Respirology Flashcards
Name 3 side effects of salbutamol
Tachycardia
Hypokalemia
Hyperglycemia
Tremors
During what time period is atrovent helpful in acute asthma exacerbation?
Within first hour
↑ FEV1 by 10% if added to β2 agonist
How long to LABAs last?
12 hours
When do you add LABAs?
Add to ICS if inadequate control with optimal dose
Can LABAs be used in isolation?
NO. Must be used with inhaled steroid (combo inhaler)
Name 3 pathophysiologic mechanisms by which steroids work in asthma?
↓Cytokine production and inhibits various factors in inflammatory cascade.
↓Mediator release for macrophages and eosinophils
Inhibits eosinophil and lymphocyte production
Name 3 side effects of ICS
Oral thrush
Hoarseness
↓linear growth with high dose
What is an indication for adding LTRAs to asthma therapy?
Mild/moderate asthmatics
Allergic asthma
Name 9 signs of good asthma control
Daytime symptoms <4 days/week Night time symptoms <1 night/week Normal physical activity Mild, infrequent asthma exacerbations No absence from school due to asthma Need for fast acting beta 2 agonists <4 doses/week FEV1/PEF >=90% personal best PEF diurnal variation <10-15% Sputum eosinophils (adults) <2-3%
What are the principles of asthma management continuum?
1) Confirm diagnosis
2) Environmental control, education and written action plan
3) B2 agonist on demand
4) Add ICS
5) If >=12 years, add LABA to low dose ICS, if 6-11 years, increase to medium dose ICS
6) If >=12 years, add LTRAl; if 6-11 years, add LABA or LTRA
7) Prednisone or anti-IgA
What dose of fluticasone is considered low, medium and high dose ICS?
Low dose
>=12 years <=250 mcg/day
6-11 years <=200 mcg/day
Medium dose
>=12 years 251-500 mcg/day
6-11 years 201-500 mcg/day
High dose
>=12 years >500 mcg/day
6-11 years >500 mcg/day
Can you develop tachyphylaxis to LABA?
YES
A patient’s asthma is not well controlled. Name 5 next steps in your management.
Assess inhaler technique Ask about compliance Ask about environmental triggers Assess for comorbidities Consider adjuncts
Causes of false negative sweat chloride
- Hypoalbuminemia
- Hyponatremia
- CFTR mutations with preserved sweat duct function
- Insufficient sweat quantity
Name 5 causes of poorly controlled asthma in a patient on ICS and B2 agonists.
Poor medication compliance
Poor technique when administering inhaled medications
Diagnosis other than asthma
Chronic exposure to asthma triggers -Smoke exposure.
Comorbidities such as obstructive sleep apnea
Significant psychosocial impact of asthma on family
Name 3 complications associated with central hypoventilation syndrome
Arrythmias-including sinus pauses
Increased risk of Hirschsprungs
Increased risk of neural crest tumours
Name 4 causes of false positive sweat chloride
- Adrenal insufficiency
- Hypothyroidism
- Anorexia nervosa
- Eczema
- GSD Type I
- Nephrogenic DI
- MPS
- Malnutrition
- Ectodermal dysplasia
Name 3 criteria for the diagnosis of asthma on spirometry
3 ways to diagnose asthma:
- Spirometry
Postbronchodilator increase in FEV1 of >=12%
Reduced FEV1/FVC (<80-90%)
Reduced FEV1 compared to normative values for age
Reduced FEF 25-75
OR
- Peak expiratory flow variability
Increase in peak expiratory flow >=20% post bronchodilator or after course of controller therapy
OR
Diurnal variation
- Positive challenge test
Metacholine challenge
OR
Exercise challenge
challenge
Name 5 causes of declining PFTs in CF
- Allergic bronchopulmonary aspergillosis
- Pulmonary exacerbation
- Non compliance
- CF diabetes
- Viral illness
What is the treatment for ABPA
Oral steroids
Name 2 tests to confirm the diagnosis of ABPA
-Aspergillus skin test
-Elevated total serum IgE concentration (typically >1000 IU/mL)
Others:
-Serum specific Aspergillus IgE
-Eosinophil count
-Precipitating serum antibodies to A. fumigatus
Name 3 organisms that colonize the airways unique to CF
- Staph aureus
- Pseudomonas aeruginosa
- Burkholderia cepacia complex (BCC)
- Aspergillus
Name 2 tests to confirm the diagnosis of ABPA
- Aspergillus skin test
- Elevated total serum IgE concentration (typically >1000 IU/mL)
Others:
- Serum specific Aspergillus IgE
- Eosinophil count
- Precipitating serum antibodies to A. fumigatus
Name 3 bacteria that can cause:
i) epiglottitis
ii) croup
iii) bacterial tracheitis
i) H. flu type B, beta hemolytic strep
ii) parainfluenza, RSV, influenza
iii) staph aureus, strep pneumoniae, h. flu
Name 3 organisms that cuse chronic pulmonary infection in CF
S Aureus (most common, esp in young) H Influenza Psuedomonas Aeruginosa (older patients) Burkholderia Cepacia Aspergillus fumigatus(ABPA)
What is a positive sweat chloride test?
Sweat Test Chloride >60mmol/l is positive
30-60 mmol/L Gray Zone – further testing
What does newborn screening for CF typically entail?
2 serial assays
1) Serum immunoreactive trypsinogen (IRT)
2) If positive, repeat IRT OR DNA analysis for mutations in CFTR.
3) If positive screen, sweat chloride
For optimal accuracy when should sweat chloride be performed?
> 2 kg and >2 weeks of age
What kind of prenatal testing can be done for CF?
CVS or amnio with DNA analysis
What kind of PFT pattern is seen in CF in a) early disease b) late disease?
Early disease-obstructive, small airways disease (decreased FEF 25-75)
Late disease-restrictive
Name 4 treatment goals in CF
Maintain normal lung function
- Regular chest physiotherapy
- Treat chronic infections with oral or inhaled Abx
- Treat acute infections with oral or IV Abx
- Use mucolytics
Maintain normal nutrition & growth
- High fat/high energy diet
- Pancreatic enzymes, vitamin supplements
- Supplements/g-tube feeds
Regular follow-up with multi-D team
Educate patient and family about CF
What is the most common CF causing mutation?
Delta F508
What kind of PFT pattern is seen in CF in a) early disease b) late disease?
Early disease-obstructive, small airways disease (decreased FEF 25-75), decreased FEV1, increased RV/TLC (increased gas trapping)
Late disease-restrictive, gas trapping
What are the clinical features of ABPA?
Present with increasing cough, wheeze, exercise intolerance
Decrease FEV1
Rust colour sputum***
CXR often has upper lobe involvement
Lab work with eosinophilia and serum IgE>1000
Name 4 treatment goals in CF
Maintain normal lung function
- Regular chest physiotherapy
- Treat chronic infections with oral or inhaled Abx
- Treat acute infections with oral or IV Abx
- Use mucolytics (hypertonic saline, DNAse)
Maintain normal nutrition & growth
- High fat/high energy diet
- Pancreatic enzymes, vitamin supplements
- Supplements/g-tube feeds
Regular follow-up with multi-D team
Educate patient and family about CF
If you see asthmatic with nasal polyp, what test should you order?
Sweat chloride
What are the clinical features of ABPA?
Present with increasing cough, wheezing
Rust colour sputum
Decrease FEV1
CXR often has upper lobe involvement, proximal
bronchiectasis
Lab work with eosinophilia and increased IgE.
What is the pathophysiology of PCD?
Dysfunction of cilia
-Ineffective mucociliary clearance
How do you diagnose PCD?
Screen: Low nasal Nitric Oxide
Diagnosis: Nasal/bronchial biopsy with EM of cilia
High speed videomicroscopy of cilia
Genetics
Name 5 clinical manifestations of PCD
Persistent rhinitis Cobblestoning of posterior pharynx*** Sinusitis Recurrent otitis media*** Bronchiectasis Chronic cough Male infertility 50% have situs inversus totalis***
***differentiate from CF
How do you diagnose PCD?
Nasal scraping or bronchial biopsy (EM of cilia)***
Low nasal Nitric Oxide
High speed videomicroscopy of cilia
Genetics
Name 5 causes of pneumothorax
Idiopathic/spontaneous (most common) Thoracic trauma RDS/ meconium aspiration CF with pleural blebs Asthma Marfans Aggressive mechanical ventilation
How do you treat large pneumothorax, not under tension?
100% O2 (nitrogen washout)
If not effective, chest tube
Name 3 signs of tension pneumothorax
Hemodynamically unstable
Decreased venous return
Mediastinal shift
Pleurodesis for recurrent PTX
Treatment of tension pneumothorax
Needle decompression (2nd ICS, midclavicular line)
AND
Chest tube
How do you distinguish between transudate and exudate on pleural fluid analysis?
Transudate
- Protein < 3g/dL
- Pleural fluid protein/serum protein ratio< 0.5
- Pleural fluid LDH/serum LDH < 0.6
- Pleural fluid LDH less than two-thirds the upper limits of the laboratory’s normal serum LDH
- pH >7.45
Exudate
- Protein > 3g/dL
- Pleural fluid protein/serum protein ratio > 0.5
- Pleural fluid LDH/serum LDH > 0.6
- Pleural fluid LDH greater than two-thirds the upper limits of the laboratory’s normal serum LDH
What is the differential diagnosis of bronchiectasis
Lobar
- Foreign body
- TB
- Aspiration
Generalized
- CF
- PCD
- Immunodeficiency (e.g. CVID, HIV)
- ABPA-proximal airway!
- Post-infectious (measles, pertussis, adeno, recurrent severe pneumonia)
Name 5 conditions that can cause digital clubbing
CF TB Pulmonary fibrosis IBD Liver cirrhosis Cyanotic CHD Infective endocarditis
What is bronchiectasis?
Irreversible dilated airways
What is the work up for bronchiectasis?
Sputum culture
CXR-
CT chest-“train track” appearance of airway
Bronchoscopy
How is alpha 1 antitrypsin deficiency diagnosed?
Decreased serum levels of AAT
What is the clinical presentation of A1AT?
Most peds pateints with AAT deficiency present with liver disease (neonatal hepatitis, cirrhosis (in children or adults), and hepatocellular Ca)
For lung disease (emphysema) present in 30s-40s
In 20s if smoker!***
What lung findings are consistent with A1AT?
Emphysematous changes
Name 10 symptoms of OSA
Night: Snoring Restless sleep Frequent awakenings Choking or gasping arousals Enuresis Apneas Paradoxical chest and abdo motion
Day: Morning headaches Mouth breathing Daytime somnolence Poor academic performance Dry mouth Chronic nasal congestion/rhinorrhea Hyponasal speech Difficulty swallowing Poor appetite Altered Mood/behaviour Difficulty in morning wakening
Name 5 complications of OSA
FTT PHTN/cor pulmonale Depression Metabolic syndrome Systemic hypertension Cognitive problems
What is the treatment for OSA?
- First line-T+A
2. CPAP-for minimal adenotonsillar hypertrophy, facial dysmorphisms, no surgical candidates
What investigations should you order for OSA?
Lateral neck x-rays
Overnight oximetry
Early morning cap gas
Sleep study
Name 5 causes of central apneas
Primary:
Idiopathic
CCHS
Arnold-Chiari malformation
Secondary: HIE Tumour Brainstem malformation Raised ICP/herniation Medications (opioids, anaesthetics) Neuromscular (e.g SMA, GBS, phrenic nerve injury) Infection (e.g. RSV)
What is the treatment of central hypoventilation?
BiPap
Trach and vent
What is spirometry?
Looking at lung volumes (TV, VC)
What does RV/TLC represent?
Gas trapping
What is normal FEV/FVC?
0.8-0.85
What cannot be measured with spirometry?
RV
TLC
Spot diagnosis: http://www.thoracicmedicine.org/articles/2012/7/4/images/AnnThoracMed_2012_7_4_250_102187_f3.jpg
Congenital lobar emphysema
Spot diagnosis: https://images.radiopaedia.org/images/219099/fc64bd9dea93b87955ecca9e28d6f0_gallery.jpg
CCAM or congenital pulmonary airway malformation
What is the risk of a CPAM?
Infection
Small risk of malignancy (pleuropulmonary blastoma (PPB) and bronchoalveolar carcinoma)
Indications for surgical removal of CPAM?
Symptomatic
Infection (after treated)
Type 4 CPAMs-cystic forms of pleuropulmonary blastoma
Consider resection with high risk features:
- Large lesions
- Bilateral or multifocal cysts
- Family history of pleuropulmonary blastoma-associated conditions
How do you make diagnosis of CDH clinically?
Bowel sounds in chest
NG tube in chest
What is the most common cause of pleuritic chest pain in CF?
Pulmonary exacerbation
vs PTX
What happens in DMD when FVC <40% predicted?
Nocturnal hypoventilation
What investigation should you order in an older child with recurrent stridor?
Laryngoscopy
Describe the appropriate technique for using an MDI without a spacer technique (adolescents)
- Shake MDI for 5 seconds.
- Hold the MDI upright
- Breathe out normally.
- Put the mouthpiece between your teeth and close your lips around mouthpiece
- Keep tongue away from the opening of the mouthpiece.
- Press down the top of the canister
- Breathe in slow over 4-6 seconds
- Hold breath 5 seconds
- Wait 15 to 30 seconds between puffs
- Recap mouthpiece.
- Rinse mouth (if steroid)
What is the best way to assess initial adequacy of ventilation?
Auscultation
O2
Venous gas
In distinguishing between diaphragmatic eventration and CDH what is the best test?
Abdominal ultrasound
What is the best way to decrease the risk of development of asthma in a child?
Elimination of environmental smoke exposure
List 3 factors that predict the persistence of asthma into adulthood
- Atopy (eczema, allergic rhinitis, food allergy, inhalant allergen sensitization)
- Reduced lung function
- Higher airway hyperresponsiveness
- Parental asthma
- Severe LRTI
- Wheezing apart from colds
- LBW
- Environmental tobacco smoke exposure
- Male gender
Above what age can PFTs normally be done?
Feasible in kids ≥ 6 who can preform full, forceful, prolonged expiration effort
List 3 conditions that can cause obstructive pattern on PFTs
Asthma
CF
Bronchilits obliterans
List 3 conditions that can cause restrictive pattern on PFTs
Obesity Late CF Neuromuscular Scoliosis Pulmonary fibrosis Interstitial lung disease Previous thoracic surgery
In obstructive lung disease, what would be expected for the following parameters: TLC VC RV RV/TLC ratio FEV1 FEV1: FVC FEF 25-75 PEF DLCO
TLC-Normal or ↓ VC-Normal or ↓ RV-Normal or ↑ RV/TLC ratio- FEV1-↓ FEV1: FVC-↓ FEF 25-75-↓ PEF-↓ DLCO-Normal or ↑
In restructive lung disease, what would be expected for the following parameters: TLC VC RV RV/TLC ratio FEV1 FEV1: FVC FEF 25-75 PEF DLCO
TLC-↓ VC-↓ RV-Normal or ↓ RV/TLC ratio-Normal or ↑ FEV1-↓ FEV1: FVC-Normal FEF 25-75-↓ PEF-↓ DLCO-Normal or ↓
What do PFTs in a patient with deconditioning look like with respect to:
i) FEV1/FVC
ii) RV/TLC
iii) FEF 25-75
i) FEV1/FVC-Normal or ↑ (decreased FVC)
ii) RV/TLC-Normal or ↑
iii) FEF 25-75-Normal or ↓
What test should you do in a patient with persistent asthma symptoms despite normal spirometry?
Metacholine challenge
List 5 important aspects of asthma education
- Involve all family members, consider literacy, social, financial factors etc.
- Review asthma pathophysiology
- Expectations for good control, goals of therapy
- Address barriers to medications compliance, misconceptions, side effects of meds
- Teach proper technique for inhalers, peak flow measures
- 2 part ‘Written management plan’ –routine care, exacerbation flags and management
How do you diagnose CF?
Clinical symptoms consistent with CF in at least one organ system
- Chronic sinopulmonary disease
- Characteristic gastrointestinal and nutritional abnormalities
- Salt loss syndromes
- Obstructive azoospermia
OR
A history of cystic fibrosis in a sibling
OR
A positive newborn screen
AND 1 of the following:
1) Elevated sweat chloride ≥60 mmol/L (on two occasions)
2) Presence of two disease-causing mutations in CFTR, one from each parental allele
3) Abnormal nasal potential difference
How does heliox work?
Reduces pulmonary airway resistance
Helium is much less dense than nitrogen. When substituted for nitrogen, helium helps maintain laminar flow across an obstructed airway, decreases airway resistance, and improves ventilation
Describe the appropriate technique for using an MDI with a spacer
- Uncap mouthpiece
- Insert MDI into spacer
- Shake canister x 5 seconds.
- Hold the MDI upright
- Breathe out normally through your mouth.
- Put the mouthpiece between your teeth and close your lips tightly around mouthpiece of spacer, or, if using a mask, place the mask completely over your nose and mouth.
- Keep your tongue away from opening of spacer.
- Press down the top of the canister
- Breathe in deeply and slowly through your mouth x 3-5 seconds three to five seconds
- Hold breath x five seconds.
- Wait approximately 15 to 30 seconds between puffs
- Recap mouthpiece
- Rinse mouth
What is the lifetime prevalence of asthma in Canada (CPS)?
1
List 4 risk factors for ICU admission in an asthmatic (CPS)
- Previous life-threatening events,
- Admissions to ICU
- Intubation
- Deterioration while already on systemic steroids.
What is a reasonable SO2 goal in asthma exacerbation (CPS)?
> =94%
Ipatropium bromide should be used with caution in patients with what allergy (CPS)?
Soy allergy
When should MgSO4 be used in acute asthma exacerbation (CPS)?
In moderate and severe asthma with incomplete response to conventional therapy during the first 1 to 2 h
List 2 side effects of MgSO4
Hypotension
Bradycardia
If you start an IV salbutamol infusion, what 3 things should you monitor? (CPS)
- Cardiac monitoring-risk of arrhythmia
- Glucose-hyperglycemia
- Lytes-hypokalemia
List 2 serious complications of intubated asthmatics (CPS)
Pneumothorax
Impaired venous return–> Cardiovascular collapse
What is the purpose of diagnosing asthma in preschoolers (age 1-5) (CPS)? Give 3 reasons.
- Wheezing in early life is associated with reduced lung function that can persist into adulthood
- Airway remodelling has been documented in toddlers
- Evidence indicates that recurrent preschool wheezing responds to inhaled corticosteroid (ICS) therapy
Diagnostic criteria for asthma in preschoolers (age 1-5) according to CPS statement
Children with frequent (≥8 days/month) asthma-like symptoms or recurrent (≥2) exacerbations
- Documentation of airflow obstruction
Preferred: Documented wheezing and other signs of airflow obstruction by physician or trained health care practitioner
Alternative: Convincing parental report of wheezing or other symptoms
of airflow obstruction
- Documentation of reversibility of airflow obstruction
Preferred: Documented improvement in signs of airflow obstruction to SABA ± oral corticosteroids* by physician or trained health care practitioner
Alternative: Convincing parental report of symptomatic response to a 3-month trial of a medium dose of ICS (with as-needed SABA)
Alternative: Convincing parental report of symptomatic response to SABA
- No clinical evidence of an alternative diagnosis
List 5 conditions in the differential for chronic wheezing
Tracheomalacia TEF Vascular rings/slings Cardiovascular disease with PA dilatation FB aspiration GER with microaspiration Immunodeficiency CF PCD BPD Bronchiolitis obliterans
When after administering ventolin and oral steroids should you reassess patient for response?
Ventolin-30 mins after 1st dose or 60 mins after vent BtoB x 3
Oral steroids-3-4 hours after dose
In children 1-5 years of age with recurrent (≥2) episodes of asthma-like symptoms, no wheezing on presentation, what treatment is recommended and for how long (CPS)?
A therapeutic trial with a medium (200 µg to 250 µg) dose ICS and ventolin prn x 3 months to confirm reversibility of airflow obstruction
Clear consistent improvement in the frequency and severity of symptoms and/or exacerbations confirms the diagnosis
In children1-5 years of age with recurrent (≥2) episodes of asthma-like symptoms and wheezing on presentation, what should you do to confirm diagnosis of asthma (CPS)?
Direct observation of improvement with inhaled bronchodilator (with or without oral corticosteroids) by HCP
In suspected preschool asthma, when should you refer to specialist (CPS)?
Diagnostic uncertainty
Repeated (≥2) exacerbations requiring rescue oral corticosteroids or hospitalization or frequent symptoms (≥8 days/month) despite moderate (200 μg to 250 μg) daily doses of inhaled corticosteroids
Life-threatening event such as ICU admission
Need for allergy testing
What is the most common cause of localized bronchiectasis in previously healthy children?
Foreign body
What is Kartageners?
PCD + situs inversus (occurs in 50% of PCD)
List 5 causes of chronic cough (>4 weeks)
Psychogenic cough-"honking" cough Post-viral Asthma Pertussis Protracted bacterial bronchitis Bronchiectasis Postnasal drip GERD ILD FB Cardiac
List 5 conditions that cause hemoptysis
Bronchiectasis FB Airway trauma Pnemonia/lung abscess TB Aspergilloma Coagulopathy Pulmonary capillaritis (Wegeners, Goodpastures, SLE, HSP) Idiopathic pulmonary hemosiderosis PE Pulmonary AVM CHD
List 3 clinical, laboratory or radiographic features consistent with atypical pneumonia
- Subacute onset
- Prominent cough
- Minimal leukocytosis
- Nonlobar infiltrate
- Usually school-age
List 10 complications of CF
Respiratory tract involvement
- Chronic productive cough
- Asthma
- Airway colonization by pseudomonas, s. aureus, B. cepacia
- Bronchiectasis
- Atypical mycobacterial infection
- ABPA
- PTX 2ndary to subpleural blebs
- Hemoptysis
Sinus disease
- Sinusitis
- Nasal polyps
GI
- Pancreatic insufficiency
- Recurrent pancreatitis (in pancreatic sufficiency patients)
- Distal intestinal obstruction syndrome (DIOS)
- Meconium ileus
- Cystic fibrosis-related diabetes
- Vitamin deficiencies
- Prolonged neonatal jaundice
- Biliary cirrhosis with portal hypertension
- Cholelithiasis
- Dermatitis resembling acrodermatitis enteropathica, with fatty acid and zinc deficiency
- Rectal prolapse
- Volvulus in fetal life
Genitourinary
- Bilateral absence of vas deferens
- Male infertility
- Reduced female fertility
Other
- Hypochloremic, hyponatremic alkalosis
- Pseudotumor cerebri
- Osteoporosis
- Clubbing
- Hypertrophic osteoarthropathy
- Recurrent venous thrombosis
- Nephrolithiasis and nephrocalcinosis
- Delayed puberty
What two complications increase the risk of liver disease in CF?
Liver disease occurs independent of genotype but is associated with meconium ileus and pancreatic insufficiency
Treatment of pulmonary exacerbation in CF (past SAQ)
-If mild →Tx with 2-3 weeks of PO antibiotics based on most recent sputum cultures; close f/u with repeated PFTs
-If moderate to severe
→admission to hospital, IV abx x 14 days, inhalational therapy, chest PT, supplemental O2, nutritional support
If concerned re: pseudomonas, need to double cover (e.g. Ceftazidime and gentamicin)
Difference between bronchopulmonary sequestration and CPAM
Sequestration lacks normal communication with the tracheobronchial tree and that receives its arterial blood supply from the systemic circulation
CPAMs are connected to the tracheobronchial tree and are supplied from the pulmonary circulation
List 2 conditions associated with extralobar pulmonary sequestration
CDH Vertebral anomalies CHD Pulmonary hypoplasia Colonic duplication
List 10 conditions with increased risk of OSA
- Adenotonsillar hypertrophy-most common
- Obesity
- Cerebral palsy
- T21
- Craniofacial anomalies (eg, retrognathia, micrognathia, midface hypoplasia)
- History of low birth weight
- Muscular dystrophy or other neuromuscular disorders
- Myelomeningocele
- Achondroplasia
- Mucopolysaccharidoses (eg, Hunter syndrome and Hurler syndrome)
- Prader-Willi syndrome
- Orthodontic problems (eg, high narrow hard palate, overlapping incisors, crossbite) 13. Family history of OSA
- History of prematurity and multiple gestation
Formula for calculating BMI
Weight (in kg)/(height in m)^2
List 2 diagnostic criteria for ARDS (past SAQ)
- Respiratory symptoms within one week
- Bilateral opacities consistent with pulmonary edema on CXR or CT
- Rule out cardiac failure or fluid overload
- A moderate to severe impairment of oxygenation must be present: Pao2/Fio2 <200
List the 4 most common causes of BRUE
- No identified cause (50%)
- GERD
- Seizure
- LRTI (RSV, pertussis)
- NAI
Less common:
Cardiac disease, upper airway obstruction, metabolic disorders, anaphylaxis, bacterial infections (including UTI), intussuseption, toxic ingestion
List 5 low risk characteristics of patients with BRUE
- Age >60 days
- Gestational age ≥32 weeks and postconceptional age ≥45 weeks
- Occurrence of only one BRUE
- Duration of BRUE <1 minute
- No CPR by a trained medical provider was required
- No concerning historical features:
- Social risk factors for child abuse
- Respiratory illness or exposure
- Recent injury
- Symptoms in days preceding the event (fever, fussiness, diarrhea or decreased intake)
- Administration or access to medications
- History of episodic vomiting or lethargy
- Developmental delay or congenital anomalies
- Family history of BRUE or sudden unexplained death in a sibling - No concerning physical examination findings
- Signs of injury, including bleeding or bruising
- Bulging fontanelle
- Altered sensorium
- Fever or toxic appearance
- Respiratory distress
- Abdominal distension or vomiting
Management for low risk BRUE
Education about BRUEs
Recommend parent CPR class
Consider brief in hospital observation (1-4 hours)
Follow up with HCP in 24 hours
Investigations for BRUE in patients that do not meet low risk criteria
CBC Lytes+extended lytes Cr, BUN Glucose UA CXR ECG Urine toxicology Consider pertussis and RSV swabs Consider metabolic w/u
Empiric antibiotics for pulmonary abscess
Clindamycin+ Gentamicin (need anaerobic coverage
What organisms are commobly involved in pulmonary abscess?
S. aureus
Oral anaerobes
Gram negatives
**Do pleural culture as often positive in pulmonary abscess
How do you differentiate transudate and exudate using Light’s criteria?
Pleural fluid is exudate if one of the following is met:
- Pleural fluid protein/serum protein ratio > 0.5
- Pleural fluid LDH/serum LDH ratio > 0.6
- Pleural fluid LDH > 2/3 upper limit of the laboratory’s normal serum LDH
List 3 characteristics of pleural fluid consistent with empyema
- Low pleural fluid glucose <3.33 mmol/L or a pleural fluid/serum glucose ratio <0.5
- Pleural fluid acidosis (pH < 7.3)
- Cell count >50,000/microL
- LDH>1000
- Pleural fluid protein/serum protein ratio > 0.5
- Pleural fluid LDH/serum LDH ratio > 0.6
List 3 complications of chest tube
Malposition
Organ injury (heart, lungs, diaphragm, liver)
Infection
Describe the clinical features of pleurodynia
Lasts 3-6 days, up to 2 weeks Fever SEVERE spasmodic chest/abdo pain Pleuritic Malaise, myalgias Pleural friction rub Normal CXR
What 2 viruses most commonly cause pleurodynia?
Coxsackie
Echovirus
List 4 groups at higher risk for severe disease from bronchiolitis (CPS)
Premature (<35 weeks GA)
<3 months of age at presentation
Hemodynamically significant cardiopulmonary disease
Immunodeficiency
