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cmn568 > Module 2 > Flashcards

Module 2 Flashcards

1
Q

4 components of a physical exam for respiratory assessment

A
  1. inspection
  2. palpation
  3. percussion
  4. auscultation
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2
Q

Normal findings for respiratory assessment (observe, inspect, palpate, percussion, auscultation)

A

-observe pattern of breathing (RR 12-14rr/min) and rhythm (regular with a sigh every 90 breaths or so), depth of breathing/tidal volume, relative time spent inspiration and expiration (ratio 2:3)
-inspect for extrapulmonary signs of pulmonary disease –> use what you find to perform more detailed exam
-palpate: 1. trachea at suprasternal notch 2. posterior chest wall (gauge fremitus/transmission through lungs of vibrations of spoken words) 3. anterior chest wall (assess cardiac impulse)
-percussion: identifies dull areas or hyperresonant areas
-auscultation of lung sounds

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3
Q

Extrapulmonary signs (4)

A

-digital clubbing (lung abscess, empyema, bronchiectasis, CF, idiopathic pulmonary fibrosis, AV malformations; late presentation: concomitant lung cx
-Cyanosis: blue or bluish-gray discoloration of skin & mm due to inc amounts of unsaturated HgB in capillary blood (anemia: may prevent cyanosis from appearing; polycythemia: cyanosis in mild hypoxemia) –> cyanosis not reliable indicator of hypoxemia = get arterial PO2 or HgB saturation measured
-Inc CVP: indirectly measures pulmonary HTN (major complication of chronic lung dx); impaired ventricular function, pericardial effusion, or restriction, valvular heart dx, COPD
-BLE edema: indirectly measures pulmonary HTN (major complication of chronic lung dx) w/ chronic lung disease = RV failure

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4
Q

Kussmaul respirations

A

rapid LARGE VOLUME breathing = intense stimulation of respiratory center r/t metabolic ACIDosis

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5
Q

Cheyne-stokes respirations

A

RHYTHMIC, waxing/waning of rate and RV, regular periods of APNEA (seen in end-stage LV failure, neurological dx, sleeping at high altitude

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6
Q

What is wheezing a powerful indicator for?

A

obstructive lung disease (asthma, COPD)

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7
Q

Does rhonchi clear after cough?

A

YES

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8
Q

Risk factors for CAP

A

older age, hx of etoh/tobacco, asthma/COPD/immunocompromised

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9
Q

Timing of CAP (in relation to the hospital)

A

Occurs prior to admission (to the hospital) or within 48 hours of admission

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10
Q

Sx of CAP

A

-Acute or subacute onset of fever (low in elderly) (FEVER)
-Cough (w/ or w/o sputum) (COUGH)
-Dyspnea/tachypnea (sensitive sign in elderly) (DYSPNEA)
-Mental status change (elderly) (MENTAL)
-Rales, bronchial breath sounds or inspiratory crackles (SOUNDS)
-Parenchymal opacity on x-ray (X-RAY)

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11
Q

What bacteria is primarily responsible for CAP?

A

S pneumoniae

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12
Q

Viruses that cause CAP?

A

RSV, Influenza A/B, adenovirus/parainfluenza virus, human metapneumonvirus

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13
Q

Is diagnostic testing required/recommended for outpatient management of CAP? Why?

A

NO (only hospitalized patients). Empiric abx is almost always effective in this population w/o need for dx tests

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14
Q

What 3 widely available rapid point of care tests are used to ID causative organism in CAP?

A
  1. Sputum gram stain
  2. Urinary antigen tests (S pneumonia, legionella species)
  3. COVID RT-PCR/Rapid Test
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15
Q

Why should you obtain a rapid flu test when dx CAP?

A

Because positive flu tests reduce unnecessary abx use

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16
Q

What imaging is required to establish a dx of CAP?

A

Pulmonary opacity on chest x-ray

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17
Q

CAP - Can a CXR identify causative organism or distinguish bacterial from viral pneumonia?

A

NO

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18
Q

CAP - If CXR shows SIGNIFICANT pleural fluid collections, what should the NP do?

A

REFER (thoracentesis)

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19
Q

CAP - If CXR shows cavitary opacities, what should the NP do?

A

ISOLATE and REFER to ED - to rule out TB

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20
Q

Recommended outpatient abx choice for CAP patient who was previously healthy with no recent (90 day) antibiotic use?

A

Amoxicillin
Doxycycline (100mgBIDx5days)
**do not use fluroquinolones in ambulatory pt w/o comorbidities or recent abx use - RISK OF TENDON RUPTURE

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21
Q

Recommended outpatient abx choice for CAP patient with previous risk of drug resistance (abx<90 days, >65yrs old, comorbid illness (COPD/CHF/DM/Cx/Chronic renal/liver), alcoholism, immunosuppression, exposed to child in daycare?

A

-Macrolide or doxy PLUS oral beta-lactam (Augmentin) OR
-Oral respiratory fluoroquinolone (moxifloxacin, gemifloxacin, levofloxiacin)
*if abx <90days, choose new one from different class

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22
Q

CAP - what is the typical abx tx for adults?

A

5 days (continue abx until pt is afebrile for 40-72hrs)
-cough, fatigue may last up to 4 weeks

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23
Q

Prevention techniques against CAP?

A

PPSV23, PCV13 (PCV15), influenza, COVID19

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24
Q

CURB-65

A

Screening tool for CAP
Assess 5 predictors to calculate a 30 day predicted mortality rate
-Confusion
-Urea: BUN >7mmol/L (20mg/L)
-Respiratory rate: >30/min
-BP: systolic <90, diastolic <60
-Age: >65 years old
0 = outpt tx is probably safe
1-2 = admit to hospital for care
3-4 = URGENT REFERRAL! Admit to ICU.

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25
Q

PSI

A

Screening tool for CAP
Pneumonia severity index
-Age, gender, nursing home status, comorbid conditions, physical exam, and labs (including blood pH) to determine hospitalization

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26
Q

Anaerobic pneumonia risk factors

A

hx of predisposition of aspiration (nocturnal asthma, chemical pneumonitis, bronchiectasis, AMS (drugs/ETOH), seizures, general anesthesia, CNS disease, neuromuscular dx, ET tube/NG tube, poor dentition)

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27
Q

Does anaerobic pneumonia have insidious or gradual onset?

A

Insidious

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28
Q

Symptoms of anaerobic pneumonia

A

insidious onset of fever, weight loss, malaise, COUGH WITH FOUL-SMELLING SPUTUM = anaerobic

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29
Q

What diagnostic test is used for anaerobic pneumonia?

A

Chest X-ray

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30
Q

Treatment for anaerobic pneumonia?

A

IV clindamycin or Augmentin q12 hr; or Pen G and Flagyl. Treat until resolution on X-ray.

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31
Q

What is a major determining factor regarding the lung zone affected at time of aspiration for anaerobic pneumonia?

A

Body position

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32
Q

What does an air-filled cavity in lung suggest?

A

Abscess

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33
Q

What does the presence of multiple areas of cavitation within an area of consolidation lead the NP to suspect?

A

Necrotizing pneumonia

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34
Q

The presence of purulent pleural fluid accompanying either lung abscess or necrotizing pneumonia would indicate what complication (anaerobic pneumonia)?

A

Empyema

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35
Q

Treatment for anaerobic pneumonia

A

1st line: IV clindamycin q8hr OR Augmentin q12hr
Alternative: Amox or PCN G + metronidazole (flagyl)

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36
Q

Length of treatment for:
-Anaerobic pneumonia
-Lung abscess
-Empyema

A

-until CXR improves (month or more)
-until CXR resolution of abscess cavity is demonstrated
-REFER (must have tube thoracostomy)

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37
Q

Key symptoms of pleuritis

A

localized pain, sharp, fleeting - worse with coughing, sneezing, deep breaths or movement; diaphragmatic involvement = referred ipsilateral shoulder pain

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38
Q

Cause of pleuritis in healthy, young adults?

A

viral resp infection or pneumonia; simple rib fracture

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39
Q

Treatment for pleuritis

A

Treat underlying dx
-Pain: analgesics/NSAIDs (indomethacin, etc.)
-Control cough: codeine or other opioid; promitozine cough syrup

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40
Q

What would you do if pleural effusion, pleural thickening, or air in pleural space observed?

A

REFER!!

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41
Q

Definition of Pleuritis

A

Inflammation of pleural lining

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42
Q

Definition of Pleural effusion

A

collection of fluid in pleural space

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43
Q

Risk factors associated with pleural effusion

A

chest pain + pleuritis, trauma, or infection

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44
Q

Common findings related to pleural effusion

A

dyspnea (large effusions –> dullness to percussion and decreased/absent breath sounds over effusion); CXR shows pleural effusion; diagnostic findings on thoracentesis

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45
Q

Sx associated with pleural effusion?

A

Unilateral chest pain, worse with inspiration or deep breathing; dullness to percussion; dec/absent breath sounds where effusion located

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46
Q

Pulmonary infiltrates - how do you diagnose in immunocompromised patient?

A

Sputum culture!

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47
Q

If no clinically apparent cause for pleural effusion, how is it diagnosed?

A

Thoracentesis

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48
Q

Symptoms of spontaneous pneumothorax

A

Acute UNILATERAL chest pain, dyspnea
UNILATERAL chest expansion
Decreased tactile fremitus
Hyperresonance

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49
Q

Types of spontaneous pneumothorax

A

Primary
Secondary

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50
Q

Signs and symptoms of small pneumothorax

A

mild tachycardia

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51
Q

Signs and symptoms of large pneumothorax

A

diminished breath sounds, decreased tactile fremitus, decreased movement of chest

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52
Q

Lab findings related to pneumothorax

A

-ABG: hypoxemia, resp alkalosis
-EKG: left-sided primary pneumothorax = QRS axis and precordial T wave changes - can appear like MI

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53
Q

Treatment for pneumothorax (primary, secondary, small, large)

A

*treat cough and pain (serial CXR q 24 hrs)
-Small, stable spontaneous pneumothorax: observation alone may be appropriate
-Large, progressive pneumothorax: needle decompression (16g needle) –> place chest tube (small-bore tube) attached to one-way Hemlich valve (provides protection against development of tension pneumothorax); may permit observation from home

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54
Q

Treatment for tension pneumothorax

A

chest tube under water seal drainage with suction (removed after air leaks subsides)

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55
Q

What causes risk of reoccurrence of pneumothorax?

A

Smoking, high altitudes, flying in unpressurized aircraft, scuba diving

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56
Q

What coexists with obstructive sleep apnea?

A

Obesity-hypoventilation syndrome (blunted ventilatory drive and increased mechanical load imposed upon the chest by obesity)

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57
Q

Patients with pulmonary venous thromboembolism have a history of what?

A

DVT

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58
Q

Symptoms of pulmonary venous thromboembolism

A

-dyspnea
-chest pain worse with inspiration
-cough
-hemoptysis
-syncope
-tachypnea
-widened alveolar-arterial PO2 difference (hypoxemia with right-to-left shunting)

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59
Q

How to diagnose PE (what diagnostic tests)?

A

-d-dimer (increased)
-CT pulmonary angiography (abnormalities/VQ Scan-for those who cannot tolerate contrast dye)
-EKG (ST or T wave change, tachycardia), then REFER

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60
Q

Substances that could embolize to lung circulation causing PE?

A

-Air
-Amniotic fluid
-Fat
-Foreign bodies
-Parasite eggs
-Septic emboli
-Tumor cells

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61
Q

Risk factors for thrombus formation

A

-Venous stasis
-Injury to vessel wall
-Hypercoagulability
-Immobility
-Inc CVP ((Dec CO states, pregnancy)
-Inherited dx (factor V Leiden)

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62
Q

Labs/Diagnostic tests for suspected PE?

A

ECG
ABG
d-dimer
CXR
CT angiogram
Venous ultrasound (rule out proximal DVT)

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63
Q

Profound hypoxia with normal CXR in absence of lung disease - what are you suspicious for?

A

PE

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64
Q

What is the clinical prediction tool for determining patient probability of PE?

A

Wells Clinical Prediction rule (modified Wells score of 4 or mess who meet all PERC criteria ORDER a d-dimer)

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65
Q

What is a form of secondary prevention (med) for PE?

A

Heparin anticoagulation therapy (standard regimen) followed by 6 month PO warfarin (another effective drug is LMWH - recommended for patients’ with cancer)

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66
Q

What is the appropriate duration of therapy for patients with PE?

A

No standard

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67
Q

What is a major complication from treatment of PE? What should you be monitoring?

A

Hemorrhage; INR (target INR = 2.0-3.0)

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68
Q

What medication therapy is instituted for an established PE?

A

Rt-PA
Alteplase: thrombolytic therapy (high risk pts) –> choose if needs lifesaving tx

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69
Q

ABSOLUTE CONTRAINDICATIONS FOR THROMBOLYTIC THERAPY

A

active internal bleeding
stroke w/i past 2 months

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70
Q

MAJOR CONTRAINDICATIONS TO THROMBOLYTIC THERAPY

A

uncontrolled HTN
Surgery/trauma within past 6 weeks

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71
Q

Symptoms of RSV

A

-low-grade fever
-tachypnea
-wheezing
-apnea
-increased mucous secretion

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72
Q

Physiologic sx of RSV

A

hyperinflated lungs, decreased gas exchange, increased WOB

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73
Q

At what ages is RSV mortality highest?

A

<5yrs; >65yrs

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74
Q

Risk factors for RSV

A

prematurity
early RSV bronchiolitis in kids + family hx of asthma –> persistent airway reactivity in life

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75
Q

Wells Score - for patients with Modified Wells <equal 4 who meet ALL of the following criteria, PE is excluded, follow off anticoagulation, and search for alternative dx. List criteria (8)

A
  1. Age <50yrs
  2. HR <100bpm
  3. Oxyhemoglobin saturation on room air >equal 95%
  4. No prior hx of venous thromboembolism
  5. No recent (w/i 4 weeks) trauma or surgery requiring hospitalization
  6. No presenting hemoptysis
  7. No estrogen therapy
  8. No unilateral leg swelling
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76
Q

How is seasonal influenza spread?

A

Droplet

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77
Q

Symptoms of seasonal influenza in relation to:
-unvaccinated adults
-kids with type B
-elderly

A

-abrupt onset of fever, chills, HA, malaise, myalgias, runny/stuffy nose, sore throat, hoarseness, cough, substernal soreness
-GI complaints
-Lassitude, confusion, w/o fever or respiratory sx

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78
Q

How long is the incubation period for seasonal influenza?

A

1-4 days

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79
Q

When to suspect secondary bacterial infection during seasonal influenza illness

A

Recurrent fever or persistent fever >4 days w/ productive cough and WBC >10,000
-most common = pneumococcal pneumonia; staph pneumonia = most serious

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80
Q

Treatment for seasonal influenza

A

Tamiflu
75mg by mouth BID 5 days
-most effective if given w/i 2 days of sx start

Relenza: inhalation powder (oral inhalation). Used for influenza A and B
-contraindicated with asthma

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81
Q

Primary risk factor for avian influenza

A

Direct of indirect exposure to infected live or dead poultry or contaminated environments (live bird markets); slaughtering or handling carcasses of infected poultry

82
Q

Treatment for avian influenza

A

Tamiflu

83
Q

How to dx avian flu?

A

-patient history (exposure to dead/il birds or live poultry markets in prior 10 days
-PCR test w/i 7d onset

84
Q

Adenovirus infections - when are you most likely to get sick with this illness?

A

Throughout the year

85
Q

Incubation period of adenovirus

A

4-9 days

86
Q

Type of adenovirus that is severe/fatal for chronic lung dx patients

A

Type 14

87
Q

What virus is commonly associated with AOM?

A

RSV

88
Q

What is a complication of seasonal influenza with kids?

A

Reye syndrome (type B)

89
Q

Tx for influenza and how quickly it should be started

A
  1. Tamiflu (drug of choice)
  2. Zanamivir (relenza)
  3. Adamantanes (amantadine & rimantadine) (not recommended d/t resistance in influenza A & B)
    **begin medication within 48 hours of illness onset
90
Q

Key symptoms of pneumococcal pneumonia (adults)

A

-productive cough
-fever
-rigors
-dyspnea
-early pleuritic chest pain
-bronchial breath sounds = EARLY SIGN

91
Q

What does CXR show in patient with pneumococcal pneumonia?
How is organism determined?

A

Consolidating lobar pneumonia
Sputum culture or rapid urinary antigen test for s pnumoniae

92
Q

What type of bacteria is seen with pneumococcal pneumonia?

A

gram+ diplococci

93
Q

What is the most common cause of community-acquired pyogenic bacterial pneumonia?

A

Pneumococcal

94
Q

Risk factors for pneumococcal

A

alcoholism, asthma, HIV+, sickle cell, splenectomy, hematologic disorders

95
Q

Tx for pneumococcal

A

Empiric abx pending isolation and identification of causative agent
-PO amoxicillin: uncomplicated cases; cephalosporins; PCN allergy = “mycins”

96
Q

Complications of pneumococcal pneumonia
-treatment of complications

A

-parapneumonic effusion (causes recurrence or persistence of fever)
-empyema
-pneumococcal pericarditis –> tamponade = EMERGENCY

Thoracentesis; echocardiogram; endocarditis - penicillin G IV; prosthetic valve implantation for moderate-severe HF d/t valve regurgitation

97
Q

Bordetella pertussis “whooping cough” - age that this bacteria impacts

A

<2yrs
-adults and adolescents are reservoirs for infection

98
Q

How is Bordetella pertussis spread? (mode of transmission)

A

Droplets

99
Q

How long to sx last for Bordetella pertussis?
How many stages of Bordetella pertussis is/are there? What is/are the stages?

A
  1. 6 weeks
  2. 3 stages
    -Stage 1 (Catarrhal)
    -Stage 2 (paroxysmal)
    -Stage 3 (convalescent)
100
Q

Catarrhal stage of Bordetella pertussis

A

Stage 1
Insidious onset - lacrimation, sneezing, coryza (head cold), anorexia, malaise, hacking night cough that becomes diurnal

101
Q

Paroxysmal stage of Bordetella pertussis

A

Stage 2
Bursts of rapid, consecutive coughs followed by deep, high-pitched inspiration (whoop)

102
Q

Convalescent stage of Bordetella pertussis

A

Stage 3
Begins 4 weeks after onset with decrease in frequency and severity of paroxysms of cough

103
Q

Is Bordetella pertussis gram+ or gram-?

A

Gram -

104
Q

Is pneumococcal pneumonia caused by gram+ or gram- bacterial?

A

Gram +

105
Q

What strain/bacteria is responsible for most disease in adults in regard to Haemophilus species?

A

H influenzae (sinusitis, otitis, bronchitis, epiglottis, pneumonia, cellulitis, arthritis, meningitis, endocarditis

106
Q

Treatment for haemophilus species: sinusitis, otitis, respiratory tract infection

A

Amoxicillin PO

107
Q

Treatment for haemophilus species: beta lactamase strains

A

Augmentin PO

108
Q

Who is at risk to develop Legionnaires disease?

A

Immunocompromised, smokers, chronic lung disease

109
Q

Symptoms of Legionnaires disease

A

high fever
grossly purulent sputum
pleuritic chest pain
toxic appearance

110
Q

How is Legionnaires disease dx?

A

CXR: focal patchy infiltrates or consolidation (blood, urine are other options)

Gram-stain of sputum - polymorphonuclear leukocytes (no organisms shown (show up poorly) = not a good test for dx)

111
Q

What is the 3rd most common cause of CAP?

A

Legionnaires disease

112
Q

How is Legionnaires disease spread?

A

Contaminated water sources, air conditioning cooling towers

113
Q

What do labs show for Legionnaires disease? (3)

A

-hyponatremia
-elevated liver enzymes
-elevated CK (enzyme)

114
Q

Treatment for Legionnaires disease

A

Azithromycin PO
Clarithromycin
Fluoroquinolone
*for 10-14 days
**NO ERYTHROMYCIN

115
Q

What antibiotic do you not use to treat Legionnaires disease?

A

Erythromycin - failure of tx and SE

116
Q

Treatment for haemophilus species: more seriously ill patient (toxic patient with multilobe pneumonia)

A

ceftriaxone IV

117
Q

Treatment for Bordetella Pertussis

A

Abx: erythromycin, azithromycin, clarithromycin, or Bactrim

118
Q

Vaccination against Bordetella pertussis
11-18 yrs
>64 yrs
Pregnancy

A

-If completed DTP or DTaP, receive single dose of either Tdap product instead of Td for booster immunization
-Single dose of Tdap
-during each pregnancy, receive single dose of Tdap regardless of prior vaccine hx (27-36wks)

119
Q

Epiglottis (in relation to Haemophilus species) symptoms

A

abrupt onset of high fever, drooling, inability to handle secretions
-complaint of severe sore throat despite unimpressive exam of pharynx

120
Q

Complications of epiglottis and how to dx it

Treatment

A

-laryngeal obstruction (stridor = respiratory distress ==> emergency)
-direct visualization of cherry-red swollen epiglottis with laryngoscopy (only performed in ICU)

ceftriaxone 1g IV

121
Q

Meningitis (in relation to Haemophilus species): treatment

A

Initial treatment: ceftriaxone IV 4g/day (treated for 7 days) until strain if proved not to produce beta-lactamase

Dexamethasone IV q6hr to reduce long-term sx of hearing loss

122
Q

Empiric antibiotics for CAP bacterial (outpatient) - healthy

A

For previously healthy patients with no risk factors for MRSA or pseudomonas
1. Amoxicillin
2. Doxycycline
3. Macrolide

123
Q

Empiric antibiotics for CAP bacterial (outpatient) - comorbidities

A
  1. Macrolide or doxycycline + oral beta-lactam (Augmentin, cefpodoxime, cefuroxime)
  2. Oral fluoroquinolone
124
Q

Pneumococcal vaccine timing for adults (for those who never received a pneumococcal vaccine or those with unknown vaccination hx)
-PCV20
-PCV15
-PPSV23

A

-PCV20: vaccination complete
-PCV15: follow with one dose of PPSV23 (interval 8wks - 1 year*)
-PPSV23: administer either PCV15 or PCV20 (interval 1 year)

125
Q

Pediatrics: 4 components of a respiratory exam

A
  1. inspection
  2. palpation
  3. auscultation
  4. percussion
126
Q

Abnormalities in child’s physical exam for respiratory illness (6)

A

-tachypnea, abnormalities of attentiveness, inconsolability, respiratory effort, color (mottled, bluish), movement had good diagnostic accuracy in detecting hypoxemia
-Shift in tracheal position
-Tactile fremitus
-Wheezing; prolonged expiratory compared to inspiratory time
-Unilateral crackles
-Extrapulmonary signs: cyanosis, altered mental status, signs of chronic respiratory insufficiency (growth failure, clubbing, osteoarthropathy); evidence of cor pulmonale

127
Q

How much longer is expiratory time vs inspiratory time?

A

2x longer

128
Q

What imaging test remains the FOUNDATION of investigating pediatric thorax?

A

CXR

129
Q

What CXR views should be ordered?

A

Frontal (posterior and anterior) and lateral

130
Q

What does a CXR show in pediatric patients? (5)

A

Chest wall abnormalities, heart size and shape, mediastinum, diaphragm, and lung parenchyma

131
Q

When a foreign body is suspected, what should FNP order?

A

Forced expiratory radiographs
-shows focal air trapping and shift in mediastinum to the contralateral side)

132
Q

When an FNP wants to differentiate croup from epiglottitis, what should the FNP order?

A

Lateral neck radiographs
-can see “thumbprint sign” with epiglottitis

133
Q

When assessing vascular or bronchial anatomical abnormalities, what should FNP order?

A

MRI

134
Q

When assessing regional ventilation and perfusion - detect vascular malformations and pulmonary emboli, what should the FNP order?

A

Ventilation-perfusion scans

135
Q

OSA in children - higher risk when have any of the following comorbities

A

obesity
down syndrome
craniofacial abnormalities
Neuromuscular disorders
Sickle cell disease
mucopolysaccharidoses

136
Q

How is OSA dx?

A

polysomnogram (PSG)

137
Q

Is diagnosing OSA in children different than adults? If so, how so?

A

Yes
The occurrence of more than 1 apneic or hypopneic event per hour with duration of at least 2 respiratory cycles = ABNORMAL

Children with apnea-hypopnea index >5 events per hour = CLNIICALLY SIGNIFICANT OSA

138
Q

Foreign body aspiration (upper airway) key findings

A

abrupt onset, hx of child running with food in mouth or playing with seeds/small coins/toys

139
Q

Symptoms of foreign body aspiration (upper airway)

A

inability to vocalize or cough, cyanosis with distress (complete obstruction)
drooling, stridor

140
Q

Highest risk (age) for foreign body aspiration upper airway?

A

6mo-3yr

141
Q

Complete obstruction FB upper airway <1yr - what should be done

A

place face down over rescuers arm, deliver 5 rapid back blows, followed by rolling infant over and delivering 5 rapid chest thrusts (repeat until obstruction is relieved)

142
Q

Complete obstruction FB upper airway >1yr - what should be done

A

abdominal thrusts (heimlich maneuver)

143
Q

Complete obstruction (any age) FB upper airway - what should be done if unresponsive?
-finger sweep?

A

CPR
**never perform a blind finger sweep

144
Q

Foreign body aspiration (lower airway) key onset

A

sudden onset of coughing, wheezing, respiratory distress
-asymmetrical breath sounds (decreased) or localized wheezing

145
Q

What should we suspect if child has chronic cough, persistent wheezing, or recurrent pneumonia?

A

Foreign body aspiration (lower airway)

146
Q

If child has FB in lower airway with coughing that goes away, can it come back again?

A

Yes, comes back as chronic cough, persistent wheezing, monophonic wheezing, asymmetrical breath sounds on chest examination, or recurrent pneumonia in 1 location

147
Q

Lab/diagnostic imagining for FB lower airway (type)?

A

CXR
However, CXR might be normal, so need positive forced expiratory study.

Complete obstruction of distal airway can lead to atelectasis and related volume loss

148
Q

If CXR is normal, does that rule out FB?

A

NO!

149
Q

FB aspiration dx is based on 2 or 3 findings:

A
  1. hx of possible aspiration
  2. focal abnormal lung exam
  3. abnormal CXR
    =REFER for bronchoscopy

-if suspected FB aspiration, admit to hospital for evaluation

150
Q

What is given to the pediatric patient who had FB aspiration after removal?

A

b-adrenergic neb treatments + chest PT

151
Q

Viral croup key symptoms
-age
-sx
-late signs

A

-young children 6mo-5yr with recent MRI
-parainfluenza virus serotypes; new onset stridor in setting of an upper resp illness or fever (mild stridor: agitated; severe stridor: at rest)
*retractions, air hunger, cyanosis are late signs

152
Q

what is the character presentation of croup? (3)
is evaluation urgent, emergency, or casual?

A

inspiratory stridor, barking “seal” cough and retractions at rest
URGENT

153
Q

What are the causative agents of croup?

A

-parainfluenza virus serotypes (most important cause of croup in kids)
-RSV
-Rhinovirus
-Adenovirus
-Influenza A/B
-M pneumoniae

154
Q

What physiologic changes does croup cause to the airway?

A

edema in subglottic space

155
Q

What precedes croup?

A

URI (leads to barking cough and stridor)

156
Q

What finding should you not see with croup?

A

Fever

157
Q

A patient with mild croup becomes agitated during physical exam, what do you expect to occur?

A

Stridor

158
Q

What would be an indication that the patient’s condition with croup has worsened?

A

Stridor at rest (early sign of worsening obstruction) –> retractions, air hunger, cyanosis (late signs)

159
Q

What signs in a patient would indicate a diagnosis of croup vs epiglottitis?

A

Presence of cough and absence of drooling

160
Q

What diagnostic imaging should the FNP obtain for patient with suspected croup?

A

Classic presentation of croup does not require CXR

161
Q

If a patient presents with an atypical presentation for croup, what would you expect to see on CXR that you wouldn’t find in tracheitis?

A

Subglottic narrowing “steeple sign” without irregularities

162
Q

Tx for mild-moderate croup

A

1 single dose dexamethasone (0.15mg/kg PO or 0.6mg/kg IM)
D/C from ED <3hr if sx resolve

163
Q

Tx for moderate-severe croup

A

Humidified O2
Dexamethasone (0.6mg/kg IMx1)
Inhaled budesonide
Nebulized racemic epinephrine
If recurrent epi tx needed = admit to hospital for observation and continued neb tx PRN

164
Q

Epiglottitis key symptoms

A

Sniffing dog position/tripod position; sudden onset of high fever, dysphagia, drooling, muffled voice, inspiratory retractions, cyanosis, soft stridor

165
Q

What vaccination helps fight against epiglottitis?

A

HiB

166
Q

What are the causative agents of epiglottitis?

A

H influenzae (in unimmunized children) OR nontypeable H influenzae, N meningitis, or Streptococcus species (immunized population)

167
Q

With epiglottitis, the FNP knows a definitive dx can be made by?

A

direct inspection of epiglottis during intubation by airway specialist

168
Q

What physical finding is observed in patient with epiglottitis?

A

Cherry-red and swollen epiglottis and swollen arytenoids

169
Q

In stable patient with epiglottitis, what type of imaging should FNP order? What classic sign is observed?

A

-CXR lateral neck
-Thumbprint sign

170
Q

Intervention of epiglottitis in children?

A

Intubation (keep as calm as possible)

171
Q

How long are children intubated with epiglottitis?
How long should abx be continued with epiglottitis?

A

-24-48hrs
-2-3 days of IV abx, followed by 10 days PO abx

172
Q

What can viral croup progress into? What does that progress into?

A

Bacterial tracheitis; SUDDEN RESPIRATORY ARREST

173
Q

What patients should be hospitalized for CAP?

A

-all infants <3months for abx (IV or PO)
-any child with apnea, hypoxemia, poor feeding, effusion of CXR, moderate or severe respiratory distress, or clinical deterioration on treatment

174
Q

If patient is managed outpatient for CAP, what does the follow-up timeline look like?

A

Close follow-up w/i 12hr-5d

175
Q

CAP bacterial pediatrics: treatment

A

-Empiric abx treatment aimed at S pneumonia: amox 80-90mg/kg/day divided BID for 5-10 days (alternatives are cephalosporins or macrolides - may be resistant)
-Children >5yrs - depends on cause: amox 80-90mg/kg divided BID for 7-10 days or Azithromycin (mycoplasma)

176
Q

CAP viral pediatrics: treatment

A

PO abx used to cover co-existent bacterial pneumonia (usually indicated)
RSV - supportive measures
Influenzae A/B - Tamiflu (age >equal 1 yr) or Relenza (age >equal 7)

177
Q

Peds: What is the MOST common organism associated with empyema?

A

S pneumoniae

178
Q

Peds: What can be expected to occur during a chest exam with effusion?

A

Dullness to percussion on the affected side, child prefers to lie on affected side

179
Q

Peds: With large effusions, what does the FNP expect to see?

A

tracheal deviation to the contralateral side

180
Q

Peds: what laboratory /diagnostic findings are expected in empyema?

A

Elevated WBC with left shift
+blood cultures
Neutrophils in pleural fluid cells retrieved by thoracentesis (<7.2pH and low glucose)

181
Q

Peds: Mycoplasma pneumonia - “walking pneumonia”
-age
-symptoms

A

->5years
-fever, dry cough at onset - changes with sputum production with progression of illness; HA, malaise, rales and chest pain

-interstitial or bronchopneumonic infiltrates in middle/lower lobes; pleural effusions

182
Q

What is the MOST common organism associated with mycoplasma pneumonia?

A

M pneumoniae

183
Q

What is the typical lab/diagnostic findings associated with mycoplasma pneumonia?

A

Normal total WBC w/ diff

-enzyme immunoassay (EIA) and complement fixation sensitive and specific for M pneumoniae

184
Q

What treatment should be provided for mycoplasma pneumonia?

A

Supportive measures and macrolide abx
-azithromycin
-Ciprofloxacin is alternative

185
Q

What is the gold standard for diagnostic testing for mycoplasma pneumonia?

A

PCR (depends on clinic)

186
Q

Key symptoms of bronchiolitis (pediatrics)
-age
-common cause
-sx

A

-<2yr old
-RSV; usually begins with URI (fever rhinorrhea, cough)
-tachypnea, rapid/shallow breathing, wheezing –> irritability, poor feeding, vomiting –> crackles, nasal flaring, retractions, hypoxia
(usually current bacterial pneumonia dx)

187
Q

What is the most common serious acute respiratory illness in infants and young children?

A

Bronchiolitis

188
Q

What are the common causes of bronchiolitis (pediatrics)?

A

RSV (viral), parainfluenza, influenza, adenovirus, human metapneumovirus, several bacterial causes less common

189
Q

S/S bronchiolitis in pediatrics

A

Starts as URI: fever, rhinorrhea, and cough

190
Q

Risk factors for severe bronchiolitis?

A

age <12 weeks, hx of prematurity (<35 weeks), underlying cardiopulmonary disease, and immunodeficiency

191
Q

Current AAP recommendations in relation to bronchiolitis instruct the FNP to forgo what testing?

A

-viral nasal swab for routine RSV testing should not be conducted unless infant has been on prophylaxis with Palivizumab as test dose not change treatment
-no CXR if no respiratory distress present
-albuterol tx and corticosteroids NOT recommended
-antibiotics not recommended unless bacterial infection present or strongly suspected

192
Q

What antiviral treatment is reserved for severely ill children with immune or anatomic cardiopulmonary defects?

A

Ribavirin antiviral aerosol treatment

193
Q

First line of treatment of OSA in children

A

Adenotonsillectomy (improves clinical status in nonobese children with normal craniofacial structure)

If obese or craniofacial abnormalities, neuromuscular disorders –> CPAP

194
Q

When does SUID deaths peak? (at what age?)

A

2-4 months, most deaths occur at night

195
Q

Risk factors associated with SUID

A

ethnic/racial minority, Socioeconomically disadvantaged; males; premature birth, low birth weight, recent infection, young maternal age, high paternal parity, maternal tobacco or drug use, crowded living conditions
**RECENT IMMUNIZATION IS NOT A FACTOR

196
Q

Herpangina
-cause
-sx
-tx

A

-coxsacki A viruses (epidemic) or coxsackie B/echovirus (sporadic cases)
-acute onset fever an dposterior pharyngeal grayish white vesicles –> quickly form ulcers (<20 in number) linearly along posterior palate, uvula, tonsillar pillars; dysphagia, drooling, vomiting, abd pain
-rest, fluids, pain relievers

197
Q

Acute lymphonodular pharyngitis
-cause
-sx
-tx

A

-coxsackievirus A10
-febrile pharyngitis with NONULCERATIVE yellow-white posterior pharyngeal papules linearly along posterior palate
-supportive tx

198
Q

HFM
-cause
-sx
-tx

A

-coxsacki virus (A5, A10, A16)
-vesicles or red papules are found on tongue, oral mucosa, hands, and feet; near the nails and heels; fever, sore throat, mild malaise
-supportive tx

199
Q

Do you administer antibiotics, decongestants, expectorants, albuterol or systemic corticosteroids (unless asthmatic or premature infant) in pediatric patients with RSV?

A

NO

200
Q

Common sx in infants with meningitis

A

high-pitched cry

cmn568 (10 decks)

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