Respirology Flashcards
1
Q
Length of “Acute cough”
A
• Acute cough <3 weeks
2
Q
Length of “chronic cough”
A
• Chronic cough >4-8 weeks
3
Q
How long can a cough last after a viral infection?
A
Persistenceofcough after viral infection:
– 10 days: 50%
– 16 days: 25%
– 25 days: 10%
4
Q
How often is there a choking history with aspiration?
A
Clinical choking history in ~40-85% of cases
5
Q
How old are most kids with FBA?
A
• Majority of cases <3 years of age
6
Q
Symptoms of FBA?
A
• Symptoms of presentation – Cough – Wheeze/stridor – Dyspnea/Respiratory distress – Asymptomatic
7
Q
CXR findings for FBA?
A
Radiologic findings – Localized emphysema – Pneumonia – Atelectasis – Normal
if you have a foreign body in a mainstem bronchi you can breathe air IN but it is hard to breathe out/ Hyperinflation of affected lung
8
Q
Consequences of missed foreign body:
A
– Recurrent pneumonia
– Bronchiectasis
- Cardiac Arrest
9
Q
Investigations if cough >4 weeks
A
CXR
PFTs
10
Q
Differential for chronic cough
A
Healthy Children
• Frequent viral respiratory 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 • Cystic Fibrosis • Immunodeficiency • Primary Ciliary Dyskenesia • Foreign Body Aspiration • Recurrent Pulmonary Aspirations • Tuberculosis • Anatomic Disorder • Interstitial Lung Diseases
11
Q
What is a honking cough that disappears with sleep?
A
psychogenic cough
12
Q
What has a Dry cough, dyspnea, restrictive spirometry
A
Interstitial Lung Disease
13
Q
What has Progressive cough, weight loss, fevers,
A
TB, Malignancy
14
Q
Red flag symptoms for chronic wet cough
A
Concerning features – Year round – Starting at early age – Not responsive to therapies – Specific pointers to other illnesses
15
Q
Chronic Wet Cough differential
A
- Cystic Fibrosis
- Primary Ciliary Dyskinesia
- Immunodeficiency
- Bronchiectasis
- Persistent Bacterial Bronchitis
- Missed Foreign body
- Chronic Infections
- Asthma+/- AllergicRhinitis
- Recurrent Viral Infections
16
Q
How does CF present in infancy
A
Infancy • Failure to thrive • Meconium ileus • Recurrent respiratory symptoms – Wheeze, cough, bronchiolitis • Hyponatremic, hypochloremic metabolic alkalsosis • Prolonged Jaundice • Severe pneumonia
17
Q
How does CF present in childhood/adolescence
A
• Recurrent respiratory symptoms
– Cough, pneumonia, wheeze poorly controlled asthma etc..
• Failure to thrive
• Recurrent rectal prolapse
• Clubbing
• Bronchiectasis
• Nasal polyps/sinus disease nasal polyps in children are CF until proven otherwise
• Chronic Pseudomonas aeroginosa colonization
18
Q
Diagnosis of CF
A
Prenatal: CVS with DNA analysis/ amnio
Postnatal:
– Newborn Screening: IRT (immunoreactive trypsinogen level)
• Sweat Chloride – ≥60mEq/L – Normal: • <30 1st 6 months • >40 after 6 months • CFTR analysis may be misleading should not do without first having SCT – >1900 associated mutations – >160 disease causing mutations • Newborn Screen programs may miss up to 5% of classic CF
Diagnostic criteria —
Both of the following criteria must be met to diagnose CF:
1) Clinical symptoms consistent with CF in at least one organ system
OR
Positive newborn screen
OR
Having a sibling with CF
AND
Evidence of cystic fibrosis transmembrane conductance regulator (CFTR) dysfunction (any of the following):
Elevated sweat chloride ≥60 mmol/L
OR
Presence of two disease-causing mutations in the CFTR gene, one from each parental allele
OR
Abnormal NPD (nasal potential difference)
19
Q
Treatment of CF
A
• Multidisciplinary Clinic
– Nurse,Physiotherapy, Dietician, Social Worker, Psychologist
• Aggressive treatment of infections, airway secretion clearance, nutrition
• Novel therapies aimed at underlying CFTR mutations
– $$$$$
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
20
Q
Why do we do genetic testing in CF?
A
To help with various treatment options
21
Q
Median survival age for CF?
A
Median survival age: 50.9
– Median age of death: 34
22
Q
Prognostic factors for CF?
A
Male > female – Lung disease • FEV1 • Burkohlderia Cepacia • Pneumothorax – Nutritional status*** • Weight/height • Diabetes
23
Q
Clinical Presentation of PCD?
A
Clinical – Year round daily wet cough – Year round nasal congestion – Recurrent Otitis media – Neonatal Respiratory distress - male infertility – Laterality defects (situs inverses totalis)
24
Q
Diagnosis of PCD?
A
Electron Microscopy
Nasal nitric oxide
Genetic testing
25
What is protracted bacterial bronchitis?
• Emerging (controversial) diagnosis
– >3-4 weeks of chronic wet cough
– Resolution of cough with antibiotic treatment
– Associated with significant pus and neutrophils on bronchoscopy
26
How old are kids who get protracted bacterial bronchitis?
Most common in children <5 years of age
27
Most common pathogens in protracted bacterial bronchitis
H influenza
S. Pneumo
S. Aureus
M Catarrhalis
28
When should you consider a diagnosis of laryngeal cleft?
```
• Associated with direct aspiration on swallowing (recurrent aspirations)
• Videoflouroscopy
• Rigid bronchoscopy required to rule out
– Grade1-4
• Consider with syndromes
– VACTRL
– CHARGE
– OpitzFrias
– MidlineDefects
```
29
What conditions pre dispose you to recurrent aspirations?
– Choking/coughing with feeds, especially liquids
– Neurologic abnormalities
– Previous intubations
– Syndromes associated with anatomic malformations (VACTRL)
30
How to diagnose a H type fistula?
Rigid Bronchocopy is gold standard
31
Characteristics of psychogenic cough?
usually do not look distressed
more often in the daytime, goes away at night
often starts with viral infection + cough —> turns into psychogenic cough can be successful to get them to drink water every time they need to cough can last years in some children
32
Treatment of Non specific chronic cough?
• Medium dose Inhaled corticosteroids
– Especially if positive family or atopic history, wheezing or other signs of asthma
• Intranasal corticosteroids +/- anti-histamines
– Especially if other signs and symptoms of chronic
rhinitis and/or upper airway symptoms
• Always look for red flags and give a time defined treatment trial
33
Chronic Wet cough should have what investigations?
Strong consideration for children with a chronic wet cough should include:
- CXR
- PFT with bronchodilator
- sweat chloride
• Further investigations based on above +/- trial of treatment
34
What is asthma
- paroxysmal or persistent symptoms such as dyspnea, chest tightness, wheezing, sputum production, and cough
- associated with variable airflow limitation and airway hyperresponsiveness to endogenous and exogenous stimuli.
- Inflammation and it’s resultant effects on airway structure are considered the main mechanisms leading to the development and persistence of asthma.
35
What are the symptoms of good asthma control?
```
Daytime Symptoms: <4 days/week
Nighttime Symptoms: <1 night/week
Physical Activity: Normal
Exacerbations: Mild, Infrequent
Absence from work/school: None
Fast acting B-agonist use: <4 doses/week*
FEV1 or PEF: ≥90% personal best
PEF diurnal variation: <10-15%
Sputum eosinophils (adults): <2-3%
```
36
Diagnosis of Asthma
```
Clinical symptoms
+
Diagnosis of Asthma
• Objective evidence
– Spirometry: obstruction (↓FEV1/FVC) + bronchodilator
response (↑FEV1 by ≥12%)
– Peak Flow: increase by ≥20% following bronchodilator
– Methacholine Challenge:
• +ve: <4 mg/mL
• Borderline: 4-16 mg/mL
• Negative: >16mg/mL
```
37
What ages should use an aerohamber?
All!!
But can switch to mouth piece at 5 years of age
38
Management pathway for asthma for kids 6-11 years of age
```
Low Dose Inhaled Corticosteroid
Low-Medium Dose Inhaled Corticosteroid
THEN
Medium Dose Inhaled Corticosteroids (201-400 mcg/day)
THEN
Add a LABA or Add a LTRA
THEN
add the other
THEN
Medium Dose Inhaled Corticosteroids + LABA + LTRA
```
39
Management pathway for asthma for kids >12
Low Dose Inhaled Corticosteroid (≤250 mcg/day)
THEN
Low Dose Inhaled Corticosteroid + LABA
THEN
Increase ICS to Medium Dose OR Add LTRA
THEN
Add the other
THEN
Low-Medium Dose Inhaled Corticosteroids + LABA + LTRA
40
Low/Med/High dose for fluticasone in kids 6-11
Fluticasone
Low Dose: ≤200
Med Dose:201- 400
High Dose: >400
41
Low/Med/High dose for fluticasone in kids >12
Fluticasone
Low Dose: ≤250
Med Dose: 251-500
High Dose: >500
42
A clinical diagnosis of asthma in preschool children is:
A clinical diagnosis of asthma can be made in preschool children with a combination of:
– Documentation of airflow obstruction
– Documentation of reversibility of airflow obstruction
– No clinical evidence of alternative diagnosis
Preferred when these are done by healthcare professionals
– Convincing parental reports
43
Low/Med/High dose for fluticasone in kids <5
Fluticasone
Low:100-125
Med: 200-250
44
Management pathway for asthma is kids less than 5
```
Low Dose Inhaled Corticosteroid
THEN
Increase ICS to Medium Dose
THEN
Medium Dose Inhaled Corticosteroid + Leukotriene Receptor Antagonist
```
45
What is the definition of recurrent pneumonia
– ≥2 pneumonias in 1 year or ≥3 lifetime
| • Radiologic clearing in between episodes
46
Differential diagnosis for recurrent pneumonia that is always in the same location?
```
• Anatomic abnormality
– External airway compression (ie – lymphadenopathy, vascular abnormality)
– Intrinsic airway abnormality
• Congenital malformation
– CPAM
– Pulmonary sequestration
– Bronchogenic Cyst
• Foreign Body
• Right Middle Lobe syndrome
• Bronchiectasis
• Persistent Infection (ie TB)
```
47
Differential diagnosis for recurrent pneumonia that is in different locations?
```
Multiple locations
• Immune deficiency
• Cystic Fibrosis
• Primary Ciliary Dyskinesia
• Recurrent aspirations – Anatomical
– Swallowingdisorder
– Neurologicimpairment
```
48
Congenital Pulmonary Malformations Diagnosis?
Majority today are diagnosed prenatally
– All symptomatic lesions require surgical resection
• Increased risk of pneumonia
• Increased risk of malignancy
49
Congenital Pulmonary Malformations Imaging?
CT chest WITH CONTRAST
50
What are the clinical symptoms of OSA?
```
Neurocognitive
– Behavioral,attention,school
performance, development
• Cardiovascular
– Hypertension,CorPulmonale
• Failure to Thrive
• Inflammatory
• Quality of Life
```
* Behavioral problems
* “ADHD” symptoms
* Poor School Performance
* Developmental delay
* Shyness
* Difficulty waking up in AM
* Failure to thrive
* Enuresis
* Daytime fatigue
51
OSA Diagnosis
```
1) Polysomnography
Benefits
– Gold Standard for diagnosis of OSA
– Best differentiation of severity
• Limitations
– Poor accessibility in Canada
– Does not always correlate with sequalae
```
```
2) Overnight Oximetry
• Benefits
– “Positive”test in context of symptoms can be diagnostic
– Easily available
• Limitations
– Poor sensitivity
– Does not differentiate causes of desaturations
– Technical limitations`
```
52
OSA treatment
Non-Pharmacologic
– Nasal hygiene saline rinses
– Sleep hygiene
• Pharmacologic
– Intranasal Corticosteroids
– Montelukast
• Surgical
– Adenoidectomy • +/- Tonsilectomy
If obesity related:
• Weight Loss
• ContinuousPositive Airway Pressure (CPAP
53
Side effects of ventolin
↑HR, tremors, hypokalemia
54
When is ipatropium bromide most effective?
Anticholinergic-BD by antagonizing Ach at receptor
↑ FEV1 by 10% if added to β2 agonist
Works best in 1st four hours
55
Main side effect of LABA?
Tachyphylaxis
- lasts ~12 hrs
• Add to IHS if inadequate control with optimal dose
• Must be used with inhaled steroid (combo inhaler)
56
Side effects of ICS?
oral thrush
hoarseness
↓ linear growth with high dose
57
What is Omalizumab and when/who is it used in?
Recombinant DNA-derived humanized IgG monoclonal antibody
• Selectively binds to human IgE
• Subcutaneous injection q 2 – 4 weeks
• For moderate to severe persistant allergic asthma,
not controlled on IHS
• For >12 years of age
• Risk of anaphylactic reaction – done in MD office
58
How do steroids help with asthma exacerbations?
They help increase the responsiveness of B2 agonists
59
Typical Age of Epiglottitis?
2-6
60
Bugs causing epiglottitis?
Bacterial: H. influen- zae type B (+++), B-hemolytic strep (+)
61
How does epiglottitis present clinically?
```
Toxic
Severe airway obstruction
Drooling, sitting forward
Stridor
Sternal recession
```
62
Age of croup?
6 months - 4 years
63
Bugs causing croup?
parainfluenza 1
RSV
Influenza
64
Clinical Presentation of Croup
```
Not toxic
Not drooling
Stridor common
Sternal recession common
Barking cough
hoarseness
coryza
```
65
Common age for bacterial tracheitis
any age
66
Bugs causing tracheitis
S. Aureus
pneumococcus
H.influenzae
67
Clinical Presentation of tracheitis
Toxic; croup-like cough Stridor
68
Inheritance of CF
Autosomal Recessive
• CFTR is abnormal- Cystic Fibrosis Transmembrane
Regulator Protein
69
PFT findings for CF
PFTs:
– Early disease - peripheral airway disease - results in airway obstruction, gas trapping, ↓FEF25-75
– Late disease - chronic inflammation- ↑lung destruction and fibrosis- late: restrictive pattern with persistent gas trapping
70
Causes of elevated sweat chloride test
```
Cystic fibrosis
• Untreated adrenal insufficiency
• Glycogen storage disease, type I
• Fucosidosis
• Hypothyroidism
• Nephrogenic diabetes insipidus
• Ectodermal dysplasia
• Malnutrition
• Mucopolysaccharidosis
• Panhypopituitarism
```
(skin and things that make you salty)
71
CF bugs
```
Bugs:
• S Aureus
• H Influenza
• Psuedomonas Aeruginosa
• Burkholderia Cepacia
• Aspergillus fumigatus
```
72
What is ABPA?
Allergic bronchopulmonary aspergillosis (ABPA)
- Hypersensitivity reaction in response to colonization of the airways with Aspergillus fumigatus
- Occurs almost exclusively in patients with asthma or CF
- In chronic cases, repeated episodes of bronchial obstruction, inflammation, and mucoid impaction can lead to bronchiectasis, fibrosis, and respiratory compromise.
73
Clinical Presentation of ABPA?
Wheezing
Increased cough
Rust colored sputum or "brown plug"
Have high suspicion in patients >6 years of age, screen yearly with IgE levels
74
Labs suggestive of ABPA?
Decreased PFTs
Peripheral eosinophilia
Increased IgE
Specific precipitants to aspergillus
75
Diagnosis of ABPA?
Skin test for aspergillus
| And IgE level
76
Treatment of ABPA?
Steroids
Remember – allergic! Decrease systemic response to aspergillus
Tx for months
Antifungals can be added but that is to decrease the aspergillus load so steroids can work
77
How do you monitor ABPA?
Monitoring
| IgE levels to trend
78
What electrolyte disturbances present with CF?
Hyponatremic, hypochloremic dehydation
79
Treatment of PCD?
Treatment
– no cure available
– Regular chest physiotherapy
– Aggressive antibiotic treatment
– Routine and other vaccinations, flu shot
– Surgical intervention • Tympanostomytubes • Sinus drainage
80
Causes of Pneumothorax
```
Causes:
idiopathic/spontaneous
thoracic trauma
RDS/ meconium aspiration CF with pleural blebs
Asthma
Marfans
+/- mechanical ventilation
```
81
Treatment of pneumothorax
```
Treatment
conservative, +/- 100% oxygen
chest tube
+/- surgery
pleurodesis for recurrent pneumothorax
```
PTX has nitrogen in it (just like regular air, 80%)
theoretically want to wash out the nitrogen - replace it by O2 - which then reabsorbs
82
Treatment of tension pneumothorax
Tension Pneumothorax
Intrapleural pressure> atmospheric pressure
Ipsilateral lung collapses
Mediastinal shift
↓venous return
Management – needle aspiration, chest tube
83
What is a transudate?
Transudates occur secondary to conditions which cause an increase in the pulmonary capillary hydrostatic pressure or a decrease in the capillary oncotic pressure
Leads to accumulation of protein poor pleural fluid
Common causes include: CHF, nephrotic syndrome, cirrhosis, hypoalbuminemia, pulmonary embolism
LOW PROTEIN
84
What is an exudate?
Exudates occur secondary to conditions which cause inflammation or increased pleural vascular permeability
Leads to accumulation of protein rich pleural fluid and cells
Common causes include: pneumonia, cancer, tuberculosis, pulmonary embolism
HIGH PROTEIN
85
What is bronchiectasis?
Bronchiectasis
- irreversible dilatation of the airways
- inflamed and easily collapsible airways
- obstruction to airflow
Diagnosis is established clinically on the basis of cough on most days with tenacious sputum production
- often one or more exacerbations/year,
86
Imaging modality to diagnose bronchiectasis?
CT:
- presence of bronchial wall thickening and airway dilatation
- "tramlines" railroad tracks that should taper but dont
- signet ring - airways diameter is bigger than neurovascular or vascular bundle beside it
87
Clinical presentation of OSA?
Night: paradoxical chest and abdo motion, snoring, apnea, sweating, cyanosis
Day: Mouth breathing, difficulty waking up, moodiness, daytime sleepiness, hyperactivity, cognitive problems
88
What is OSA?
Repeated events of partial or complete U/A obstruction during sleep, disrupting normal gas exchange and sleep patterns
89
AHI for moderate OSA?
>5
90
AHI for severe OSA?
>10
91
Investigations for OSA?
```
Investigations
• Lateral Neck Xray
• overnight oximetry
• early morning capillary blood gas
• polysomnography
```
92
Treatment of OSA?
Treatment
• T&A (if severe and clinical signs of tonsillar hypertrophy)
• NIPPV-CPAP
93
D/Dx for central apnea/hypoventilation
```
Insufficient resp drive
– CCHS (10)
– Arnold-Chiari malformation (10)
– Asphyxia (20)
– Tumour (20)
– Central System Infarct (20)
– Medications (20)
– Decreased muscle strength (e.g SMA) (20)
```
Rx: Depends on etiology
94
Pattern of restricted PFT?
Small...lower lung volumes. Small loop
Ddx
- pulmonary fibrosis (eg post radiation)
- chest wall deformity
- ??neuromuscular
95
Pattern of obstructed PFT?
SCOOP
- asthma for sure
CF - would be obstructive but no increase in FEV1 post bronchodilator
- if no response to bronchodilators THINK BRONCHIECT ASIS
- CF
-PCD -Bronciolitis obliterans -asthma still
