Unit 2 Flashcards
T or F: Clinicians should NOT perform testing or initiate abx in pt with bronchitis unless PNA is suspected
True
T or F: Pt should be tested with symptoms of group A strep pharyngitis by rapid antigen detest and/or culture for GAS
True
T or F: Clinicians should treat ever pt with abx is they have suspected strep pharyngitis
False
They should only treat those who have CONFIRMED sterp pharyngitis with abx
Examples of acute respiratory tract infections
Uncomplicated bronchitis
pharyngitis
rhinosinusitis
common cold
T or F: abx have the highest number of medication related adverse reactions
True
1 in 5 ER for adverse drug reactions
Symptomatic tx for adults with ARTI
decongestants
analgestics
antipyretics
cough suppressants
Symptoms of croup
barking cough
inspiratory stridor
retractions
What is croup
Rapid onset of narrowing of subglottic airway secondary to inflammation associated with VIRAL RTI
Usually between ages 6mo-3y
Tx for croup
corticoseroids (Dexamethasone)
nebulized racemic epi
OTC meds = NO relief
Immunizations to help with croup
Diptheria
Rubella
Pertussis coughing fits can last for up to ___ weeks
10
Best way to prevent pertussis
IMMUNIZE with DTaP and Tdap
Pertussis pathogens
B. pertussis
gram-negative requires isolation
Pertussis- how does it work?
Bacteria attach to the cilia of respiratory epithelial cells> produce toxins that paralyze the cilia> cause inflammation of respiratory tract > interferes with clearing of pulmonary secretions
Pertussis incubation period
symptoms usually develop within 5-10 days
infections through the 3rd week after onset of paroxysms or until 5 days after start of effective antimicrobial tx
Cough persists for 1-6 weeks
Pertussis older than 1 treated within ___ weeks and <1y and pregnant women treated within __ weeks of cough onset
3 weeks
6 weeks
Pertussis treatment
Macrolides:
Azithro*
Clarithro
Erythro
Pertussis in infants
APNEA coryza exhaustion no "whoop" low-grade fever paroxysms minimal cough posttussive vomiting
Dx pertussis
NP swab or aspirate and culture
influenza spread by ____
DROPLET
Incubation period for influenza
1-4 days
can infect 1 day before sx and 5-7 days after
s/sx flu
fever myalgia HA malaise nonproductive cough sore throat rhinitis
CHILD: otitis, N/V
T or F: Rapid antigen tests have a sensitivity of 99% and specificities or 25-30%
FALSE
Sensitivity 50-70%
Specificities 90-95%
Tx for flu
Antivirals: 5 DAYS
Zanamivir
Oseltamivir
can reduce duration by 1 days wihen administered within 48 hr of onset
T or F: Antivirals are recommended for all persons with suspected or confirmed flu requiring hospitalization or who have progressed, severe, or complicated
True
Who gets tx for flu
Child <2 Adult >65 COPD, cardio disease, renal,hepatic, hematologiccal, metabolic disorsers, neuro disorders, developmental delay, muscular dystrophy immunocompromised pregnant or postpartum <19 who are on ASA long-term Indians/Alaska natives morbidly obese nursing home resident
Zanamivir (Relenza)
inhaled
for uncomplicated acute illness
For child >7 and older
*NOT recommended for underlying airway disease (asthma, COPD)
Oseltamivir (Tamiflu)
PO
uncomplicated acute illness
For child >2 weeks and older and chemopropylaxiz >1 and older
Marboxil (Xofluza)
uncomplicated flu within 2 days of illness
>12 y and older and at least 40kg
NOT for pregnant or breastfeeding
Peramivir (Rapivab)
IV
acute uncomplicated flu within 2 days
>2y
NOT recommended for chemphylaxis a
T or F: FluMist (LAIV) is not recommended to give now
FALSE
it is recommending LAIV as a suitable option in age appropriate pt
Vaccine forms that contain eggs
Trivalent
Quadrivalent
Approved for 65 y and older
Only vaccine that does not contain eggs
RIV (Recombinant hemagglutinin flu)
Must be 18
Live attenuated influenza vaccine (LAIV4)
2-49 y/o who are not pregnant
healthcare personnel
person in close contact with high-rsk groups
precaution for influenza IIV and LAIV
mod-sever acute illness with or without fever
HX guillain-barre within 6 weeks following dose of flu vaccine
LAIV contraindications
<2 18 and younger receiving ASA therapy prengany asthma >50 y underlying medical contiion( immuno, renal, pulmonary, neuro, hepatic, CV disease. close contact with immuno pt CSF leak or cochlear implant allergic reaction 2-4y with asthma use of antiviral within 48 hr
Risk factor for COVID
> 65
poorly controlled medical conditions
Transmission for COVID
direct person-to-person
Respiratory droplets
lives on contaminated surfaces
less likely to happen 7-10 days illness
mucous membranes in the mouth, eyes, or nose
Clinical manifestation for COVID- child, adult
more infectious in early stages
out-pt management for COVID-child, adult
telehealth
monitor for deterioration
symptomatic and supportive care
usually quarantine for 15 days
Adequate vitamin D intake
Amylase (AML)
enzyme that digest starch and glucose
produced by pancreas, salivary glands, and lung tumors
Increase: pancreatitis, CRF, follow up for perforated peptic ulcer
Decrease: usually insignificant
chronic pancreatitis
pancreatic CA, liver disease
toxemia of prego
In pancreatitis, will rise in 2hr, peak at 12-48hr, return innn 3-4days
Albumin
Bloods main protein, produced by liver, responsible for oncotic pressure
Increase: dehydration
Decrease: malnutrion, liver disorder, chronic disease, burns, nephrotic syndrome, CRF, Hodkins
USes: evaluating edema, liver disease, suspected malnutrition
Total protein
50% albummin
Increase: multiple myeloma
Decrease: prego, cytotoxic drugs, dietary deficiency
USE: suspected hepatic disease, suspected protein deficiency
ALT and AST
Primary located in hepatocytes, leaked when liver is injured ALT(L for liver), AST (S for skeleton or cardiac)
Increase: Both=liver injury, AST= muscle or cardiac injury
Decrease: advanced cirrhosis or hepatitis
Use: dx and monitor liver disease, screen test of pt on meds
Alkaline phosphatase (ALP)
found in all body tissue, produced by liver and bones, unknown function
Increase: obstructed bile ducts, new bone formation in child and pagets disease
Use: detect biliary obstruction, supplement from other liver study
Prostate-specific antigen (PSA)
produced by normal, hyperplastic, and CA
Increase: BPH, CA, following massage, biopsy
Decrease: insignificant
Use: detect disease, stage PA CA
TSH or Thyrotropin
secreted by anterior pituitary and responsible for increasing T3 and T4 by thyroid gland
Increase: hypothyroidism, thyroiditis, inadequate hormone therapy
Decrease: hyperthyroidism
excess levothyroxine
pituitary failure
hypothalamic failure
use: dx thyroid
Elevated TSH indicates
primary hypothyroidism
BUN 8-26
Product of protein metabolism, formed by the liver from ammonia and excreted in urine
Increase: renal insufficiency, increased protein intake, decrease water intake, decrease urine flow, blood in GI tract, inhibition of anabolism, hyperthyroidism, increased protein catabolism
Decrease: nephrosis, liver failure or hepatitis, late prego, overhydration
USE: eval renal, aid in hydration
Creatinine
end product of creatine metabolism
A better measure of renal damage
Bad sensitivity
Increase: a falling GFR, renal impairment, increase muscle mass
Use: screen for renal injury (HTM or DM)
Serum Calcium
Controlled by parathyroid hornome, calcitonin, and adrenal steroids
Ca regulates neuromuscular activity, skeletal development, blood coag
Increase:Hyperparathyroid, parathyroid tumor, pagets, metastatic CA, prolonged immobility, renal disease, diuretics, overuse of antacids, excess ingestion, adrenal insufficiency
Decrease: hypoparathyroid, malabsorption, cushings
Use: neuromuscular, skeletal, and endocrine disorders, aid in arrhythmias, blood clotting problem, acid-base imbalanace, muscle crampy or tetany
Chloride
extracellular anoin, present in blood and stomach, abdosrbed from intestines and excreted by kidney
Increase: nephritis, eclampsia, anemia, cardiac disease, dehydration from diarrrhea
Decrease: fever, DM, PNA, GI loss, CHF, thiazide diuretic
Potassium
intracellular cation
Increase: renal disorder, meds, abnormal intake, burns or crush injury, MI, DKA, , causes hemolyzed specimen
Decrease: renal disorder, meds, excess licorice ingestion
Use: monitor renal, diuretic, arrhythmias, c/o weakness
Sodium
extracellular cation, affects H2O distribution, maintains osmotic pressure, promotes neuromuscular functions
Increase: excess ingestion, inadequate water, aldosteronism
Decrease: HF, cirrhosis, nephrotic syndrome, D/V, CRI, diuretic
Use: elav HF, liver disease, CRF, acid-base
Bilirubin
Degrade RBC,
Increase in unconjugated or indirect: hepatic damage or severe overload in hemolytic disease or SCC
Conjugated or direct: blocked pathway from liver to biliary tree
Neutrophils are what % of total WBC and the role
50-70%
First line of defence against bacteria and inflammation
Lymphocytes are what % of total WBC and the role
25-35%
Increase in chronic or viral infection or in leukemia
Monocytes are what % of total WBC and the role
2-6%
Secondline of defense
stronger and longer lived than neutrophils
respond to viral infections & chronic bacterial infections and inflammation
Eosinophils are what % of total WBC and the role
0-3%
Elevated in allergies, parasites infection, and drug reactions
Basophils are what % of total WBC and the role
1-3%
similar to neutrophils
play a role in preventing blood clotting
elevtated in allergic reactions and hypothyroidism
Immature granulocytes (bands) are what % of total WBC and the role
0-5%
immature or early stage neutrophils
Elevated when body first launching response to bacterial or viral infection and are a sign of acute infection
Shift to the left
increase in bands
Means acute infection
Elevated in leukemia and pernicious anermia
Shift to the right
Increase in mature neutrophils
Seen in disease f liver
Children 2 weeks to 12yr have inverse neutro:lymph relationship
Neutro: 29-47%
Lymph: 38-63%
palpate for respiratory exam
- trachea at suprasternal notch
- posterior chest wall (fremitus/transmission of vibration)
- Anterior chest wall (assess cardiac impulse)
Pulmonary function test measures what 3 things
Airflow rates
Lung volumes
Ability of lung to transfer gas across alveoli-cap membrane
What indicates to the FNP that the pt needs PFT
type/extent of lung dysfunction
dx of causes of dyspnea and cough
detect early lung dysfunction
follow-up response to therapy
pre-op assessment
disability eval
T or F: A pt with acute severe asthma should have PFT done
FALSE
Contraindicated in acute severe asthma, resp. disress, angina, pneumothorax, hemoptysis, active TB
T or F: To measure PFT, you compare the pt values to values derived from a large study
TRUE
What is Kussmals resp
RAPID, LARGE-VOLUME breathing = intense stimulation of resp center r/t METABOLIC ACIDOSIS
What is Cheyne-stokes
RHYTHMIC, wax/waning of rate and TV
Regular periods of apnea
Seen in LV failure, neuro dx, sleep at high altitude
Digital clubbing is a sign of what?
lung abscess empyema bronchiectasis CF idiopathic pulm fibrosis AV malformation late presentation concomitant lung cx
What is cyanosis
blue-bluish gray discoloration of skin & mm due to increase amount of UNSATURATED HgB in capillary blood
T or F: cyanosis if a reliable indicator of hypoxemia
FALSE
Need to get PaO2 or Hgb measurement
increased CVP indicates
measure pulmonary HTN Impaired ventricular function Pericardial effusion or restriction Valvular hear dx COPD
BLE edema indicates
Pulmonary HTN with chronic lung disease= RV failure
Expansion of the chest but collapse of abd on inspiration indicates what
weakness of diaphragm
Causes of asymmetric chest expansion
Unilateral vlm loss
unilateral airway obstruction
Asymmetry pulmonary/pleural fibrosis
Splinting from chest pain
Dull percussion indicates?
Lung consolidation,
Pleural effusion
Hyperresonant percussion Indicates?
emphysema
pneumothorax
Bronchial lung sounds heard over periphery of lung
Imply consolidation
Globally diminished lung sounds indicates?
Predicitive of significant airflow obstruction
Wheezing indicates?
high-pitched, muscial, distinct whistle sounds
BRONCHOSPASM, MUSCOSAL EDEMA, EXCESSIVE SECRETIONS due to narrow airway
- powerful indicator of obstructive lung disease
Rhonchi indicates
lower-pitched, snorous, gurgling quality- larger airways=excessive secretions and abnormal airway collapse
CLEARS AFTER COUGH
Fine crackles indicates
soft, high-pitches, crisp
with interstitial dx or early pulmonary edema
Fine-late inspiratory crackles indicates?
pulmonary fibrosis
Coarse crackles indicates?
louder, lower-pitches,
PNA, obstructive lung dx, late pulm edema,
Early coarse crackles indicates what?
PNA or HF
Normal lung sounds hear over suprasternal notch are ?
tracheal or bronchial (louder, higher-pitched, hollow quality, louder on expiration
T or F: spirometry is good for measuring lung vml to assess presence or severity of obstructive/ restrictive pulmonary dysfunction
TRUE
expressed in FEV and FVC
FEV is?
Forced expiratory vlm.
Measure how much air a person can exhale during a forced breath
FEV1?
amnt of air exhaled during 1st forced breath
FVC?
forced vital capacity
total amnt of air exhaled during entire FEV test
Obstructive dysfunction
decreased FEV1/FVC ratio
reduced airflow rates seen in asthma, COPD, bronchiectasis, bronchiolitis, upper airway obstruction, CF
Decreased FEV1/ FVC ratio seen in what disease
asthma
COPD
bronchiectasis, bronchiolitis, upper airway obstruction, CF
T or F: If obstruction is evident (decrease FEV1/FVC) you need to repear spirometry 50 minutes after inhaled bronchodilator to help assess if dx is reversible
FALSE
Do it 10-20minutes after bronchodilator
Restrictive dysfunction (Decreased FVC) Chest Wall
ankylosing spondylitis
kyphosys
obesity
scholiosis
Restrictive dysfunction (Decreased FVC) DRUGS
amio
methotrexate
Restrictive dysfunction (Decreased FVC) Interstitial lung dx
asbestosis PNA idiopathic pulm fibrosis Sarcoidosis Large PE pleural thickening prior lung resection
Restrictive dysfunction (Decreased FVC) NEuromuscular Dx
GBS
amyotrophic lateral sclerosis
MD
MG
Those at risk for CAP
older
etoh/tobacco
asthma/copd/immuno
PNA signs
fever (low in eldery) dyspnea tachypnea mental status change bronchial breath sounds inspiratory crackles
CAP pathogens
S pneumo
M pneumo
C pneumo
Viruses that can cause CAP
influenza
RSV
adenovirus
parainfluenza
3 rapid PCR test to identify CAP organism
sputum gram stain
urinary antigen test
rapid antigen test
T or F: obtain a flu swab before starting suspected CAP
TRUE
to r/o flu for abx
CXR with CAP
pulmonary opactiy
Can take 6 weeks to clear
Pt present with significant pleural fluid collect. What do you do?
REFER
probably need thoracentesis
CXR with cavitary opacities. What do you do?
REFERE and ISOLATE d/t TB
Previously health patients with no recent (within 90 days) use of abx – what is the recommended outpatient abx
choice?
MACROLIDES or Azithromycin, Doxy
DONOT USE FLUROS in ambulatory pt without comorbidities or recent abx use- risk tendon rupture
Patient w/ risk of drug resistance (abx <90 days, >65yr old, comorbid illness, immunosuppression, exposed to
child in daycare) – what is recommended abx choice?
Resp fluoroquinolone or a macrolide + b-lactam OR
cefpodoxime
What is the typical abx treatment duration for adults?
minimum of 5 days of therapy and
continue abx until pt is afebrile for 48-72hr
Vaccines to prevent CAP
influenza
pneumococcal
2 clinical prediction rules to guide admission or traige of CAP
CURB-65
PSI
CURB-65
Confusion Urea: BUN >7 Resp: >30 BP: S <90, D <60 Age: >65
0=outpt tx
1-2= admit to hospital
3-4=URGENT REFERRAL,ICU
PSI score
PNA severity index
age, gender, nursing home status, comorbid conditions, physical exam, labs
T or F: Hospital -acquired PNA occurs after 25 hr
FALSE
Has to be more than 48 hr after admission
S aureus P aerugi Enterobacter K pneumo E coli
Ventilator-associated occurs when
More than 48hr after ET intubation and mechanical ventilation
Acinetobacter species
S maltophilia
symptoms of vap
fever, leukocytosis, purulent sputum + new or progressive parenchymal
opacity on chest x-ray
What are the 3 factors used to distinguish nosocomial pneumonia (HAP/VAP) from CAP?
Different
infectious causes, different abx susceptibility patterns (higher incidence of drug resistance), poorer
underlying health status of pt (increased risk for more severe infections)
When should FNP initiated treatment for nosocomial pneumonia
ASAP
NEED blood cultures, WBC, chem panel, ABG
What is the initial treatment of HAP/VAP? What is the treatment duration?
Individualized based on
pathogen, severity of illness, response to therapy, comorbid conditions (VAP study suggested 8 days was as
effective as 15 days – except in cases caused by P. aeruginosa)
Single drug therapy for HAP/VAP
Zosyn**
Cefepime
Levofloxacin
Meropenem / Imipenem
2 combo drug therapy for HAp/VAP
CHOOSE ONE Zosyn** Cefepime / Ceftazidime Levofloxacin/ Ciprofloxacin Meropenem / Imipenem Aztreonam
+ ONE OF THESE
Vancomycin
Linezolid
2 combo drug therapy for HAP + risk factors for pseudomonas and other gram - bacilli
CHOOSE ONE Zosyn** Cefepime / Ceftazidime Meropenem / Imipenem Aztreonam \+ ONE OF THESE Levofloxacin/ Ciprofloxacin Gentamycin / Tobramycin Aztreonam
Cough with foul-smelling sputum=
anaerobc either abscess or PNA
The film is noted to have a thick-walled solitary
cavity surrounded by consolidation and air-fluid level present. What do you suspect?
Lung abscess
The film is noted to have multiple areas of
cavitation within an area of consolidation What do you suspect?
Necrotizing PNA
the presence of purulent pleural fluid accompanying either lung abscess or necrotizing pneumonia – this would
indicate what complication?
Empyema
ultrasound should be ordered to locate fluid, reveal pleural loculations
Tx for empyema
1st line: Clindamycin IV q8hr (witch to PO with improvement) OR amoxicillin-clavulanate (Augmentin) q12hrs
• Alternative: amoxicillin or PCN G + metronidazole
How long tx for
- anaerobic PNA
- Lung abscess
- Empyema
Anaerobic pneumonia: continued until chest x-ray improves (process could take a month or more)
• Lung abscess: until chest x-ray resolution of abscess cavity is demonstrated
• Empyema treatment: REFER! must have tube thoracostomy
Pleuritis key sx
localized pain, sharp,
fleeting – worse with coughing, sneezing,
deep breaths or movement; diaphragmatic
involvement = referred ipsilateral shoulder
pain
Tx pleuritis
treat underlying dx
• Pain: analgesics / NSAIDs (indomethacin, 2-
3x/day)
• Control cough: codeine or other opioid:
Pleural Effusion sx
chest pain + pleuritis, trauma, or infection; dyspnea (large effusions à dullness to percussion and decreased/absent
breath sounds over effusion); CXR shows pleural effusion; diagnostic findings on thoracentesis
bronchial breath sounds, egophony just above effusion indicate
compressive atelectasis
5 processes that cause pleural effusions
- increased hydrostatic pressure/decreased oncotic pressure= transudates
- abnormal cap permeability=exudates
- Decreased lymphatic clearance from pleural space=exudates
- Infection of pleural space=empyema
- Bleeding into pleural space= hemothorax
90% of transudates in pleural effusions are caused by HF or CA
HF
CA= exudative
Pulmonary infiltrates
hx of HIV, WBC <1000, current or recent
chemo, taking more than 5/mg day of prednisone presents
with pulmonary infiltrates; XRAY NOT HELPFUL to dx!
MUST HAVE SPUTUM CX!
T or F: Xray are helping in dx of pulmonary infiltrates in immunocompromised pt
FALSE
Must get sputum cx
Infectious and noninfectious causes of pulmonary infiltrates
Infectious causes: bacterial, mycobacterial, fungal,
protozoal, helminthic, viral pathogens
Noninfectious causes: pulmonary edema, alveolar
hemorrhage, med reaction, pulmonary thromboembolic
dx, malignancy, radiation pneumonia
Causes of neutropenia PNA
s aureus
aspergillus
gram- bacilli
candid
Fulmiant PNA or occuring 2-4 weeks after organ transplant- bacterial or viral
Bacterial
Insidious PNA causes
viral
fungal
protozoal
mycobacterial infection
Organism in pulm infiltrates occuring several months after organ transplant
viral (P jirovecii- cytomegalovirus)
fungi (aspergillus)
The FNP knows that she must order what diagnostic testing to
definitively dx cause of pneumonia?
Sputum cx
T or F: 40-80% exudative pleural effusions are malignant
TRUE
common breast and lung CA,
What is parapneumonic pleural effusions>
exudate that accompanies bacterial pneumonias
pleural effusion with purulent drainage is most likelt
empyema
Pleural exudate
ratio of pleural fluid protein to serum protein
ratio of pleural fluid LD to serum protein
Pleural fluid LD greater than 2/3 upper limit of normal serum LD
Pleural Fluid H
<7.30= drain the fluid
T or F: Diagnostic thoracentesis can be done when there is a new pleural effusion and no reason
FALSE
They MUST be done
Transudative pleural effusion:
pleural disease absent
direct treatment at underlying condition
What is an empyema
gross infection indicated by gram stain or culture. ALWAYS drain by thora
Spontaneous pneumo
acute onset of UNILTARAL chest pain, dyspnea;
UNILATERAL chest expansion, decreased tactile fremitus, hyperresonance,
diminished breath sounds
small pneumothorax (mild tachycardia); large pneumothorax (diminished breath sounds, decreased tactile fremitus, decreased movement of chest)
Tension pneumo
mediastinal shift, cyanosis, hypotension EMERGENCY REFER
ABG finding on spontansoue pneumo
hypoxemia and respiratory alkalosis
Risk for tension pneumo
smoking
high altitudes
flying inunpressurized plane
scuba
Hyperventilation syndrome
Increase in alveolar ventilation à hypercapnia (pregnancy, hypoxemia, obstructive/infiltrative lung disease, sepsis, hepatic dysfunction, fever, pain)
Central neurogenic
monotonous,
sustained pattern of rapid and deep
breathing (comatose patients with brainstem
injury)
Functional (acute) hyperventilation
hyperpnea, paresthesia, carpopedal spasm,
tetany, anxiety; tx: breath through pursed
lips/nose with one nostril pinched,
rebreathing expired gas from paper bag over
face (decrease respiratory alkalemia);
anxiolytic drugs
Functional (chronic) hyperventilation
fatigue, dyspnea, anxiety, palpitations,
dizziness à symptoms re-produced during
voluntary hyperventilation
Tx for PE
heparin then followed by 6 months of PO warfarin
ABSOLUTE CONTRAINDICATIONS TO THROMBOLYTIC THERAPY:
active internal
bleeding and stroke within past 2 months
MAJOR CONTRAINDICATIONS TO THROMBOLYTIC THERAPY:
uncontrolled HTN,
surgery/trauma within past 6 weeks
Patient w/recurrent thromboembolisms despite blood thinners wants to know what can be done help decrease incidence of
DVT breaking off into lungs?
Placement of an inferior vena cava filter
In patient who are very ill or cannot be given thrombolytic therapy, what should you do?
embolectomy
RSV
low-grade fever, tachypnea, wheezing, apnea; increased mucus secretion; hyperinflated lungs, decreased gas exchange, increased WOB; children à major cause of morbidity / mortality @ extreme ages (<5yr, >65yr)
leading cause of hospitalizations in children
Risk factors for RSV
prematurity (severe disease);
early RSV bronchiolitis in kids + family hx
of asthma = persistent airway reactivity in
life
Influenza
presence of fever (>38.2C) and
cough during flu season = influenza in ages >4 years old
Unvaccinated adults: abrupt onset of fever, chills, HA, malaise,
myalgias, runny/stuffy nose, sore throat, hoarseness, cough,
substernal soreness
Kids w/Type B: GI complaints
Elderly: lassitude, confusion, without fever or respiratory
symptoms
Incubation period for influenza
1-4 days
Fever last 1-7 days
What do you expect with influenza that has persistent fever >4 days with nonproductive cough, w/productive cough and WBC >10,000?
Suspect secondary bacterial infection
Avian Influenza
occurs from exposure to infected poultry or birds as hosts; does not easily transmit between humans; illness ranges from mild disease to rapid progressive
Risk factor for avian flu
direct or indirect exposure to
infected live or dead poultry or contaminated
environments (live bird markets); slaughtering or
handling carcasses of infected poultry
Symptoms of avian influenza
hx of exposure to dead/ill birds or live
poultry markers in prior 10 days, recent travel to
Southeast Asia/Egypt, contact with known case =
HOW YOU DISTIGUISH FROM REGULAR
INFLUENZA!
Adenovirus
56 stereotypes, divided into 7 subgroups A-G; occurs throughout the year; usually self-limited and occur most commonly in infants, young kids, military recruits
Incubation period 4-9 days
S/sx of adenovirus
Common cold: rhinitis, pharyngitis, mild malaise without fever Conjunctivitis Pharyngitis (fever lasts 2-12 days + malaise, myalgia) Lower respiratory infection cough, rales, pneumonia (types 1,2,3,4,7 – acute resp dx, atypical pneumonia) Type 14: severe/fatal pneumonia in chronic lung dx
tx RSV
supportive
hydration
humidified air
vent support as needed
Prevent with PNA vaccine
____ syndrome is a complication in children with Type B flu
Reye
Tx avian flu
severe illness and confirmed cases with
mild disease = ASAP TREATMENT!
1st line: neuraminidase inhibitor oseltamivir
for 5 days administered
within 48hr of onset of illness; hospitalized
patients receive 10 days
Adenovirus dx
Chest CT scan à
multifocal consolidation or “ground glass”
opacity without airway inflammation
What is an early sign in pneumococcal PNA
bronchial breath sounds
Risk factors for pneumococcal PNA
alcoholism, asthma, HIV+, sickle cell, splenectomy, hematologic disorders
Pneumococcal PNA tx
empiric abx pending isolation and identification of causative agent (amoxicillin PO – uncomplicated cases; cephalosporins; PCN allergy = “mycins” à monitor all patients for clinical response (less cough, within 2-3
days due to pneumococci becoming increasingly resistant to PCN and 2nd line agents)
Complications of pneumococcal PNA
parapneumonic effusion
empyema
pneumococcal pericarditis>tamponade=emergency
Bordetella pertussis
effects infants under 2 yrs. old; adolescents /
adults are reservoirs for infection; transmitted by DROPLETS;
symptoms last 6 weeks in 3 consecutive stages
incubation period 7-17 days
Stages of pertussis
Stage 1 (Catarrhal): insidious onset – lacrimation, sneezing, coryza,
anorexia, malaise, hacking night cough that becomes diurnal
Stage 2 (Paroxysmal): bursts of rapid, consecutive coughs followed by
deep, high-pitched inspiration (whoop)
Stage 3 (Convalescent): begins 4 weeks after onset with decrease in
frequency and severity of paroxysms of cough
H. influenza can causes
sinusitis otitis bronchitis epiglottis PNA cellulitis arthritis meningitis endocarditis
Sinusitis, otitis, respiratory tract infection: Amoxicillin PO
Beta-lactamase strains: Augmentin PO
More seriously ill- ceftriaxone IV
Legionnaires disease
immunocompromised,
smokers, chronic lung disease; high fever,
grossly purulent sputum, pleuritic chest
pain, toxic appearance; CXR: focal patchy
infiltrates or consolidation; gram-stain of
sputum – polymorphonuclear leukocytes
and shows no organisms
Tx for pertussis
antibiotics (erythromycin, azithromycin, clarithromycin, or Bactrim)
What disease has a cherry-red swollen epiglottis
Epiglottitis
Tx with ceftriaxone IV
Legionnaires spread by
contaminated water source
legionnaires tx
azithromycin PO, clarithromycin, or a
fluoroquinolone for 10-14 days (21-days for
immunocompromised patient)
NO ERYTHROMYCIN!
T or F: Can tx legionnaires with erythromycin
FALSE
ACute bronchodilators
short-acting B-agonists/ anticholinergics
Anti-inflammatory meds
inhaled corticosteroids, cromones
Nebulized abx beneficial in?
CF
T or F: spacers must be used in <4mo
TRUE
nebulized mucolytics
used in CF and other conidtions with impaired secretion control
tactile fremitus is a sign of
change with consolidation or air in the pleural space
rapid shallow breathing
Wheezing or prolonged expiratory compared to inspiratory time sign of
intrathoracic airway obstruction
Tachypnea with an equal inspiratory and expiratory time sign of
decreased lung compliance
unilateral crackles sign of
PNA
signs of cor pulmonale
loud pulmonic component of the 2nd hear sound , , hepatomegaly, elevated neck veins
the FOUNDATION for
investigating pediatric thorax
CXR
frontal (posteroir-anterior) and lateral view
eval chest wall abnormalities, heart size and shape, mediastinum, diaphragm, and lung parenchyma
When pleural fluid is suspected, what should the FNP
order?
Lateral decubitus radiographs (helps in determining the
extent and mobility of the fluid)
When a foreign body is suspected, what should the FNP
order?
Forced expiratory radiographs (shows focal air trapping
and shift of mediastinum to the contralateral side)
When an FNP wants to differentiate croup from epiglottitis,
what should the FNP order?
Lateral neck radiographs (useful
in assessing the size of adenoids and tonsils, and seeing the
“thumbprint sign” associated with epiglottitis)
To detect swallowing dysfunction in patients with suspected
aspiration, tracheoesophageal fistula, vascular rings and
slings, and achalasia – what should the FNP order?
Fluoroscopic studies (upper GI series, videofluoroscopic swallowing studies)
To detect paralysis of the diaphragm, what should the FNP
order?
Fluoroscopy or ultrasound (demonstrates paradoxic
movement of the involved hemidiaphragm)
To evaluate for congenital lung lesions, pleural disease,
mediastinum, pulmonary masses/nodules, what should the
FNP order?
Chest CT (effusions, recurrent pneumothorax; lymphadenopathy)
To evaluate for ILD or bronchiectasis (while decreasing
radiation exposure compared to a standard CT), what
should the FNP order?
high-resolution CT
When assessing vascular or bronchial anatomical
abnormalities, what should the FNP order?
MRI
When assessing regional ventilation and perfusion – detect
vascular malformations and pulmonary emboli, what
should the FNP order?
ventilation-perfusion scan
When assessing the pulmonary vascular bed more precisely,
what should the FNP order?
pulm angio
Obstructive sleep apnea CAN ONLY BE
DIAGNOSED by
polysomnogram
“sleep study”
Children with apnea-hypopnea index >5 events per hour =
OSA
PSG recommended for
obesity downs craniofacial abnormalities neuromuscular disorders sickle cell disease mucopolusaccharidoses
*discordance between tonsillar size on eam and severity of symptoms
high risk age for upper foreign body aspiration
6mo-3yr
lower foreign body aspiration sx
sudden onset coughing, wheezing, respiratory distress, *asymmetrical breath sounds or localized wheezing
what sx should you NOT see with croup
fever
T or F: A cxr is needed to dx croup?
FALSE
not needed, may show steeplet sign
tx mild-mod croup
supportive therapy (oral hydration) cool mist (not effective)
1 dose dexamethasone
D/C <3hr is sx resolve
tx mod-severe croup
humidified O2, nebulized epi
bacterial tracheitis
severe form of laryngotracheobronchiis
severe upper airway obstruction and fever, viral coinfection, sniffing dog position/tripod
Sudden onest of high fever, dysphagia, drooling, muffled voice, inspiratory retractions, stridor
disease progression in bacterial tracheitis
viral coup> doesnt improve> develop high fever, toxicity, and severe upper airway obstruction
Typical lab finding in bacterial tracheitis
elevated WBC with left shift, tracheal secretions
signs of CAP bacterial
fever>39, tachypnea, cough, crackles, decreased breath sounds over consolidation, abnormal CXR
may have other areas of infection (meningitis, OM, sinusitis, pericarditis, epiglottitis, abscess)
Signs of CAP viral
URI prodrome (fever, coryza, cough, hoarseness), wheezing and rales, myalgia, malaise, H/A
causes: RSV, parainfluenza, influenza, A/B,
What is the MOST common bacterial cause of CAP in children?
S. pneumo
When patients should be hospitalized for CAP?
all infants <3mo for abx (IV or PO), any child with
apnea, hypoxemia, poor feeding, effusion of CXR, moderate or severe respiratory distress, or clinical
deterioration on treatment
If patient is managed outpatient, what is the treatment? Follow-up?
F/U within 12hr-5days
Tx for bacterial pna
amoxicillin
tx for viral pna
if influsenza: tramiflu, relenza
Key sx of empyema
<5, current bacterial PNA, respiratory distress and chest pain, fever, meniscus or layering fluid
S. pneumo
What sounds is percussed on the affected side with empyema
dullness
T or F: large parapneumonic effusions can cause tracheal deviation
TRUE
to the contralateral side
Mycoplasma PNA sx
fever, <5, dry cough> sputum production, HA, malaise, RALES and CHEST PAIN, bronchpneumonic infiltrates in middle/lower lobes, pleural effusions
mycoplasma PNA tx
azithromycin , cipro
bronchiolitis sx
<2, begins as URI>tachypnea, rapid, shallow breathing, wheezing>irritability, poor feeding, vomiting>crackles, nasal flaring, retractions, hypoxia
meniscus or layering fluid
- starts as URI: fever, rhinorrhea & cough
common causes of bronchiolitis
RSV, parainfluenza, adenovirus,
Bronchiolitis on xray
non-specific hyperinflation and increased interstitial markings
which lobe is most commonly affected by aspiration PNA
right upper lobe in a supine pt
will see perihilar infiltrates with or without bilateral air trapping
complications of aspiration PNA
empyema or lung abscess,
CHRONIC- bronchiectasis- need CT
tx for aspiration PNA
clinda
Key sx of empyema
<5, current bacterial PNA, respiratory distress and chest pain, fever, meniscus or layering fluid
S. pneumo
What sounds is percussed on the affected side with empyema
dullness
T or F: large parapneumonic effusions can cause tracheal deviation
TRUE
to the contralateral side
Mycoplasma PNA sx
fever, <5, dry cough> sputum production, HA, malaise, RALES and CHEST PAIN, bronchpneumonic infiltrates in middle/lower lobes, pleural effusions
mycoplasma PNA tx
azithromycin , cipro
bronchiolitis sx
<2, begins as URI>tachypnea, rapid, shallow breathing, wheezing>irritability, poor feeding, vomiting>crackles, nasal flaring, retractions, hypoxia
meniscus or layering fluid
- starts as URI: fever, rhinorrhea & cough
common causes of bronchiolitis
RSV, parainfluenza, adenovirus,
Bronchiolitis on xray
non-specific hyperinflation and increased interstitial markings
which lobe is most commonly affected by aspiration PNA
right upper lobe in a supine pt
will see perihilar infiltrates with or without bilateral air trapping
complications of aspiration PNA
empyema or lung abscess,
CHRONIC- bronchiectasis- need CT
tx for aspiration PNA
clinda
