Respiratory Flashcards
The most common pathogens associated with the common cold
Rhinoviruses - most common
Coronaviruses
The most common complication of a cold is
otitis media
- Sinusitis is another complication of the common cold
- diagnosis of bacterial sinusitis should be considered if rhinorrhea or daytime cough persists without improvement for at least 10-14 days or if signs of more-severe sinus involvement such as fever, facial pain, or facial swelling develop
Clinical control of asthma is defined as
No (twice or less/week) daytime symptoms
No limitations of daily activities, including exercise
No nocturnal symptoms or awakening because of asthma
No (twice or less/week) need for reliever treatment
Normal or near-normal lung function
No exacerbations
When are the best times to monitor PEF (peak expiratory flow)?
PEF is measured first thing in the morning before treatment is taken, when values are often close to their lowest, and last thing at night when values are usually higher
How is the diagnosis of asthma confirmed through PEF?
60 L/min (or 20% or more of pre-bronchodilator PEF) improvement after inhalation of a bronchodilator,
OR
diurnal variation in PEF of more than 20% (with twice daily readings, more than 10%) suggests a diagnosis of asthma
What are the parameters that describe partly controlled asthma?
Any measure present would be sufficient to categorize px as having partly controlled asthma:
LANDR (Lung fcn, limitation of Activities, Nocturnal, Daytime Sxs, need for Reliever tx)
L- 2x/wk
R - > 2x/wk
What are the parameters that describe uncontrolled asthma?
Three or more features of partly controlled asthma
LANDR (Lung fcn, Activity limitation, Night sxs, Daytime Sxs, Reliever tx)
What is the single best measure of assessing severity of airflow obstruction?
FEV1 (forced expiratory volume in one second)
The primary therapies for asthma exacerbations are
Reference: GINA
- repetitive administration of rapid-acting inhaled bronchodilators
- early introduction of systemic glucocorticosteroids
- oxygen supplementation
Normal rates of breathing in awake children
< 2 mos
2-12 mos
1-5 yrs
6-8 yrs
< 2 mos < 60
2-12 mos < 50
1-5 yrs. < 40
6-8 yrs < 30 breaths/min
In the management of acute asthma exacerbation, what is the best and most cost-effective method of achieving rapid reversal of airflow limitation?
repeated administration of rapid-acting inhaled β-agonists
2 to 4 puffs every 20 minutes for the first hour
In a patient with acute exacerbation of asthma, what is the O2 sat value indicative of the need for hospitalization?
< 92%
- Oxygen saturation in children should normally be greater than 95%, and oxygen saturation less than 92% is a good predictor of the need for hospitalization
In managing a patient in acute asthma exacerbation, it was noted that the patient progressed further from moderate to severe exacerbation. What would be the difference in treatment between moderate and severe exacerbation?
Primary difference: from oral glucocorticosteroids, patient will be given systemic glucocorticosteroids and magnesium
Treament of moderate exacerbation:
Oxygen • Inhaled B2-agonist and inhaled anticholinergic every 60 min • Oral glucocorticosteroids • Continue treatment for 1-3 hours, provided there is improvement
Tx of severe exacerbation:
Oxygen • Inhaled B2-agonist and inhaled anticholinergic • Systemic glucocorticosteroids • Intravenous magnesium
What is the PEF in a patient in moderate exacerbation vs severe exacerbation?
Moderate: 60-80 % of personal best / predicted
Severe: <60% of personal best/predicted
What procedure should be done to ascertain the diagnosis of asthma?
Spirometry
- Increase in FEV1 of ≥ 12% and ≥ 200 ml after administration of a bronchodilator indicates reversible airflow limitation consistent with asthma
- An improvement of 60 L/min (or≥ 20% of the pre-bronchodilator PEF) after inhalation of a bronchodilator
- Diurnal variation in PEF of more than 20% (with twice-daily readings, more than 10%), suggests a diagnosis of asthma.
What is the predicted normal PEFR for Filipino children between 6-17 yo with a height of at least 100 cm?
male: (Ht in cm - 100)5 + 175
female: (Ht in cm - 100)5 + 170
What is the only accurate method of diagnosis of bacterial sinusitis but is not practical for routine use for immunocompetent patients?
Sinus aspirate culture
- clinical diagnosis of acute bacterial sinusitis is based on history
- persistent URTI, nasal discharge, and cough for 10-14 days without improvement
- purulent nasal discharge for 3-4 consecutive days
What is the treatment for acute uncomplicated bacterial sinusitis?
amoxicillin (45 mkD)
alternatives: co-tri, cefu, clarithro, azithro
if not responsive in 72h, shift to high dose co-amoxiclav (80-90 mkD)
What is the treatment for acute uncomplicated bacterial sinusitis?
amoxicillin (45 mkD)
alternatives: co-tri, cefu, clarithro, azithro
if not responsive in 72h, shift to high dose co-amoxiclav (80-90 mkD)
Complications of acute bacterial sinusitis
- characterized by edema and swelling of the forehead
- chronic inflammatory lesions commonly located in the frontal sinuses that can expand, causing displacement of the eye with resultant diplopia
- osteomyelitis of the frontal bone (Pott puffy tumor)
- mucoceles
periorbital and orbital cellulitis are also common complications
- meds usually started if with intracranial complications: broad spectrum IV antibiotics (ceftri + vanco)
What are the most important agents causing pharyngitis in children?
- viruses (adenoviruses, coronaviruses, enteroviruses, rhinoviruses, respiratory syncytial virus [RSV], Epstein-Barr virus [EBV], herpes simplex virus [HSV], metapneumovirus)
- group A β-hemolytic streptococcus (GABHS)
What are the symptoms suggestive of allergic rhinitis?
2 or more of the following symptoms for > 1 hr on most days: – watery anterior rhinorrhea – sneezing, especially paroxysmal – nasal obstruction – nasal pruritis ± conjunctivitis
** Purulent discharge, postnasal drip, facial pain, and loss of smell are common symptoms of sinusitis
What is the probable etiology of pharyngitis characterized as rapid in onset, not associated with cough, with the following symptoms: fever, red pharynx, enlarged tonsils covered with yellow blood-tinged exudate, doughnut lesions on soft palate and red stippled uvula?
a. Streptococcal pharyngitis
b. Viral pharyngitis
A. Streptococcal pharyngitis (GABHS)
Viral pharyngitis is more gradual in onset, associated with cough, coryza and conjunctivitis, with hoarseness and sometimes with accompanying diarrhea
What is the probable viral etiology of the ff case descriptions
A. pharyngitis + concurrent conjunctivitis and fever
B. pharyngitis + small grayish vesicles and punched out ulcers in posterior pharynx
C. pharyngitis + small yellowish-white nodules in posterior pharynx
D. pharyngitis + prominent tonsillar enlargement with exudate, cervical lymphadenitis, hepatosplenomegaly, rash and generalized fatigue
A. pharyngoconjunctival fever caused by adenovirus
B. Herpangina caused by coxsackievirus
C. acute lymphonodular pharyngitis caused by coxsackievirus
D. infectious mononucleosis caused by EBV
What is the primary benefit of treatment of acute streptococcal pharyngitis even if spontaneous resolution of symptoms is expected ina few days?
What is the drug of choice?
- prevention of acute rheumatic fever
- Penicillin
- prevention is almost completely successful if antibiotic treatment is instituted within 9 days of illness
- Antibiotic therapy should be started immediately without culture for children with symptomatic pharyngitis and a positive rapid streptococcal antigen test, a clinical diagnosis of scarlet fever, a household contact with documented streptococcal pharyngitis, a past history of acute rheumatic fever, or a recent history of acute rheumatic fever in a family member.
- oral amoxicillin is preferred in children, 50 mkD x 10 days
What is treatment regimen most effective for eradicating streptococcal carriage?
clindamycin
20 mkD TID for 10 days
When is tonsillectomy considered in a patient with recurrent strep pharyngitis?
If pharyngitis occurs >7 episodes in the previous year, or >5 in each of the preceding 2yr
- Tonsillectomy lowers the incidence of pharyngitis for 1-2yr among children with recurrent, culture-positive GABHS pharyngitis that has been severe and frequent
Encircles the airway just below the vocal cords and defines the narrowest portion of the upper airway in children <10yr of age.
the cricoid cartilage
- 4 major cartilages that constitute the larynx, in descending order: epiglottis, arytenoid, trachea, cricoid cartilage (EAT-C)
Refers to a heterogeneous group of mainly acute and infectious processes that are characterized by a bark-like or brassy cough and may be associated with hoarseness, inspiratory stridor, and respiratory distress
croup
Harsh, high-pitched respiratory sound, which is usually inspiratory but can be biphasic and is produced by turbulent airflow; it is not a diagnosis but a sign of upper airway obstruction
stridor
viral infection of the glottic and subglottic regions
laryngotracheobronchitis (croup)
- laryngotracheitis - most common form of croup
- laryngotracheobronchitis - severe form that is considered an extension of laryngotracheitis associated with bacterial superinfection that occurs 5-7 days into the clinical course
viral infection of the glottic and subglottic regions
laryngotracheobronchitis (croup)
- laryngotracheitis - most common form of croup
- laryngotracheobronchitis - severe form that is considered an extension of laryngotracheitis associated with bacterial superinfection that occurs 5-7 days into the clinical course
How is croup diagnosed?
it is a clinical diagnosis. radiographs of the upper airway are not necessary, radiographically, a STEEPLE SIGN can be seen on PA view of the neck, usually indicative of subglottic narrowing
** radiographs do not correlate well with disease severity
What is the most common form of acute upper respiratory obstruction?
croup (laryngotracheobronchitis)
- usually viral in etiology
Characterized by an acute rapidly progressive and potentially fulminating course of high fever, sore throat, dyspnea, and rapidly progressing respiratory obstruction; potentially lethal
Acute epiglottitis (supraglottitis)
What is the classic radiographic sign of acute epiglottitis?
“thumb sign” on lateral neck radiograph
How is acute epiglottitis diagnosed?
diagnosis requires visualization of a large, cherry red, swollen epiglottis by laryngoscopy.
What is the treatment for croup?
airway management
treat hypoxia
racemic epinephrine nebulization
oral corticosteroids + budesonide
** antibiotics rarely needed
What is the treatment for epiglottitis?
this is a medical emergency
requires immediate placement of artificial airway under controlled conditions
** racemic epinephrine and corticosteroids are ineffective
start antibiotics: ceftri, cefotax, meropene
chemoprophylaxis (rifampin) of contacts for HiB needed in the fr situations:
- any contact <12mo who has not received the primary vaccination series
- an immunocompromised child in the household
Lymphoid tissue that surrounds the opening of the oral and nasal cavities into the pharynx
Waldeyer ring
- Lymphoid tissue of Waldeyer ring is most immunologically active between 4 and 10 yr of age, with a decrease after puberty
What are the two major complications of untreated GABHS infection?
PSGN and ARF
Septic thrombophlebitis of the jugular vein, which manifests with fever, toxicity, neck pain and stiffness, and respiratory distress due to multiple septic pulmonary emboli and is a complication of a parapharyngeal space or odontogenic infection from Fusobacterium necrophorum
Lemierre syndrome
Must be considered in any child with a cough that has lasted for weeks or months, that has been refractory to treatment, and that disappears with sleep or with distraction
habit cough (psychogenic or cough tic)
- assurance, together with speech therapy techniques that allow the child to reduce musculoskeletal tension in the neck and chest and that increase the child’s awareness of the initial sensations that trigger cough, has been very successful
The most common congenital laryngeal anomaly and the most common cause of stridor in infants and children
laryngomalacia
- stridor exacerbated by exertion (crying, feeding)
- diagnosed by flexible laryngoscopy
Vascular anomalies that result from abnormal development of the aortic arch complex, causing expiratory wheezing and cough and, rarely, reflex apnea or “dying spells.”
vascular ring
- double aortic arch is the most common complete vascular ring, encircling both the trachea and esophagus, compressing both
- diagnosis by barium esophagram, revealing a posterior indentation of the esophagus by the vascular ring
In which bronchus do most airway foreign bodies lodge?
- right main bronchus (~58% of cases)
- 3 stages occur:
initial event: choking, gagging, coughing
asymptomatic interval: foreign body becomes lodged, reflexes fatigue
complications: obstruction, erosion, infection
A previously healthy 8 mo old infant brought in for respiratory distress with the following history:
preceded by exposure to an older contact with a minor respiratory syndrome within the previous week. The infant 1st developed a mild upper respiratory tract infection with sneezing and clear rhinorrhea, accompanied by diminished appetite and fever of 38.5-39?C (101-102?F). Gradually, respiratory distress ensued, with paroxysmal wheezy cough, dyspnea, and irritability. The infant is tachypneic, which interferes with feeding. The child does not have other systemic complaints, such as diarrhea or vomiting.
On PE: px in respiratory distress, increased work of breathing, nasal flaring, and retractions noted. on auscultation, there was wheezing in all lung fields with prolongation of the expiratory phase of breathing. Liver and spleen palpable.
Diagnostics: CXR showed infiltrates on both lung fields and hyperinflation, flattening of diaphragm
What is the probable diagnosis? Most common etiology?
acute bronchiolitis
- most common etiology: RSV
- diagnosis is clinical
- mainstay of therapy is supportive: bronchodilators, inhaled corticosteroids (for the infant with mod-sev wheezing and atopic hx), humidified O2, suctioning of secretions, elevate head to prevent aspiration
- Corticosteroids are not recommended in previously healthy infants with RSV.
- There is a higher incidence of wheezing and asthma in children with a history of bronchiolitis unexplained by family history or other atopic syndromes.
A child 1st presents with nonspecific upper respiratory infectious symptoms, such as rhinitis. Three to 4 days later, a frequent, dry, hacking cough develops, which may or may not be productive. After several days, the sputum can become purulent, indicating leukocyte migration but not necessarily bacterial infection. Many children swallow their sputum, and this can produce emesis. Chest pain may be a prominent complaint in older children and is exacerbated by coughing. The mucus gradually thins, usually within 5-10 days, and then the cough gradually abates. The entire episode usually lasts about 2wk and seldom >3wk.
On pe: Early findings are absent or are low-grade fever and upper respiratory signs such as nasopharyngitis, conjunctivitis, and rhinitis; unremarkable chest findings. As the syndrome progresses and cough worsens, breath sounds become coarse, with coarse and fine crackles and scattered high-pitched wheezing. Chest radiographs are normal or can have increased bronchial markings.
What is the probable diagnosis?
acute bronchitis
- principal objective is to rule out pneumonia
- usually viral in etiology, prominent feature is cough
- treatment is supportive
What is the difference between acute and chronic bronchitis?
Chronic bronchitis is formally defined as ≥3mo of productive cough each year for ≥2yr. The disease can develop insidiously, with episodes of acute obstruction alternating with quiescent periods.
Acute bronchitis has a more shortened onset and its entire course frequently lasts for only 2 wks, seldom >3 wks
What are the indications for hospitalization in a patient with bronchiolitis?
Infants with acute bronchiolitis who are experiencing respiratory distress (hypoxia, inability to take oral feedings, extreme tachypnea) should be hospitalized;
risk factors for severe disease include age <12wk, preterm birth, or underlying comorbidity such as cardiovascular, pulmonary, or immunologic disease
What is the most dangerous consequence of acute hydrocarbon ingestion?
aspiration and pneumonitis
- Hydrocarbons with lower surface tensions (gasoline, turpentine, naphthalene) have more potential for aspiration toxicity than heavier mineral or fuel oils
- ingestion of >30 ml – increased risk for developing pneumonitis
- radiographic changes occur in 2-8 hrs
- gastric emptying almost always contraindicated except for pxs who ingested CHAMP (camphor, halogenated carbons, aromatic HC, metals, pesticides) of >30 ml – may benefit from gastric emptying
Patient with chronic cough and production of copious purulent sputum, with difficulty clearing secretions. Diagnosed case of TB disease. Crackles localized to the affected area, (+) wheezing and digital clubbing. (+) anorexia and poor weight gain.
CXR: increase in size and loss of definition of bronchovascular markings, crowding of bronchi, and loss of lung volume
What is the probable diagnosis?
What ancillary procedure should be requested to ascertain the diagnosis?
Bronchiectasis (from TB infection)
Request for thin section high resolution CT scan (HRCT) - gold standard for dx of bronchiectasis
- other causes may be from obstruction (tumor, foreign body, impacted mucus, external compression) or infection (pertussis, measles, rubella, RSV, TB, adenovirus) and chronic inflammation
- difficulty clearing secretions and recurrent infections lead to airway injury and inflammation
- tx: chest physiotherapy, antibiotics and bronchodilators
- 2-4 wks of parenteral antibiotics are often necessary
- in this case, treat underlying infection, which is TB
What are the three pathologic forms of bronchiectasis seen through HRCT?
cylindrical - tram lines and signet rings
varicose - beaded contour
saccular - strings and clusters (the most severe kind)
Accumulation of extrapulmonary air within the chest, most commonly from leakage of air from within the lung
A male patient was brought in, in respiratory distress, with retractions, markedly decreased breath sounds, and a tympanitic percussion note over the involved hemithorax. The larynx, trachea, and heart are shifted toward the unaffected side.
What is the probable diagnosis?
tension pneumothorax
- primary spontaneous: male, thin, tall, with subpleural blebs, assoc w pxs with Ehlers Danlos and Marfan Syndrome
- secondary spontaneous: with underlying condition but no trauma eg pneumonia, abscess, CF
- iatrogenic: with trauma, from medical procedures like needle aspiration or thoracentesis
- mediastinal shift in stuctures to contralateral side usually indicate tension pneumothorax
- On occasion, the diagnosis of tension pneumothorax is made only on the basis of evidence of circulatory compromise or on hearing a “hiss” of rapid exit of air under tension with the insertion of the thoracostomy tube.
- dx: radiographic exam
When is chest tube drainage indicated in a patient with pneumothorax?
If the pneumothorax is recurrent, secondary, or under tension, or there is >5% collapse, chest tube drainage is necessary
One of the most common radiographic findings in foreign body aspiration, usually seen if foreign body aspiration is >2 wks
atelectasis
- typical radiographic findings: elevation of the diaphragm, narrowing of intercostal spaces, displacement of mediastinal structures and heart toward affected side
most frequent neurologic sequel of meninggococcemia
deafness
What are the cardiac complications of BPD?
pulmonary hypertension, cor pulmonale, systemic hypertension, left ventricular hypertrophy, and the development of aortopulmonary collateral vessels, which, if large, may cause heart failure.
most frequent neurologic sequel of meninggococcemia
deafness
nonsuppurative complications of meningococcemia
4-9 days after the onset of illness:
- arthritis (monoarticular or oligoarticular, involves large joints)
- cutaneous vasculitis (erythema nodosum) are most common
Prediction of asthma includes
a) major risk factors
b) minor risk factors
major (parent asthma, eczema, inhalant allergen sensitization) and minor (allergic rhinitis, wheezing apart from colds, ≥4% eosinophils, food allergen sensitization) risk factors
poor prognostic factors of meningo
o hypothermia
o hypotension or shock
o purpura fulminans
o seizures
o leukopenia
o thrombocytopenia (DIC)
o acidosis
o high circulating levels of endotoxin and TNFα
o low or normal ESR
o petechiae for <12 hr before admission
o hyperpyrexia
o absence of meningitis
Pleural fluid transudate values
appearance cell count cell type LDH LDH ratio Protein ratio protein >3 g pH glucose
Pleural fluid transudate values
appearance: clear
cell count: 3 g: unusual
pH: normal
glucose: normal
Pleural fluid empyema values
appearance cell count cell type LDH LDH ratio Protein ratio protein >3 g pH glucose
Pleural fluid empyema values
appearance: purulent cell count: >50,000 cell type: PMNs (neutrophils) LDH: >1000 LDH ratio: 3 g: common pH: <40 mg/dL)
