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Pediatrics Clerkship > Aquifer - Pulmonary > Flashcards

Aquifer - Pulmonary Flashcards

26

1
Q

DDx - wheezing (infants and toddlers)

A

Most common: viral bronchiolitis, asthma, foreign body aspiration, gastroesophageal reflux

Less common: tracheomalacia, extrinsic compression (adenopathy, mass, vascular ring/sling, other anatomic lesion), CF

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2
Q

Important history questions to ask when investigating wheezing in infants and toddlers?

A
  1. Timing of wheeze
  2. Association with feeding
  3. Change with position or activity
  4. Other exacerbating factors
  5. History of wheezing in the past + response to treatment (bronchodilator or steroids)
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3
Q

True or false - for a first episode of wheezing, diagnoses other than asthma need to be higher on the differential.

A

True

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4
Q

What are two observations to consider when initially looking for signs of respiratory distress?

A

Can the patient speak in full sentences? Do they appear short of breath while talking?

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5
Q

List 6 signs of respiratory distress.

A
  1. Paradoxical breathing
  2. Tachypnea
  3. Retractions
  4. Nasal flaring
  5. Grunting
  6. Head bobbing
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6
Q

What is paradoxical breathing?

A

Occurs when the force of contraction generated by the diaphragm exceeds the ability of the chest wall muscles to expand the rib cage. As a result, the chest is drawn inward with inspiration, and the abdomen rises due to downward displacement of abdominal contents.

(Seen more in younger children/infants due to greater compliance of the chest wall)

Almost always a sign of very severe respiratory distress due to respiratory muscle fatigue

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7
Q

What is the difference between hyperpnea and hypopnea?

A

Hyperpnea - increased depth and rate of breathing (without respiratory distress, may suggest a non-pulmonary condition such as fever, acidosis, or extreme anxiety - hyperventilation syndrome)

Hypopnea - reduced tidal volume (increases the proportion of each breath used to ventilate dead space, so may result in hypoventilation even in the setting of a normal or elevated RR)

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8
Q

What are retractions and what causes them?

A

Abnormal use of accessory muscles to augment breathing during respiratory distress

Reflect increased WOB due to decreased lung compliance (primary pathology or edema)

Suprasternal and intercostal retractions occur due to excessive negative pleural pressure

Subcostal retractions occur when the diaphragm is flattened during inward pulling on the chest wall

May be seen in severe obstructive airway disease, including asthma, bronchiolitis, and foreign body obstruction

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9
Q

What does nasal flaring indicate?

A

Accessory muscles are being used for respiration

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10
Q

What does grunting indicate?

A

Seen in infants
Audible sound of air being expelled through a partially closed glottis, is thought to help infants generate the positive pressure necessary to stent airways open, increase lung volumes, and improve gas exchange

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11
Q

What causes head bobbing?

A

Seen in young infants

Due to the use of accessory muscles (neck strap muscles) - in synchrony with each inspiration, the head is noted to bob forward due to neck flexion caused by the use of neck strap mucsles (best observed in sleep)

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12
Q

What may reduce signs of respiratory distress even though a patient’s condition is deteriorating?

A

Respiratory muscle fatigue (check a blood gas in this situation for possible elevated PCO2 indicative of hypoventilation)

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13
Q

If a patient is hypoxemia, what should be done?

A

Oxygen therapy as soon as indicated; can be administered via a variety of methods including blow-by, nasal cannula, facemask, or endotracheal tube (most serious)

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14
Q

True or false - oxygen should be withheld in cases of severe hypoxemia in patients with chronic hypercarbia.

A

False - although some patients with chronic hyeprcarbia depend on their hypoxemia for their respiratory drive, oxygen should never be withheld in cases of severe hypoxemia. These patients should be monitored closely and given only as much oxygen as they need to maintain reasonable saturation.

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15
Q

What are the most common infectious causes of respiratory diseases in children?

A

Viruses

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16
Q

Discuss the triphasic course of pertussis.

A
  1. Catarrhal (1-2 weeks) - URI symptoms
  2. Paroxysmal (4-6 weeks) - repetitive, forceful coughing episodes followed by massive inspiratory effort, resulting in the characteristic “whoop.” Of note, infants do not usually develop a whoop due to relative weakness of their inspiratory effort
  3. Convalescent - paroxysms of cough gradually decrease in frequency and severity; episodic cough may persist for months
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17
Q

Complications of pertussis?

A

Infants > older children

Difficulty feeding (due to cough), CNS complications (e.g., apnea)

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18
Q

Discuss immunization against pertussis.

A

Acellular pertussis vaccine recommended for all children; even with full immunization, it is only 70-90% effective. Protection also wanes with time such that many adolescents are unprotected unless reimmunized.

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19
Q

What is the most common cause of epiglottitis historically? Now?

A

H. influenza type b (Hib); staph and strep

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20
Q

What ages is epiglottitis most likely to present?

A

2-5 years

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21
Q

Presentation of epiglottitis?

A

Fever, stridor, drooling, dysphonia, dysphagia, respiratory distress

Toxic-appearing, sniffing position

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22
Q

When suspected on clinical grounds, what should be done for epiglottitis?

A

Prompt intervention in a controlled environment to secure the airway - most often done in the OR - while waiting, do not disturb or examine the child due to risk of acute deterioration

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23
Q

How does epiglottitis appear on XR?

A

Thumb sign (thickening of the epiglottis and the aryepiglottic folds)

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24
Q

When should diphtheria be considered?

A

Child with pharyngitis and a low-grade fever, particularly if stridor or hoarseness is present + characteristic gray pseudomembrane seen in the pharynx

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25
Q

What is asthma?

A

Chronic disorder of the airways that involves a complex interaction of airflow obstruction, bronchial hyperresponsiveness, and underlying inflammation

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26
Q

What is the most common chronic disease in children in developed countries?

A

Asthma

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27
Q

List 3 risk factors for asthma.

A
  1. Gender (M>F)
  2. Race/ethnicity (non-Hispanic black children)
  3. Lower SES
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28
Q

Discuss the pathophysiology of asthma.

A

Infiltration of inflammatory cells into the airway mucosa, mucus hypersecretion, and mucosal edema , accomopanied by bronchoconstriction

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29
Q

How is asthma diagnosed?

A

Diagnosis requires:

  1. Symptoms of recurrent airway obstruction by H&P
  2. Demonstration that airway obstruction is at least partially reversible (Children >5 should do spirometry; younger children should do a trial of bronchodilator treatment)
  3. Exclusion of other causes of obstruction

CXR can help exclude other causes of wheezing, but would not be essential in establishing a diagnosis

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30
Q

Presentation of asthma? Acute and chronic

A

Acute - cough, wheezing, tachypnea, dyspnea, wheezing (typically diffuse, but can be focal in the setting of mucus plugging)/diminished air exchange on chest exam

More severe exacerbation - minimal air exchange, absence of wheezing due to poor airflow, cyanosis, and pulsus paradoxus

Chronic - recurrent episodes of dyspnea and/or cough

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31
Q

Discuss the asthma classification system.

A

During initial presentation, emphasis is on assessment of severity as a guide to starting therapy. Once treatment is initiated, emphasis is on assessment of control as a guide to maintaining or adjusting therapy.

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32
Q

What elements are used to assess severity and control of asthma?

A 
Frequency of daytime symptoms
Frequency of nighttime awakenings related to asthma
Interference with activity
Pulmonary function
Use of SABAs
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33
Q

What is the difference between intermittent and persistent asthma?

A

Intermittent - daytime symptoms for 2 or fewer days/week, nighttime awakening less than 2x/month, no interference with activity (Rx with SABA prn)

Persistent: more frequent symptoms, more interference witha activity (Rx with daily controller + SABA prn)

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34
Q

Radiographic findings of asthma?

A

Hyperinflation due to air trapping, increased interstitial markings, patchy atelectasis

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35
Q

What are the primary goals of therapy in treating asthma?

A

Reduce airway inflammation

Dilate the airways

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36
Q

How is an acute asthma exacerbation treated?

A

Anti-inflammatory therapy (corticosteroids) + bronchodilation with SABAs + supportive care for hypoxemia or dehydration

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37
Q

Most commonly prescribed inhaled steroids?

A

Beclomethasone, fluticasone, and budesonide

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38
Q

When do inhaled steroids become beneficial?

A

After several weeks of daily use

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39
Q

Which population of children with asthma may require daily use of anti-inflammatory medications for a limited period of time?

A

Children with only seasonal symptomatlogy; may start several weeks before the expected exposure

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40
Q

Children receiving long-term inhaled corticosteroid therapy should be routinely monitored for what?

A

Elevation in BP, serum blood sugar, growth delay, and cataract development

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41
Q

What does spirometry measure?

A

Active lung volume (i.e., air volumes that a patient actively blows into the spirometer while the rate of air flow is measured)

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42
Q

Describe the process of obtaining a volume-time spirogram.

A
  1. Tidal breaths to determine tidal volume
  2. Slow and forced vital capacity breath performed to determine the maximum amount of air that can be inspired (TLC) and released
  3. Forced exhalation (rate of airflow) - FEV1

Measurements are obtained before and after bronchodilator use

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43
Q

Spirometry findings in obstructive lung disease?

A

Reduction in airflow and trapping of air inside the thorax behind tight, plugged airways lowers the FEV1 more than the FVC, leading to a low FEV1/FVC ratio

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44
Q

Spirometry findings in restrictive lung disease?

A

Low FEV1 + proportionately reduced FCV - normal FEV1/FVc ratio

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45
Q

What is the most common cause of wheezing in infants?

A

Acute bronchiolitis (viral disease of the lower respiratory tract)

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46
Q

Pathophysiology of bronchiolitis? Most common cause?

A

Bronchiolar obstruction due to edema, mucus, and cellular debris

RSV is the most common cause, but other viruses such as influenza and parainfluenza may cause bronchiolitis as well

47
Q

Signs and symptoms of bronchiolitis?

A

Wide spectrum - most children have mild URI symptoms and often a fever of 38.5-39 C. Symptoms can progress to cough, wheezing, and dyspnea

(typically <2 years old, peak 2-8 months, more severe in babies 1-3)

(Winter)

(Risk factors - heart disease, BPD, prematurity, smoking in home)

48
Q

CXR findings in bronchiolitis?

A

Hyperinflation, increased interstitial markings, peribronchial cuffing, and scattered atelectasis from bronchial obstruction

49
Q

Treatment of bronchiolitis?

A

Supportive aimed at maintaining adequate oxygenation and hydration

Use of additional therapies such as corticosteroids, bronchodilators, and hypertonic saline is controversial. Antibiotics may be indicated if there is evidence of secondary bacterial infection.

50
Q

Pathophysiology of pneumonia?

A

Inflammation of the lung parenchyma, generally due to microorganisms, although non-infectious causes include aspiration of gastric contents or hydrcarbons

51
Q

Most common cause of pneumonia in children? Other causes?

A

Respiratory viruses (adenovirus, RSV, parainfluenza, influenza)

Bacterial infections - less common but more severe

52
Q

Discuss the most common causes of pneumonia in neonates, infants-toddlers, and school-aged/older children.

A

Neonates: GBS, E. Coli, Klebsiella (from maternal genital tract), chlamydia pneumonia is also possible

Infants-toddlers up to 5-6 years: S. pneumonia

School-aged and older children: Mycoplasma pneumonia, S. pneumonia

53
Q

Unique presenting feature of Chlamydia pneumonia?

A

Staccato cough presenting between 4-12 weeks

54
Q

Signs and symptoms of viral pneumonia?

A

Prodrome of URI symptoms including cough and rhinorrhea; cough progresses and is accompanied by fever, tachypnea, and crackles on exam

55
Q

CXR findings in viral vs. bacterial pneumonia?

A

Viral - variable, may show diffuse or patchy interstitial infiltrates, hyperinflation, and small pleural effusions

Bacterial - airspace disease with lobar or segmental consolidation and air bronchograms

56
Q

Lab findings in viral vs. bacterial pneumonia?

A

Viral - normal or slightly elevated peripheral WBC count; viral antigen testing of respiratory secretions may be helpful but is not usually necessary

Bacterial - elevated peripheral WBC counts with a neutrophilic predominance

57
Q

Treatment of viral vs. bacterial pneumonia?

A

Viral - supportive, majority of children recover without sequelae

Bacterial - appropriate antibiotics and supportive care

58
Q

What is croup (laryngotracheobronchitis)?

A

Viral disease of the UR tract (and lower respiratory tract leading to erythema and edema of the tracheal walls and narrowing of the subglottic region); common cause of cough and stridor in children with a peak age of incidence of 2 years

(Winter months)

59
Q

Most common and other causes of croup + pathophysiology?

A

Most common - parainfluenza
Other viruses - rhinovirus, RSV, influenza, adenovirus

Inflammation and edema of the pharynx and upper airways, with maximal airway narrowing occurring in the subglottic region

60
Q

Presentation of croup?

A

Cold-like symptoms (congestion, coryza, sore throat, cough, fever); may progress to inspiratory stridor and a seal-like or barky cough

61
Q

Croup - CXR?

A

Steeple sign (narrowing in the subglottic region)

62
Q

Treatment of croup?

A

Generally supportive; breathing humidifed air or mist therapy can improve laryngospasm. Racemic epinephrine can be used for acute improvement, and oral or IM dexamethasone can reduce the severity of symptoms

63
Q

List the 9 major findings on lung exam.

A
  1. Stridor
  2. Wheezing
  3. Rhonchi
  4. Crackles
  5. Air entry
  6. Bronchial breath sounds
  7. Tracheal deviations
  8. Retractions
  9. Egophany
64
Q

What is stridor, what causes it, and when is it seen?

A

High-pitched inspiratory noise (can be biphasic)

Due to airway narrowing/partial obstruction of the extrathoracic airways such as the larynx or trachea (above the thoracic inlet)

DDx - croup (most often), inhaled foreign body with partial obstruction, laryngomalacia

65
Q

What is wheezing, what causes it, and when is it seen?

A

Expiratory only - mild obstruction
May be biphasic or disappear completely with increasing obstruction
Typically diffuse, but may be focal with mucus plugging
Polyphonic (multiple pitches) - asthma
Monophonic (single pitch) - focal airway obstruction

Due to airway narrowing below the thoracic inlet

DDx - intraluminal obstruction (edema, mucus, foreign object) or external compression (lymphadenopathy, neoplasm)

66
Q

What are rhonchi and what causes them?

A

Coarse, continuous, polyphonic, low-pitched rattling sounds - heard best in expiration, may be biphasic

Due to secretions/mucus and narrowing of the airways

67
Q

What are crackles and what causes them?

A

Finer, discontinuous breath sounds typically heard on inspiration

Associated with fluid in the alveoli or small airway conditions such as pneumonia, pulmonary edema, and bronchitis, or with opening and closing of stiff alveoli as in interstitial disease

Coarse - purulent secretions (pneumonia)
Fine - pulmonary edema or interstitial lung idsease

68
Q

When is decreased air entry seen?

A

Consolidation, atelectasis, pneumothorax, pleural effusion, airway obstruction

69
Q

What are bronchial breath sounds and what causes them?

A

Lower pitched, more hollow-sounding

Caused by air moving through areas of consolidated lung

70
Q

What can cause tracheal deviation?

A

Mediastinal mass, pneumothorax, or foreign body aspiration

71
Q

What happens to the I:E ratio in obstructive disorders?

A

Ratio of time for full inspiration to full expiration is normally 1:1 or 1:2; expiration is prolonged in obstructive disorders, leading to a decrease in the ratio

72
Q

What can cause hyperresonance and dullness to percussion?

A

Hyper - localized air trapping behind a mucus plug, foreign body, or mass

Dullness - lobar consolidation form pneumonia or atelectasis

73
Q

What is egophany and what causes it?

A

Patient says “ee,” examiner hears “ay” through the stethoscope; suggests lobar consolidation (airless lung)

74
Q

How is concern for foreign body aspiration worked up?

A
  1. PA/lateral chest films in the setting of asymmetric breath sounds - CXR helps account (or not account) for asymmetry
  2. Bilateral decubitus or inspiratory/expiratory films - helps evaluate for a larger airway obstruction
  3. Chest fluoroscopy - dynamic evaluation that visualizes the airways over several breaths
  4. Bronchoscopy - not the initial test - used to visualize the ariways
75
Q

In an aspiration obstructing the right airway, what is seen on PA film (sitting position) and right and left decubitus?

A

PA - right hemidiaphragm flattening (unilateral hyperexpansion on the right

R - mediastinal structures remain in the midline rather than shifting toward the right lung due to gravity (fixed hyperinflation)

L - mediastinal structures shift toward L lung as expected

76
Q

Most common aspirated foods?

A

Hot dogs, hard candy, nuts, grapes, popcorn

77
Q

Pathophysiology of cough?

A

Protective action
Can be initiated both voluntarily and via stimulation of cough receptors located throughout the respiratory tract (ear, upper/lower airways, pleura, pericardium, and diaphragm)

Receptors signal the cough center in the medulla -> vagus, phrenic, and spinal motor nerves to produce cough

78
Q

Acute vs. chronic cough?

A

Acute - <4 weeks

Chronic >4 weeks

79
Q

Typical causes of acute cough?

A

Most commonly due to infectious cause (viral URI vs. viral or bacterial pneumonia) or a clear precipitating event like trauma or choking

80
Q

Typical causes of chronic cough?

A

Infection, inflammation, irritation, anatomic, psychogenic; rarely due to cardiac or GI causes

Usually benign resulting from a viral URI, which can induce airway reactivity in a healthy host of weeks

Infants are more likely to have anatomic malformations (congenital vocal cord dysfunction, laryngotracheomalacia, vascular ring, laryngeal web, tracheal stenosis, or TE fistula)

Toddlers - consider foreign body aspiration

81
Q

Differentiating causes of dry vs. wet cough?

A

Dry - environmental irritant, asthma

Wet/productive - lower respiratory tract infection, post-nasal drip, GER, bronchictatic disease like CF

82
Q

Differentiating causes of barking vs. brassy/honking cough?

A

Barking - croup, subglottic disease, foreign body

Brassy/honking - habitual cough, tracheitis

83
Q

Differentiating causes of paroxysmal vs. worse at night vs. disappears at night cough?

A

Paroxysmal - pertussis, chlamydia, mycoplasma, foreign body

Worse at night - asthma, sinusitis, allergic or vasomotor rhinitis (postnasal drip)

Disappears at night - habitual cough

84
Q

Cough associated with gagging or choking?

A

GER

85
Q

Clues for a school-aged child with cough - change in voice (dysphonia or hoarseness)

A

Laryngeal irritation due to chronic rhinitis or GER

86
Q

Clues for a school-aged child with cough - chest pain

A

Probe for evidence of GI causes, not cardiac conditions. True cardiac chest pain is rare in children

While rare, CHF (most commonly due to infectious myocarditis) can present in school-aged children with cough and wheezing and can be mistaken for a common pulmonary condition

87
Q

Clues for a school-aged child with cough - fever?

A

Suggests infectious etiology, primarily pneumonia and sinusitis

Lobar pneumonia may also present with abdominal pain, mimicking appendicitis

88
Q

Clues for a school-aged child with cough - headaches?

A

Frontal or orbital headaches may suggest sinusitis (common cause of persistent cough in children due to the associated post-nasal drip, which is often worse at night when supine)

89
Q

Clues for a school-aged child with cough - sore throat?

A

Post-nasal drip and pharyngeal irritation due to allergies or sinusitis

90
Q

What are some environmental effects of coughing in children?

A

Exposure to secondhand smoke, wood smoke, air pollution, and a dry dusty environment (typically present with chronic cough WITHOUT wheeze)

91
Q

DDx - cough?

A

Many conditions

Viral URI
pneumonia
Post-nasal drip due to allergies and/or sinusitis
Foreign body aspiration
GER
92
Q

What is used to diagnose CF?

A

Sweat chloride test

93
Q

Sensitivity and specificity of sweat chloride test? Causes of false negatives and false positives?

A

Sensitivity - 99%
Specificity - 90%

False negative - specific rare CF mutation
False positive - metabolic disorders including adrenal insufficiency and hypothyroidism

94
Q

What does the neonatal screening detect to diagnose CF?

A

Immunoreactive trypsinogen in blood

95
Q

Most common mutation of the CFTR gene associated with CF?

A

Delta-F508

96
Q

Inheritance pattern of CF?

A

AR

97
Q

Components of CF treatment?

A

Nutritional management, with enzymes, vitamins, and extra calories

Airway clearance

Treatment of airway infections

98
Q

Signs of CF?

A 
Pancreatic insufficiency (steatorrhea and malabsorption
Chronic cough
Chronic sinusitis
Poor weight gain
Abnormal stools

Presentation can be variable

99
Q

The age at diagnosis of CF has a major impact on ___ of the child.

A

Nutritional status

100
Q

DDx - Tachypnea in a newborn

A
  1. Respiratory distress syndrome (RDS)
  2. Transient tachypnea of the newborn (TTN)
  3. Pneumothorax
  4. Meconium aspiration
  5. Hypoglycemia
  6. Hypothermia
  7. Cardiac abnormalities
  8. Neonatal sepsis
  9. Congenital diaphragmatic hernia
101
Q

Most common cause of respiratory distress in premature infants?

A

Respiratory distress syndrome

102
Q

Cause of respiratory distress syndrome?

A

Deficiency of lung surfactant and delayed lung maturation

specifically increased risk in infants of diabetic mothers due to a delay of sufficient surfactant production

103
Q

Cause of transient tachypnea of the newborn (TTN)?

A

Delayed clearance of fluid from the lungs following birth; more common in infants born to diabetic mothers and those born by C-section

104
Q

Cause of pneumothorax and common risk factors?

A

Collection of gas in the pleural space with resultant collapse of lung tissue

Mechanical ventilation or underlying lung disease (especially meconium aspiration or severe RDS in a premature infant)

105
Q

Common congenital heart defects can cause tachypnea - which ones and why?

A

VSD, PDA, AVC, due to pulmonary overcirculation

106
Q

Presentation of tachypnea due to cardiac abnormalities in infants?

A

Typically not present in the newborn period

Develops as the pulmonary resistance falls, typically by 6-8 weeks of age

107
Q

Coarctation of the aorta can lead to tachypnea - why and when does this occur?

A

Pulmonary venous congestion from left heart obstruction

Around 3-7 days of age as the PDA closes

108
Q

What happens in congenital diaphragmatic hernia?

A

Malformation resulting from a defect in the development of the diaphragm, allows the passage of organs from the abdomen into the chest cavity and severely impairs lung development

109
Q

Most congenital diaphragmatic hernias occur on which side? Most common type?

A

Left side; Bochdalek hernia (located posterolaterally)

110
Q

Compare CXR findings in RDS vs. TTN vs. neonatal pneumonia.

A

RDS: diffuse reticulogranular appearance of the lung fields (ground glass appearance) and air bronchograms

TTN: wet-looking lungs, no consolidation, no air bronchograms

Neonatal pneumonia: similar to TTN or RDS, but clinical findings more concerning for sepsis

111
Q

CXR findings of a diaphragmatic hernia?

A

Air-filled loops of bowel in the chest most often on the left side displacing the heart and mediastinum contralaterally

112
Q

What is persistent pulmonary hypertension of the newborn?

A

Abnormal transition to extrauterine life resulting from elevated pulmonary vascular resistance to the point that venous blood is diverted to various degree through fetal channels into the systemic circulation and bypasses the lungs, resulting in systemic arterial hypoxemia.

113
Q

What can cause PPHN?

A

Several conditions including meconium aspiration syndrome, diaphragmatic hernia, hypoplastic lungs, and in utero asphyxia.

114
Q

How should infants in respiratory distress be fed?

A

No evidence from controlled studies that feeding a tachypneic infant by mouth is contraindicated

Many infants with RR of 60-80 tolerate oral feeds, but some may need NG feeding or IV fluids if respiratory distress worsens with feeding

Pediatrics Clerkship (14 decks)

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