Respirology Flashcards
What are 3 main side effects of salbutamol
Tachycardia
Tremors
HYPOKALEMIA
Why is iprtropium bromide used in the ER
Study indicated increased FEV1 by 10% if added to B2 agonist
Works best in 1st 4 hours
What is the mechanism for steroids in asthma
Decreases cytokine production and inhibits various factors in inflammatory cascade
Decreased mediator release for macrophages and eosinophils
Inhibits eosinophils and lymphocyte production
What are some side effects of inhaled steroids (3)
Oral thrush
Hoarseness
Decreased linear growth with high dose
What are 4 examples of inhaled steroids
Pulmicort
Flovent
Alvesco
QVar
What are 3 combination inhalers?
ICS + LABA
Advair
Symbicort
Zenhale
What is omalizumab (anti IgE) used for in asthma
For moderate to severe persistent allergic asthma that isn’t controlled with inhaled steroids
Risk of anaphylactic reaction- must get subcutaneous injection q2-4w in MD office
key thing to know is that there is a risk of anaphylaxis
What are symptoms of good asthma control: Daytime symptoms: Nighttime symptoms: Physical Activity: Exacerbations: Absence from school due to asthma: Need for fast acting beta 2 agonist: FEV1 or PEF PEF diurnal variation Sputum eosinophils (adults)
Daytime symptoms: <4 d/week Nighttime symptoms: <1 night/week Physical Activity: Normal Exacerbations: mild, infrequent Absence from school due to asthma: None Need for fast acting beta 2 agonist: <4doses/week FEV1 or PEF: >/=90% personal best PEF diurnal variation: <10-15% Sputum eosinophils (adults): <2-3%
What is the next step in treatment after low dose ICS for age 6-11? Age >/=12?
6-11: increase ICS to medium dose
>/=12: add LABA to low dose ICS (ideally combination inhaler)
What is considered a positive sweat chloride test? grey zone? negative?
Sweat chloride >60 mmol/l is positive
30-60 mmol/l is grey zone and they require further testing
<30 mmol/l is negative
What is the genetic pattern for CF
Autosomal recessive
What is seen on PFTs early in the disease for CF? Late in the disease?
Early disease- peripheral airway disease results in airway OBSTRUCTION, gas trapping, decrease in FEF 25-75
Late disease- chronic inflammation, increased lung destruction and fibrosis- see restrictive pattern with persistent gas trapping
If both parents are carriers what is the risk the child will get CF? Be a carrier?
1/4 or 25% risk of being affected
2/4 or 50% risk of being a carrier
What can cause an elevated sweat chloride besides CF?
Endocrine things: panhypopituitarism
Hypothyroidism
Nephrogenic diabetes insipidus
Untreated adrenal insufficiency
Metabolic: mucopolysaccharoidosis
Fucosidosis
Glycogen storage disease
Malnutrition
Skin things: ectodermal dysplasia
What bug is considered a CF bug
Pseudomonas aeruginosa
What is ABPA
Allergic bronchopulmonary aspergillosis
Severe allergic reaction after being exposed to aspergillus
What is the clinical presentation of ABPA? Diagnosis? Treatment?
Wheeze, worsening cough, mucous plugs that are brown in color
Diagnosis- skin test for aspergillosis and IgE level
Treatment- steroids
Trend IgE to see if it gets better or worse
What is the standard test for CF
Sweat chloride
See Hyponatremic, hypochloremic dehydration
If you see nasal polyps in an asthmatic what should you do?
Sweat chloride!
What vitamins must be supplemented for cystic fibrosis
ADEK (fat soluble vitamins)
How do you maintain normal lung function for CF patients
Regular chest physio (BID)
Treat chronic infections with oral or inhaled abx
Treat Acute infections with oral or IV antibiotics
Use mucolytics (pulmozyme or hypertonic saline)
what is PCD? signs on physical exam/history?
dysfunction of cilia
ineffective mucociliary clearance
- year round daily wet cough
- persistent rhinitis (year round nasal congestion)
- sinusitis
- recurrent otitis media
- neonatal respiratory distress (most have prolonged O2 need at birth)
- bronchiectasis, chronic cough
- male infertility
- 50% have situs inversus totalis
* if given an X-ray with situs inversus totalis- think PCD!
diagnosis- biopsy fo cilia (nose or bronchial biopsy)
screening test- nasal nitric oxide (not invasive)
neonate can present with head cold from day 1 (nasal stuffiness), atelectasis
what are some treatment options for PCD
no cure available chest physiologic aggressive antibiotic treatment routine vaccination surgical interventions: tympanostomy tubes, sinus drainage
Causes of pneumothorax:
idiopathic/spontaneous thoracic trauma RDS/meconium aspiration CF with pleural blebs asthma marfans \+/- mechanical ventilation
what is the treatment for recurrent pneumothorax?
pleurodesis
what are the signs of tension pneumothorax
intrapleural pressure>atmospheric pressure
ipsilateral lung collapse
mediastinal shift
decreased venous return
tx: OXYGEN and needle decompression (2nd intercostal space mid clavicular line above the 3rd rib) on the side of the pneumothorax, chest tube
what is bronchiectasis?
irreversible dilatation of the airways
what are causes of focal/local bronchiectasis (3)
foreign body
TB
aspiration
what are causes of generalized bronchiectasis (6)
CF
PCD
Immunodeficiency syndrome (HIV, hypo/dysgammaglobulinemia)
ABPA
post infectious (measles, pertussis, adenovirus)
what is alpha 1 antitrypsin deficiency?
decreased serum levels of AAT
what is the most common phenotype of alpha-1 antitrypsin?
PiZZ is the phenotype most common
emphysema secondary to AAT def
most patients present with liver disease
lung disease presents typically in 30s-40s
what is vital capacity
is the maximum amount of air a person can expel from the lungs after a maximum inhalation.
what is residual volume
what’s left in your lungs after complete exhalation
what is TLC
VC + residual volume
what is tidal volume
the normal volume of air displaced between normal inhalation and exhalation when extra effort is not applied
what cannot be measure on spirometry?
residual volume
what does a scooped out pattern on PFT suggest? Ddx?
obstructive pattern Asthma (would see bronchodilator response) CF PCD BO
what does a steep slope and decreased volume on PFT suggest?
restrictive pattern
what are two treatment options for OSA
T & A
NIPPV- CPAP
what investigations can be done for OSA (4)
lateral neck xray (for adenoid hypertrophy)
overnight oximetry
morning capillary blood gas
polysomnography
what are signs of OSA on history
snoring** hallmark symptom restless sleep/frequent awakenings excessive sweating enuresis (especially secondary) apneas mouth breathing** common chronic rhinorrhea difficulty waking up in the morning morning headaches difficulty at school/attention deficit excessive daytime sleepiness
what are causes of central apnea (absence of effort in breathing)
CCHS (congenital central hypoventilation syndrome) arnold-chiari malformation secondary: asphyxia brain tumour central system infarct medications decreased muscle strength (Duchenne's, SMA)
what is OSA
repeated events of partial or complete upper airway obstruction during sleep, disrupting normal gas exchange and or sleep patterns (arousals)
what is considered a positive methylcholine challenge? negative?
<4mg/mL
4-16 is borderline
>16mg/mL is considered negative
what is considered a positive PEF (peak expiratory flow) variability?
≥ 20%
diurnal variation not recommended
what is considered a positive PFT for asthma
reduced FEV1/FVC (less that lower limit of normal for age 0.8-0.9)
and
Increase in FEV1 after a bronchodilator (>12%)
what is considered a positive exercise challenge
≥ 10-15% decrease in FEV1 post exercise
What are 3 PFT criteria supportive of an asthma diagnosis
spirometry showing reversible airway obstruction
PEF variability
positive test such as methylcholine or exercise challenge
what type of aerochamber should be used in a child >5? <5?
> 5 one with a mouthpiece
<5: mask
at what age can you consider dry powder inhalers?
> 6
ICS low dose age 6-11? >12?
Low dose:
6-11: ≤ 200
<12: ≤ 250
ICS medium dose age 6-11? >12?
high dose?
Medium dose:
6-11: 201-400
>12: 251-500
High dose:
6-11: >400
>12: >500
what are the major criteria for asthma predictive index?
minor criteria?
1 Major Criteria
– Parental Asthma
– Doctor Diagnosed Eczema
– Sensitization to aeroallergen
2 Minor Criteria
– Wheezing in between episodes
– Peripheral eosinophilia
– Sensitization to food allergens
AND >3 wheezing episodes
helps predict who will continue to wheeze
how can cystic fibrosis present in infancy?
failure to thrive
Meconium ileus*
recurrent respiraron symptoms (wheeze, cough, bronchiolitis)
hyponatremic, hypochloremic metabolic alkalosis *
prolonged jaundice
severe pneumonia
how does cystic fibrosis present in childhood/adolescents?
recurrent respiratory symptoms (cough, wheeze, poorly controlled asthma)
failure to thrive
recurrent rectal prolapse *
bronchiectasis *
nasal polyps/ sinus disease
chronic pseudomonas aeroginosa colonization
clubbing
Newborn screen programs for CF may miss what percentage?
5% of classic CF
Laryngeal cleft is associated with what syndromes
VACTRL CHARGE Opitz Fritz Midline defects - rigid bronchoscopy to rule out
what is the gold standard for diagnosing H type fistula?
rigid bronchoscopy
DDX for recurrent aspirations (2)
laryngeal cleft
H type fistula
what investigations should you consider for a child with chronic wet cough?
CXR
pulmonary function testing with bronchodilator testing
sweat chloride testing
DDX wheeze
asthma/transient wheezing cystic fibrosis large airway obstruction (extrinsic, intrinsic, wall abnormality) foreign body aspiration chronic aspiration PCD TB Fungal infection Chronic lung disease of prematurity rare interstitial lung disease congestive heart failure GERD
sudden wheezing without URTI symptoms might suggest?
foreign body
recurrent wheeze and cough at a young age should always elicit the possibility of?
cystic fibrosis
Beclamethasone= Budesonide= Fluticasone= Ciclesonide= Mometasone=
Beclomethasone: QVAR Budesonide: Pulmicort Fluticasone: Flovent Ciclesonide: Alvesco Mometasone: Asmanex
ICS low dose in children less than 5? medium dose?
Low dose (mcg):
beclomethasone: 100
ciclesonide 100
fluticasone 100- 125
medium dose (mcg:
beclomethasone: 200
ciclesonide: 200
fluticasone: 200-250
what is the definition of recurrent pneumonia?
≥ 2 pneumonias in 1 year or ≥ 3 in a lifetime
- radiologic clearing in between episodes
what is the most common cause of recurrent pneumonia?
viral respiratory infections with atelectasis
DDX for recurrent pneumonia in the same location
anatomic abnormality (external airway compression- lymphadenopathy, vascular abnormality, intrinsic airway abnormality)
congenital malformation ( CPAM, pulmonary sequestration bronchogenic cyst)
foreign body
right middle lobe syndrome
bronchiectasis
persisten infection (ie TB)
DDX for recurrent pneumonia in multiple locations (4)
immune deficiency
Cystic fibrosis
PCD
Recurrent aspirations (anatomical, swallowing disorder, neurologic impairment)
what are common congenital pulmonary malformations
CPAM/CCAM (Congenital pulmonary airway malformation)
pulmonary sequestration
bronchogenic cyst
Children with congenital pulmonary malformations are at increased risk of what?
pneumonia*
malignancy eventually
what investigation is required to investigate for pulmonary sequestration?
CT with contrast
- need to know where the vessels are pre-op
what are the sequelae of OSA
Neurocognitive
- behavioural
- attention
- school performance
- development
Cardiovascular
- HTN
- Cor pulmonale
Failure to thrive
inflammatory
quality of life
what syndromes increase your risk of OSA
craniofacial abnormalities
- micrognathia
- retrognathia
- glosoptosis
- midface hypoplasia
- macrogloassia
- nasal deformities
hypotonia
trisomy 21
what are some symptoms suggestive of OSA
behavioural problems "ADHD" symptoms poor school performance developmental delay shyness difficulty waking in AM failure to thrive enuresis daytime fatigue
what is the gold standard for diagnosis of OSA
polysomnography
- best differentiation of severity
what are the benefits and limitations fo overnight oximetry
benefits:
- positive test in context of symptoms can be diagnostic
limitations:
- poor sensitivity
does not differentiate causes of desaturations
what are some treatment options for adenoidal hypertrophy
Non- pharmacologic:
- nasal hygiene
- sleep hygiene
Pharmacologic:
- intranasal corticosteroids
- montelukast
surgical:
adenoidectomy
what are 2 treatment options for OSA associated with obesity
weight loss (primary treatment) CPAP (continuous positive airway pressure)
what is the definition of a chronic cough
cough >4-8 weeks
what is the definition of an acute cough
<3 weeks
how many viral infections do children have per year?
3-8
10-12% have ≥12
what are 2 red flags for foreign body aspiration?
witnessed choking episode
sudden onset of cough
what is the most common foreign body aspiration
food items!
majority of cases < 3 years of age
what are some radiologic findings associated with foreign body aspiration?
pneumonia
atelectasis
localized emphysema
normal
what are 3 consequences of a missed foreign body
recurrent pneumonia
bronchiectasis
cardiac arrest and death
DDX chronic cough
healthy children:
frequent viral respiaroty tract infections
postviral cough
pertussis/pertussis like cough
chronic cough: cough variant asthma chronic rhinitis persistent bronchitis GERD Psychogenic cough non-specific isolated chronic cough
Potentially serious lung disorder: CF PCD immunodeficiency foreign body aspiration recurrent pulmonary aspirations tuberculosis anatomic disorder interstitial lung disease
what should you think of with a “honking cough”? brassy/barking cough?
honking cough: psychogenic cough
brassy/barking cough: airway malacia, tracheal compression
dry cough, dyspnea, restrictive spirometry
interstitial lung disease
Causes of anterior mediastinal masses
5 T's Teratoma Terrible lymphoma Thymus Thyroid T cell leukemia
Most common airway tumor in children
bronchial carcinoid
3 criteria used to make the diagnosis of asthma in a preschooler (age 1-5)
1) airflow obstruction
wheezing is the most specific sign
≥ 2 asthma like exacerbations**
2) reversibility
documented improvement in airflow obstruction to SABA +/- corticosteroids
symptomatic response to 3 month trial of ICS
convincing parental report of response to SABA
3) no alternative diagnosis
Name 3 reasons for RSV prophylaxis
Children with hemodynamically significant CHD or CLD (defined as a need for oxygen at 36 weeks’ GA) who require ongoing diuretics, bronchodilators, steroids or supplemental oxygen, should receive palivizumab if they are <12 months of age at the start of RSV season
In preterm infants without CLD born before 30 + 0 weeks GA who are <6 months of age at the start of RSV season, it is reasonable (but not essential) to offer palivizumab.
Infants in remote communities who would require air transportation for hospitalization born before 36 + 0 weeks’ GA and <6 months of age
List 3 organisms that colonize airway of patients with CF
Staphylococcus aureus
Pseudomonas aeruginosa
and Burkholderia cepacia complex
What is the most common reason for obstructive sleep apnea in children
Tonsillar and Adenoid Hypertrophy
Name 2 severe complications of OSA (4)
pulmonary HTN
systemic HTN
cor pulmonale
ventricular hypertrophy
comorbid conditions you should treat with asthma
rhinitis- detected in 90% of children with asthma
sinusitis
GERD
The most commonly encountered ICS adverse effects are?
oral candidiasis
dysphonia
CXR shows right aortic arch. You suspect vascular ring. 3 investigations.
Echo – not helpful for seeing ring itself but to rule out any associated congenital heart defects.
50% of vascular rings will have assoc cardiac anomaly
CT
MRA
Bronchoscopy
how does a vascular ring present
presents before 1 year of age
stridor improves with neck extension
50% associated with cardiac abnormalities
What are the causes of a false negative sweat test?
Dilution Malnutrition Edema Insufficient sweat quantity Hyponatremia
Mild
moderate
severe OSA
mild: AHI 2-5
moderate: AHI 5-10
severe: AHI >10
salbutamol
ipratropium bromide
salbutmol- B2 agonist
ipratropium bromide- anticholinergic
what is the benefit of Symbicort over Advair
Symbicort has formeterol which has a faster onset of action then Advair (salmeterol)
better for exercise
what are 2 LABAs
fometerol (faster onset of action)
salmeterol
what’s an example of an antileukotriene used to treat asthma? main side effect we worry about?
montelukast (Singulair)
Modest bronchodilator effects
Attenuates bronchoconstriction in EIA
risk of suicidality
what is the most common bug to cause epiglottis?
H influenza B
How can CF be diagnosed prenatally?
CVS with DNA analysis or amniocentesis
Physical exam findings of CF
head and neck
lungs
abdo
head and neck: nasal polyps
opacification of the sinuses (chronic sinusitis)
they taste salty (baby presents to ER with low sodium, low chloride, appears dehydrated but no history of vomiting or diarrhea)- have to do a sweat test
Lungs- chronic infections asthma (but not increased risk) pneumothorax hemoptysis (airway blood not a pulmonary hemorrhage but bronchial arteries supplied by systemic therefore they can exsanguinate) bronchiectasis ABPA (brown plugs or rust color sputum)
Pancreas: pancreatic insufficiency (90%)
CF related diabetes
pancreatic sufficient (10%)- can get pancreatitis
Liver- CF related cirrhosis
prolonged jaundice
Gallbladder- increased risk of gallstones
Intestines- distal intestinal obstructive syndrome (DIOS)
meconium ileus (CF until proven otherwise)
volvulus
intussusception
rectal prolapse
clubbing
Males are infertile (absence of the vas deferens)
Women: decreased fertility in CF because cervical mucous is thicker (main reason)
delayed puberty
osteoporosis (don’t have great vitamin D levels)
what is the median survival in Canada for CF?
52 years but increasing yearly
which has a higher protein content exudate or transudate?
exudate-infectious
high protein
high LDH
Ddx restrictive pattern on PFT (4)
lung fibrosis
neuromuscular
chest wall deformity
obesity
what is the most common mutation for CF
delta 508
CFTR protein
what tests are done to diagnose CF (2)
sweat chloride
CFTR genetic analysis
how would you determine pancreatic insufficiency
72 hour fecal fat fecal elastase (spot test)
how do you diagnose PCD
nasal brush biopsy
EM of cilia- gold standard
what are 3 causes of a positive TB skin test
- active or latent TB
- BCG vaccine
- non tuberculosis mycobacterium
What two other investigations will you do to determine latent TB
CXR
acid fast bacilli smear and culture
What are the 3 most important interventions in CF that affects prognosis?
- Nutrition
- Antibiotics
- Chest physiotherapy
What are 3 complications of bronchiectasis?
- Increased risk of infection secondary to trapping of secretions
- Increased risk of pneumothorax
- Increased risk of pulmonary hemorrhage (and thus hemoptysis)
What is the treatment for acute vocal cord dysfunction exacerbations? (2)
- Relaxation breathing techniques
2. Inhalation of heliox to relieve vocal cord spasm
What is the gene involved in congenital central hypoventilation syndrome?
PHOX2B gene: essential to embryologic development of the autonomic nervous system from the neural crest
- 90-95% are de novo mutations and the rest inherit the mutation from asymptomatic mosaic parent (autosomal dominant)
- an individual with CCHS has 50% chance of passing on the mutation to their children
In a child with congenital central hypoventilation syndrome presenting with constipation, what condition should be ruled out?
Hirschsprung disease: 20% of CCHS children
-should undergo rectal biopsy to screen for absence of ganglion cells
What is the polysomnographic parameter most commonly used in evaluating sleep disordered breathing?
Apnea/Hypopnea index (AHI): tells us number of apneic and hypopneic events per hr of sleep
AHI> 5 should be treated
What is the treatment of a pneumothorax that is small
No treatment needed: will self-resolve usually in 1 wk
What is the difference between a primary and secondary lung abscess?
Primary: occurs in previously healthy patient with no underlying medical conditions
-more commonly found on right side
Secondary: occurs in patient with underlying medical conditions
-more commonly on the left side
Which conditions predispose children to the development of pulmonary abscesses? (6)
- Aspiration pneumonia
- Cystic fibrosis
- GERD
- TEF
- Immunodeficiencies
- Neurological conditions
* *anything that can lead to aspiration of infected materials with oral organisms
* *can also occur secondary to a pneumonia
What is the classic finding on CXR for a lung abscess?
Parenchymal inflammation with a cavity containing an air fluid level
What are the causes of ARDS?
-two broad categories
Direct lung injury
- Pneumonia (most common)
- Aspiration
- Pulmonary contusion
- Submersion injury
- Inhalational injury
Indirect lung injury:
- Sepsis
- Shock
- Burns
- Transfusion related
- Trauma
What are the 3 phases of ARDS?
- Exudative phase: decreased pulmonary compliance, increased hypoxia, increased tachypnea
- see inflammation, diffuse alveolar infiltrates, pulmonary edema - Fibroproliferative phase: increased alveolar dead space, pulmonary hypertension
- scarring of lung, epithelial damage, surfactant deactivation - Recovery phase: restoration of pulmonary epithelial barrier
What is the treatment for alpha-1-antitrypsin deficiency?
IV enzyme replacement from pooled human plasma
What is the gold standard for diagnosis of PE?
- what is the diagnostic test of choice?
- what is the utility of a V/Q scan?
Gold standard: pulmonary angiography
- not necessary except in unusual cases since spiral CT is almost always available
- diagnostic test of choice: spiral CT with IV contrast (specificity 90%)
- V/Q scans are noninvasive and sensitive: use if pre-test probability is low
What recreational drug is associated with pneumothorax?
Ecstasy! (MDMA)
In children with prolonged or high inhaled corticosteroid therapy, what are two things you should monitor for?
-does the use of inhaled corticosteroids affect adult height?
- Height velocity
- Cataracts
***Does not affect adult height
What is the differential diagnosis for middle mediastinal mass?
A+B
- Adenopathy: infectious (histoplasmosis most common), neoplastic, metastatic, sarcoidosis
- Bronchogenic cyst
What is the differential diagnosis for posterior mediastinal mass?
The Ns
- Neurogenic tumor: neuroblastoma, benign ganglioneuroma, ganglioneuroblastoma
- Neurofibroma
- Esophageal duplication cysts
- Pulmonary sequestration
What is a clue on exam that can help you differentiate between laryngomalacia vs. tracheomalacia?
- Laryngomalacia = inspiratory stridor (above thoracic inlet)
- tracheomalacia (weak tracheal rings collapse with expiration)= expiratory or biphasic stridor (below thoracic inlet)
A patient with a pleural effusion receives a chest tube for drainage. The pleural fluid is chocolate colored. What is your diagnosis?
Amebiasis (entamoeba histolytica)
Where is the acute airway obstruction seen in croup?
Subglottic narrowing at the cricoid cartilage!!
What are the 3 most common causes of epiglottis in the post-HIB vaccine era?
- Strep pneumo
- GAS
- Staph aureus
What is the role of azithromycin therapy in the treatment of CF?
Azithromycin = shown to reduce lung inflammation if given 3x weekly, thus decreasing pulmonary exacerbations
What medication class should be avoided in individuals with history of obstructive or central sleep apnea?
OPIOIDS!!!! They are very sensitive to these medications and have worsening of apnea
Why should you never put O2 on a child with history of OSA and walk away?
Children with OSA are chronic CO2 retainers and thus their respiratory drive is dependent on hypoxia! If you give them O2, then there will be no more respiratory drive and they will become apneic
What are poor prognostic indicators in CF? (4)
- Poor nutritional status
- Pneumothorax
- Burkholderia cepacia (very deadly bug in CF)
- Poor FEV1
What is the best test to rule out laryngeal cleft?
-clinical feature of laryngeal cleft?
Clinical feature: coughing/choking occurs DURING swallowing
-best test: rigid bronchoscopy is REQUIRED to rule it out!
How do you diagnose TEF? Name 2 tests.
UGI series to start, rigid bronchoscopy is gold standard
What is the differential diagnosis for vocal cord paralysis?
-unilateral vs. bilateral?
Bilateral vocal cord paralysis (hear inspiratory stridor)
-congenital CNS lesion (myelomeningocele, arnold-chiari malformation, hydrocephalus) = think of things that compress the brainstem (CN X)
Unilateral vocal cord paralysis (see choking, aspiration, coughing, weak cry)
-usually damaged by surgery/intubation to the recurrent laryngeal nerve
Dx: flexible awake laryngoscopy, need MRI head if bilateral vocal cord palsy, consider Neuro and Cardio consult
Tx: most spontaneously resolve within 6-12 mo but some bilateral paralysis require trach temporarily
You are unable to obtain a sweat sample in a neonate. List 3 other ways to confirm the diagnosis of CF.
- nasal potential difference
- genetic test for common mutations
- newborn screen (serum immunoreactive trypsinogen)
IV antibiotic treatment for lung abscess
clindamycin and gent
Treatment regimens should include a penicillinase-resistant agent active against S. aureus and anaerobic coverage, typically with clindamycin or ticarcillin/clavulanic acid. If gram-negative bacteria are suspected or isolated, an aminoglycoside should be added.
A 7 year old with CP, severe GERD and frequent choking spells while eating is admitted to the hospital with fever and increased RR. On CXR there is an air bubble in the LLL with surrounding consolidation and pleural effusion. What is the most likely organism that is causative:
anaerobes
