Aquifer - Pulmonary

Question 1

DDx - wheezing (infants and toddlers)

Answer 1

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

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

Question 2

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

Answer 2

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)

Question 3

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

Answer 3

True

Question 4

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

Answer 4

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

Question 5

List 6 signs of respiratory distress.

Answer 5

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

Question 6

What is paradoxical breathing?

Answer 6

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

Question 7

What is the difference between hyperpnea and hypopnea?

Answer 7

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)

Question 8

What are retractions and what causes them?

Answer 8

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

Question 9

What does nasal flaring indicate?

Answer 9

Accessory muscles are being used for respiration

Question 10

What does grunting indicate?

Answer 10

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

Question 11

What causes head bobbing?

Answer 11

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)

Question 12

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

Answer 12

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

Question 13

If a patient is hypoxemia, what should be done?

Answer 13

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)

Question 14

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

Answer 14

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.

Question 15

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

Answer 15

Viruses

Question 16

Discuss the triphasic course of pertussis.

Answer 16

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

Question 17

Complications of pertussis?

Answer 17

Infants > older children

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

Question 18

Discuss immunization against pertussis.

Answer 18

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.

Question 19

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

Answer 19

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

Question 20

What ages is epiglottitis most likely to present?

Answer 20

2-5 years

Question 21

Presentation of epiglottitis?

Answer 21

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

Toxic-appearing, sniffing position

Question 22

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

Answer 22

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

Question 23

How does epiglottitis appear on XR?

Answer 23

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

Question 24

When should diphtheria be considered?

Answer 24

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

Question 25

What is asthma?

Answer 25

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

Question 26

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

Answer 26

Asthma

Question 27

List 3 risk factors for asthma.

Answer 27

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

Question 28

Discuss the pathophysiology of asthma.

Answer 28

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

Question 29

How is asthma diagnosed?

Answer 29

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

Question 30

Presentation of asthma? Acute and chronic

Answer 30

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

Question 31

Discuss the asthma classification system.

Answer 31

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.

Question 32

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

Answer 32

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

Question 33

What is the difference between intermittent and persistent asthma?

Answer 33

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)

Question 34

Radiographic findings of asthma?

Answer 34

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

Question 35

What are the primary goals of therapy in treating asthma?

Answer 35

Reduce airway inflammation | Dilate the airways

Question 36

How is an acute asthma exacerbation treated?

Answer 36

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

Question 37

Most commonly prescribed inhaled steroids?

Answer 37

Beclomethasone, fluticasone, and budesonide

Question 38

When do inhaled steroids become beneficial?

Answer 38

After several weeks of daily use

Question 39

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

Answer 39

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

Question 40

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

Answer 40

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

Question 41

What does spirometry measure?

Answer 41

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

Question 42

Describe the process of obtaining a volume-time spirogram.

Answer 42

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

Question 43

Spirometry findings in obstructive lung disease?

Answer 43

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

Question 44

Spirometry findings in restrictive lung disease?

Answer 44

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

Question 45

What is the most common cause of wheezing in infants?

Answer 45

Acute bronchiolitis (viral disease of the lower respiratory tract)

Question 46

Pathophysiology of bronchiolitis? Most common cause?

Answer 46

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

Question 47

Signs and symptoms of bronchiolitis?

Answer 47

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)

Question 48

CXR findings in bronchiolitis?

Answer 48

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

Question 49

Treatment of bronchiolitis?

Answer 49

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.

Question 50

Pathophysiology of pneumonia?

Answer 50

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

Question 51

Most common cause of pneumonia in children? Other causes?

Answer 51

Respiratory viruses (adenovirus, RSV, parainfluenza, influenza) Bacterial infections - less common but more severe

Question 52

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

Answer 52

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

Question 53

Unique presenting feature of Chlamydia pneumonia?

Answer 53

Staccato cough presenting between 4-12 weeks

Question 54

Signs and symptoms of viral pneumonia?

Answer 54

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

Question 55

CXR findings in viral vs. bacterial pneumonia?

Answer 55

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

Question 56

Lab findings in viral vs. bacterial pneumonia?

Answer 56

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

Question 57

Treatment of viral vs. bacterial pneumonia?

Answer 57

Viral - supportive, majority of children recover without sequelae Bacterial - appropriate antibiotics and supportive care

Question 58

What is croup (laryngotracheobronchitis)?

Answer 58

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)

Question 59

Most common and other causes of croup + pathophysiology?

Answer 59

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

Question 60

Presentation of croup?

Answer 60

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

Question 61

Croup - CXR?

Answer 61

Steeple sign (narrowing in the subglottic region)

Question 62

Treatment of croup?

Answer 62

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

Question 63

List the 9 major findings on lung exam.

Answer 63

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

Question 64

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

Answer 64

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

Question 65

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

Answer 65

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)

Question 66

What are rhonchi and what causes them?

Answer 66

Coarse, continuous, polyphonic, low-pitched rattling sounds - heard best in expiration, may be biphasic Due to secretions/mucus and narrowing of the airways

Question 67

What are crackles and what causes them?

Answer 67

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

Question 68

When is decreased air entry seen?

Answer 68

Consolidation, atelectasis, pneumothorax, pleural effusion, airway obstruction

Question 69

What are bronchial breath sounds and what causes them?

Answer 69

Lower pitched, more hollow-sounding Caused by air moving through areas of consolidated lung

Question 70

What can cause tracheal deviation?

Answer 70

Mediastinal mass, pneumothorax, or foreign body aspiration

Question 71

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

Answer 71

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

Question 72

What can cause hyperresonance and dullness to percussion?

Answer 72

Hyper - localized air trapping behind a mucus plug, foreign body, or mass Dullness - lobar consolidation form pneumonia or atelectasis

Question 73

What is egophany and what causes it?

Answer 73

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

Question 74

How is concern for foreign body aspiration worked up?

Answer 74

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

Question 75

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

Answer 75

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

Question 76

Most common aspirated foods?

Answer 76

Hot dogs, hard candy, nuts, grapes, popcorn

Question 77

Pathophysiology of cough?

Answer 77

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

Question 78

Acute vs. chronic cough?

Answer 78

Acute - <4 weeks | Chronic >4 weeks

Question 79

Typical causes of acute cough?

Answer 79

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

Question 80

Typical causes of chronic cough?

Answer 80

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

Question 81

Differentiating causes of dry vs. wet cough?

Answer 81

Dry - environmental irritant, asthma | Wet/productive - lower respiratory tract infection, post-nasal drip, GER, bronchictatic disease like CF

Question 82

Differentiating causes of barking vs. brassy/honking cough?

Answer 82

Barking - croup, subglottic disease, foreign body Brassy/honking - habitual cough, tracheitis

Question 83

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

Answer 83

Paroxysmal - pertussis, chlamydia, mycoplasma, foreign body Worse at night - asthma, sinusitis, allergic or vasomotor rhinitis (postnasal drip) Disappears at night - habitual cough

Question 84

Cough associated with gagging or choking?

Answer 84

GER

Question 85

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

Answer 85

Laryngeal irritation due to chronic rhinitis or GER

Question 86

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

Answer 86

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

Question 87

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

Answer 87

Suggests infectious etiology, primarily pneumonia and sinusitis Lobar pneumonia may also present with abdominal pain, mimicking appendicitis

Question 88

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

Answer 88

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)

Question 89

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

Answer 89

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

Question 90

What are some environmental effects of coughing in children?

Answer 90

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

Question 91

DDx - cough?

Answer 91

Many conditions ``` Viral URI pneumonia Post-nasal drip due to allergies and/or sinusitis Foreign body aspiration GER ```

Question 92

What is used to diagnose CF?

Answer 92

Sweat chloride test

Question 93

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

Answer 93

Sensitivity - 99% Specificity - 90% False negative - specific rare CF mutation False positive - metabolic disorders including adrenal insufficiency and hypothyroidism

Question 94

What does the neonatal screening detect to diagnose CF?

Answer 94

Immunoreactive trypsinogen in blood

Question 95

Most common mutation of the CFTR gene associated with CF?

Answer 95

Delta-F508

Question 96

Inheritance pattern of CF?

Answer 96

AR

Question 97

Components of CF treatment?

Answer 97

Nutritional management, with enzymes, vitamins, and extra calories Airway clearance Treatment of airway infections

Question 98

Signs of CF?

Answer 98

``` Pancreatic insufficiency (steatorrhea and malabsorption Chronic cough Chronic sinusitis Poor weight gain Abnormal stools ``` Presentation can be variable

Question 99

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

Answer 99

Nutritional status

Question 100

DDx - Tachypnea in a newborn

Answer 100

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

Question 101

Most common cause of respiratory distress in premature infants?

Answer 101

Respiratory distress syndrome

Question 102

Cause of respiratory distress syndrome?

Answer 102

Deficiency of lung surfactant and delayed lung maturation | specifically increased risk in infants of diabetic mothers due to a delay of sufficient surfactant production

Question 103

Cause of transient tachypnea of the newborn (TTN)?

Answer 103

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

Question 104

Cause of pneumothorax and common risk factors?

Answer 104

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)

Question 105

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

Answer 105

VSD, PDA, AVC, due to pulmonary overcirculation

Question 106

Presentation of tachypnea due to cardiac abnormalities in infants?

Answer 106

Typically not present in the newborn period | Develops as the pulmonary resistance falls, typically by 6-8 weeks of age

Question 107

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

Answer 107

Pulmonary venous congestion from left heart obstruction Around 3-7 days of age as the PDA closes

Question 108

What happens in congenital diaphragmatic hernia?

Answer 108

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

Question 109

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

Answer 109

Left side; Bochdalek hernia (located posterolaterally)

Question 110

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

Answer 110

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

Question 111

CXR findings of a diaphragmatic hernia?

Answer 111

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

Question 112

What is persistent pulmonary hypertension of the newborn?

Answer 112

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.

Question 113

What can cause PPHN?

Answer 113

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

Question 114

How should infants in respiratory distress be fed?

Answer 114

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