Respiratory Diseases (Peds)

Question 1

Croup:

Parainfluenza 1 or 3, influenza A or B

Answer 1

-Age 3mos-5yrs; URTI symptoms: Deep barking cough, Rhinorrhea, Sore throat, Hoarseness, inspiratory stridor, tachypnea - symptoms are worse at night

Question 2

Croup: Dx (always suspect epiglottis)
Croup = hypoxia on presentation
Epiglottis = imminent/danger of

Answer 2

• Clinical diagnosis

- Confirmed by: Neck XR (steeple sign - narrowing of air column in trachea)

Question 3

Croup: Tx

-spontaneous resolution in 1 week

Answer 3

1) Humidified Oxygen (cool mist)

2) Nebulized/racemic epinephrine (epinephrine, inhalation) 3) Oral corticosteroids (dexamethasone, oral)

Question 4

Epiglottis:
(H. Influenzae type B; S. Pyogenes; S. pneumoniae;
S. aureus; Mycoplasma)

Answer 4

• Sudden onset ,muffled voice, drooling, dysphagia, high fever, inspiratory stridor
• Pt in tripod position, toxic appearance

Question 5

Epiglottis: Dx

Answer 5

Med Emergency; Straight to tx based on clinical dx
Perform diagnostic workup after stabilization:
(1) Neck XR: thumb print sign (2) blood cultures (3)nasopharyngoscopy OR epiglottic swab culture

Question 6

Epiglottis: Tx

Answer 6

1) Transfer to hospita/OR/call ambulance/send to ED
2) Consult ENT/Consult anesthesia 3) Intubate in OR
4) Give ceftriaxone IV 7-10 days 5) Give steroids

Question 7

Epiglottis: Prophylaxis

Answer 7

IF H. influenza (+); give household contacts: Rifampin

Question 8

Bacterial Tracheitis

S. Aureus

Answer 8

-Brassy cough, high fever, respiratory distress, but NO drooling or dysphagia; following URTI, usually < 3yo

Question 9

Bacterial Tracheitis: Dx

Answer 9

Clinical + laryngoscopy:
CXR: subglottic narrowing, ragged tracheal air column
Blood cultures, Throat cultures

Question 10

Bacterial Tracheitis: Tx

Answer 10

Antistaphylococcal antibiotics; may require intubation if severe - risk of airway obstruction

Question 11

Bronchiolitis (inflammation of small airways)

-leads to obstruction; air trapping; overinflation

Answer 11

Cause: RSV (50%); Parainfluenza; Adneovirus
Classic: child < 2 yo in fall/winter months

Question 12

Bronchiolitis: symptoms

Answer 12

P/E: wheezing + prolonged expirations + fever
+/- Mild URI; Paroxysmal wheezy cough;
Dyspnea; Tachypnea; Apena

Question 13

Bronchiolitis: diagnosis

Answer 13

-Clinical diagnosis
best initial: CXR (hyperinflation with patchy atelectasis)
most specific: viral antigen testing (ELISA) of nasopharyngeal secretions

Question 14

Bronchiolitis: treatment

Answer 14

Supportive only;
- Hospitalize, give bronchodilators, isolate if:
Hypoxic; Tachypnea > 60/min; Intercostal retractions

Question 15

Prevention in high risk patients only:

MC complication of RSV bronchiolitis:

Answer 15

prevention: RSV IVIG; monocolonal ab to RSV F protein
complication: Asthma/reactive airway disease

Question 16

Viral Pneumonia: MCC < 5 yo (RSV)

Answer 16

URI + low-grade fever + tachypnea
Tx: withhold antibiotics; give if deteriorating
(30% coexisting bacterial infection)

Question 17

Bacterial Pneumonia: MCC > 5 yo

S. pneumoniae, M. pneumoniae, C. pneumoniae

Answer 17

Acute-onset + shaking chills + high fever + prominent cough + pleuritic chest pain + dullness to percussion

Question 18

Bacterial Pneumonia Tx: S. pneumoniae
Outpatient/mild: Amoxicillin
Inpatient: IV Cefuroxime (+Vancomycin if S. aureus)

Answer 18

Bacterial Pneumonia Tx: Chlamydia or Mycoplasma

Oral Erythromycin or other macrolide

Question 19

Pneumonia - Best initial test: CXR

Answer 19

Viral: bilateral interstitial infiltrates
Pneumococcal: confluent lobar consolidation
Mycoplasma/Chlamydia: unilateral lower lobe interstitial

Question 20

Chlamydia Trachomatis: (different than c. pneumoniae)

• Infants 1-3 months old
• Insidious onset > 3 weeks

Answer 20

Distinguish from RSV: no fever, no wheezing

H/P: staccato cough, peripheral eosinophilia +/- conjunctivitis at birth Tx: Oral erythromycin

Question 21

CF: Autosomal recessive;

CFTR1 gene mutation (codes for chloride transport)

Answer 21

First step: Sweat chloride test

-Chloride > 60mEq/L on at least 2 occasions

Question 22

CF: presentation

Answer 22

MC: Meconium ileus (bilious vomiting, distention at birth);
- failure to thrive/diarrhea (malabsorption); rectal prolapse;
persistent cough (copious purulent mucous production)
infertility, allergic bronchopulmonary aspergillosis

Question 23

CF: treatment

Answer 23

Supportive: Aerosol tx; albuterol/saline; chest physical therapy; postural drainage; pancrelipase

Question 24

CF: G551D mutation (present in 5%)

• interferes with activation of CFTR chloride channel
• all pts should be tested (at least 1 copy for Ivacaftor)

Answer 24

Tx: Ivacaftor (VX-770) - first CF approved therapy that restores function of mutant CF protein

Question 25

CF: Improves survival

Answer 25

• Ibuprofen (reduces inflammatory lung response)
• Azithromycin (slows decline of FEV1 in pts < 13 yo)
• Antibiotics (during exacerbations delay progression)

Question 26

CF: (most common pathogens - S. aureus; P. Aeruginosa)
Empiric tx in severe exacerbation:
Tobramycin + Ticarcillin-Clavulanate + Vancomycin

Answer 26

CF: mild disease
-Tobramycin; TMP-SMX; or Ciprofloxacin
Resistant pathogens: Inhaled tobramycin