Cough (Quiz 2) Flashcards

Question

Diagnosis of flu

Answer 1

* Specimen collection methods: * Nasopharyngeal swab (optimal method overall) **cannot** be collected in infants * Nasopharyngeal aspirate/wash **may not** be possible in infants * Combined nasal/throat swab: can be done for infants * Tests: * Rapid Antigen Detection * Viral tissue cell culture * Direct and indirect fluorescent antibody assays * RT-PCR: most sensitive and specific

Answer 2

* Laboratory confirmation should not delay antiviral therapy initiation * **Antiviral therapies:** * Oseltamivir (Tamiflu) * FDA approved in ages ≥ 2 weeks of age who have been symptomatic for ≤ 2 days * Approved for prophylaxis of influenza in those ≥ 1 year of age * Peramivir (Rapivab): very limited data on use in neonates * Zanamivir (Relenza): Only approved for those ≥ 7 * Rimantadine and amantadine previously used but now most flu viruses are resistant to them * **Supportive care:** * Hydration, relief of nasal congestion

Answer 3

* •Trivalent shot (6 months and older) * •Quadrivalent shot (6 months to \< 36 months) * •Quadrivalent shot (\> 36 months) * •Flumist (2- 49 years old)

Answer 4

* Should receive 2 doses of the vaccine if they have never received ≥ 2 total flu vaccines prior to July 1st of that year. * Doses should be administered 4 weeks apart.

Answer 5

* •Flu mist is a live attenuated vaccine: * §Other live vaccines that are not administered on the same day should be administered at least 4 weeks apart.

Answer 6

* •Croup (laryngotracheobrochitis): generic term for a spectrum of common viral respiratory tract illness * •Edema of the subglottic structures (larynx, trachea, and sometimes bronchi), leading to the brassy/barky cough * •Most often caused by parainfluenza virus and sometimes adenovirus or RSV

Answer 7

* •Affects children 6 months- 6 years of age * •Leading cause of hospitalizations in children under 4 * •Tends to occur in the fall and early winter

Answer 8

* •Usually begins with nasal congestion, rhinorrhea * •Within 12-24 hours: followed by relatively acute onset of fever, hoarseness, barky, seal-like cough, stridor (Johnson, 2009) * •Symptoms worse at night * •Usually lasts less than one week

Answer 9

* •Severity scoring: * •Cough frequency * •Degree of stridor * •Degree of respiratory distress

Answer 10

* Epiglottitis: drooling, trouble swallowing, vaccination status? * Peritonsillar abscess: displaced uvula, visible abscess? * Allergic reactions: known allergen and exposure, hives, rash? * Foreign body aspiration: cyanosis, wheeze, diminished breath sounds in focal area?

Answer 11

* •Physical Exam * •Steeple Sign

Answer 12

* •Fever treated with antipyretics * •Oral or IM/IV dexamethasone * •Nebulized epinephrine * •Increase fluids * •Avoid smoke exposure * •Keep head of bed elevated * •Cough medicines and decongestants not routinely recommended and can mask symptoms * •Humidifier mist for comfort * **•Moderate to severe croup** should be evaluated in the emergency department or clinic capable of handling urgent respiratory illness

Answer 13

* •Pertussis (whooping cough) caused by bacteria, Bordetella pertussis * •Bacteria attach to the lung cilia and release toxins, causing the airway to swell

Answer 14

* •Most common in \< 1 year olds * •About half of those \< 1 year old are hospitalized * •Often transmitted to babies by caregivers who do not yet know they have the disease * •Infants and pregnant women are high risk

Answer 15

* **Catarrhal Stage** (last 1-2 weeks) (highly contagious): * Rhinorrhea, low-grade fever, mild, occasional cough * **Paroxysmal Stage** (lasts up to 10 weeks): * Numerous coughing fits, with rapid cough followed by “whoop” sound * Posttussive emesis and exhaustion from coughing * **Convalescence stage** (lasts 2-3 weeks): * Coughing lessens, but fits may return ## Footnote *Whoop not always present in infants*

Answer 16

* Clinical diagnosis * Can confirm via: * PCR testing * If available: nasopharyngeal specimen * Serology testing: not standardized. Gold standard: in the presence of pre-existing immunity, rise in titers using paired specimens 2 to 3 weeks after onset of clinical illness.

Answer 17

Pneumonia, TB, RSV, flu, or other viral illness

Answer 18

* Humidifier mist * Increase fluids * Avoid irritants that can trigger cough * Treat with antibiotics: * **First line:** Azithromycin, erythromycin or clarithromycin * For infants \< 1 month: azithromycin is preferred and clarithromycin is not recommended * **Second line:** Trimethoprim-sulfamethoxazole (TMP-SMX) for children \> 2 months who have a contraindication to first line therapy

Answer 19

* •DTap series: 2 months, 4 months, 6 months, 15-18 months, 4-6 years * •TDap: 11-12 years * •Waning protection seen among adolescents

Answer 20

* •**GER**: passage of gastric contents into the esophagus (nl physiologic process, very common in infants) * •**GERD**: when reflux is associated with complications (i.e. esophagitis, poor weight gain) * •**Regurgitate**: reflux into oropharynx * •**Vomit**: expulsion of reflux contents

Answer 21

* Regurgitation in healthy infants is extremely common * 50% of 0-3 month olds * 75% of 4 months olds * 5-10% of 1 year olds * Increased risk with prematurity, cystic fibrosis

Answer 22

* •Regurgitation * •Choking * •Gagging * •Irritability * •Opisthotonic posturing * •Excessive hiccups * •Refusing feeds * •Respiratory involvement (less common): cough, wheeze, stridor * Back arching characteristic

Answer 23

* •Weight gain * •Irritability directly following feeds? * •Amount infant is feeding (make sure not overfed) * •Breastfeeding or formula * If breastfeeding, assess mom’s diet

Answer 24

* •Colic: crying ≥ 3 hours, ≥ 3 days/week, ≤ 3 months of age? * •Milk protein allergy: atopic dermatitis, diarrhea? * •Eosinophillic esophagitis: unresponsive to GERD meds, dysphagia, vomiting, weight loss? * •Pyloric stenosis: projectile vomiting in a 3-6 week old, “hungry vomiter”?

Answer 25

* •Clinical diagnosis: based on history and PE in the absence of warning signs * Diagnostic Studies * •Endoscopy and Esophageal Biopsy * •Can pursue if infant has significant symptoms and trial pharmacotherapy and lifestyle/feeding modifications not responsive * •Upper GI series * Not routinely recommended for evaluation of GERD. Would be done to rule out anatomic abnormalities.

Answer 26

not indicated for infants with uncomplicated reflux, because of lack of efficacy and modest safety concerns, and because the symptoms resolve without treatment in many infants (Winter et al., 2016)

Answer 27

Also called: Paradoxical Vocal Fold Motion ## Footnote •Adduction of vocal cords during inspiration instead of abduction. –Can more rarely occur during exhalation

Answer 28

Vocal cord movement during inspiration A: Normal vocal cord movement B: Adduction C: Adduction with “chinking”

Answer 29

\*Prevalence increased in females and early adolescence: controversial

Answer 30

* •HPI: * –Triggered by emotional stress * –Reflux, exercise, chemical irritant exposure in last 24H (chlorine, perfume, smoke) * –Throat tightness, difficulty swallowing * –Anxiety, panic * •PMH: Asthma, GERD * •Social: * –Elite athletes * –Recent traumatic event involving breathing * –Playing wind instrument * –Voice demands (singing, drama) * •Meds: Asthma treatments may have been ineffective

Answer 31

ASTHMA * Comorbid with asthma in as many as 40% of pediatric patients * Average time of asthma treatment: 4.8 years * Asthma co morbid and misdx * Elite athletes: prone to VCD, asthma * Traumatic event: near-drowning, suffocation, witnessing severe asthma attack

Answer 32

* •HPI and Exam – signs are often intermittent and may not be present in office: * –Dizzy, heavy extremities, paresthesias * –Aphonia /dysphonia / hoarseness * –Throat clearing, sensation of choking * –Dry cough * –Stridor: loudest over neck, * quieter in chest, * often inspiratory * –Dyspnea * –Tachypnea * –Throat / upper chest tightness * –Harder to get air “in” than “out”

Answer 33

* 1.History and physical * 2.Spirometry with inspiratory loops * 3.Document normal O2 sat during episodes * 4.Gold standard: Laryngoscopy, if needed can do after exercise or irritant challenge Attenuation is extrathoracic, asthma causes intrathoracic Spirometry shows attenuation/flattening

Answer 34

* •Manage underlying conditions (GERD, asthma) * •Speech and language pathologist * –Breathing exercises and relaxation techniques: Focusing attention away from larynx, abdominal breathing, neck relaxation, pursed lip breathing * •Possible: Psychologist, otolaryngologist (lesions, paralysis) * •Providing information to school, coaches, work 18-53% of patients with VCD have underlying GERD. VCD may resolve once GERD is managed.

Answer 35

* •Inflammation of pulmonary parenchyma * –Aspiration: food, saliva, gastric contents enters airways * –Bacterial: * Streptococcus pneumoniae (gram+): 3w to 4yo * mycoplasma pneum and chlmydophilia pneum (gram negs): \>5yo * –Viral: most common cause of LRTI, 2 - 3 yo, decreases aftr * –Incidence 3-5%, most often in children \<5yo

Answer 36

* •Younger age, previous URI, asthma history, more that three children at home, smoking * •Fall and winter

Answer 37

* •Several days of URI symptoms * •Fever * •Abrupt onset of chills, cough * •Change in activity, feeding * •Abdominal, neck or chest pain

Answer 38

* •General: ill appearing, “something is wrong”, splinting of affected side, knees drawn up to chest * •VS: Fever, decreased O2 sat * •Wet cough * –Pneumonia cough * •Respiratory: * –Tachypnea (*most specific)* * –Increased WOB (retractions, nasal flaring) * –Wheezing * –Early: Crackles, rhonchi, diminished breath sounds * –Late: Dullness to percussion, diminished breath sounds * •Variable rash from viral etiology * •Nausea/vomiting

Answer 39

* •Clinical \>\> enough if stable * •CXR \>\> confirmation, severe or failed treatment * –Infiltrate * •Consider: PPD, Influenza test for viral cause, CBC w/diff * •Bacterial vs. viral vs. aspiration * Labs: * -CBC with diff * -VIRAL: 20,000 WBC with lymphocytes * -BACT: 15,000-40,000 WBC with granulocytes * -Sputum cultures difficult to obtain and do not accurately reflect the cause of the LRTI * -Aspiration: * -History of level of consciousness change, predisposing condition * -Unwitnessed choking event à foreign body à weeks later, pneumonia develops. Often treated as pneumonia and aspiration not identified. Abx will help symptoms but infiltrates will remain and pneumonia will recur.

Answer 40

CXR normal vs infiltrate pneumonia

Answer 41

* •Viral: self limited within one month * –Most pre-school cases are viral * –Antivirals (even after 48h if sever) * •Bacterial * –Amoxicillin 90 mg/kg/day divided in 2 or 3 divided doses with max of 4g/day for 10-14 days * –If atypical: Azithromycin 10 mg/kg day 1, 5 mg/kg days 2-5 once daily with max of 500mg day 1, 250mg days 2-5 * •Aspiration * –Amoxicillin-clavulanate 40-50mg/kg/day in 2 or 3 divided doses (max 1750 Amoxicillin component) * •Follow up 12 hrs – 5 days\* * •Supportive care: antipyretics, nasal suctioning, fluids

Answer 42

* •\*48-96 hr improvement with abx * •Cough may last 1 month after resolution * •No repeat CXR needed

Answer 43

* –Any child \<3-6 mo unless mostly asymptomatic * –Sustained O2 sat \<90% * –Dehydration (older) /inability to feed (infants) * –Toxic * –Immunocompromised * –Cap refill \>/= 2 seconds * –Severe respiratory distress * •RR \> 70 in infants \<12 mo * •RR \>50 in older children * •Moderate to severe retrations in infants \<12 mo * •Severe difficulty breathing in older children * •Grunting, nasal flaring, apnea, Significant SOB * –Temp \>101.3 * –Outpatient failure / complications

Answer 44

•Pleural effusion, empyema, necrotizing pneumonia, pneumatocele, lung abscess

Answer 45

* •2 or more episodes in one year OR 3 or more lifetime episodes * •Must be radiographically clear between

Answer 46

* •Return to list of differentials * •Complications * •CXR * •Consider adding antibiotic coverage

Answer 47

* •Most common cause of cough in children \>3 yo * •Cough - often sole presenting complaint * –Nocturnal _(*unlike vcd)*_ * –Seasonal * –Exposure history (cold air, laughing, crying) * –\>3 weeks * –Usually associated wheezing, atopy, exceptional dyspnea * –Dry and hacking * •Can be productive with clear/white sputum but consider bronchitis

Answer 48

* •Spirometry (\>5yo) * •Asthma medication trial for 2-4 weeks – ICS and SABA * •3-5 days oral prednisolone * •Bronchoprovocation test

Answer 49

* Foreign body in larynx, trachea, right lung, left lung or bilaterally * •80% of cases in 1-3 yo

Answer 50

* •HPI: * –Choking event (witness or apparent) * –When (if days or weeks before may present with complications) * –Activity while eating, older siblings, access to small objects/improper foods * •PMH: asthma nonresponsive to therapy * •Exam: * –Cough – sudden onset (most common), wheeze * –Tachypnea (2nd most common) * –Stridor, wheeze (2nd most common) * –Decreased, regional difference in breath sounds * –Dullness/crackles if pneumonia develops * –Location specific findings: * •Laryngotracheal: wheeze, dyspnea, stridor, hoarseness * •Large bronchi: cough and wheeze * •Lower airways: little acute distress * -Triad (cough, wheeze, decreased breath sounds): specific (96-98%) but not sensitive (27-43%)

Answer 51

* •Chest or neck X-ray * •Possible CT * •Rigid bronchoscopy for diagnosis and removal * •Follow up 2-3 days if no findings and low clinical suspicion

Answer 52

•Hemoptysis, recurrent or acute pneumonia, lung abscess, bronchiectasis, atelectasis

Answer 53

A, Normal inspiratory chest radiograph in a toddler with a peanut fragment in the left main bronchus. B, Expiratory radiograph of the same child showing the classic obstructive emphysema (air trapping) on the involved (left) side. Air leaves the normal right side allowing the lung to deflate. The medium shifts toward the unobstructed side. *Peanuts don’t show up on x ray – very commonly aspirated*

Answer 54

* Definition * •Congenital defect * •Malfunctioning cilia à impaired mucociliary clearance * •Component of cilia is missing * Background * •Autosomal recessive * •Situs inversus

Answer 55

* •HPI * –Recurrent URI and LRI infections * •Chronic, productive cough * •Worsens through day * –Recurrent AOM * –Rhinosinusitis (cardinal sign) * •Headache, fatigue * –Supplemental O2 at birth * –Associated with: pyloric stenosis, epispadias, cardiac abnormalities, transposition of great arteries * •Exam * –Voice nasal * –Crackles, wheezes * –Nasal polyps

Answer 56

* •No gold standard * •Nasal nitrous oxide, nasal brushing and videomicroscopy… * •CXR/CT * •Genetic testing

Answer 57

* •Refer to pulmonology * •Clear secretions and selective antibiotics * •Chest physiotherapy * •Monitoring * •Manage OME, nasal polyps, chronic rhinosinusitis

Answer 58

* •Men infertile, women decreased fertility * •Chornic rhinosinusitis can influence work

Answer 59

* •Affects 10% to 30% of children and adults in the U.S. * •Accounts for at least 2.5% of all clinician visits and 2 million lost school days per year

Answer 60

* •Paroxysms of sneezing * •Rhinorrhea * •Nasal obstruction * Other common symptoms * •Itching of the eyes, nose * •Palateostnasal drip * •Cough * •Irritability * •Fatigue * \*\*Young children typically do not blow their noses, and instead, may repeatedly snort, sniff, * cough, and clear their throats. Some scratch their itchy palates with their tongues, producing a * clicking sound (palatal click).

Answer 61

* •Family history of atopy (ie, the genetic predisposition to develop allergic diseases) * •Male sex * •Birth during the pollen season * •Firstborn status * •Early use of antibiotics * •Maternal smoking exposure in the first year of life * •Exposure to indoor allergens, such as dust mite allergen * •Serum IgE \>100 int. units/mL before age six * •Presence of allergen-specific immunoglobulin E (IgE)

Answer 62

* •Symptoms * •Physical exam * –Enlarged nasal turbinate * –Clear rhinorrhea * –Cobblestoning of oropharynx * •Allergy skin testing confirms sensitivity to aeroallergens (not necessary for the initial diagnosis)

Answer 63

* •A second-generation oral antihistamine, administered regularly or as needed (ideally 2-5 hours before an exposure) * •An antihistamine nasal spray * •A glucocorticoid nasal spray (more effective than antihistamines), administered regularly or as needed * •Montelukast or Cromolyn, administered regularly or as needed (ideally 30 minutes before an exposure)

Answer 64

* Glucocorticoid nasal * If fail to respond, add a second agent - antihistamine nasal spray, oral antihistamines, montelukast, cromolyn, antihistamine/decongestant combination products

Answer 65

* Definition * •Inflammation of the lining of the nose and sinuses * Prevalence * •6%-8%

Answer 66

* **•Ethmoid sinus**. Located inside the face, around the area of the bridge of the nose. This sinus is present at birth, and continues to grow. * **•Maxillary sinus.** Located inside the face, around the area of the cheeks. This sinus is also present at birth, and continues to grow. * **•Frontal sinus**. Located inside the face, in the area of the forehead. This sinus does not develop until around 7 years of age. * **•Sphenoid sinus.** Located deep in the face, behind the nose. This sinus does not develop until adolescence.

Answer 67

Most colds have a runny nose with mucus that typically starts out clear, becomes cloudy or colored, and improves by about 10 d. Some colds will also include fever (temperature \>38°C [100.4°F]) for 1 to 2 days. In contrast, acute bacterial sinusitis is likely when the pattern of illness is persistent, severe, or worsening. ## Footnote *Uncommon in newborns 2/2 sinuses not fully developed*

Answer 68

* •A cold lasting more than 10 to 14 days, sometimes with a low-grade fever * •Thick yellow-green nasal drainage * •Post-nasal drip, sometimes leading to or exhibited as sore throat, cough, bad breath, nausea and/or vomiting * •Headache, usually in children age six or older * •Irritability or fatigue * •Swelling around the eyes

Answer 69

* •Acute bacterial sinusitis when acute URI with the following: * Persistent illness, ie, nasal discharge (of any quality) or daytime cough or both lasting more than 10 days without improvement; OR * •Worsening course, ie, worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement; OR * •Severe onset, ie, concurrent fever (temperature =39°C/102.2°F) and purulent nasal discharge for at least 3 consecutive days”

Answer 70

* •Antibiotic therapy: * –Amoxicillin 90 mg/kg/day PO divided q8-12h x 10 days * –Unresponsive/allergic: Cefpodoxime 10mg/kg/day PO divided q12 x 10-14 d * – Nasal decongestant/saline nasal sprays: short-term relief of stuffiness * •Nasal saline: thins secretions and improves mucous membrane function * •OTC decongestants and antihistamines generally not effective * •Important to complete therapy even if symptoms improve

Answer 71

* •One or more symptoms of sinusitis for at least 12 weeks * •Chronic sinusitis or recurrent episodes of acute sinusitis (\> 4-6/yr) à refer to ENT * •Surgery: for severe or persistent sinusitis symptoms despite medical therapy

Answer 72

* •When mucus drips down the throat, it tickles the nerves of the nasopharynx, triggering a cough * •Generally a symptom secondary to rhinitis and sinusitis * •If it lingers after the primary condition, it is considered Upper Airway Cough Syndrome

Answer 73

* •Cough more at night * •Tickling feeling at the back of throat

Answer 74

* Diagnosis * •History and physical exam * •Diagnosis generally based on response to treatment * Treatment * •Decongestant or antihistamine or combination * •Home remedies such as inhaling steam or nasal irrigation

Answer 75

* Prevalence * •Up to 10% of children and adolescents * Etiology * •No pathologic cause of the cough (chronic cough of unknown origin that does not respond to observation and primary care interventions ) * •No response to commonly used antitussive medications

Answer 76

* •Tickling in the throat * •Cough usually prominent during visits to the clinic, absent at night and rarely interrupts play, speech, or eating * •Distinctive in nature: short, single dry coughs (tics) or may be similar to laryngotracheobronchitis (a barking or honking sound after a short inhalation) * •Loud and disruptive in a classroom (leads to excessive absences from school

Answer 77

* •Abnormal gag reflex * •Abnormal corneal reflex * •Loud paroxysmal barking or honking sound (usually not heard when provider not in room) ## Footnote *Cough: Often loud cough in exam room but if you stand outside room and patient does not know you are there, there is no coughing.*

Answer 78

* Diagnosis * • Diagnosis of exclusion * Treatment * •Suggestion therapy * •Bedsheet wrap: Tightly wrap a sheet around the child's chest which provides the support to stop the cough (suggestion technique that convinces patient that chest muscles have become too weak to contain the cough) ## Footnote *Ace wrap may be more practical than bedsheet*

Answer 79

* •23,076 cases last 15yrs, 1.7% were pediatric * –15-19 years old (44.3%) * •2-9% of pediatric pneumonia * •“Legionnaires' disease” * –1976 American Legion Convention, Philadelphia * •221 cases, 34 deaths

Answer 80

* •Wheezing * No hx of asthma * Wet cough – gradually getting worse x 3 days * No crackles/rhonchi * No dyspnea or pleuritic chest pain * Temp 100.8 * •Neurologic findings (especially confusion), fever \>39ºC, hyponatremia, hepatic dysfunction, hematuria * •Failure to respond to beta-lactams and/or aminoglycosides ## Footnote *-Beta-lactam inhibitors – Penicillins, Cephalosporins, Cephamycins, Carbapenems, Monobactams, Beta-lactamase inhibitors*

Answer 81

* •No person-person transmission * –Inhalation of aerosols (showers, grocery store mist, cooling stations, decorative fountains, whirlpool spas) * Incubation period 2-10 days

Answer 82

* •Nationally notifiable disease * •Levofloxacin * –500 mg PO once daily x 10-14 days * •Azithromycin * –10 mg/kg (maximum dose: 500 mg) as a single dose on the first day, followed by 5 mg/kg/day (maximum dose: 250 mg) on days 2 through 5.

Answer 83

CXR: Diffuse bilateral interstitial infiltrates

Answer 84

“atypical pneumonia” •20% of pediatric pneumonia

Answer 85

* •Wheezing (no hx asthma) * •Gradual onset of sx’s, minimal respiratory distress * •Chest auscultation (-) early stages, but CXR (+) * •Extrapulmonary sx’s * – Rash, joint involvement, GI * •Dutifully investigate differential dx’s * Common infectious cause of SJS

Answer 86

* not feasible/useful in outpatient settings * CXR: no distinguishing features

Answer 87

•Azithromycin –10 mg/kg in one dose (maximum dose 500 mg) on the first day and 5 mg/kg in one dose (maximum dose 250 mg) for four days

Answer 88

•6% of childhood cancers -- highest incidence 15-19 y.o.

Answer 89

* •75% will have a mediastinal mass * –Of these, 30% with a mass \> 1/3 diameter of intrathoracic cavity * •At risk for acute respiratory compromise * •Dysphagia, dyspnea, stridor * •Cough is prolonged (\> 2 weeks) and has no identifiable cause * •80% painless adenopathy * – supraclavicular or cervical area * •25% non-specific constitutional symptoms * –Cough, fatigue, anorexia, weight loss, pruritus, night sweats, low grade fever * •EBV =\> HL ?? * –25-50% cases classical HL are EBV+

Answer 90

* •Treatment/Prognosis * –Stage, B symptoms, bulky disease (size) * •Fever, night sweats, \>10% wt. * •Multidisciplinary team * –Primary care practitioners * –Pediatric surgeons * –Pediatric medical oncologists and hematologists * –Rehabilitation specialists * –Social workers * –Child life professionals * –Psychologists * •5-year survival 95% * •Ongoing surveillance for years - 90-95% cure rate

Answer 91

* •123 deaths of children * •750,000 poison control center calls 2000-2011 * •Recommendations: * –Do not use in children * –Recommended against in children 6-12 (UpToDate) * –Single use symptomatic relief if needed in children \>12 yo * •Why? * –Not proven more efficacious * –Untested dosing guidelines for children * –Potential for enhanced toxicity * –Associated with fatal overdose * –Other ingredients: dye and alcohols

Answer 92

* Antitussives * •No studies showing efficacy and safety * •Act on cough center of medulla to elevate coughing threshold * Antitussives – Dextromethorphan * •Well tolerated * •No evidence of cough improvement (placebo and DM treated groups both improved in 3d) * •Deaths from DM ingestion in children * •Abuse potential * •Recommendations: * –WHO: DM may be okay if interfering with sleep/feeding but should consider different diagnosis (pertussis, asthma, pneumonia) * –AAP: No antitussives

Answer 93

* -Symptoms can occur at 1.5 mg/kg (first plateau, mild stimulation) to 7.5-15mg/kg (third plateau, out of body state) * - Hallucinations, euphoria * -School age, adolescents * -“dex, DXM, robo, skittles, triple-C, vitamin D, tussin, red devils, poor man’s PCP” * -Consume large amounts, as much as 20oz/day * -Coricidin HBP, RobitussinDM and Delsym have high concentrations of DM

Answer 94

* •What’s the problem? * –No more effective than placebo * –No proven efficacy in children * –Significant safety concerns (respiratory depression). * –Variations in metabolism * –Will never achieve full cough suppression even at highest dose * •Recommendations: removed or cautioned against by: AAP, WHO, American College of Chest Physicians, FDA * –Canadian Ministry of Health, European Medicines Agency: possibly ok \> 12yo * •National variance in prescribing practices * for cough suppression * Variations in metabolism: 30% of population are slow metabolizers, 8% are ultra rapid metabolizers converting 5-30 times more than typical into the active form (higher percentage in Middle Eastern and North African)

Answer 95

* •Hydration: Thins secretions, relieves cough-inducing irritation * •Warm liquids: loosens secretions, relieves cough-inducing irritation, increases flow of secretions * •Saline solution: : removes secretions, improves mucous clearance, vasoconstriction * –½ teaspoon salt + 1 C sterile warm water/boiled water * –Gargle or instillation/drops into nose * •Cool mist humidifiers: clean weekly! * •Lozenges/hard candy: \> 6yo – coats thr throat * •Vapor rub: reduces frequency and severity of cough, No effect on rhinitis, Irritant effect possible

Answer 96

* •½ to 1 teaspoon straight or diluted * •Buckwheat, dark or any; corn syrup * •Eases night-time coughing * •Decreases severity and frequency * •Improves sleep quality * •Better than placebo, nothing and diphenhydramine, equal to DM in 2014 study of children 1-5 yo (N=300) * •No significant adverse effects * •Endorsed by WHO and AAP for children \> 1yo

Answer 97

* Important History and Physical components ( age related) * Definitions: * wet, dry, productive * rales, rhonchi, wheeze, stridor,crackles, staccato, whoop * Conditions common to specific ages * Unique presentation * Associated symptoms * Methods of objective eval ( if recommended) * Guidelines to diagnosis, if applicable * Management ( not specific dosings) * OTC products * Alternative management * Keep study focused on primary care – not hospital or not specialist

Cough (Quiz 2) Flashcards

(132 cards)