Test #2 Flashcards
Croup causative agent
Parainfluenza virus
Can also be caused by:
RSV
Influenza virus
Adenovirus
Croup hallmarks
Occurs between 6 months and 3 years most commonly
URI sx with barking cough and stridor on inspiration with absent/low grade fever
Triggered by circaidian rhythms (happens @ night)
Croup treatment
Stridor at rest: Racemix epi via nebulizer
Steroids - Decadron (liquid or powder)
Barking, no stridor at rest: mist therapy, cold air to dilate bronchioles
Worse on 3rd day
Epiglottitis causative agent
Most commonly H. flu Type B
Can also be cause by Group A Strep
Worry about asplenic kids - encapsulated bacteria
Epiglottotis hallmarks
Drooling, muffled “hot potato” voice
“Cherry red spot” epiglottis, stoic child
Can have grunting or soft stridor
Epiglottitis treatment
Be ready to intubate
Call in pediatric anesthesia
Get STAT soft-tissue lateral portable xray
Bronchiolitis (in peds)
Inflammatory process of smaller, lower airways
Can proceed to respiratory failure -> death
Preemies or infants with congenital heart/chronic lung/immunodeficiencies at risk for more severe disease and poorer outcomes
Bronchiolitis presentation
Fever, URI sx, tachypnea, wheezing
WBC normal
CXR clear
Mucopurulent sputum is possible, usually always viral
Bronchiolitis causative agents
RSV
can also be caused by Adenovirus and parainfluenza
Bronchiolitis Treatment
Only effective agents are oxygen and Ribavirin (reserved for immunocompromised/severly ill/premature infants
Palivizumab (Synagis) - IM monoclonal Ab providing passive immunity against RSV
Pneumonia in kids
Most cases are viral, but unable to predict so usually tx w/ Abx
Bacterial pneumonia presentation is more abrupt
Viral often with prodrome
Pneumonia in kids - causative agents
Varies with age
Newborns: group B Strep, Listeria, Gram negatives (E. coli, Klebsiella_
After 3 months of age: Strep pneumonae
Adolescent: Mycoplasma
Pneumonia in kids - presentation
Varies more, can be as little as tachypnea
Bacterial: Sudden, rapid onset with shaking chills, higher fevers
Viral: prodrome of rhinorrhea, cough, low-grade fever, pharyngitis
Newborns: poor feeding, irritable early on but become stoic later, cyanosis, hypoxic
Pneumonia in kids - labs
WBC elevated
CXR is more variable than adults, typically lacks classic lobar consolidation
Pertussis
“Whooping Cough”
Highly communicable, not all vaccinated seroconvert - can lose immunity over time
Dangerous for small infants - respiratory distress from coughing is what kills them
Lasts 4-12 weeks
Pertussis causative agent
Bordetella pertussis (Gram negative, aerobic, encapsulated coccobaccilus)
Pertussus presentation
Insidious onset with URI sx, +/- slight fever, cough but not paroxysmal
Cough for weeks, becomes paroxysmal with classic “whoop” after 2 weeks - this lasts 2-4 weeks
Cough so hard they vomit
Pertussis labs
Nasal swab for culture (Bordet-Gengou medium)
Or nasal swab for PCR - more sensitive, results in 3-7 days
Pertussis Treatment
Tx while awaiting labs - only shortens cough if tx in early phase
Tx prevents further transmission
Erythromycin for 14 days
Azithromycin for 5-7 days
Pt can cough for 3 months - educate!
Pediatric Infectious Disease Pearls
Bronchiolitis - RSV w/ wide spectrum -> peaks ~6 months old
Difficult to distinguish bronchitis from pneumonia or bacterial from viral -> tx with Abx
Pertussis -> Tx w/ confirmed exposure, dont wait for labs
Cystic fibrosis pneumonia treatment
Aminoglycoside (cover pseudomonas)
Piperacillin/Ticarcillin (antipseudomonal PCN)
bronchodilators, O2 as needed, myolytics, possible steroids
Cystic fibrosis diagnostic tests
Sweat chloride testing
DNA Assay
IRT Assay
Cystic fibrosis
Autosomal recessive
Exocrine gland system disease
defective chloride channels -> highly viscous secretions
Causes both respiratory and pancreatic insufficieny
Cystic fibrosis treatment
Pulmonary: bronchodilators, mucolytics, steroids, Abx
Pancreatic: enzyme and vitamin supplements, high-caloric high-protein diet
Cystic fibrosis morbidity
Progressive obstructive lung disease
Cystic fibrosis presentations
Meconium ileus (not passed w/in 24 hrs of birth)
abdominal distention with thick, sticky meconium
infantile failure to thrive, respiratory compromise, or both
Fetal lung development
Cannalicular stage - 16-25th week -> lungs transition to viable
Sacular stage - 24th week -> gas exchange is now possible
Surfactant delivered during 3rd trimester
Respiratory Distress Syndrome of Newborn
Commonly in preterm infants
Due to pulmonary surfactant deficiency
Inflammation, pulmonary edema, and hypoxemia also contribute
28 weeks and less at greatest risk
Respiratory Distess Syndrome of the Newborn Clinical manifestations
Tachypnea
Nasal flaring
Expiratory grunting
Accessory muscle breathing
Cyanosis
Abnormal pulmonary function w/in 48 hrs post-birth
Respiratory Distress Syndrome of Newborns Treatment
Surfactant
CPAP
O2
Antinatal glucocorticoids
Acute bronchitis common causes
Viral (80-90% all cases) - usually influenza A and B
Bacteria - strep pneumo, h-flu, Chlamydia and Mycoplasma
Have to r/o Bordatela pertussis cause
Whooping cough organism and treatment
Bordatella pertussis
Tx w/ a macrolide
Acute bronchitis Abx for <65 yo, no cardiac disease, FEV1> 50%, or <3 exacerbations per year
Azithromycin - 500 mg PO day 1 - 250 mg PO x4 days
Clarithromycin - 250-500 PO BID x7-14 days
Doxycycline - 100 mg PO BID x7 days
Bactrim (160/800) - 1 tab PO BID x10-14 days
Cefuroxime - 250-500 PO q12 hrs x10 days
Cefdinir - 300 PO BID x5-10 days
Cefpodoxime - 200 PO q12 hrs x10 days
Make sure to tx w/ alternative class if Abx use w/in 3 months
Acute bronchitis Abx for pts w/ COPD exacerbation, >65 y/o
Consider hospitalization
Augmentin - 1 tab PO BID x7-10
Fluroquinalones - Cipro if Pseudomonas risk
Latent TB treatment
Isonazid for 6-9 months ->9 if HIV+
OR isonizaid + rifapentine for 3 months if HIV-
OR isonizaid + rifampin for 3 months if HIV+
Active TB treatment
Isonazid + Rifampin + Ethambutol + Pyrazinamide for 2 months
THEN Isonazid + rifampin for 4 months
Increase tx to 9 months if sputum culture is not negative at 8 weeks
Aspergillosis
Commonly affect immunosuppressed
Fungal spores found in soil/dead matter
Hemopytsis, cough, fever, malasie, wheezing, weight loss
CXR nonspecific
Aspergillosis treatment
Voriconazole
Ampho B - watch for dizziness, N/V/D, SOB, fever, weight loss
Abx effective against bactera lacking a cell wall
Macrolides
Imipenim
Pneumonias with a non-productive cough
Mycoplasma
Chlamydia
CXR shows cavitary lesion and pleural effusions
H-flu
Staph aureus
Anaerobic
TB
Legionella in lung
lower lobes
Klebsiella in lungs
upper lobes
HAP common bacteria
Pseudomonas
Staph aureus
Enterobacter
Klebsiella
E. coli
leukopenia sign of
sepsis
Intrapulmonary pressure
pressure w/in the alveoli
becomes more negative with chest expansion to suck air into lungs
Intrapleural pressure
Negative pressure in the pleural space
Keeps lungs flush against chest wall and eases chest wall expansion
May be lost if fluid collects in pleural space -> lung cannot fully expand
Light’s criteria
Has to meet any one => exudative
- Pleural fluid protein/serum protein ratio > 0.5
- Pleural fluid LDH/serum LDH > 0.6
- Pleural fluid LDH > 2/3 lab normal serum LDH (~ >200)
Benign pulmonary neoplasms
grow in fairly ordered manner
stick together w/out migration
encapsulated with smooth borders
Hamartomas and granulomas
Hamartoma
local tissue grows in disorganized manner
often have bronchial tissue and calcifications
Granuloma
chronic inflammatory lesions with macrophages
TB, sarcoidosis, histoplasmosis, cryptococcosis
Most common metastatic to lungs
Breast
Colon
Prostate
Bladder
Malignant cells
Tumors
rapid growth w/ continuous division
Little/no differentiation with most normal function lost
Irregular, invasive borders that metastasize
Malignant cell spread routes
Transcoelomic
Lymphatic
Hematogenous
Iatrogenic
Transcoelomic spread
Along the surface of an organ
Mesothelioma
Lymphatic spread
Most common route for carcinomas
Hematogenous spread
Most common route for sarcoidosis
Iatrogenic spread
Transplantation or implantation
Small cell lung cancer (SCLC)
Primitive neuroendocrine cells
Metstasizes early, commonly to brain (90%)
Aggressive, rapidly fatal, few curable
Highly prevelant among smokers
SCLC hormone production
Adrenocorticotrophic hormone (ACTH)
Arginine vasopressin (AVP)
Atrial natriuretic factor (ANF)
Gastrin-releasing peptide (GRP)
Types of non small cell lung carcinomas
80% all lung cancers
Adenocarcinoma
Squamous cell carcinoma
Large cell carcinoma
Adenocarcinoma most common
All have similar prognosis and treatment, but different locations and spread patterns
Adenocarcinoma
Associated w/ smoking, but also most common lung CA in never-smokers
Peripheral -> arises from epithelium
May see metastatic dx before primary symptoms
Bronchoalveolar adenocarcinoma
subtype of adenocarcinoma
More aggressive, rapidly progressive
Occurs in young (2nd decade) - non-resolving focal/bilateral “pneumonia”
Squamous cell carcinoma
“Epidermoid carcinoma”
Occurs in proximal bronchi - tends to obstruct
local, infiltrating nest of tumor cells w/ central necrosis -> cavitation
late metastasis
Large cell carcinoma
Lest common, Dx of exclusion
Large, poorly differentiated cellular mass w/ prominent necrosis
Occurs peripherally
Syncytial (multinucleate cytoplasmic mass) groups and single cells
Lung cancer commonly metastasizes to:
Brain
Adrenals (50%)
Liver(30-50%)
Lymph node
Bone
Routine lab test indicitave of metastatic disease
Hematocrit: <40% men, <35% women
Elevated alkaline phosphatase, GGT, SGOT, and calcium levels
Horner’s Syndrome
Miosis (smaller pupil), eyelid droop, and loss of sweating on one side of face
Due to superior cervical ganglion lesion
OR inflammatory involvement of cervical lymph nodes and proximal brachial plexus
Pancoast’s Syndrome
Shoulder pain radiaing in the ulnar distribution
Due to apex tumor extension to C8, T1, T2 nerves
Rib destruction possible
Superior vena cava syndrome (SVCS)
Venous dilation
90% due to bronchogenic cancer
Swelling of face/tongue/neck/arms, SOB, hoarseness, nasal congestion
HA, syncopy, lethargy from cerebral edema
Pediatric Respiratory rate
Newborn: 30-50
Infant-12yo: 20-30
Adolescent (13+): 12-20
Pediatric Heart rate
Newborn: 120-160
Infant-5yo: 80-140 (120 5yo)
6-12 yo: 70-110
13+: 55-105
Pediatric Systolic BP
Newborn: 50-70
Infant (1-12mo): 70-100
1-12 yrs: 80-120
Paraneoplastic syndromes
Cachexia - common w/ NSCLC
Hypercalcemia - common w/ squamous cell CA
Hypertropic pulmonary osteoarthropathy - clubbing of fingers and toes
Eaton-lambert syndrome
Autoimmune response -> proximal muscle weakness w/ depressed deep tendon reflexes
usually occurs in lower extremities
r/o Myasthenia gravis: strength should improve w/ serial effort
Solitary pulmonary nodule
Likely benign if <5mm
Likely malignant if >3cm
If likely benign - serial CT over 2 years - shouldnt grow
If likely malignant - tissue bx & resect
Multiple pulmonary nodules
Usually malignant if >1cm - usually mets
If benign - infection, wegners, AV malformation, pneumoconiosis
Pattern matters
Lung cancer workup
CBC, CMP, CXR, PFT
Bronchoscopy or fine needle bx (for peripheral)
Stage: CT, PET, MRI
TNM Staging
T = primary tumor, get location and size
N = regional lymph node metastasis
M = distant metastasis
Small cell lung cancer stages
- Limited = confined to single hemi-thorax
- Extensive = malignant pleural effusion or metastatic disease
Non small cell lung cancer stages
Stage 1 = confined to lung
Stage 2 = spread to lung lymph nodes
Stage 3 = spread to mediastinal lymph nodes
- IIIA = lymph nodes on same side as lung
- IIIB = wider spread
Stage 4 = spread to other lobes or distal metastasis
Surgical lung cancer treatment
limited disease w/ resectable lesion
lobectomy most effective w/ NSCLC
Chemotherapy lung cancer treatment
4-6 cycles recommended
Drug combinations to kill cancer cells
May lessen symptoms with widespread disease
Radiation lung cancer treatment
Mediastinum, node positive-limited stage disease
High energy X-rays to kill cells
Significant side effect - radiation pneumonitis in 15%
Get PFTs first to ensure sufficient function
Targeted lung cancer treatment
Stop action of abnormal proteins that promote growth
Avastin - prevents new blood vessel formation
Tarceva - helps in NSCLC
Adjucant lung cancer treatment
Treatment w/ chemo/radiation/target therapy before or after surgery to prevent reoccurance
SCLC treatment
Limited stage: 4-6 cycles chemo w/ simultaneous radiation
Extensive stage: chemo, consider radiation w/ painful bone mets or SVC syndrome
Cranial mets are common - consider prophylactic radiation
NSCLC treatment
Stage 1: resect, consider adjucant tx
Stage 2: resect w/ nodes, chemo +/- radiation
Stage 3 - IIIA: radiation + chemo, consider resection
IIIB: chemo +/- radiation
Stage 4: chemo
Types of Respiratory failure
Type 1 - Hypoxia (pO2 <60)
Type 2 - Hypercapneia (pCO2 >50)
Type 1 Respiratory failure reasons
- low PiO2 - high altitute
- Hypoventilation
- Diffusion - pneumonia, fibrosis
- Shunt - blood not getting oxygenated
- V/Q mismatch - treat w/ O2 to differentiate from shunt - will respond
Type 2 respiratory failure reasons
Increased CO2 production (sepsis, fever, burn)
Alveolar hypoventilation
- reduced minute volume
- increased dead space
Hypoxemia signs
Cyanosis
Restlessness
Confusion
Anxiety
Tachypnea
Signs of Hypercapnia
Dyspnea
HA
HTN
Tachycardia w/ Tachypnea
AMS
BiPAP good for what pts in emergency cases?
COPD and CHF
Danger signs of impending respiratory failure
Deteriorating mental status
silent chest
pulsus paradoxus
CO2 retention
Acidosis/Cyanosis/Hypoxemia
Acute asthma medical therapy
Albuterol - 4-8 puff MDI q20 mins for up to 4 hours
Ipratropium bromide - 8 puffs MDI q20mins up to 3 hrs
Methylprednisolone - 60-125 g IV
Epinephrine - .3-.5 mg IM
Terbutaline - .25 mg SQ q20 mins x3 doses
DO NOT GIVE BOTH EPI AND TERBUTALINE
Emphysema predominant COPD exacerbation first complaint
Dyspnea
appear uncomfortable, accessory muscle use
COPD Chronic bronchitis pts exacerbation first complaint
Chronic, productive cough
Overweight and cyanotic, can appear comfortable
COPD Exacerbation treatment
Ipretropium MDI 4-8 puggs q1-2 hrs
Albuterol 4-8 puffs q1-2hrs
Corticosteroids - 30-40 prednisome, 125 methylprednisone
May need NIPPV if severe, hypercapnic, acidemia
High altitude illness parameters
Moderate altitude - 8000-10000ft
High altitude - 10,000-18,000 ft
High altitude sickness pathophysiology
Hypobaric hypoxic condition
- fluid retention
- vasoconstriction
- pulmonary artery HTN
- increased endothelial permeability
- edema
High altitude illness management
Stop ascent/descend
Supplemental O2
Axetazolamide (250 BID/TID)
Dexamethasone (8mg loading, 4 mg q6hrs)
Antiemetics
High altitude pulmonary edema (HAPE)
Most common fatal high-altitude ilness
-occurs above 8,000 ft, usually 2-4 days after activity
Dyspnea @ rest, cough, fatigue, HA
HAPE treatment
Hyperbaric tx
2,000 ft descent
O2/CPAP
Rest/warth
Acetazolamide/dexamethasone
Ascend no more than 2,000 ft/night
Carbon monoxide treatment
100% O2 for 4 hours
Hyperbaric if severe/underlying illness/pregnant
Cyanide poisoning
Hard to confirm
Consider in all pts w/ smoke inhalation and CNS/CV findings
Can cause immediate respiratory arrest
Increased lactate production with anion gap metabolic acidosis
Cyanide poisoning treatment
Inhaled and injected nitrites, injected sodium thiosulfate
-promotes cyanide binding/excretion via kidneys
3-step kit
CI w/ concomitant CO poisoning
supplemental O2
Pneumothorax treatment
Needle decompression
16 G needle mid-clavicular line over 2nd rib
