Respiratory Conditions

Question 1

Tacypnea RR by age
< 2 months
2-12months
1-5 years
> 5years

Answer 1

< 2 months = 60/min
2-12 months = 50/min
1-5 years = 40/min
5+ years = 30/min

Question 2

Reading a Pediatric CXR
considerations

Answer 2

Considerations
chest = pyramidial shape (comes to a point at the top)

Cardiac silhouette: can occuy up to 65% of the chest

Bronchial branching is more visable: may be air bronchogram looking - but normal

Thymus : see anterior medistianl sail
- seen up to age 6

Babygram: chest and abd. in a sinlge image

Question 3

Bronchiolotis
etiology
symptoms
dx.
tx.

Answer 3

etiology
- a very common infection of the small airways
- most commonly in kids under 2
- viral: RSV usually (can be rhinovirus in fa//spring, covid,etc.)
- hospitalization: peaks between 2mo and 6mo.

Symptoms
- URI prodrome
- the LRI: wheezing, tachypnea, WOB, brief apnea

Dx.
- PE: hear wheezing/crackles due to inflammation
- CXR: not needed, hyperinflations
- viral stuides are used, not needed: quad panel (RSV, COVid, Flu A, Flu B)

Treatment
- respiratory support (NC)
- nasal suction
- can try: SABA, steroids ystemic, hypertonic saline)
- high risk kids get palivizumab (immunocomp.)

Question 4

Bronchiolitis
when to admit

Answer 4

when to admit
- toxic appearing
- poor feeding or dehydration risk
- lethargy
- those with moderate/severe respiratory distress: nasal flaring, retractions, RR >70, dyspnea cyanosis
- apnea
- hypoxia < 95% on RA with or without hypercap.
- caregiver cant help pt at home

age < 12 weeks is considered high risk for disease, but alone not an indication ot admit

Question 5

Croup
etiology
symptoms
dx.
tx.
when to admit

Answer 5

etiology
- respiratory illness in kids < 6 y/o
- parainfluenza MC
- RSV, flud, covid too

Symptoms
- inspirator dtridor
- barking cough
- hoarseness

Dx.
- clinical
- CXR: Steeple sign due to inflammation of the airway

Tx.
- self-limitiing
- hoe care: steam, antipyretics, fluids
- outpt: single dose dextamethasone
- moderate/severe: dextamethados & nebulized epinephrine

Croup: When to Admit
- severe croup: poor air entry, alter consciousness, impending respiratoyr failure
- mode/severe: those not responding to 1-2 treatments of neb. epi and dex.
- toxic looking
- need O2 support or severe dehydartion

consider admitting kids < 6 months, those coming in the nighttime (worst)

Question 6

Pertussis
etiology
symptoms
younger infants
older kids

Answer 6

Etiology
- Bordetella pertussis bacteria
- very contagiouse!!!
-prolonged clinical course: preventable with vaccine

Symptoms
Infants/Young Kids
- incubation 7-10 days
- Catarrhal phase: 1-2 weeks = nonspecific URI signs; low grade or no fever, cough will gradually worsen over this time: shows its not viral
- Paroxymals phase: 2-8 weeks = stable but intense from week 3-5
- in paroxymal: intermittent dry, hacking cough fits with post tussive emisis possible
- +/- the classic “whoop” sound in infatns gaggin, gasping, apnea seen
- Convalescent Stage: weeks to months: will diminish

older kids symptoms
- cattahral stage: URI classic symptoms
- paroxymsmal phase: mild cough without the features of whooping, or post tussive emisis

Question 7

Pertussis
dx.

Answer 7

Dx

CDC Criteria = acute cought illness > 2 weeks with at least one of the following…..
- paroxyms of coughing
- inspiratoyr whoop
- post tussive emisis
- apnea, with or without cyanosis

any illness with acute cough and at least 1 of the above + lab confirmed = purtussis

Lab Confirmation
- leukocytosis with lymphyocytes > 1000
- in infants: level of leukoyctosis direclty releates to the severity of disease process
- CXR: nonspecific
- PCR and culutres canbe done to confirm and for reporting to CDC

can be clinical too

Question 8

Pertussic

tx.
when to admit

vaccine

Answer 8

Treatment
antibiotics: azithromycin, erythromycine, clairthromycin

infatns < 1mo . = azithro. preferred

supportive
- neubulizer, steroids, sprays

when to admit
- respiratory distress pt: tacypnea, retractions, flaring, grunitng, accessory muscle use
- PNA evidence
- inabiltiy to feed
- seizures
- cyanosis/apnea with or without coughing
- Age < 4 months need to be admitted

vax.
- DTAP: 2, 4, 6 months then 15-18 months and 4-6 years (5 doses)

TDAP (adolecents) - 11-12 years, then booster Q10 years

Question 9

Pneumonia (PNA) - CAP
etiology
symptoms

Answer 9

ETiology
- CAP is most common cause of nonaccidentl death in kids
- increased vax. has decreased inpt and deaths

those at risk
- lower ses
- school aged kids in the house: bringing germs
- underlying cardiopulmonary diseases
- smoker in th ehouse
- alcohol/drug use in teens

CAP: Bugs
- Step pneumo is most common across all ages
- pseudomonas risk: is rare in kids: think CF pt. or prolonged intubation (NICU)

Viral: can be possible too
- think RSV, influ A/B, paraflu, etc.

other bacterial
- chlamydia in those under 3 months as well as syphilis and mycoplasma

Question 10

PNA
- workup & dx.
- when should you get a CXR
- labs

Answer 10

Workup

when to get CXR
- PE focal findings of consolidation (decreased TF, dull to percussion)
- severe respiratory distress
- ill enough to be admitted
- rule out other causes of respiratory distress
- fever with unknown source, with leukycytosis or sus of lower reps. in a baby under 1

Labs: typically only gotten if you need to workup fever of unknonw origin or for kids sick enough to be inpt.
- CBC
- blood cultures
- quad screen (viral)
- CRP/ESR

Question 11

PNA
Outpt. treatment

Answer 11

PNA - Outpt tx.
emerically: not normally culutred

1-3 months
- amoxicillin preferred
- or azithromycin (add clairthryomycin for chalmyida)

3months - 5 years
- amoxicillin preferred
- or arythromycin

school aged kids
- macrolide: azithromycin, eryhromycine, clairthromycine

Question 12

PNA: when to admit

when to send to the PICU

Answer 12

when to admit
- hypoxemia
- those under 6 months old with CAP suspected
- always admit babies under 1month
- (babies 1-6 months need to have o2 > 95% with no fever to let go home) aka rare aka admit all under 6 months
- tacyhpnea & respiratory distress (apnea and grunting)
- poor feeding/dehydration
- delayed cap refill
- toxic looking
- those with underlying comborities
- complications (effusions, empyema)
- failed outpt. management (48-72 hours of outpt. abx.)

PICU Admission
- those with impending respiratory failure: the floors dont have respiratory support for this
- recurrent apnea
- CV monitoring needed

Question 13

PNA
inpt. treatment

Answer 13

Inpt treatment CAP

those under 1 month
- ampucillin + gentamycin +/- cefotaxime
- (add erythromycine for chalmyinda concerns)

those 1-6 months
- ceftriaxone or cefotaxime
- (add arythromycine if chalymida, add vanc/clinda if MRSA)

those > 6 months
- ampucillin or PCN G or cefotaxime, ceftraxone

Complicateid PNA (with effusion, empyema)
- ceftriaxone/cefotaxime PLUS clindamycin
- chest tube

severe PNA
- Ceftriaxone plus arythr.erythro.doxy.

Severe PNA in the PICU
- vancomycine plus ceftriaxone/cefotaxime pluse axirthro pluse antiviral

Question 14

Asthma
Etiology
risk factors for fatiality

Answer 14

Etiology
- a chronic inflammatory condition of the airyway due to episodic obstruction

3 features
- airway obstruction that is partly reversible with a bronchodilator
- airway hyperresonsiveness
- chornic inflammation chatacterized by mast cells activation + inflammation

Risk Factors for Fatalities due to asthma
- hx. of sudden and severe exacerbations
- prior intubation
- 2+ admissions or 3+ ED vitis in one year
- frequent use of their rescule
- chronic oral steroids
- those with difficuluty percieving their airway flow

Question 15

Asthma
Triggers
Sympotms on Presentations

Answer 15

Triggers
- viral respiratory conditions
- environmetnall allergen
- pulonary irritants: tobacco smoke, pollution, etc.
- cold, dry air
- emotions and exercise
- comorbid conditions

Presentation
- intermittenet and repetitive episodes of cough and nosit breathing with wheezing or airflow obstruction
- cough, wheeze, SOB: known obstruction with NO wheeze = BAD
- chronic cough, recurrent bronchitis, etc.
- first dx before 5 but many kids missed!!!

kids with asthma will NOT have failure to thrive, cyanosis or clubbing

Question 16

Asthma
Diagnosis & Monitoring

Answer 16

Diagnosis
- Spirometer: pre and post bronchdilator improvement after
- can dx. the obstruction and the reversibility
- able to monitor change overtime: done PRN and annually
- methacholine challenege test (provactive) can be done if initial testing inconclusive but high suspicion

Monitoring : Peak flow monitoring
- at home device with zones to establish after 2 weeks of BID use
- determines when to seak care, what triggers are and when lung function changes

Question 17

Asthma Management

Answer 17

Management

SABA: albuterol
- rapid and effective
- good for exercised induces
- watch side effects of palpations tremor, HA

SAMA: Ipatropium
- can be used in combo with albuterl to decreased need for hospitalization
_________________________________ other options

inhaled corticosteroids

LABA (fomoterol, salmetrol)
combo ICS/fomoterol
leukotriene modifers: monteleukast
mas cell stablizers (sodium cromyln)
theophyillne
malizumab
low does oral steoirds

Question 18

Asthma
when to refer to specialist
when to admit

Answer 18

Refer
- kids who are 5+ years old with step 4 or higher asthma
- kid who is under 5 with step 3 or higher asthma
- goal of tx. not reached by 3-6 months
- comorbbid conditions
- additional dx. testing
- those with life thereatening exacerbations or ICU admissions

when to admit
- kids who are moderately ill & NOT responding to bronchodilators
- continued symptoms despite treatment
- wheezing and retractions = significant
- peak flow < 50% best
- Requiring SABA every 2-3 hours
- need for continued supp. O2
- hx. of rapid exacerbations in the past: to monitor

Question 19

Specifics of the ENT exam in kids

Answer 19

ENT hold: have parent sit with kid in lap, 1 arm holding kids arms and the other arm holding head

• use smaller ear piece

TM appears
- healthy while, peraly, non-buldging, can see the tympanostomy tubes
- unhealthy: red, buldging with poor movement
- isolated red tympantic membrane can be a result of crying
- eaxm ear last

dont forget to palpate behinda nd in front of ear, traagus and pull on ear

Question 20

Otitis Media
etiology
bugs
types of OM

Answer 20

Etiology
- most common reason of abx use in kids
- inflammation of the inner ear
- tobaccoa expsoure, windter seasons, pacifier used, day care, celft palapt, lower SES

Bugs
- strep penumo.
- staph aures
- h. flu
- GABHS
- M. cat

Types of OM

Acute: the inflammatory fluid with ear pain, disotortion of teh tympanic membrane +/- fever

OM with effusion: there is inflammaotyr fluid in the middle ear (see air bubbles) in otherwise asymptomatic kid, commonly following a URI or AOM (serous OM)

Recurrent OM
- 3+ episodes in 6 motnhs or 4+ in 12 months, 1 in past 6

Chronic OM : OM lasting longer than 3 months OR fails to respond to abx. treatment

Question 21

Otitis Media
symptoms

Answer 21

Symptoms
infants: fever, tugging/rubbing ears, unexplained crying, decreased appetite poor sleep (Cries when laying down)

older: those with hx. of recurrent URI, acute onset of fever and ear pain

ruptured TM: marked improvement in the ear pain suddenly, with otorrhea

Question 22

AOM treatment

Answer 22

AOM treatment
- most cases will self resolve within 3days treat pain and fever with motrin/tylenol
- if the pain worsens or does not improve in 3 days - abx. use

start abx. immediately when they are
- under 6 months
- immunocomp.
- toxic lookking
- those with craniofacial abnormalities

ABX.
- high dose amoxicillin
-augmentin if not improved within 48-72 hours
(pcn allergic = cefdinir, cefuroxime)

Question 23

Recurrent AOM treatment

Serous OM Treatment

Answer 23

Recurernt AOM
- tympanostomy tubes for these kids

Serous OM Tx.
- middle ear fluid: can be realted to speech d/o
- if fluid there for 3+ months impacting speech: tympanostomy tubes
- myringotomy, adenoidectomy

Question 24

Mastioditis
etiology
risk factors
bugs

Answer 24

Etiology
- acute supperative complications of AOM, bacterial infection in the aircells of teh mastoid bone (behind ear)
- the problem = bacteria will break down the bone making the aircells

risk factor s
- AOM (treated or undetreated)
- immunocomp.
- cholesteatoma: abormoal collection of skin cells from chronic ear infections

Bugs
- strep penumo, strep pyogenes
- m. cat
- h. fllu
- staph
- pseumondas

Question 25

Mastoiditis
symptoms
dx.
tx.

Answer 25

Symptoms
- fever + ear pain with AOM present
- erythema, tenderness of the mastoid bone
- proptosis: outward protrusion of the ear
- can have AMS and CN VI or VII changes!!! in severe cases

DX and Tx.
- clinical dx. can be confirmed by CT

management
- referral to ENT (EMERGENT)
- IV abx. zosyn (pip-taz) + vanco.
- insertion of tubes (even when sick, dont wait)

complications
- abcess
- meningitis
- speis s
- otitc hydrocephalus

Question 26

Otitis Externa
etiology
symptoms
dx.
tx.

Answer 26

Etiology
- inflammation of the outer ear canal
- “swimmers ear”
- risk factors = aggressive ear cleaning, swimming, ear pluds/headphones, contact derm.
- BUG: PSEUDOMONAS!!

Symptoms
- erythema, pruritis, drainage (wihtout TM rupture)
- PAIN when moving tragus

Dx. and tx.
- clincial dx.; can cluture if needed

Treatment
- debris removal: if you known TM intact = can use hydrogen peroxide — if not send to ENT
- WIck Placement if you cant remove debris or swollen

Ear Drops
- ciprodex, tobridex
- ofloxacin

Oral ABx. = if severe OE or those with AOM and OE together
augmentin
if PCN allergey: cirpo, levo.

Question 27

Sinusitis
etiology
viral v bacterial
who get which
bugs

Answer 27

etiolog y
- kids born with : maxillary sinus and ethomoid sinuses
- inflammation in the mucosal lining of 1+ paransal sinus

VIRAL
uncomplciated viral: with URI is selt limiting and resolves

BACTERIAL
- some viral URI can become complicated with bacterial sinusitis
- MC in kids 4-6 not likely in those under 2
- because in kids under 2, more liekly to lead to AOM and abx. use helps prevent these sinutitis of bacteria from occuring

etiology: BUGS
- strep pneumo
- h. flu
- m. cat
- staph
- GABS

Question 28

Sinusitis : Bacterial

symptoms
dx.
tx.

Answer 28

Symptoms of bacterial
- more than 14 days of being sick, double sickness: meaning sick, got better than got worse
- cough
- nasal congetion
- HA
- focal pain/tooth pain
- swelliing or preorbital tissues
- fever
- worsening URI syptoms

Dx.
- clinically made, imaging not needed (CT if its recurring)

Treament
- high dose amoxicillin
- agumentin
- PCN allergic: can do ceph. or if severe, levoflox.
- additional: saline sprays or intranasal steroids
- start with 10 days of meds

complicaitons include: meningitis, cavernous sinus thromb. intracranial abcess, orbital cellulis, osteomylieis, extrdural/epidural empyma

Question 29

Gingivostomatitis
etiology
symptoms
dx.
tx.

Answer 29

Etiology
- most common manifestation of Primary herpes simplex HSV during childhood
- pathogen: HSV1
- common in kids 6mo-5 years
- direct contact with lesions or oral secretions from another person (asymptomatic or symptomatic)

Sympptoms
- prodrome: fever, malaise, irratibility and decreased PO intake
- red, errythematous gingivae which bleed easy + clusters of vesicles that form large ulcers on the oral and perioral tissue
- typically heal 1 week later

Treament
- symptomatic: NSADIS, tylenol
- antibacterial mouthwash, warm water rises
- magin mouthwash: beadryl, maalox, vicious lidocaine

Question 30

Epiglottitis
etiology
symptoms

Answer 30

Etiology
- inflammation of the epiglottis causing airway compromise
- less commont because of hib vax.
- BUGS: H. FLU!!!! , meningiditis, streps

Symptoms :SUDDEN ONSET
- high fever
- dysphagia
- drooling
- muffled voice
- retractions on inspiration
- cyanosis
- stridoe (soft)
- can progross to total airway obstruction

Question 31

Epiglottis
dx and tx.

Answer 31

dx.
- XR: thumbrpinting sign : but, youre not getting an xray because this is an EMERGENCY!!! no time for this
- definitive dx. will need direct visualizing of the epiglottitis

Treament
- intubation asap
- ceftriaxone

Question 32

Peritonsillar Abcess
etiology
symptoms
dx.
tx.

Answer 32

Etiology
- most common deep neck infection
- BUGS: Group A beta- hem strep , staph, strep

Symptoms
- HIGH FEVER
- severe swollen throat
- unilateral swelling of the soft palate
- displaced uvula
- trismus: aka cant open mouth all the way
- remember: enlarge tonsils doesn t= PTA
- drooling, uncomfy to swallow

Diagnosis
- clincal: visualize or palpate for fluctuance mass
- CT if unsure between abcess v cellulits : can wait to do this until abx. have been on board for 24hr.

Treatment
- augmentin, clindamycin, unsyn
- drainage immediately or after 24 hours with needle or I&D with ENT

Question 33

Retropharyngeal Abcess
etiology
symptoms
dx.
tx.

Answer 33

Etiology
- abcess in toe retropharyngeal lymph nodes: behind the airway in the back of the neck really
- so when you look inside the neck you wont see anything
- BUGS: GABS, staph

Symptoms
- fever
- respiratory symptoms
- DECREASED NECK ROM: particuallry with extension move mom around room to see if baby moves neck
- dysphagia, drooling
- voice changes : hot potatoe
- Unilater neck swelling

DX.
- not clinical: you wont see naything in the mouth
- XRAY: retropharyngeal tissue will be WIDER than the C4 vertebral body
- CT: to visualize the abcess might wait to get this until abx onbooard

Treament
- admit and start IV abx unsayn or clinda
- after 12-24: check rom neck, fever, po intake etc.
- surgery if not improvement or airway comp

Question 34

Trachoiomalacia
etiology
symptoms
dx.
tx.

Answer 34

Etiology
- a common anomaly of the URI due to dymanic collapsing of the trachea during breathing, resutling in airway obstruction
- teh lesions are usually intrathoracic: so tehy are collapsing during expiration : hear the wheeze/stridor

congential or acquired: defect in cartilage of trachea, or a surgical complications

Symptoms
- intrathoracic lesion: recurrent, harsh barking croup like cough
- extrathroacic: inspiratory stridor
- ferquent URI that is severe

Dx.
- Airway endoscopy or bronchoscopy (asleep pt.)

Treatment
- isolated: can resolve as cartialge grows
- need CPAP (invasive with trach or not)
- surgical repair or stenting if severe