Respirology Flashcards
What is the most sensitive PFT for small airways disease:
a) FEV1
b) FEV1/FVC
c) FEF 25-75
d) peak flow velocity
c) FEF 25-75
● FEF 25-75: mean expiratory flow in middle half of FVC maneuver
o Reflects flow through small airways (< 2mm diameter)
A 15 year old boy with recurrent pneumonia. RML x3, RLL, LLL in the past. Next test:
a) Quantitative immunoglobulins
b) Pulmonary function tests
c) Lung scan
a) Quantitative immunoglobulins
Recurrent Pneumonia= 2 or more episodes in single year or 3 or more episodes ever (with CXR clearing between occurrences) - think primary immune deficiency
*if recurrent in same lobe suspect structural abnormality
14 year old boy with Duchenne’s, who is in a wheelchair, has recently seen his FVC fall from 30% to 21% predicted. What symptom will he most likely complain of?
a) Headache early in morning
b) Headaches in the afternoon
c) Tingling of his fingers
d) Dyspnea with exertion
a) Headache early in morning
- Nocturnal hypoventilation (early sign of muscle weakness) - morning headache, daytime fatigue
A 12 year old presents to your office with a history of quickly fatiguing with exercise. Her physical exam is unremarkable in your office. You send her for PFTs. What would you expect the results to be if her trouble was related to deconditioning? What if it was related to asthma? What about restrictive lung disease?
a. Fill in a table with normal, increased or decreased for the following PFTs: FEV1/FVC, MMEF25-75 and RV/TLC (rows for asthma and deconditioning).
Asthma: FEV1/FVC decreased - MMEF25-75 decreased - RV/TLC increased Deconditioning: FEV1/FVC normal - MMEF25-75 normal - RV/TLC normal Restrictive: FEV1/FVC normal/increased - MMEF25-75 normal - RV/TLC normal/increased
Newborn has significant respiratory distress and CXR that is consistent with pneumonia. She is ventilated with PIP 36, PEEP 5 rate 60 bpm, FiO2 1.0, she is not saturating very
well. What is the likely diagnosis? What intervention should you start now?
- PPHN
2. iNO
You see a 6 year old girl with a history of a productive cough and persistent otitis media. On physical exam, you note cobblestoning of the oropharynx. What is the most appropriate diagnostic test: a. Immunoglobulins b. CT chest c. tracheal aspirate d. bronchial biopsy e. call a psychic hotline
a. Immunoglobulins
- primary immune deficiency (chronic cough and otitis media)
- cobblestoning more related to GERD/postnasal drip
8 year old girl with cough at night and with exertion for the past three months. PFTs are all normal. What would you do next: A) CXR B) Treat with b2 agonist C) Methacoline challenge D) PH probe
C) Methacoline challenge
- very specific for asthma
7 year old with sore throat in the mornings, bad breath, chronic cough with abdominal pain for 2 weeks. Her cough is worse with activity. What test will give you the diagnosis?
a) Throat swab
b) Pulmonary function tests with methacholine challenge
c) pH probe
d) Upper GI series
c) pH probe
pH monitoring- quantitative and sensitive documentation of acid reflux episodes (pathologic)- insufficient to prove/disprove diagnosis of GERD, can’t measure non-acid reflux- better for acid suppression during treatment, apneas and atypical presentations (cough, stridor, asthma)
6y F with chronic cough x 8 mos. Occurs unrelated to illness. It is a harsh cough during the day that decreases at night. Previous unsuccessful treatment for croup x 4 What is the likely diagnosis?
a. Athma
b. Post-viral cough
c. Habit cough
d. Vascular ring
c. Habit cough
A 1 year old child has a cough, and mom wants to know if she can use an over-the- counter cough preparation for him/her. What do you tell her?
No safe cough medications for kids under 6
- no studies show significant benefit, and there is risk of serious side effects with over the counter cold medications
A child is seen at 4 weeks of age in your office. They have had viral URTI symptoms for a week and now have cough and tachypnea. There is no increased work of breathing or wheezing. On CXR there is patchy atelectasis and interstitial infiltrates. What is the most likely etiology:
a. Ureaplasma urealyticum
b. Chlamydia pneumonia
c. RSV
b. Chlamydia pneumonia
- young infants, afebrile illness, insidious onset between 1-3m
- repetitive cough “staccato”, tachypnea, rales in afebrile 1 month old is characteristic
- absence of fever and wheezing helps distinguish from RSV
A 2 year old child is transferred to your center after 12 hours in a peripheral centre being treated for croup. They have had an acute onset of stridor and a barking cough after 1-2 days of viral URTI symptoms. There has been minimal response to 2 doses of neb racemic epinephrine and 2 doses of corticosteroid. On arrival the child is anxious, stidorous and has increased work of breathing. What is the next step in your management process:
a. Orotracheal intubation
b. Heliox
c. IV ventolin
a. Orotracheal intubation
- think bacterial tracheitis in kid with croup who is not responding to croup treatment
- tx: vanco or cloned and cefotax or ceftriaxone
3 mo with recurrent URTI. Has had on + off stridor since birth. On exam looks well, afebrile, VSS, intermittent stridor on inspiration. Most likely diagnosis?
a. Laryngomalacia
b. Viral croup
c. Laryngeal web
d. Vascular ring
a. Laryngomalacia
o Sx at 1-2 weeks and increase up to 6m (vs vascular ring where symptoms present at about 3 months)
A 4-year-old child has a chest x-ray done for a different reason, but it shows an asymptomatic solid circular lesion in the anterior mediastinum:
a) ganglioneuroma
b) neuroblastoma
c) lymphoma
d) teratoma
e) metastasis from a Wilms’ tumor
ANSWER: d) teratoma (more rare but anterior ONLY, in adults asymptomatic; missing kids info)
a) ganglioneuroma (posterior)
b) neuroblastoma (posterior)
c) lymphoma (can be anterior or other areas of mediastinum); non-Hodgkin or Hodgkin’s; but typically older age peak incidence
e) metastasis (not common site for mets)
Newborn with respiratory distress and cystic lesion in LUL with tracheal deviation. What is the most likely diagnosis:
- CCAM
- Pulmonary sequestration
- Pneumonia
- CCAM
congenital pulmonary airway malformation (CPAM)
o Sx- asymptomatic, resp distress, resp infections, pneumo, hydrops, hypoplasia of other lobes, chest pain, mediastinal shift away
o Ix- CT scan (even if asymptomatic)
o Rx- resection by 1 year (malignant potential)
In asthma, bronchiolar hyperresponsiveness:
a. Is present even if spirometry is normal
b. Decreases with a URI
c. Is not a sensitive test for the diagnosis of asthma
d. Is not inherited
a. Is present even if spirometry is normal
3-year-old with asthma exacerbation in moderate respiratory distress. Can speak in sentences.
Tachypneic and wheezing. Which test would you do:
a) chest x-ray
b) arterial blood gas
c) spirometry (FVC, FEV 1 )
d) O 2 saturation by pulse oximetry
e) flow, end tidal CO 2
d) O 2 saturation by pulse oximetry
5 year old with asthma. Treated with ventolin overnight and Q 30 this morning. Aminophyline added this morning to help improve oxygenation. Child complaining of nausea and weakness. You should check: A) serum sodium B) serum glucose C) serum potassium D) serum magnesium
C) serum potassium
hypokalemia
o Symptoms: nausea (GI decreased peristalsis), neuromuscular excitability (hyporeflexia, paralysis), arrhythmias
You are called about an asthmatic with a unilateral pneumothorax. In arranging medical air transport to your Intensive Care Unit, you suggest:
a) insert a chest tube on the affected side
b) insert a chest tube if the pneumothorax is greater than 10%
c) insert a chest tube only if the patient requires intubation
d) insert a needle into the 2nd intercostal space, midclavicular line
e) transfer without intervention
a) insert a chest tube on the affected side
Which is true regarding asthma management:
a) beta-2 agonists act primarily on small airways
b) systemic beta-2 agonists work better than inhaled
c) steroids increase the responsiveness to beta-2 agonists
d) Cromolyn is useful in the acute phase of asthma
c) steroids increase the responsiveness to beta-2 agonists
Patient on budesonide 200 mcg bid for five years for poorly controlled asthma. Best to monitor?
a. No investigations
b. Height velocity
c. Cortisol levels
b. Height velocity
A 6-year-old asthmatic has been receiving 400 mcg of budesonide 4 times daily for the past 2 months with no improvement. His cough is worse at night. Physical examination is normal. His inhalation technique is adequate. What next:
a) increase budesonide to 600 mcg 4 times daily
b) add oral prednisone for 5 days
c) add sodium cromolyn
d) add theophyline
e) add a long-acting beta-2 adrenergic medication
e) add a long-acting beta-2 adrenergic medication
● Add-On Therapy to ICS if symptomatic or experiencing significant AE despite optimal use of moderate dose inhaled steroids
o (1) consider increasing steroid dose
o (2) add long-acting beta two agonist (if min. 4 y.o.)
▪ combined meds= Advair (fluticasone + Salmeterol), symbicort (budesonide + formoterol), zenhale (mometasone + formoterol)
The following is true about MDI’s in adolescents with asthma
a. pinch nose when using MDI
b. dispense medication at beginning of exhalation
c. hold breath for 3 seconds after puff
d. take medication in slowly through the whole of inspiration
e. hold MDI in mouth
d. take medication in slowly through the whole of inspiration
- consider put in mouth depending on how question is phrased
- should hold breath for 10 seconds after inhalation
- with spacer: slow (5 sec) inhalation with 5-10sec breath-hold OR regular breathing for 30 seconds (5-10 breaths)
Teenager with an MDI for asthma without aerochamber.
Method of proper administration:
A) put in mouth
B) hold breath for 3 secs with inhalation
C) hold breath for duration of inhalation
D) hold nose during inhalation
A) put in mouth
Indication that asthma is in poor control:
a. 2 ventolins per week pre-exercise
b. 2 ventolins per week for symptomatic wheeze
c. 2 ventolins per week for night-time cough
d. 2 ventolins per month with colds
c. 2 ventolins per week for night-time cough
- well controlled: daytime symptoms max twice per week with no night time symptoms
- very poorly controlled: more than 1 night per week
What is the best indicator for mortality in asthma
a) previous intubation
b) previous oral steroids
c) family history
d) history of atopy
a) previous intubation
Which of the following is correct with respect to the use of a spacer with an MDI:
- Decreases spray effect
- Increases oral deposition
- Decreases bronchial deposition
- Usually requires a normal tidal volume
- Does not require coordination
- Does not require coordination
Asthma Question re: atopy. What is an indication of bad control? What should be monitored in chronic asthma for control?
- bad control: any night time symptoms, limitations of activity, 2+ exacerbations per 6 months, daytime symptoms more than twice weekly
- monitor PFTs, ventolin usage, ED visits and hospitalizations
A 6 year old boy has been on moderate dose inhaled corticosteroids continuously for his asthma. His mother is concerned about his final adult height. What do you tell her about the current literature in the area:
a. He will be slightly shorter than his expected adult height
b. There will be no effect on his adult height
a. He will be slightly shorter than his expected adult height
8 yo with BMI 25, SOB with exertion. Dad with allergic rhinitis. Patient has mild eczema. PFTs show. FVC 80%, FEV1 84% → 87% with bronchodilator and FVC to 85%. What is the treatment?
a. BID fluticasone
b. Salbutamol prior to exercise
c. Montelukast
d. Physical training
d. Physical training
- BMI 25 super obese for an 8 year old
- normal PFTs and no bronchodilator response (response is 12% increase)
Which of the following is the most helpful measure to decrease risk of asthma?
a. dust mite covers
b. elimination of environmental smoke exposure
c. removing pets from the home
d. breastfeeding
d. breastfeeding
- all of them except removing pets will decrease risk of asthma (exposure to pets is protective against asthma)
- choosing BF over elimination of smoke because the therapeutic effect comes from long standing avoidance of cigarette smoke even prenatally
Teen with asthma. Still symptomatic on inhaled fluticasone 125 mcg BID and monteleukast. Uses ventolin QID. Best treatment to address acute and chronic symptoms.
a. Salmeterol and fluticasone
b. Formoterol and budesonide
c. Salmeterol and ciclesonide
b. Formoterol and budesonide
“in adult patients who are poorly controlled the use of budesonide/formoterol in a single inhaler as a rescue medication instead of a SABA in addition to its regular use as a controller therapy has been shown to be effective”
Teenager with history of asthma. She is currently on Fluticasone 125 mcg bid. She has been needing to use her Ventolin puffers, two to three times a week in the day time over the past while. What four suggestions could you make for her management?
- review proper puffer technique including use of aerochamber and ensure patient compliance with medication
- eliminate environmental exposures
- no tobacco smoke (first or second hand)
- allergens (pets, dust mites, mold)
- wood burning stoves, strong chemical odours, dust
- could increase to medium dose ICS
- could add LABA (formoterol)
- could add LTRA (montelukast)
- if significant allergic component could use omalizumab
4 year old with asthma on inhaled steroids. Name 2 mechanisms of delivery of asthma medication.
- multiple dose inhaler
- DPI (dry powder inhaler) device (diskus, flexhaler autohaler, twisthaler)
- nebulized solution
Child in status asthmaticus who has been given inhaled beta agonists, ipratroprium bromide and iv steroids. Heʼs still in trouble. What are FOUR other medications that can be tried?
- IV magnesium sulphate
- IV ventolin
- IV aminophylline
- heliox