respiratory-final

Question 1

s/s pnuemonia

Answer 1

Cough Fever Wheezing Dyspnea Poor Feeding Lethargy Vomiting Abdominal pain

Question 2

clinical findings of Pneumonia

Answer 2

ENT: May be normal or nasal congestion, OM, pharyngitis may be present Lungs: Rales, diminished breath sounds, rhonchi. Respiratory distress Heart: Tachycardia Abdomen: Right sided pain/tenderness General: Poor perfusion, lethargy; ill appearing

Question 3

who should get a chest xray if pnuemonia is suspected?

Answer 3

Healthy, immunized children who will be treated as an outpatient do not require CXR Particularly helpful when the dx is uncertain Hospitalized children and children with respiratory distress should have a CXR

Question 4

are blood cultures necessary with pneumonia?

Answer 4

not necessary for patients treated on an outpatient basis Indicated for hospitalized patients as well as for patients who deteriorate or do not improved

Question 5

additional testing for pneumonia is

Answer 5

CBC CMP Influenza RSV Strep

Question 6

Indications for hospitalization with pneumonia

Answer 6

Infants Apnea/Grunting/respiratory distress Respiratory rate >70 Poor feeding Comorbidities SaO2 <92% Older Children Grunting/respiratory distress Respiratory rate >50 SaO2 <92% Unable to tolerate po fluids Comorbidities

Question 7

Outpatient Antimicrobial Therapy for pneumonia

Answer 7

Outpatient Antimicrobial Therapy 60 days to 5 years: Amoxillin 90mg/kg/day; divided bid If penicillin allergic: Zithromax (10mg/kg x1 day then 5mg/kg/day x5d Biaxin (15mg/kg/day; divided bid) Cefzil (30mg/kg/day; divided bid) School aged children & adolescents Amoxillin Consider macrolide if mycoplasma is suspected Zithromax Biaxin

Question 8

Asthma: clinical manifestations

Answer 8

Chronic Inflammation Bronchial hyper-responsiveness after exposure to allergens, viruses, cold air, exercise, irritants leads to Wheezing Bronchospasm Dyspnea Cough

Question 9

Asthma Risk Factors

Answer 9

Asthma Risk Factors Frequent Colds Frequent OM Food Allergies Atopic Dermatitis (Eczema) Allergic Rhinitis Persistent Wheezing after age 3

Question 10

The Road to Asthma

Answer 10

The Road to Asthma Food Allergies Allergy to milk proteins IgE antibody response Markers for atopy Dermatitis 3mo – 3 years Follows exposure to food or external allergen

Question 11

Diagnostic Criteria

Answer 11

Diagnostic Criteria Periodic symptoms of airway obstruction Airflow obstruction symptoms that can be at least somewhat reversed Exclusion of alternate diagnosis

Question 12

symptoms of asthma

Answer 12

Asthma Symptoms Cough Wheeze Cough with exercise and/or nocturnal Dyspnea Sensation of chest tightness Sputum Asthma Pattern of Symptoms Continuous or Intermittent Day or Night Time Seasonal, Perennial or Both Onset and Duration

Question 13

Asthma Precipitating Factors

Answer 13

Asthma Precipitating Factors Allergens (outdoors & indoors) Irritants Viruses Drugs Stress Foods Seasonal changes Other GERD, Sinusitis, rhinitis, menses

Question 14

Asthma Diagnosis

Answer 14

Asthma Diagnosis Difficult to diagnose if child <3 History Family History Social History Physical PFT

Question 15

asthma Prevention

Answer 15

Prevention Primary Prevention Breast feeding Hold solid foods until 4 months Healthy diet Exposure to smoke Minimize home allergens Abx sparingly Prevention Secondary Prevention Flu Vaccine Immunotherapy Avoid Triggers Pharmacology ICS, LTRA, Oral Steroids Prevention Tertiary Prevention Daily meds Pre-exercise prophylaxis Management of acute exacerbations

Question 16

asthma Classification & Treatment

Answer 16

Classification & Treatment Mild Intermittent Day: 2 times or less per week Night: 2 nights or less per month PEF/FEV 80% of expected No daily meds needed SABA PRN Mild Persistent Day: >2/week, less than 1/day Night: 2 or more/month PEF/FEV 80% of expected Low dose ICS SABA PRN Moderate Persistent Day: Daily Night: More than 1/week PEV/FEV 60-80% of expected Low dose ICS (,<5), Med >5) LABA Severe Persistent Day: Continual Night: Frequent PEF/FEV: 60% or less than expected High dose ICS LABA

Question 17

cf

Answer 17

Cystic Fibrosis Exocrine gland dysfunction Chronic respiratory infections Pancreatic enzyme deficiency 90% of patients have lung involvement Principle cause of death is respiratory failure

Question 18

cf

Answer 18

Resultant reduced height of epithelial lining fluid and decreased hydration of mucus results in mucus that is stickier to bacteria, which results in infection and inflammation. These abnormalities result in viscid secretions in the respiratory tract, pancreas, GI tract, sweat glands, and other exocrine tissues. Increased viscosity of these secretions makes them difficult to clear. defects result in decreased chloride excretion, increased sodium and water reabsorption across endothelial cells

Question 19

Cystic Fibrosis
History intestinal symptoms? respiratory? pancreatic? gu symptoms

Answer 19

Intestinal Symptoms Infants Intestinal obstruction at birth Meconium Ileus, Volvulus, Intestinal Atresia Delayed Meconium passage; prolonged jaundice Infants and Children Frequent Stooling; oil/fat in stools FTT Intussusception Rectal prolapse Pancreatic Symptoms Pancreatic Insufficiency Fat soluable vitamin deficiency Malabsorption of protein, carbs and fats Steatorrhea (frequent, poorly formed, large, bulky, foul-smelling, greasy stools that float in water) FTT, flatulence, abd pain, abd distention, anorexia, GER Respiratory Symptoms Chronic or recurrent cough; dry and hacking at the beginning and can produce mucoid (early) and purulent (later) sputum. Prolonged symptoms of bronchiolitis occur in infants. Coughing fits that can lead to vomiting Recurrent wheezing, recurrent pneumonia, atypical asthma, pneumothorax, hemoptysis, and digital clubbing (may be the initial manifestation) Dyspnea on exertion, history of chest pain, recurrent sinusitis, nasal polyps, and hemoptysis may occur GU Symptoms Males Vas deferens absence causes males sterility. Hyrdoceles Undescended Females Fertility is maintained, but may be decreased. Secondary sexual development is often delayed. Amenorrhea may occur in patients if the patient has severe nutritional or pulmonary involvement.

Question 20

Cystic Fibrosis
Physical

Answer 20

Cystic Fibrosis
Physical Pulmonary Tachypnea Respiratory distress Wheeze and/or rales Cough (dry or productive of mucoid or purulent sputum) Increased anteroposterior diameter of chest Clubbing Cyanosis Hyperresonant chest upon percussion Cystic Fibrosis
 GI Abdominal distention Hepatosplenomegaly (fatty liver and portal hypertension) Rectal prolapse Dry skin (vitamin A deficiency) Other Findings Scoliosis Kyphosis Swelling of submandibular gland or parotid gland Rhinitis Nasal Polyps

Question 21

Work Up for cf

Answer 21

Work Up Sweat Test quantitative pilocarpine iontophoresis test (QPIT) to collect sweat and perform a chemical analysis of its chloride content is currently considered to be the only adequately sensitive and specific type of sweat test Neonatal Screening: Multiple states in the US have implemented neonatal screening for cystic fibrosis. All screening algorithms in current use in the United States rely on testing for immunoreactive trypsinogen (IRT) as the primary screen for cystic fibrosis.7 The presence of high levels of IRT, a pancreatic protein typically elevated in infants with cystic fibrosis, warrants second level testing in the form of repeat IRT testing, DNA testing, or both. Within these 2 categories, various modifications are used.

Question 22

findings on cxr for cf

Answer 22

CXR Hyperinflation peribronchial thickening

Question 23

Cystic Fibrosis
Treatment

Answer 23

Cystic Fibrosis
Treatment Multidisciplinary Approach Medical Home PCP, Pulmonology; Gastroenterology, Nutritionist, ENT, Cardiology, Surgery Diet: High energy, high fat Exercise Bronchodilators, pulmonary hygiene Pancreatic Enzyme Replacement

Question 24

ages for Croup

Answer 24

Croup Common viral respiratory illness Kids 6-36 months, but can occur in older children as well, especially up to age 5 More common in the fall and winter Pathogens Viruses Parainfluenza virus accounts for approximately 80% of cases Adenovirus RSV Enterovirus

Question 25

Pathogens croup

Answer 25

Pathogens Viruses Parainfluenza virus accounts for approximately 80% of cases Adenovirus RSV Enterovirus

Question 26

podromal symptoms and s/s of croup

Answer 26

Croup is often preceded by mild URI symptoms Sore throat, low grade fever, rhinorrhea Stridor and respiratory distress generally develop suddenly and generally late in the evening Symptoms include: Barky cough Stridor Respiratory distress

Question 27

What is used to test child for croup?

Answer 27

Westley Score 0-3 = Mild Occasional barking cough, no stridor at rest, and mild or absent suprasternal or subcostal retractions. 3-6= Moderate frequent cough, audible stridor at rest, and visible retractions, but little distress or agitation. >6 = Severe frequent cough, prominent inspiratory (and, occasionally, expiratory) stridor, conspicuous retractions, decreased air entry on auscultation, and significant distress and agitation. Lethargy, cyanosis, and decreasing retractions are harbingers of impending respiratory failure.

Question 28

Croup Clinical Diagnosis

Answer 28

Croup Clinical Diagnosis Soft – Tissue neck films Strep Testing Influenza Laryngoscopy

Question 29

Croup Treatment

Answer 29

Croup Treatment Decadron .6mg/kg IM .15-.3mg/kg have been shown to be effective Racemic Epinephrine 3 hour observation Humidified oxygen or misty air Little empircial evidence of efficacy

Question 30

what is Bronchiolitis

Answer 30

Bronchiolitis is a virally induced acute inflammation of the lower respiratory tract in children <2 years old Inflammation increased mucous production, airway edema and necrosis of epithelial cells Clinically children may have rhinitis, cough, tachypnea, wheeze, rales, accessory muscle use, and/or nasal flaring

Question 31

what age does bronchiolitis usually occur

Answer 31

< 2

Question 32

bronchiolitis Clinically

Answer 32

Clinically children may have rhinitis, cough, tachypnea, wheeze, rales, accessory muscle use, and/or nasal flaring

Question 33

how long does bronchiolitis last

Answer 33

bronchiolitis is a self limited disease, with a median duration of 12 days Bronchiolitis is the top cause of hospitalization for children less than 1 year old

Question 34

Diagnose of Bronchiolitis

Answer 34

Diagnose Bronchiolitis by History and Physical (B; Strong Recommendation) Assess risk factors for severe disease (B; Moderate Recommendation) Age < 12 weeks Premature gestation Cardiopulmonary disease Immunodeficiency Radiographic or Laboratory studies should not be obtained routinely (B; Moderate Recommendation) Virological testing should not change management

Question 35

So when should you consider obtaining a CXR?

Answer 35

So when should you consider obtaining a CXR? Severe respiratory distress/ potential ICU admission Child has signs/symptoms of airway complication such as pneumothorax Child with suspected bronchiolitis is not following anticipated clinical course Unclear diagnosis

Question 36

meds for bronchiolitis

Answer 36

2006: “A carefully monitored trial of an a -adrenergic or B–adrenergic medication is an option. Inhaled bronchodilators should be continued only if there is a documented positive clinical response to the trial using an objective means of evaluation”

Question 37

albuterol for bronchiolitis?

Answer 37

2014: “Clinicians should not administer albuterol to infants and children with a diagnosis of bronchiolitis (B; Strong Recommendation)

Question 38

epi and bronchiolitis?

Answer 38

“Clinicians should not administer epinephrine to infants and children with a diagnosis of bronchiolitis” (B; Strong Recommendation)

Question 39

So when should you consider using epinephrine for bronchiolitls?

Answer 39

So when should you consider using epinephrine? “potentially as a rescue agent in severe disease” Be weary of using in ER to prevent hospital admission Short action of medication No overall reduction in rate of hospitalization by day 7

Question 40

nebulized hypertonic saline and bronchiolitls?

Answer 40

2006: No recommendation provided. 2014: “Nebulized hypertonic saline should not be administered to infants with a diagnosis of bronchiolitis in the ED” (B; Moderate Recommendation) 2014: “Clinicians may administer nebulized hypertonic saline to infants and children hospitalized for bronchiolitis” (B; Weak Recommendation)