Respiratory Flashcards
What are the patterns of results of VC, TLC, FEV1, FEV1/FVC, and RV in patients with intrathoracic restriction?
VC - decreased TLC - decreased FEV1 - decreased FEV1/FVC - increased >80% RV - decreased
What are the patterns of results of VC, TLC, FEV1, FEV1/FVC, and RV in patients with extrathoracic restriction?
VC - decreased TLC - decreased FEV1 - decreased FEV1/FVC - increased >80% RV - normal
What are the patterns of results of VC, TLC, FEV1, FEV1/FVC, and RV in patients with lower airway obstruction?
VC - decreased TLC - increased FEV1 - decreased FEV1/FVC - decreased <70% RV - increased
What is vital capacity? Which smaller lung volumes make it up?
VC = the volume you have available for breathing
VC =IRV +TV +ERV
When is the methacholine bronchoprovocation test performed?
Done in people with normal spirometry and intermittent asthma-like symptoms, or other symptoms suggestive of airflow obstruction, to determine if they have bronchial hyperreactivity
What is the 1st test performed in the evaluation of a patient with suspected asthma?
Pre and post bronchodilator spirometry
What is the most common cause of stridor in the newborn?
Laryngomalacia
Which chromosomal abnormality is tested for in patients with glottic webs?
22q11 deletion (DiGeorge)
How does tracheal stenosis present?
Expiratory stridor
SOB and Retractions
What is pulmonary venolobar syndrome?
Scimitar syndrome (congenital pulmonary venolobar syndrome)
- Rare disorder
- Pulmonary venous blood from all or part of the right lung returns to the IVC just above or below the diaphragm
- Left to Right shunt
Clinical
- Infantile form, abnormalities of venous drainage (e.g., hemianomalous pulmonary venous drainage to the IVC) can present as:
- HF and/or pulmonary HTN in the newborn period
Ix
- CXR - may show the shadow of these veins as they course, giving a scimitar-like (Turkish sword) appearance
Prognosis
- Worse if present with heart failure
- Usually due to associated anomalies, including left-sided heart malformations
- Mortality high
Tx
- Transcatheter occlusion of aortopulmonary collateral
- Other = reimplantation of the vein or pneumonectomy
Why is bronchoscopy not useful in diagnosing pulmonary sequestrations?
Sequestration is NOT connected to the airways
Muscle weakness from neuromuscular disease results in which specific problems that can lead to respiratory failure?
Upper airway compromise, inspiratory muscle (i.e., diaphragm, intercostals, accessory) compromise, and/or expiratory muscle compromise
-> swallowing and secretion clearance problems, aspiration, mechanical obstruction of the upper airway, inadequate lung expansion resulting in hypoxemia from V/Q mismatch, and inadequatecough
What are some of the neuromuscular diseases that can cause respiratory failure?
GBS Myasthenia Gravis SMA Muscular Dystrophy CP
Which virus causes most cases of croup?
Parainfluenza Type 1 and 2
What is the treatment for croup?
Cool-mist humidifiers, using a shower to steam up the bathroom, and/or taking a child outside in the cool night air
Single 0.15 to 0.6 mg/kg (max 10 mg) dose of oral dexamethasone
If Moderate stridor at rest, moderate retractions, or more severe symptoms = Adrenalin neb
What are the typical causes of epiglottitis?
HiB
H. influenzae (nontypeable) most common cause
Streptococcus pneumoniae
Streptococcus pyogenes (a.k.a. group A β-hemolytic Streptococcus [GAS])
Staphylococcusaureus
If you visualize a cherry-red epiglottis, what is your diagnosis?
Epiglottitis
What is the treatment of epiglottitis?
Oxygen Keep calm Anasthetic r/v - likely intubate Prompt antibiotic therapy: - Antistaphylococcal agent (oxacillin, cefazolin, or clindamycin) and either ceftriaxone or cefotaxime - Most are bacteremic - Vanc if MRSA prevalent
Which organism most often causes bacterial tracheitis?
S. aureus - most common
Others = parainfluenza virus Type I, Moraxella catarrhalis, nontypeable H. influenzae, and anaerobes
Which pathogen most commonly causes acute bronchiolitis?
RSV – most common
Other = rhinovirus, paraflu, human metapneumovirus, influenza
In children, the absence of which vital sign abnormality makes the diagnosis of pneumonia unlikely?
FEVER
When do you get a CXR in a child with fever?
- Children
Are blood cultures routinely recommended in the management of outpatient pneumonia in children?
NO
chance of +ve is <5%
Gram-positive diplococci seen in a sputum sample with a large number of PMNs and few epithelial cells most likely indicate which organism?
Strep pneumonia
What do you do about a pleural effusion in a child with recent pneumococcal pneumonia who clinically is responding to therapy?
Pleural effusions often persist for weeks and resolve without specific therapy
What do you do about pneumatoceles if they occur in S. pyogenes pneumonia?
Common and disappear spontaneously but often take weeks to resolve
A patient with influenza develops a secondary bacterial pneumonia. Besides pneumococcus, which bacterial pathogen do you especially consider?
Suspect S. aureus pneumonia in a patient with recent URI, chicken pox, or influenza who presents with abrupt onset of fever, tachypnea, tachycardia, and cyanosis.
CXR showing distinct pneumatoceles is classic!
Which antibiotic is commonly used for presumed anaerobic pneumonia?
Clindamycin
What are the extrapulmonary manifestations of Mycoplasma infection?
Hemolytic anemia Splenomegaly Erythema multiforme (and Stevens-Johnson syndrome) Arthritis Myringitis bullosa Pharyngitis Tonsillitis Neurologic changes—especially confusion
Name the geographical areas for histoplasmosis, coccidioidomycosis, and blastomycosis?
Histoplasmosis = Missisipi, Ohio River
- soil, bird and bat droppings
Coccidioidomycosis = San Joaquin Valley
- fungal spores, dry desert areas
Blastomycosis = Central, southeastern, and mid-Atlantic seaboard states
A patient presents with worsening control of their asthma and an extremely high IgE level. What do you suspect as an etiology?
ABPA
How do you treat ABPA?
Oral corticosteroids
Itraconazole
Describe the location of the obstruction based on inspiratory versus expiratory stridor?
Inspiration = Subglottic area Expiration = Intrathoracic portion of trachea
What are the 2 main diagnoses if a patient with acute onset stridor also presents with high fever and rapid deterioration?
Epiglottitis
Bacterial tracheitis
Does having an abnormal sinus x-ray indicate bacterial infection in a child with asthma?
No
What is the preferred treatment for the prevention of exercise-induced bronchospasm?
Montelukast (requires days or even weeks to start working)
Or pretreatment with an inhaled short-acting β-adrenergic agent and/or ipratropium (10–20 minutes before exercise)
What do asthma action plans provide for the families of children with asthma?
Clear mgx
Avoidance of triggers
When do you consider stepping down controller therapy in a child with asthma?
No or minimal daily (including nighttime) symptoms
No or minimal exacerbations
No limitations on daily activities
No missed school or work
Minimal use of SABAs, such as albuterol
And minimal-to-no adverse effects from therapy
What are some complications of prolonged use of systemic corticosteroids?
Suppression of the hypothalamic-pituitary-adrenal axis Immunosuppression Osteoporosis Cataracts Hyperglycemia Weightgain Thinning of the skin, easybruisability Abdominalstriae Growthretardation
What are some complications of prolonged use of inhaled corticosteroids?
Growth velocitychanges
Dermal thinning and increased ease of skinbruising
Rarely, cataracts form and hypothalamic-pituitary-adrenal axis function isaffected
Oral candidiasis (thrush) is common and can be prevented by using a spacer (valved holding chamber) with metered-dose inhalers and rinsing the mouth afterinhalation.
Are long-acting beta-agonists useful for rescue therapy in acute asthma attacks?
No
What does adding erythromycin to a patient’s regimen that already includes theophylline potentially do to the theophylline level?
Increase serum levels
Is omalizumab an appropriate therapy for a 6-year-old asthmatic child with mild disease?
NO
Omalizumab is an anti-IgE monoclonal antibody given intramuscularly to patients ≥6 years of age who have severe, difficult-to-control, allergic asthma
Is the CXR abnormal in all cases of foreign body aspiration?
NO
10-15% have a normal X-ray
Which viruses most commonly cause bronchiolitis obliterans?
Adenovirus 3, 7 or 21
How do you diagnose bronchiolitis obliterans?
Lung Biopsy
An adolescent presents with multiple episodes of “bronchitis” that clear with antibiotics and then recur in a month or two. He has had 6 episodes now. What diagnosis do you entertain?
Cryptogenic Organising Pneumonia
Is apnea of prematurity a risk factor for SIDS?
NO
But prematurity is a RF
Is prematurity itself a risk factor for SIDS?
YES
Which strategy has had the greatest impact on reducing incidences of SIDS?
Safe to Sleep Campaign
Does maternal smoking during pregnancy increase the risk of SIDS?
YES
maternal factors = young age, and smoking during pregnancy
What is the mode of inheritance for CF?
AR
Which gene is responsible for CF?
CFTR gene on Long arm of Chromosome 7
Most common mutation is DeltaF508
Which factor correlates best with survival in CF patients?
Patients level of fitness
What sinus and nasal findings commonly occur in CF patients?
Nasal polyps
Pansinusitis
Early in CF, which bacterial organisms are most likely to cause pulmonary infection?
S. aureus,
H. influenzae,
and common gram-negative organisms such as Klebsiella
Later in CF, which bacterial organisms are most likely to cause pulmonary infection?
Pseudomonas
When does pancreatic insufficiency occur in CF?
Present at birth in 50% of children with CF
Although 90% have signs/symptoms of pancreatic insufficiency by 9 years of age
Which GI findings are more common in CF?
Bowel obstruction Meconium Ileus Intussusception DIOS Rectal prolapse Liver cirrhosis
What is the abnormality of the sweat glands in patients with CF?
Produce HIGH salt content
What is the abnormality of the reproductive tract in males with CF?
Atresia of the vas deferens -> obstructive azoospermia and sterility
What is the laboratory test for diagnosing CF?
Sweat test
Who should have a sweat test?
FTT, steatorrhea, and chronic pulmonary disease
Meconium ileus Rectal prolapse Prolonged neonatal jaundice Chronic diarrhea Steatorrhea
Nasal polyps Pansinusitis Chronic cough Recurrent wheezing S. aureus pneumonia Finding Pseudomonas in throat, sputum, or bronchial cultures
Digital clubbing
Family history of CFFTT
“My baby tastes salty”
Male infertility
How does newborn screening detect CF?
Screens for elevated blood immunoreactive trypsinogen (IRT)
Is ceftriaxone acceptable therapy for Pseudomonas?
No - does not cover
Does the finding of a pneumothorax suggest more severe lung disease in a CF patient?
YES
Which vitamin deficiency do you consider in a CF patient who has hemoptysis with heavy bleeding and a history of easy bruisability?
Vitamin K def
What is Kartagener syndrome?
Occurs when one or both dynein arms of the cilia are absent
Presents with recurrent infections (i.e., sinusitis, otitis, pneumonia), bronchiectasis, situs inversus totalis, and reduced male fertility
Sporadic or familial
AR
Which pulmonary abnormalities are seen with α1-antitrypsin deficiency?
Homozygotes = early onset emphysema
Heterozygotes = Often have no resp disease
Which liver abnormalities are seen in children with α1-antitrypsin deficiency?
Homozygotes = early liver fibrosis and cirrhosis, hepatoma
Heterozygotes = ?
What are the common causes of hemoptysis in children?
Infection
Foreign Body
Bronchietcasis (especially CF related)
What is diagnostic for a pulmonary source of hemoptysis?
Hemosiderin-laden macrophages on BAL
What does the CXR characteristically show in sarcoidosis?
Bilateral hilar and/or mediastinal adenopathy +/–reticulonodular or alveolar infiltrates
What does the biopsy of an affected bronchial wall in sarcoidosis show?
Noncaseatinggranuloma
True or false: Erythema nodosum is a poor prognostic indicator in sarcoidosis?
FALSE
is good prognosis
In a patient with pulmonary alveolar proteinosis, hypoxemia is often due to what?
Large R-to-L shunt because gas exchange is impaired secondary to cloggedalveoli.
Which collagen vascular disease causes pulmonary hypertension out of proportion to the pulmonary disease noted?
Scleroderma
Which laboratory test is positive in many patients with GPA?
c-ANCA
