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primary care midterm > Acute Respiratory- Peds > Flashcards

Acute Respiratory- Peds Flashcards

1
Q

Croup s/s

A

spasmoidic barky cough

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2
Q

croup tx

A

o Humidifier in room at night
o For a croupy cough, take the child into the bathroom with steam and stay in there for 5 minutes; take them immediately from the bathroom, to the freezer, open the freezer door and have them breath in the cold air. This helps with the croupy cough.
o Monitor for symptoms of difficulty breathing, as we discussed: nasal flaring, sucking in of the skin between the ribs and the clavicle. If concerned about respiratory distress, they should be seen immediately by their Pediatrician or in the Emergency Department.
o Push fluids
o VicksVapoRub on the chest
o Steroids
* Methylprednisolone only indicated when increased WOB/retractions present

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3
Q

acute upper respiratory infections (common cold): s/s

A

o Nasal congestion
o Headache
o Sore throat
o Cough
o Runny nose/nasal congestion
o Low grade fever (not always present)

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4
Q

acute upper respiratory infections (common cold): tx

A
  • Zarbee’s cough syrup (if over 1 year of age; do not use in 12 months or younger d/t potential botulism– contains honey
  • Loratadine/Cetirizine
  • Flonase nasal spray: 1 squirt in each nostril twice daily
  • Diphenhydramine before bed
  • Humidifier in room at night
  • Vicks VapoRub on chest/feet or behind the ears to help open eustachian tubes
  • Can last for several weeks:
  • Reassurance; should return to be seen again if:
  • Increased WOB
  • High fever not responsive to antipyretics or persisting
  • Worsening cough that is affecting sleeping/mood/energy
  • Increasingly fussy while tugging at ears
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5
Q

common cold/URI: s/s in children <6 years old

A

o Average of 6-8 colds/year (one per month)
o Typical symptom duration of 14 days
o Infants
* Fever and nasal discharge common manifestations—fever uncommon in older children and adults
* Additionally may be fussy, have difficulty feeding, decreased appetite and difficulty sleeping

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6
Q

common cold/URI: older children and adults

A

o Average of 2-4 colds per year
o Typical symptom duration of 5-7 days, duration increased among cigarette smokers
o Fever uncommon

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7
Q

prevention of common cold

A

o Handwashing, use of alcohol-based hand disinfectant, gloves, masks
o Zinc supplements
o Probiotics
o Gargling tap water or diluted povidone iodine solution
o Ginseng
o Exercise (45 mins)

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8
Q

tx of common cold

A

o Antihistamine
o Antihistamine combo
o Decongestant
o Intranasal ipratropium
o Antitussives
o Vapor rub
o NSAIDS
o Abx if it is bacterial

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9
Q

pneumonia

A
  • Infection in the lung parenchyma (functional tissue)
    *Common or “typical” bacterial etiology is S. Pneumoniae
  • Atypical bacteria (i.e. Mycoplasma) are more common in older children
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10
Q

pneumonia: physical exam

A

Full HEENT and respiratory exam
* Significant findings: rales that do not clear with cough, bronchial breath sounds, dullness to percussion, egophony

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11
Q

s/s of pneumonia

A

o Fever
o Cough
o Wheezing (if >5 yrs old and no hx of wheezing, may be atypical pna)
o Vomiting
o Chest pain
o Shoulder pain (UL) or Abdominal pain(LL)
o Difficulty feeding
o Restlessness
o Fussiness

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12
Q

clinical presenation of pneumonia

A

o Fever
o Tachypnea
o Respiratory Distress
* Tachypnea
* Working to breathe (infants: grunting, nasal flaring, retractions, use of accessory muscles)
* Hypoxemia
* Altered mental status

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13
Q

diagnosis of pneumonia

A

o Confirmed by Chest X-Ray (adults this is gold standard, however in peds, most outpatient cases do not require it)
* Anterior-posterior view and lateral
* Imaging:
CXR: can be normal in early disease, may show infiltrative changes

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14
Q

pneumonia: risk factors

A

o Neonates- prolonged rupture of membranes, maternal amnionitis, premature delivery, fetal tachycardia, maternal intrapartum fever
o Airway anomalies
o Severe underlying disease
o Prolonged hospitalization
o Hx of pneumonia
o Delayed care
o Household smoking

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15
Q

pedi tachypnea

A
  • Younger than two months: >60 breaths/min
  • Two to 12 months: >50 breaths/min
  • One to 5 years: >40 breaths/min
  • ≥5 years: >20 breaths/min
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16
Q

bacterial “typical” pneumonia: CAP

A
  • May follow URI symptoms
  • Abrupt in onset, with febrile patient appearing ill and sometimes toxic
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17
Q
  • X-ray findings suggestive of bacterial pneumonia:
A

o Segmental consolidation
o Alveolar infiltrates
o Lobar consolidation
o “Round” PNA

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18
Q

“Atypical” Bacterial Pneumonia

A
  • AKA “Walking” pneumonia
  • Children of all ages, common in those >5y
  • M. pneumonia (school, military, college) or C. pneumonia(neonates- Chlamydia trachomatis)
  • Gradually worsening nonproductive cough despite improvement of other symptoms
  • Diffuse rales and wheezing is a frequent finding in atypical bacterial
  • Spreads diffusely along bronchial tree
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19
Q

x ray findings for atypical bacterial pneumonia

A

bilateral diffuse interstitial infiltrates

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20
Q

atypical

A

bilateral

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21
Q

typical

A

unilateral

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22
Q

pneumonia typical s/s

A

o Age: less than 5, over 40
o Onset: Abrupt
o Cough: Productive
o Sputum: Rusty/Purulent
o Rigors: Frequently present
o Fevers: > 39.5° c
o Consolidation: present
o Leukocytosis: 15- 25,000 with neutrophilia

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23
Q

pneumonia atypical s/s

A

o Age: < 40
o Onset: Gradual, coryzal prodrome
o Cough: Paroxysmal, non-productive
o Sputum: Minimal, mucoid
o Rigors: Absent
o Fever: Usually less than 39.5 °C
o Consolidation: Usually absent
o Leukocytosis: usually absent

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24
Q

tx

A
  • Children-PIDS-IDSA Guidelines
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25
Q

CAP typical tx

A
  • 1st line: amoxicillin
  • Non-type 1 hypersensitivity to PCN: Cefdnir
  • Type 1 hypersensitivity to PCN:
    o Levofloxacin
    o Clindamycin
    o Erythromycin
    o Azithromycin
  • Communities with high rate of pneumococcal resistance to PCN:
    o Levofloxacin
    o Linezolid
  • Infants <3-6 months with suspected bacterial pneumonia should be hospitalized
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26
Q

CAP atypical tx

A

azithromycin

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27
Q

viral pneumonia

A
  • Usually children <5 years
  • Onset of viral pneumonia is gradual and associated with preceding URI symptoms
  • Child does not appear toxic
  • Lung findings are usually diffuse and bilateral, wheezing is a frequent finding
  • Consider rapid flu swab/COVID testing
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28
Q

x-ray findings for viral pneumonia

A

o Bilateral diffuse interstitial infiltrates

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29
Q

tx for viral pneumonia

A

o No antibiotics
o No antivirals, unless flu and high risk
o Just supportive treatment!

30
Q

aspiration pneumonia

A

Antecedent aspiration event  swimming and swallowed a ton of water, started choking after drinking a bottle of milk
* Organisms from the oral cavity introduced into the respiratory system

31
Q

tx of aspiration pneumonia

A
  • Treatment may take into consideration oral pathogens (although current adult IDSA guidelines do not recommend expanded coverage due to low rates of anaerobic isolates and risks of abx overuse)
    o Expanded Coverage would use:
  • Amoxicillin/clavulanate(Augmentin)
  • Clindamycin
32
Q

influenza (“the flu”)

A
  • caused by influenza viruses A & B in the respiratory tract
  • can cause severe illness and life-threatening complications (esp for very young, elderly, comorbid conditions)
33
Q

high risk groups for influenza

A

o Children <5 years, particularly those less than 2 yrs
o Asthma
o Neurological and neurodevelopmental conditions
o Chronic lung diseasecystic fibrosis
o Heart diseasesuch as congenital heart disease
o Blood disorders (such as sickle cell disease)
o Endocrine disorders (such as diabetes mellitus)
o Kidney disorders
o Liver disorders
o Metabolic disorders (such as inherited metabolic disorders and mitochondrial disorders)
o Immunosuppression/compromised-cancer treatment, HIV/AIDS, steroid treatments
o People younger than 19 years of age who are receiving long-term aspirin therapy
o People who are morbidly obese (Body Mass Index, or BMI, of 40 or greater)

34
Q

diagnostic for influenza

A

rapid test

35
Q

tx for influenza

A

o Symptomatic
o Antivirals
* Typically reserved for hospitalized, severely ill, or high-risk groups
* Benefits
* Lessen degree of symptoms
* Shorten time sick by 1 day
* Prevent serious flu complications
* Lessen amount of viral shedding (not duration)

Side Effects
* Oseltamivir-GI symptoms, neuropsych (headache, dizziness) most common (~15% of patients will experience nausea and vomiting)
* Zanamivir (inhaled powder) is not recommended in patients with underlying respiratory disease
* May not see much benefit if not started within 48 hours of symptoms but may have benefit beyond 48 hours for hosp, severely ill, pregnant pts

Supportive therapy
 Analgesics (acetaminophen, NSAID)
 Cough suppressants (little evidence)
 Decongestants (little evidence)
 Persons with the flu should remain out of school/work until they are fever free for 24 hours without antipyretics

36
Q

prevention of influenza

A

o The first time a child between ages 6 months and 8 years receives the flu vaccine 2 doses are required at least 28 days apart
o Egg allergy modifications
o Chemoprophylaxis is not recommended by the CDC for the general population (exceptions: institutional outbreak or for immunocompromised/high risk who are exposed and either cannot be or waiting for response to immunization)
o Hand washing!!!
o Covering mouth with sneezing, coughing
o Masks when appropriate
o All persons 6 months and older should be vaccinated annually, ideally by October

37
Q

pertussis (“whooping cough”)

A
  • Caused by Bortadella Pertussis – highly contagious
38
Q

presentation of pertussis

A

o Stage 1: Catarrhal period 7-10 days
o Stage 2: Paroxysmal coughing fits that can last 1 - 6 weeks or more
-Characteristic “whoop” or barking cough
o Stage 3: Convalescent – less persistent cough lasts 2-3 weeks

39
Q

prevention of pertussis

A

o Tdap: tetanus booster + reduced dose of diptheria and pertussis approved for age 11 and older (no longer age restrictions)
o Pregnant women- CDC (administer a dose of Tdap during each pregnancy, irrespective of the patient’s prior history of receiving Tdap (preferably between 27 and 36 weeks).

40
Q

tx of pertussis

A

o Macrolide antibiotics(i.e. azithromycin—1st line), close contacts should also be treated- TX reduces transmission but does not shorten illness

41
Q

croup

A
  • A group of viral illnesses that result in inflammation and swelling of the larynx and subglottic region
42
Q

croup s/s

A

o Fever
o Rhinorrhea/congestion
o CoughBarking cough (Seal-like)– Worse at night
o Hoarseness
o Stridor (occurs upon inhalation)–With activity vs. at rest
o Respiratory Distress
* Nasal flaring
* Grunting
* Retractions

43
Q

croup supportive tx

A

o Cool-mist humidifier
o Antipyretics
o Encouragement of fluid intake
o Bathroom filled with steam generated by running hot water from the shower(low evidence)
o Exposure to cold night air

44
Q

pharm tx for croup (only for respiratory distress)

A

o (ER-only) epinephrine
o Dexamethasone (Decadron)
o Nebulized budesonide
o Less ER visits with dexamethasone

45
Q

bronchiolitis

A
  • Viral illness characterized by URI symptoms followed by lower airway
  • Narrowing of the bronchioles of lower airway due to inflammation:
    o Wheezes and crackles (rales)
    o Difficulty getting air out
  • Caused by Respiratory Synctial Virus (RSV)
46
Q

bronchiolitis s/s

A

o Fever (usually ≤38.3ºC or 101F)
o Nasal congestion/discharge
o Cough
* Peaks on day 5-7
* Can persist for up to 3-4 weeks
o Respiratory distress
* Increased respiratory rate
* Retractions, Wheezing, Crackles

47
Q

complications of bronchiolitis

A

o Recurrent viral-triggered wheezing
o Dehydration
o Apnea
o Respiratory distress
o Secondary bacterial infections
* Excluding acute otitis media, secondary infections are uncommon

48
Q

work up for bronchiolitis

A

o Diagnosis is clinical
o Testing
* Nasal wash
* Rapid RSV antigen swabs
o Lab work
* May do in severe cases to assess for any secondary bacterial infections
* CBC with diff
* Chest xray
o Contagious while cough present

49
Q

high risk groups bronchiolitis

A

o Prematurity (gestational age <37 weeks)
o Age <12 weeks
o Chronic pulmonary disease, particularly bronchopulmonary dysplasia
o Congenital and anatomic defects of the airways
o Congenital heart disease
o Immunodeficiency
o Neurologic disease

50
Q

tx of bronchiolitis

A

o Supportive Care:
* Anticipatory guidance of expected symptoms
* Supportive measures
* Humidification
* Nasal suctioning
* Rest, avoid triggers (cold air exposure)
o Bronchodilator therapy
* Subset of young children with bronchiolitis may have virus-induced wheezing and may benefit from treatment with albuterol
* Trial of albuterol
* 0.15mg/kg (min dose 2.5mg, max dose 5mg) diluted in 3 mL of NS and administered over 5-15 minutes OR 4-6 puffs via MDI with spacer/mask
* If clinical response, can be administered as needed every 4-6 hours and discontinued when signs and symptoms of respiratory distress improve
o *AAP does NOT recommend using albuterol routinely in the management of bronchiolitis.

51
Q

when do I got to ER

A

o Any persistently increased respiratory effort including:
* Tachypnea
* Nasal Flaring
* Retractions
* Grunting
* Hypoxemia
* Apnea
* Acute Respiratory Failure

52
Q

AAP bronchiolitis guidelines: diagnosis

A

o hx and PE usually sufficient, no role for routine testing
o Risk factors for severity (<12 wks, prematurity, cardiopulm dx, immunodeficent)

53
Q

AAP bronchiolitis guidelines: tx

A

o corticosteroids should not be given
o Inhaled albuterol or epinephrine not been shown to be consistently beneficial
o No antibiotics
o Hypertonic saline in ER and chest PT not indicated

54
Q

AAP bronchiolitis guidelines: prevention

A

o Palivizumab not for healthy infants >29 weeks GA but may be used as discussed in next slides for at-risk
o Alcohol rubs for hand washing recommended. Gloves indicated in hospital.
o Counsel family on benefits of smoking cessation/breastfeeding through 6mos

55
Q

RSV

A
  • Transmission: droplets
  • Incubation period: 2-8 days, but most symptoms show up between 4-6 days s/p exposure.
  • Most common cause of lower respiratory tract infections (LRTI) in children <1 y/o and the most common cause of medically attended LRTI in children <5y/o.
  • Common cold to most (aside from infants, elderly and immunocompromised). Sx: cough, coryza, rhinorrhea, conjunctivitis, cough, increased WOB (retractions/stridor).
  • Most common in winter months
56
Q

RSV s/s

A
  • Infants: LRTI symptoms; can cause apnea (approx. 20% of infants develop RSV associated wheezing in first YOL); only 2-3% typically require hospitalization
  • If required hospitalization/apnea, more likely to develop long term pulmonary sequelae (persistent decreased pulmonary function, increased risk of developing COPD later in life)
57
Q

RSV concerns

A

o Under <1
o Elderly
o Immunocompromised: can lead to respiratory failure (among hematopoietic cell transplant recipients, the mortality rate is 70-100%).

58
Q

RSV tx

A

o Supportive measures
o IVIG if concerned for Kawasaki; Glucocorticoids; Palivizumab

59
Q

RSV diagnosis

A

o Based on symptoms
o PCR testing/viral culture testing
o CXR recommended to rule out comorbid pneumonia if severe symptoms

60
Q

Palivizumab for RSV

A
  • Monoclonal antibody against a protein on the RSV virus
  • For prevention of RSV bronchiolitis
  • Given IM
    o Once monthly throughout RSV season
    o First dose administered prior to commencement of RSV season
    o Max: 5 doses per season
61
Q

Palivizumab for RSV prevention

A
  • Recommended For:
    o Infants born at ≤28 weeks 6 days gestational age and <12 months at the start of RSV season
    o Infants <12 months of age with chronic lung disease (CLD) of prematurity
    o Infants ≤12 months of age with hemodynamically significant congenital heart disease (CHD)
    o Infants and children <24 months of age with CLD of prematurity necessitating medical therapy within 6 months prior to the beginning of RSV season
  • Suggested for:
    o Infants <12 months of age with congenital airway abnormality or neuromuscular disorder that decreases the ability to manage airway secretions
    o Infants <12 months of age with cystic fibrosis with clinical evidence of CLD and/or nutritional compromise
    o Children <24 months with cystic fibrosis with severe lung disease or weight for length less than the 10th percentile
    o Infants and children <24 months who are profoundly immunocompromised
    o Infants and children <24 months undergoing cardiac transplantation during RSV season
62
Q

Reactive Lymph Nodes/Cervical Adenitis: s/s

A

o Painful/swollen lymph nodes
o Some individuals have recurrent lymphadenopathy in the same area each time they are sick
o Typically there will be associated symptoms of illness
o Lymphoma concerns
* Fatigue
* Weight loss
* Night sweats
* Itchy skin/rash
* Lymphadenopathy
* Supraclavicular lymphadenopathy is common in Lymphoma

63
Q

Reactive Lymph Nodes/Cervical Adenitis: tx

A

o Attempt to relieve fears
* Discuss lack of concerning symptoms if appropriate:
* Most people immediately think Lymphoma when they have swollen lymph nodes; discuss lack of symptoms concerning for lymphoma (no extreme fatigue, weight loss, night sweats, itching/rash)
o Warm compresses
o Ibuprofen with food for pain/swelling
o Educate about duration of symptoms
* Lymph nodes can remain swollen/intermittently swell for several weeks-months after an illness. This is normal. Reassure them of this.
o PO steroids can be considered if:
* Tonsils are so swollen, you are concerned for a potential occluded airway
* Lymph nodes are so swollen, that you are concerned for potential occluded airway
* Methylprednisolone

64
Q

COVID-19: cold-like s/s

A

o Runny nose
o Chills
o Shortness of breath/difficulty breathing
o Fatigue
o Nasal congestion
o Headache
o Fever
o Cough
o Body/muscle aches
o Rash (hives or other rashes)
o Abdominal pain/vomiting/diarrhea
o Loss of taste/smell
* Anosmia: loss of smell
* Ageusia: loss of taste

65
Q

tx for COVID-19

A

o Supportive care
o Isolation/Quarantine
o If Immunocompromised and over the age of 12
* Monoclonal antibody infusion is recommended

66
Q

Multisystem Inflammatory Syndrome in Children (MIS-C)

A
  • Different parts of the body can become inflamed due to recent infection with/known exposure to COVID-19
    o Heart
    o Lungs
    o Kidneys
    o Brain
    o Skin
    o Eyes
    o GI organs
67
Q
  • Call NP/Pediatrician if:
A

Ongoing fever PLUS more than one of the following:
* stomach/abdominal pain
* Bloodshot eyes
* Diarrhea
* dizziness/lightheadedness
* Skin rash
* Vomiting

68
Q
  • If concern for MIS-C, child will be admitted and closely monitored
A

o Can present similarly to Kawasaki; important to use diagnostics to rule out Kawasaki
* If concerns for Kawasaki: treat with IVIG, Aspirin (if over 16) and possibly glucocorticoids (Methylprednisilone)
o They need blood work, CXR, echocardiogram and abdominal ultrasound
o IV fluids
o Antipyretics/anti-inflammatories

69
Q

outpatient tx of CAP

A
  • Infants <3 months with suspected bacterial pneumonia, should be hospitalized.
  • Typical bacteria: (Streptococcus pneumoniae, Staphylococcus aureus, Group A Streptococcus, Klebsiella pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, anaerobes, and gram-negative organisms)
    o Amoxicillin
    o Augmentin
  • If sensitivity/allergy to Penicillin
    o Cefdinir
    o Levofloxacin
    o Clindamycin
    o Erythromycin
    o Azithromycin
    o Clarithromycin
70
Q

influenza tx

A
  • Oseltamivir (Tamiflu):
    o Greatest benefit when administered within the first 48 hours
71
Q

Tamiflu Renal/Hepatic Impairment

A
  • Oseltamivir Renal Impairment: Children and Adolescents:
  • Intermittent hemodialysis (IHD): Fixed dosing for confirmed/suspected influenza:
  • Prophylaxis: There are no pediatric specific recommendations for renal/hepatic considerations.
  • Oseltamivir Hepatic Impairment: Children and Adolescents:
    o Mild to moderate impairment: No dosage adjustment necessary.

primary care midterm (12 decks)

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