, sob, hypoxia, unable to speak, and retractions unresponsive to treatment are in?
status asthmaticus
What type of asthma occurs less than or equal to 2 days/week
intermittent asthma
What type of asthma occurs > 2 days/week but not daily
mild asthma
In what type of asthma do s/s once occur daily?
moderate asthma
What type of asthma has s/s that occur several times daily?
severe asthma
In asthma and ETT may cause further ____ making it difficult to _____
bronchoconstriction, ventilate
The gold standard diagnostic test for asthma is a?
chest x-ray
What may a chest x-ray in a child with asthma show?
chest hyperinflation and flattened diaphragm
In the ER, what is the last treatment modality used in a step-wise approach to help decrease bronchial constriction?
Magnesium sulfate
What do you need to monitor for s/p mag sulfate infusion?
hypotension
Admission criteria for a child with asthma include
* > _____ min of s/s despite txt
* oxygen needs via ____
* The need for q _____ hour albuterol
or ____ albuterol
* a history of?
60
CPAP or BiPAP
Q2-3 hour, continuous
prior admissions
If a child with asthma requires sedation, sedate with?
ketamine
When intubated, children with asthma are at risk for ___ ___ and permissive ______
air leak and permissive hypercapnia
Pertussis, also known as whooping cough most often occurs in what age group?
less than 2 months of age before vaccination
In what trimester is the Tdap vaccination recommended?
third trimester
What type of bacteria is pertussis?
gram-negative
Pertussis causes respiratory tract _____ and is contacted via _____
inflammation….droplets
In pertussis, the Catarrhal stage (first stage) presents as a _____. Clinical manifestations include?
URI
congestion, rhinorrhea, low-grade fever, non-productive cough
The second stage of Pertussis, the paroxysmal stage lasts for about ____ weeks.
Clinical manifestations include a
* cough which is more severe at ____
* decreased o___ i____
* episodes of ______ and
* instances where the infant is not _____
1-2 weeks
night
oral intake
hypoxia
breathing
In what Pertussis stage does the whooping cough develop?
Whooping cough is due to pulmonary _____.
The Paroxysmal stage
spasms
Parents of children in the last stage of pertussis also known as the convalescence stage should expect a cough lasting up to ____ weeks.
6-10 weeks
What CBC finding is seen in children with pertussis?
high leukocyte count
What is the gold standard pertussis diagnostic test?
P____ c____
PCR culture
Pertussis has the highest mortality rate in infants less than what age?
6 months of age
What is the gold standard pertussis treatment?
E_______
Erythromycin
Azithromycin is an alternative treatment for pertussis. Keep in mind that azithromycin is contraindicated in what age group?
Infants less than 1 month of age
Children with pneumonia will have a history of prolonged?
cold or URI
When considering what fever, viral pneumonia, and mycoplasma pneumonia will cause?
a low grade fever
Children with bacterial pneumonia will present with what type of fever?
high fever
What diagnostic test helps rule out the presence of Mycoplasma pneumonia?
cold agglutins
The following gram-negative organisms: GBS, E. Coli, listeria, chlamydia, and Klebsiella are common pneumonia etiologies for what age group?
neonates
What are the common organisms for pneumonia in late-onset neonates?
staph and strep
What is the etiology of pneumonia in infants + toddlers (2 M.O.A - 2 Y.O.A)?
viral etiology
Strep Pneumonia and H. Flu type B are organisms of pneumonia most often seen in what age group?
2-5
Mycoplasma and strep are organisms of pneumonia most often seen in what age group?
5-teen years
What is the first-line antimicrobial outpatient treatment for pneumonia?
p______
penicillin
What is the first-line antimicrobial inpatient treatment for pneumonia?
ampicillin
What antimicrobial should be added when chlamydia is suspected as a cause of pneumonia?
azithromycin
What antimicrobial should be added for mycoplasma coverage in children with pneumonia?
zithromax
Children with aspiration pneumonia should be treated with?
cl______
clindamycin
What is a complication of bacterial pneumonia?
parapneumotic/pleural effusion
Initial inpatient management of a parapneumotic/pleural effusion includes _________, followed by coverage with?
drainage via chest tube followed by coverage with broad-spectrum antibiotics
A child with bacterial infection spread into pleura with purulent fluid has an?
empyema
Children with empyema require what surgical procedure?
V___\th_____
VATS/thoracentesis
What diagnostic test can help identify the presence of a pleural effusion?
A lateral decubitus X-ray
What are the pneumonia admission requirements?
toxic appearance,
children with an underlying condition
presence of an effusion or empyema
Staph or Strep CAP
Oxygen need via HFNC/CPaP/BiPaP
ARDS is characterized by ____ injury.
alveolar
The following conditions:
Direct lung injury, shock, sepsis, drowning, trauma, aspiration, contusion, TRALI, heart attack.
Increase the child’s risk for the development of what?
Acute Respiratory Distress Syndrome (ARDS)
Clinical Manifestations of ARDS include:
H_____
R_______
Decreased a_____
Increased _____
Decreased ______
Hypoxia
Respiratory Distress
Decreased aeration
Increased CO2
Decreased PaO2
What PaO2/FiO2 value is diagnostic for ARDS?
PaO2/FiO2 < 200
What is the inheritance pattern for Cystic Fibrosis?
autosomal recessive
What is the Cystic Fibrosis gene?
CFTR
What clinical manifestation is characteristic of Cystic Fibrosis?
Sticky secretions
Children with CF may benefit from ____ to assist with sticky secretions
CPT
Sticky secretions increase the child with CF risk for?
More lung infections
What other body systems are affected by CF?
pancreas, intestine, liver, sinus, reproductive tract, sweat glands.
What is the gold standard diagnostic test for CF?
S____ c_____ test
Sweat chloride test
GI-wise, children with CF are at increased risk for?
Polyps
Children with CF need _____ diet + ____ replacements
high-calorie diets with enzyme replacements
During infections, children with CF require gram ____ coverage. The antibiotic of choice is ci_____.
Negative
Ciprofloxacin
Along with airway clearance management, children with CF need to have their ____ ____ monitored.
blood glucose
A complication of cystic fibrosis includes the need for _____ transplantation
liver
This is the typical presentation for what pulmonary condition:
Adolescent female, who is overweight and on birth control.
pulmonary embolism
In the presence of a P.E., the D.Dimer will be?
elevatd
The gold standard diagnostic test for a P.E. is a?
VQ scan or a spiral (helical) CT scan
The treatment for a P.E. includes what low molecular weight heparin?
Lovenox
Tracheoesophageal fistula’s are most commonly seen in the ____ setting.
NICU
Tracheoesophageal Fistulas are often identified when?
Right before or after birth
Clinical manifestations of an infant with a Tracheoesophageal Fistula include?
C_____
C_____
c______
s/s are worse when ______
Abdominal _______
coughing
choking
worse when feeding
abdominal distension
What is the treatment for Tracheoesophageal Fistula?
Surgery, Consult team
Tracheoesophageal Fistula management includes the passage of an ____ and keeping the _______, to prevent aspiration
NGT
-won’t advance
and keeping the HOB elevated
The following conditions cause what type of blood gas finding?
Hypo/Hyperventilation
CNS depression
Respiratory Neuromuscular disorders
CPOD
Hypoxemia
Respiratory Acidosis
The best oxygen modality for bronchiolitis is via?
HFNC
The best oxygen modality for asthma and OSA is via?
BiPAP or CPAP
During invasive ventilation, what change in the settings affects CO2?
Rate
What ventilation setting assists with oxygenation?
P____
PEEP
The Tidal Volume setting is based on the child’s size and weight. What is pediatric tidal volume calculation?
4-6 ml/kg
An intubated child’s chest rise is dependent on what ventilator setting?
Tidal volume
Ventilator respiratory rate is dependent on age, what is a good ventilator RR range?
12-30
The following inspiratory time settings are appropriate for what age group?
0.4-0.6
neonates and infants
The following inspiratory time settings are appropriate for what age group?
0.6-0.8
2 years of age and older
To improve the oxygenation of an intubated child, increase the?
PEEP and FiO2
To improve the ventilation of an intubated child, increase the?
T___
+ r_____
tidal volume and respiratory rate
In pediatrics, what is the maximum tidal volume?
6
What oxygen modality is best to assist in ventilating a child having difficulties with oxygenation?
High Flow NC
HFNC is contraindicated in children with:
* Increased i _____
* Hy____
* Increased ai_____ re____
* pn______-m____
ICP
hypotension
increased airway resistance
pneumomediastinum
Tracheostomy is indicated in children with:
* Failure to maintain a ____ _____
* airway o_____
* severe T____/B_____
patent airway
airway obstruction
severe tracheo/bronchomalacia
What sterile procedure with sedation is indicated to drain pleural fluid or air?
chest tube
Pneumococcal 12-valent conjugate vaccination is recommended at what age groups?
2, 4, and 6 months of age
In high-risk populations, the 23-valent pneumococcal vaccine should be administered at what age?
2 years of age
What vaccine is only recommended at 6 months of age for any infant who will be traveling internationally:
6 months of age
Pneumomediastinum is caused by?
al_____ rupture
alveoli rupture
In children under the age of 7, pneumomediastinum is often associated with a?
lower respiratory infectoin
In older children and adolescents, pneumomediastinum is most often associated with?
asthma
The following children are at risk for the development of what?
* Children s/p vomiting
* Children on high-flow nasal cannula therapy
* Patients with anorexia nervosa
pneumomedastinum
Upon evaluation of a pneumomediastinum, a chest x-ray will reveal increased _____ and ____ in the mediastinum.
lucency and air in the mediastinum
While patients can be asymptomatic, Common presenting signs and symptoms of pneumomediastinum are?
C___ ____
D____
N___ ____
chest pain, dyspnea, and neck pain
Pneumomediastinum physical exam findings include ____ sign. Described as _____ heart sounds or subcutaneous ______
Hamman’s
crunching heart sounds
subcutaneous emphysema
As long as there is no circulatory compromise, pneumomediastinum is ______ and does not require _____.
self-limiting
treatment
Chest pain associated with pneumomediastinum can be treated with?
NSAIDs
Subcutaneous emphysema leading to tracheal compression includes management with a ______ which _____ the mediastinum
tracheotomy
decompresses
Pneumothorax radiograph demonstrates?
air in the pleural space
Children with pneumothorax typically present with
C___ ____
D_____
____ or ____ breath sounds
and T______
chest pain
dyspnea
decreased or absent breath sounds on side of pneumo
tachycardia
Tracheal deviation to the contralateral side is characteristic of a?
tension pneumothorax
Tension pneumo treatment includes a?
needle decompression
What is the major cause of morbidity and mortality in the first 6 months following pediatric lung transplantation?
infection
S/P lung transplantation, antimicrobial prophylaxis includes coverage for?
b____, v_____, f_____ pathogens
bacterial, viral, and fungal pathogens
What is the most common cause of serious viral infection following a lung transplant?
CMV
S/P lung transplant CMV infection can cause br____ on_____ leading to graft d___ and d_____
bronchiolitis obliteran
graft dysfunction and death
Those at highest risk for CMV pneumonia s/p lung transplant are seronegative recipients of lungs from?
seropositive donors
Step wise approach to a moderate asthma exacerbation
1) supplemental _____, maintain % > ___
2) I_____ B____, administering up to ___ doses in the first hour
3) systemic ______ (IV or PO) every ____ hour
4) nebulized ___ with ____, H___ or C_____
1) supplemental oxygen, > 90%
2) inhaled B2 agonist, 3
3) corticosteroids, 12
4) nebulized short-acting B2 agonist with ipratropium, hourly or continuous
Intubation criteria
* unresponsive to ____
* persistent or increasing _____
* worsening M____ status
* absence of ____ or _____
oxygenation
hypercapnia
mental
breath sounds or wheezing
What is the infant tidal volume calculation?
6-7 ml /kg
Children on pressure support ventilation have the ability to _____ all breaths and determine the ____ of breaths on his/her own
initiate
volume
Children on pressure support demonstrating adequate tidal volumes as per age parameters, are ready for?
extubation
During mechanical ventilation, what is a marker of poor lung compliance?
High p_____ pressures
high peak pressures
Peak pressures in infants should be less than?
____ cm H2O
20 cm H2O
Inhaled nitric oxide necessitates what for delivery?
m_____ v____
Mechanical ventilation
Infants post-operative from atrioventricular canal repair, are at risk for?
pulmonary hypertension
To maintain oxygenation and the distension of alveoli, infants s/p congenital diaphragmatic hernia repair require what vent setting?
High P____
high PEEP
Congenital diaphragmataic hernias impede lung ____ and limit lung _____
lung expansion
Limit lung volumes
Prior to extubation, what is the standard PEEP goal?
PEEP of 5
Hemoptysis, respiratory distress, hypoxia, subcutaneous emphysema, and consolidation on chest radiograph are clinical manifestations of a?
P_____ C_____
Pulmonary contusion
20 % of patients with pulmonary contusion will develop?
ARDS
Secondary complications of a pulmonary contusion include?
as______ and
in______
aspiration and infection
ARDS Management aimed at minimizing ventilator-induced lung injury includes targeting
* Low ___ ____ (__-__ ml/kg) = MOST IMPORTANT
- Permissive _______
- titration of ____ and ____ to maintain lower _____
- Prevent oxygen toxicity by maintaining PaO2 at ___-__ mmHg
tidal volumes (6-8 ml/kg)
permissive hypercapnia
titration of PEEP and FiO2, oxygenation
55-80
Cough, rales, rhonchi, retractions, and nasal flaring are highly specific for?
pneumonia
hoarseness, barking cough, and stridor are highly specific for?
laryngotracheobronchitis (croup)
Due to bronchial anatomy, what foreign body aspiration is more common in smaller children?
left-sided aspirations
assess for decreased or absent breath sounds over the left lung
Tracheitis is ____ in origin. Children present with high _____ and ____ airway symptoms.
bacterial
fever
upper
In neonates, the most serious complications of assisted ventilation include?
air leak syndromes
Pulmonary interstitial emphysema, pneumomediastinum, and pneumothorax are all examples of>
air leak syndromes
In air leak syndrome, distal alveoli rupture. High ventilator _____ and severe lung _____ are causative factors.
pressures and severe lung disease
Pneumomediastinum can progress into a?
tension pneumothorax
What presents as an elevation of the diaphragm or wedge-shaped opacity on the chest radiograph?
a pleural effusion
pulmonary interstitial emphysema is an air leak syndrome that occurs predominantly in what age group?
extremely premature
When intubation is indicated for septic shock, induction agents increase the risk for worsening ______. In this scenario, what sedative is the agent of choice?
hypotension
due to myocardial depression and vasodilator effects
ketamine
-maintains cardiovascular stability
Tracheostomy patient with mechanical ventilation experiences the delivery of higher PIP pressures, low tidal volume, and increased RR.
What are the two differential diagnoses?
tracheal plug or dislodgement
A Pneumothorax can lead to mediastinal shift and subsequently?
c______ collapse
cardiovascular collapse
A tension pneumothorax is an emergency. Immediate needle thoracostomy is achieved by inserting the needle into the?
2nd intercostal space at the midclavicular line
What needs to be placed s/p tension pneumothorax decompression?
a chest tube
TRALI onset may be delayed as long as ____ hours post-transfusion. A chest x-ray will show?
6
bilateral pulmonary infiltrates
higher PEEP decreases p____ leading to h_____
preload, hypotension
What is the best method for primary confirmation of endotracheal tube placement?
c______
capnography
Management of a child S/p submersion injury includes the administration of _______, and monitoring up to ____ hours post submersion.
100% supplemental oxygen
6
Peritonsillar abscess inpatient treatment includes?
1) am______
2) c______ +c_____ for severe cases
3) c______ or v_____ or l____ is MRSA resistant
Ampicillin
Ceftriaxone + clindamycin
Clindamycin, vancomycin, linezolid
- continue IV Atbx until patient is afebrile, transition to oral ATBX x 14 days
