Review + OSA + OHS + Croup Flashcards
Review histoplasmosis
Inhalation of soil with bat and bird droppings Ohio+Mississippi river
Flu like symptoms, atypical pneumonia
Disseminated in immunocompromised: fever, weight loss, hepatosplenomegaly
PCR antigen assay w urine or sputum
Cultures
Chest radiograph shows infiltrates
If asymptomatic, no tx
Mild: itraconazole
Severe: amphotericin B
Review cryptococcosis
Soil + bird feces inhalation
Immunocompromised
Starts in lungs and may spread to brain - MCC of fungal meningitis
Pneumonia. Cough, pleuritic chest pain, dyspnea, Pulmonary nodules
Lumbar puncture with India ink staining
Respiratory cultures
Review coccidiomycosis
Soil in desert regions of southwestern US
inhalation of spores w minor soil disruption
MC asymptomatic.
Pulmonary: flu-like symptoms and pneumonia.
Cutaneous: Erythema nodosum on anterior shins 2-20 days after onset.
Disseminated: meningitis. Lungs, skin, soft tissues, bones.
EIA for IgM and IgG antibodies
Lumbar puncture for antibodies and fungal pattern
CXR: hilar lymphadenopathy, cavitations.
If asymptomatic, no tx
If CNS: PO fluconazole or itraconazole.
If severe, amphotericin B
Review blastomycosis
Immunocompetent outdoor activities also in Ohio + Mississippi river valleys
Pulmonary: asymptomatic, cough w/ or w/o sputum, fever, pleuritic chest pain, pneumonia.
Cutaneous: papules progress to verrucous, crusted, or ulcerated lesions.
Disseminated: skin, bone (osteomyelitis), GU (prostatitis or epididymitis)
Urine antigen or sputum shows yeast.
CXR: alveolar infiltrates or mass lesion.
Mild-moderate: Itraconazole 6-12 mo.
Severe: Amphotericin B then voriconazole
Review epiglottitis
H flu historically
Dysphagia, drooling, respiratory distress, high fever, odynophagia, inspiratory stridor, muffled hot potato voice, tripoding
CXR shows enlarged epiglottis (thumbprint sign)
Airway maintenance. ENT intubates.
Ceftriaxone, cefotaxime, or cefuroxime. Dexamethasone for swelling in some.
What does this presentation indicate:
- witnessed breathing pauses, restless/non-refreshing sleep, awakenings w/ gasping/paroxysmal nocturnal dyspnea, insomnia, excessive daytime sleepiness, fatigue?
obstructive sleep apnea
What are RFs for OSA?
obesity, large neck circumfrence, male sex, older age, snoring, cigarette smoking, use of alcohol/sedatives before sleeping, abnormalities, endocrinopathies (Hypothyroidism)
Blacks, Asians, NAs, Hispanics
With OSA + HTN, what should you screen for?
primary aldosteronism
What do you need to assess in order to get a sleep study for your OSA patient?
Epworth Sleepiness scale and neck circumfrence
What may you see on a PE that could lead you to OSA?
Modified Mallampati score (3-4), retrognathia or increased overjet, peritonsillar narrowing, hypertrophy, macroglossia, enlongated/enlarged uvula, odd shaped hard palate, nasal abnormalities, “bull neck”
What is common in bloodwork of OSA?
erythrocytosis
also consider thyroid tests
What is the gold standard of Dx for OSA? What values are necessary for diagnosis?
in-lab polysomnography – confirmed by number of obstructive events >/5 events/hour WITH symptoms or >15 events/hour w/o symptoms
How do you rate OSA?
mild - RDI>/ 5 events<15
moderate - RDI>/15<30
severe RDI>/30/hour
How can you treat OSA?
weight reduction, avoidance of alcohol and hypnotic medications
CPAP = TOC
What is indicated for OSA patients w/ mild/moderate OSA, unresponsive to CPAP, or not candidates for CPAP, or fail behavioral measures?
Oral appliances (MAD, tongue retaining devices)
When are surgical procedures indicated for OSA?
obvious anatomical obstructions, fail or do not tolerate initial therapy w/ CPAP or MAD
always f/u to assess improvement
What’s the presentation of obesity hypoventilation syndrome?
obesity + daytime hypoventilation + sleep-disordered breathing
nocturnal hypoventilation: waking headaches, peripheral edema, hypoxemia (<94% on RA), unexplained polycythemia
stable may be consistent w/ OSA
What are risk factors for OHS?
Obesity (especially BMI>40), pre-existing OSA
T/F: OHS have higher risk of complications in surgery so you must recognize this ahead of time
T
What does this PE indicate:
BMI>/30
breathing pattern shallow + rapid
large neck circumference
jugular venous distention –> RHF
peripheral edema –> RHF
OHS
What could you workup with OHS?
ABG, overnight in-lab polysomnography, daytime finger pulse oximetry, PFTs, ECG, TTE, TSH, Hgb
What is the diagnostic criteria for OHS?
1) BMI>/ 30
2) hypoventilation during awake hours (hypercapnia PaCO2 >/ 45mmHg)
3) sleep disordered breathing confirmed by polysomnography
4) exclusion of other causes
What should you suggest for OHS?
reduce weight, avoid contributors to hypoventilation (alcohol and sedatives)
What is your treatment for OHS?
CPAP
what should you avoid for OHS?
sedative hypnotics, alcohol, opioids
adjunct therapy = dietary consult, physical activity, oxygen
What does this indicate: Gradual onset w/ URI symptoms (nasal congestion, rhinorrhea, cough, low fever) –> barking cough, hoarseness, stridor, for 3-5 days but infectious up to 2 weeks?
croup
Who’s at risk for croup
6 mo -3 years old
What pathogens can cause croup?
parainfluenza virus, RSV, influenza
croup is the MC cause of ______ in children
airway obstruction
What does a steeple sign and leukocytosis indicate?
croup
What do all croup patients need?
humidified room + one time PO steroid (dexamethasone)
What do you use to treat moderate-severe croup (stridor at rest)?
nebulized racemic epinephrine in addition to supportive care w humidifier and one time steroid (dexamethasone)
What’s croup also called?
Laryngotracheitis
