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Pediatrics > Respirology > Flashcards

Respirology Flashcards

1
Q

What is the diagnostic criteria for BRUE?

A

BRUE: a sudden, brief, and now resolved episode in a child <1 year of age, including ≥ 1 of the following:

1. Cyanosis or pallor
2. Absent, decreased, or irregular breathing
3. Marked change in tone (hyper- or hypotonia)
4. Altered level of responsiveness
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2
Q

Which areas of the lung are the “dependent areas” of the lung?

A
  • R and LUL

- Apical segment of the RLL

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3
Q

What antibiotics should be used in empiric treatment of lung abscess?

A

• 2-3 wks IV antibiotics for uncomplicated cases
• Follow with 4-6 wks of PO antibiotics
• Guide Abx choice with Gram stain results
• Empiric treatment: Penicillinase-resistant agent + aerobic coverage
i.e. Cloxacillin + Clindamycin/Clavulanic acid)

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4
Q

What is the definition for ARDS (Berlin definition)?

A
  • Acute onset (<7 days)
  • Severe hypoxemia (PaO2/FiO2 <300 for acute lung injury, or <200 for ARDS)
  • Diffuse bilateral pulmonary infiltrates consistent with pulmonary edema (can be patchy and asymmetric, and pleural effusions can be present)
  • Absence of L atrial hypertension (pulmonary artery wedge pressure <18 mm Hg if measured)
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5
Q

In what situations is pulse oximetry unreliable?

A
  • In highly deoxygenated states
  • In the presence of carboxyhemoglobin (overestimates as in cases of carbon monoxide poisoning)
  • In the presence of methemoglobin (over-/underestimates)
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6
Q

What are the diagnostic criteria to confirm asthma?

A
  • Change in 12% in FEV1 following use of bronchodilator
  • Positive methacholine challenge (PC20 < 4 mg/mL) or exercise stress test (> 10-15% decrease in FEV1 post-exercise)
  • FEV1/FVC ratio <0.8 of predicted
  • Increase of at least 20% in peak expiratory flow after use of bronchodilator
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7
Q

What are the Canadian Thoracic Association’s guidelines for GOOD control of asthma symtoms?

A
  • Daytime symptoms <4 days/wk
  • Night time symptoms <1 night/wk
  • Physical activity - normal
  • Exacerbations - mild/infrequent
  • No absences from work or school due to asthma
  • Need for a fast-acting beta2 agonist <4 doses/week
  • FEV1 or PEF ≥90% personal best
  • Sputum eosinophils < 2-3%
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8
Q

What are common allergenic triggers for children with asthma?

A
  • Indoor: Animal dander, dust mite, cockroach, molds
  • Seasonal aeroallergens: Pollens (trees, grass, weeds), seasonal molds
  • Air pollutants: Environmental tobacco smoke, ozone, N2O2, sulfur dioxide, particulate matter, wood/coal burning smoke, mycotoxins, endotoxins, dust
  • Strong/noxious odours/fumes: Perfumes, hairspray, cleaning agents
  • Occupational: Farm/barn exposures, formaldehydes, cedar, pain fumes, cold dry air, exercise, crying/laughter/hypeventilation
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9
Q

What side effects of chronic inhaled steroid use should be discussed with families?

A

• Most common:
- oral candidiasis (thrush) –> propellant induced mucosal irritation and local immunosuppresion
- dysphonia (hoarse voice) –> vocal cord myopathy
• Long-term, prospective NIH-sponsored CAMP study - slight height reduction of 1 cm in final adult height

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10
Q

What is generally a medium dose of ICS?

A

200-400 mcg/day

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11
Q

How does the treatment algorithm for asthma change based on age?

A
  • In children > 12 yoa, start with SABA, add low dose ICS and then consider LABA first before either medium dose ICS or leukotriene receptor inhibitor, then steroids or anti-IgE
  • In children 6-12 yoa, start with SABA, add low dose ICS then move to medium dose ICS before considering either LABA or leukotriene receptor inhibitor, then steroids or anti-IgE
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12
Q

What is the criteria for diagnosing asthma in a preschooler?

A
  • Documented or reliable history of wheeze or obstructive airflow by health care provider (or parent)
  • Documented response to inhaled SABA or oral steroids
  • Does not meet criteria for any other illness
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13
Q

What considerations should be made for asthmatic children preparing for elective surgery?

A
  • Asthma should be well controlled prior to surgery

* Caution should be used when using volatile inhalants for induction, particularly desflurane

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14
Q

What are some potential complications with chest tubes?

A
  • Injury on insertion (diaphragm, nerves, blood vessels)
  • Pneumothorax
  • Dislodgement
  • Malposition
  • Occlusion
  • Pain
  • Pulmonary re-expansion pulmonary edema
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15
Q

Causes of chylothorax

A

• Post cardiothoracic surgery
- Chest injury, ECMO
• Primary or metastatic intrathoracic malignancy (i.e. Lymphoma)
• Thoracic duct rupture during delivery
• Lymphangiomatosis
• Thrombosis of the duct, SVC or subclavian vein
• Infection: TB, histoplasmosis
• Congenital anomalies of the lymphatic system
- Missense mutation in integrin aα9 gene
• Trauma/Child abuse
• Idiopathic

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16
Q

How to manage a child with chylothorax?

A
  • Enteral feedings with a low fat or MCT, high-protein diet or TPN
  • Thoracentesis (repeated)
  • Pleuroperitoneal shunt, thoracic duct ligation or application of fibrin glue
  • Parenteral octreotide (0.5 - 1 µg/kg/hr to a maximum of 10 µg/kg/day) can be used
  • PPV with PEEP
17
Q

What condition is associated with PHOX2B mutations?

A

Congenital central hypoventilation syndrome

may also see a subset with Hirshsprung’s Disease

18
Q

What clinical manifestations are seen in cases of OSA?

A
  • Sleep related: Loud, frequent and disruptive snoring, Breathing pauses, Choking or gasping arousals, Restless sleep, More frequent partial arousal parasomnias (i.e. Sleepwalking and sleep terrors), Hyperextension of neck to maintain airway patency
  • Daytime: Mouth breathing, Dry mouth, Chronic nasal congestion/rhinorrhea, Hyponasal speech, Morning headaches, Difficulty swallowing, Poor appetite, Secondary enuresis, Daytime sleepiness with drowsiness, Increased irritability, mood instability and emotional dysregulation, Low frustration tolerance, Anxiety/depression, Aggression, impulsivity, hyperactivity, oppositional behaviour, conduct problems
19
Q

What is the gold standard test for OSA?

A

Polysomnogram

20
Q

What does the CPS recommend with respect to empiric treatment of pneumonia?

A
  • If uncomplicated, first line is amoxicillin
  • If requires hospitalization, ampicillin (IV)
  • If hospitalized and in resp distress, 3rd generation cephalosporin such as ceftriaxone
  • May add vancomycin if there is concern for MRSA

Standard treatment duration in Canada is 7-10 days (5 days if as outpatient)

21
Q

What are the most common pathogens in the case of pneumonia (immunocompetent host)?

A
  • Strep pneumo
  • S. aureus
  • Strep pyogenes (GAS)
  • MRSA
22
Q

What does the CPS recommend in the case of complicated pneumonia?

A

Cefotaxime/ceftriaxone +/- clindamycin (anaerobic infections/CA MRSA) OR vancomycin (MRSA)

No consensus on duration, typically 3-4 weeks

23
Q

What are the most common causes of pleurisy (inflammation of pleura)?

A

Bacterial pneumonia!!!

• Next most common causes:
○ Heart failure
○ Rheumatologic causes
○ Metastatic intrathoracic malignancy

24
Q

What is the genetic inheritance pattern of Kartagener Syndrome?

A

Heterogeneous group of disorders; generally AR but there are AD, X-linked conditions

25
Q

What is the classic Kartagener triad?

A
  • Situs inversus totalis
  • Chronic sinusitis
  • Bronchiectasis
26
Q

How is diagnosis of primary ciliary dyskinesia made?

A

• Nasal/tracheal mucosa biopsy & electronic microscopy (AbN ciliary structure; will not defect function defects in PCD)
• Electron microscopic analysis as the gold standard
□ Identifies abnormal structure i.e. Absence of inner/outer dynein arms, radial spokes or of the central microtubular pair
□ Normal - 9 outer doublets in a circular pattern surrounding a central pair of microtubles, maintained by radial spikes and intertubular linkage
• Genetics: 2 dz causing mutations in trans (DNAH5, DNAI1, DNAI2, DNAH11)
• High speed videomicroscopy & ciliary beat frequency (technically difficult, hard to do reliably)

27
Q

What clinical findings are suggestive of PCD?

A
  • Hx of neonatal respiratory distress, tachypnea, hypoxemia or respiratory failure
  • Chronic, daily nasal drainage that is non-seasonal, may be purulent, and may be present as early as the first weeks after birth
  • Chronic wet or productive cough, often worse in the early morning
  • Chronic otitis media or otorrhea, often requiring tympanostomy tube placement; complications include regional spread of chronic middle ear infection (e.g. Mastoiditis) and hearing loss
  • Recurrent or chronic bronchitis or pneumonia
  • Bronchiectasis
  • Male infertility
28
Q

What is the most common fatal AR inherited gene disorder among Caucasians?

A

CFTR (responsible for cystic fibrosis)

The most common CF gene mutation is Delta F508

29
Q

How many classes of Cystic Fibrosis are there and what are the associated defects?

A
  1. Class I: defective protein production, complete absence of CFTR protein
  2. Class II: defective protein processing which prevents the protein from going to the right location. This includes delta F508
  3. Class III: defective regulation which means diminished activity in response to ATP
  4. Class IV: defective conductance which means the rate of ion flow and duration of channel opening is reduced
  5. Class V: reduced number of active CFTR
30
Q

What is the diagnostic criteria for children with cystic fibrosis?

A

• Must have clinical symptoms + evidence of CFTR dysfunction
○ Sweat chloride > 60mmol/L on 2 occasions
○ Presence of 2 disease causing mutations
○ Abnormal nasal potential difference

• Clinical symptoms not required if identified by newborn screening

31
Q

What are some potential causes for a false positive sweat chloride test?

A
  • Eczema
  • Ectodermal dysplasia
  • Malnutrition
  • Hypoparathyroidism
  • Adrenal insufficiency
  • CAH
  • Pseudohypoaldosteronism
  • Hypothyroidism
  • Nephrogenic DI
  • Pancreatitis
  • Hypogammaglobulinemia
32
Q

What are some potential causes for a false negative sweat chloride test?

A
  • Edema
  • Done too early (<48 hrs)
  • Wt <7 lbs (3.1 kg)
  • Poor technique
  • Meconium ileus
  • Hyponatremia
33
Q

What nutritional deficiencies are expected in children with CF?

A
  • Fat soluable vitamins: ADEK
  • Iron
  • Zinc
34
Q

What organisms are commonly seen in CF patients? Which are more concerning for long term prognosis?

A
  • Staph aureus and Haemophilus influenzae (will also see stenotrophomonas and achromobacter)
  • Pseudomonas (biofilm makes eradication almost impossible)
  • Burkholderia cepacia can cause rapid decline in lung function
35
Q

How do you diagnosis allergic bronchopulmonary aspergillosis?

A
  • Patients may present with rust coloured sputum that is non-responsive to antibiotics
  • Confirm with blood work and investigations
    • ↑ total IgE levels, specific aspergillus IgE and IgG
    • Positive sputum culture
  • CT showing central bronchiectasis and mucous plugging
36
Q

At what point should a lung transplant be considered for a patient with CF?

A

An FEV1 < 30 is often an indication for transplant

37
Q

What antibiotics should be used to treat CF exacerbations?

A
  • Ceftazidime and tobramycin

* (oral steroid and itraconazole for ABPA)

38
Q

What interventions should be done to treat a CF exacerbation?

A
  • Bronchodilators
  • Hypertonic saline (7%)
  • DNase/pulmozyme
  • Chest physiotherapy
  • Azithromycin for anti-inflammatory properties
  • GI support via enzyme replacement, PPI, PEG3350 as required

Pediatrics (27 decks)

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