Peds Pulmonary - Hughes Final Flashcards
(71 cards)
1
Q
What are vascular rings?
A. Underdevelopment of cartilaginous tissue of epiglottic structures
B. The fusion of the vocal cords
C. An outgrowth in the esophagus
D. Congenital anomalies of the aortic arch
A
D. Congenital anomalies of the aortic arch
2
Q
What are the two most common types of complete vascular rings?
A
- Double aortic arch
- Right aortic arch
These make up 85-95% of cases
3
Q
A 10 month old male presents with continued respiratory distress, a cough, and stridor. The parent of the child expresses the child has had recurrent respiratory infections, poor feeding, and has noticed his symptoms become worse while laying on his back. What are you concerned this patient may have?
A. Croup
B. Vascular Rings
C. Foreign Body Aspiration
D. Epiglottitis
A
B. Vascular Rings
Clinical Presentation:
- Stridor most frequent
- Recurrent respiratory infections
- Respiratory distress
- Wheezing
- Cough
- Esophageal complaints (dysphagia, poor feeding, etc)
- Often worse in supine position – trachea pushing down
4
Q
What imaging would you order if you were concerned for vascular rings?
A
CXR and ECHO may miss - may want to go straight to better modalities:
- Angiography
- CTA
- MRI angiography
- Bronchosopy
5
Q
What is the treatment for vascular rings?
A
Surgery (if significant symptoms or double aortic arch)
6
Q
T/F: Foreign body aspiration is commonly observed
A
False - rarely observed
*keep in mind with FB a positive history is not to be ignored, and a negative history can be misleading
7
Q
What age group is at higher risk for foreign body aspiration?
A
- Ages 6 months - 4 y/o
- < 3 y/o = 80% of cases
8
Q
What clinical presentations would you expect for upper airway foreign body aspiration?
A
Abrupt onset
- Coughing
- Choking
- Wheezing
9
Q
With foreign body aspiration how would the clinical presentation differ between complete upper airway obstruction and incomplete obstruction?
A
Complete obstruction
- Acute onset of choking with inability to vocalize or cough
- Cyanosis with distress
Incomplete obstruction
- Drooling, stridor, ability to vocalize
10
Q
What is the treatment for upper airway foreign body obstruction?
A
Complete obstruction (Emergency)
- < 1 y/o = on stomach and forceful blows
- > 1 y/o = Heimlich maneuver
Do not attempt to blind finger sweep (can lodge it down further)
PALS (advanced life support)
11
Q
What clinical presentations would you expect for lower respiratory tract foreign body aspiration?
A
Signs and symptoms vary
- Sudden onset of coughing, wheezing, respiratory distress
- Consider foreign body aspiration if:
- chronic cough
- recurrent pneumonia
- persistent wheezing
12
Q
Diagnosis of foreign body aspiration?
A
- Asymmetrical decreased breath sounds or localized wheezing
- CXR (PA view, inspiratory and expiratory views)
- 30% can be normal - if HPI and PE points to suspicion do not let this deter you
- Asymmetric findings:
- Inspiration: localized hyperinflation
- Expiration: mediastinal shift away from affected side
- Lateral decubitus or fluoroscopy
13
Q
What is the treatment for lower respiratory tract foreign body aspiration?
A
- Bronchoscopy
- B-adrenergic nebulizer (Albuterol)
14
Q
Laryngotracheobronchitis (Croup) is a viral infection of?
A
glottic and subglottic regions
15
Q
Croup is usually preceded by what type of infection?
A
URI (viral)
- Days 1-3: rhinorrhea, pharyngitis, mild cough, low-grade fever
- Days 3-7: “barking” cough, hoarseness, inspiratory stridor (upper airway obstruction)
16
Q
What age group is most susceptible to croup?
A
6 months to 3 years
17
Q
Diagnosis of croup?
A
Clinical Dx - CXR only if this would change management
18
Q
Croup is most common during what seasons?
A
Fall and Winter
19
Q
What is the most common organism that causes croup?
A. Parainfluenza
B. Staph aureus
C. Adenovirus
D. H. Influenzae
A
A. Parainfluenza
Think “Para Crouper!”
20
Q
What would you find on a CXR of a patient with croup?
A
- Steeple Sign
- Subglottic narrowing
- Not always present
- Does not correlate well with severity of disease
21
Q
What are the key clinical features of a patient with mild croup and what would be the treatment of choice?
A
- Stridor only with activity/agitation
- Normoxia, no tachypnea, no tachycardia
- Able to talk and feed
Tx: Dexamethasone only (if not previously given) - can take a couple of hrs for onset
22
Q
What are the key clinical features of a patient with moderate croup and what would be the treatment of choice?
A
- Inspiratory stridor at rest
- Intercostal and suprasternal retractions
- Normal sat, mild tachypnea and tachycardia
- Difficulty talking/feeding
Tx: Racemic Epinephrine and Dexamethasone
- Immediate reassessment for imrpovement - observe
- No improvement = racemic epi can be given Q 2 hrs - consider admission
23
Q
What are the key clinical features of a patient with severe/life threatening croup and what would be the treatment of choice?
A
- Biphasic stridor or absent due to poor resp effort
- Severe retractions - intercostal, nasal flaring
- Hypoxemia, cyanosis, marked tachycardia or bradycardia
- Unable to talk or feed
Tx: Racemic Epinephrine and Dexamethasone (if not prev given)
- Inititate resuscitation and continue racemic epi Q 20 mins
- Admit to ICU
24
Q
Resolution of symptoms of croup should occur within how many hours of giving racemic epi and steroids?
A
Within 3 hours
- Keep in mind if you are giving racemic epi the pt must be on monitors
- If pt is admitted and symptoms persist >3-4 days - consider another underlying cause
25
How do the signs and symptoms of epiglottitis progress?
**Acute, rapidly progressive symptoms (Emergency!)**
_Initially_
* High fever, sore throat, dyspnea, rapidly progressing respiratory obstruciton
_Within hours_
* Toxic-appearing, difficult swallowing, labored breathing
* Drooling, hyperextended neck
26
How would a pediatric patient with epiglottitis present?
**Tripod position or "sniffing dog"**
* Sitting upright, Leaning forward
* Chin up, mouth open
* Bracing with arms
* High fever
* Sore throat, muffled voice
"AIR RAID" - see photo
27
What would be considered a _late finding_ in a pediatric patient with epiglottitis?
Inspiratory stridor (complete airway obstruction)
28
What is the _most common_ organism that causes epiglottitis?
A. Staph aureus
B. Strep pneumo
C. H. influenzae
D. Parainfluenza
C. **H. influenzae**
\*if immunized MC organisms:
* Non-typeable H. influ
* Strep pneumo
* Streptococcus species
* Staph aureus
29
How do you diagnose epiglottitis?
1. Imaging: laternal neck XR can show **Thumb Sign**
2. Direct visualization of epiglottis (only by airway specialist in controlled environment)
3. **Cherry red and swollen** epiglottis
30
What is the treatment for epiglottitis?
1. Establish airway!
2. Cultures of epiglottis and IV ABX
3. Hospitalization
31
What is the most common pediatric _airway emergency requiring PICU admission?_
A. Epiglottitis
B. Croup
C. Foreign Body Aspiration
D. Bacterial Tracheitis
D. **Bacterial Tracheitis**
Severe and life-threatening!
32
What is the _most common_ organism that causes Bacterial Tracheitis?
A. Staph aureus
B. Moraxella catarrahlis
C. Group A Strep
D. Adenovirus
A. **Staph aureus**
Others: H. influ, Group A Strep, Neisseria, Moraxella catarrahlis
33
What is the pathophysiology of bacterial tracheitis?
* **Localized mucosal invasion in patients with viral infection**
* **Purulent secretions** - Staph aureus creates a lot of pus!
* Inflammatory edema
* Pseudomembranes
34
At what age does bacterial tracheitis usually occur?
* Usually occurs in **first 6 years of life**
* Most in previously healthy children in setting of respiratory viral infection
35
Clinical presentation of bacterial tracheitis?
* Early on similar to viral croup but non-responsive to conventional croup treatment
* High fever, toxicity, progressive, intermittent severe upper airway obstruction, rapid deterioration
36
What would you expect to see on the CBC and cultures of a pediatric patient with bacterial tracheitis?
CBC
* Bands common (immature neutrophils)
* WBC variable
* These do not correlate with severity of illness (amount)
Cultures
* Tracheal secretions _positive_
* Blood cultures _negative_
37
What type of XR would you order to diagnose bacterial tarcheitis? What would it show if positive?
Laternal neck XR
* Normal epiglottis
* Severe subglottic and tracheal narrowing
38
What bronchoscopy findings would be diagnositic of bacterial tracheitis?
* **Subglottic narrowing**
* **Copious purulent tracheal secretions and membranes**
39
What is the treatment for bacterial tracheitis?
1. Visualization of the airway in controlled envrionment and airway debridement
2. Intubation
3. **IV ABX** - Cover Staph aureus and H influ (broad spec)
\*Mortality rate is low if recognized and managed early
40
Summary Slide:
Croup, Bacterial Tracheitis, Epiglottitis
Radiographic Summary
Hughes said to know all DDx that can cause Stridor!
41
Bronchiolitis is the most common serious ____ respiratory illness in infants and young children
Bronchiolitis is the most common serious **_acute_** respiratory illness in infants and young children
\*1 month to 15 months (usually \< 2yrs) - due to tiny airways
42
Clinical presentation of bronchiolitis?
* 1-2 day fever, rhinorrhea, cough, then...
* Tachypnea
* Expiratory wheezing
* Prolongation of expiratory phase
* Possibly nasal flaring, cyanosis, retractions, grunting
43
What is the treatment for bronchiolitis?
**1. Suction and Oxygen**
**2. Maintain hydration**
* \*Albuterol and racemic epi should **NOT** be routinely used
* Admit if moderate tachypnea with feeding difficulties, dehydration
44
What are some common complications of influenza?
1. MC = **Otitis media**
2. Pneumonia - coinfection with Staph aureus
45
What is the treatment for influenza?
1. Neuraminidase Inhibitors - start within 48 hrs of onset
* **Oseltamivir (Tamiflu)**
* **Zanamivir (Relenza)** - only 7 years and older
* **Peramivir (Rapivab)** IV
2. Endonuclease Inhibitor
* Balaxavir (Xofluza)
\*usually NO prophylaxis until 3 months
46
What is the best way to prevent influenza?
Annual vaccination (Quadravalent vaccine)
47
What is the most common organism that causes Pertussis (Whooping Cough)
A. H. influenzae
B. Strep pneumo
C. Bordetella pertussis
D. Bordetella periopertussis
C. Bordetella pertussis
Milder form = Bordetella **_para_**pertussis
48
How do you diagnose pertussis?
* 2 weeks into illness cough paroxysmal (10-30 coughs followed by "whoop")
* Vomiting common
* WBC 20-30,000 with 70-80% lymphocytes
* B. pertussis identified by PCR nasal swab
* CXR may show thickened bronchi or "shaggy" heart border
49
What is the treatment for pertussis?
1. Azithromycin preferred (esp \< 1 month)
7 days of Clarithromycin or 5 days of Azithromycin is equal to 14 days of Erythromycin
50
What is the clinical presentation of Community Acquired Pneumonia (CAP)?
* Fever and cough
* Tachypnea
* Hypoxemia (inc WOB)
* The longer the symptoms the greater the likelihood of PNA
* Lungs: Crackles, Dec. breath sounds, wheezing
51
What are the most common complications of CAP?
1. **Empyema** (Staph and GAS)
2. Necrotizing pneumonia, necrosis
* **S. pneumoniae** (esp. serotype 3 and serogroup 19)
* **Group A Strep**
52
What is the treatment for CAP in infants/pre-school aged children?
1st line: **Amoxicillin**
* **\*\*Do not** use Azithroycin (resistant to S. pneumoniae)
* If covering for H. influ as well - Augmentin
* ABX _not_ routinely required for pre-school aged children because viral pathogens are responsible for most CAP
53
What is the most important question to ask parents of children with suspicion of pulmonary fungal infections?
What is their travel history or where have they been/lived
54
What is the causative organism of TB?
***Mycobacterium tuberculosis***
55
What are common symptoms seen in active TB patients?
* Chronic cough
* Weight loss
* Anorexia
* Fever
* Night sweats
56
If an infant, child, or adolescent presented with an induration of **5 mm or greater,** what other history/signs would be indicative of a positive TB result?
* Children in close contact with known/suspected people with TB
* Children suspected to have TB (findings on CXR, clinical evidence)
* Children receiving immunosuppressive tx or with immunosuppressed conditions (HIV)
57
If an infant, child, or adolescent presented with an induration of **10 mm or greater**, what other history/signs would be indicative of a positive TB result?
* Children at inc. risk of disseminated TB
* \< 4 y/o, other medical conditions - Hodgkin dz, lymphoma, DM, renal failure, malnutrition
* Children with likelihood of increased exposure to TB
* Born in high prevalence region or travel to these regions
* Frequently exposed to adults who are HIV infected, drug users, homeless, in nursing homes, incarcerated
58
If an infant, child, or adolescent presented with an induration of **15 mm or greater,** what other history/signs would be indicative of a positive TB result?
Children age 4 years or older without any risk factors
59
If a positive PPD is obtained what is the next step? How does the treatment for TB vary once the next step is completed?
**Obtain CXR**
* _Abnormal_ or extrapulmonary dz
* Tx: **2 months of Isoniazid, Rifampin, Pyrazinamide, and Ethambutol**
* **Followed by 4 months of Isoniazid and Rifampin**
* _Normal_ or calcified lesions, hilar adenopathy
* Latent TB
* 9 months **Isoniazid**
* 4 months **Rifampin**
* 12 weeks Isoniazid and Rifapentine once a wk
60
Cystic Fibrosis is an autosomal ____ disease
Cystic Fibrosis is an autosomal **_recessive_** disease
61
15% of newborns with CF present with?
* **Meconium ileus** (bowel obstruction) - 1st stool passed after birth should come within 24 hrs
* Diagnostic of CF
62
What is the clinical presentation of CF?
* Severe **dehydration and hypochloremic alkalosis**
* **Chronic sinusitis**
* Inc. cough and sputum production
* Malaise, anorexia
* Change in lung functions/CXR
* _Unexplained sx:_
* **nasal polyps common**
* bronchiectasis
* rectal prolapse
* pancreatitis
* cirrhosis
63
How do you diagnose CF?
1. Sweat chloride test - concentration \> 60 mmol/L and at least one of the following:
* Chronic sinopulmonary dz
* Pancreatic insufficiency
* Salt loss syndrome
* FHx (sibling, 1st cousin)
2. Genotyping
3. Newborn screening
64
What is the treatment for CF?
1. Accredited CF care center
2. GI (pancreatic enzymes)
3. Lungs: airway clearance and ABX
65
What are the most common pathogens prevalent in CF patients?
1. H. influ and S. aureus in first few months of life
2. Progresses to infections with Pseudomonas aeruginosa
66
15-month-old male presents with **inspiratory stridor** audible without a stethoscope and RR of 40 bpm. There are moderate intercostal retractions, and **no cyanosis.** After one course of racemic epinephrine, which is the next best _management plan_?
A. Cool mist room humidification
B. Dexamethasone IM, one dose
C. Aerosolized ribavirin
D. Chest physical therapy
B. **Dexamethasone IM, one dose**
Pt has Croup
A. Cool mist room humidification - traditionally used but clinical data lacking
C. Aerosolized ribavirin - RSV bronchiolitis - not helpful in Croup
D. Chest physical therapy - Asthma or CF to loosen secretions
67
A 10-month-old presents for evaluation of noisy breathing and **barking cough** that gets worse at night. There is a one week history of **rhinorrhea, low-grade fever, and cough**. The cough has progressively worsened over the past 3 days. On exam: RR 50bpm, **T 100.6**, **inspiratory stridor, barking cough**. Remainder of exam unremarkable. What is the most likely diagnosis?
A. Croup
B. Epiglottitis
C. Foreign Body in trachea
D. Pneumonia
A. **Croup - classic presentation**
B. Epiglottitis - more acute onset
C. FB - no URI or barking cough
D. PNA - more systemic symptoms, high fever, GI
68
A 4-month-old infant presents with **acute onset** of tachypnea, cough, rhinorrhea, expiratory wheezing. Which is the most likely cause?
A. Influenza
B. Adenovirus
C. Step pneumo
D. Bronchiolitis
D. **Bronchiolitis**
69
An 18-month-old child is brought into the ED several hours after the onset of **acute dyspnea, cough, and stridor**. On exam: inspiratory **stridor** **and wheezing** over the right upper lobe. What _medication_ is most likely to relieve the symptoms?
A. Bronchoscopy
B. Oral steroid therapy
C. Chest psotural frainage
D. Albuterol nebulizer
D. **Albuterol nebulizer**
70
An 18-month-old child is brought into the ED several hours after the onset of **acute dyspnea, cough, and stridor**. On exam: inspiratory **stridor and wheezing** over the right upper lobe. What is the most appropriate _intervention_ for this patient?
A. Bronchoscopy
B. Albuterol nebulizer
C. Chest postural drainage
D. Oral steroid therapy
A. **Bronchoscopy**
Inspiratory stridor and unilateral wheezing = classic FB
71
What diseases/diagnosis can cause stridor?
* Croup
* Bacterial Tracheitis
* Epiglottitis
* Retropharyngeal Abscess
* Laryngomalacia
* Congenital Subglottic Stenosis
