Respiratory Flashcards
(92 cards)
1
Q
PE of asthama?
labs?
A
Allergic: Eosinophilic inflammation - in blood work
Expiratory wheeze or rhonchi
2
Q
Hx questions to ask pt with suspected asthma?
A
How frequent cough, wheezing, difficulty breathing Nighttime awakening Medication response Activity response Exacerbations required oral steroids
3
Q
Med must know for tx asthma in pts 6 and older?
A
NO SABA alone (death in 6 and older), only under age of 5
4
Q
Asthma differentials?
A
Allergic rhinitis/sinusitis Respiratory infection GERD Medication induced cough (ACE Inhibitors) COPD Heart Failure Vocal cord dysfunction
5
Q
GINA Asthma Guidelines
- mild
- moderate
- severe
A
Mild:- well controlled with PRN alone or with low ICS (6 or older) -> STEP 1/2
Hard to diagnose under 5
Moderate- well controlled with low dose ICS.
-> LABA (STEP 3) SABA prn
Severe: high dose ICS/ LABA, -> remains uncontrolled (Step 4), saba prn
No ICS for kids under 6 y.o ,9
6
Q
What age is treated as an adult for asthma
A
Over 6 years
<5 cant do spirometry
7
Q
Pedi Asthma Differentials
A
VIral URI
Allergic rhinitis
Foreign body
8
Q
How to treat pedi asthma? 1-11 years old
A
- Montelukast chewable
- Neb ICD until able to use inhaler
1-11 y/o
Neb with albuterol
Oral steroid burst : 60 mg/day
Liquid prednisone : 1-2mg/kg/day QAM for 3-10 days
Orapred 15mg/ml (has sorbitol- can make diarrhea worse)
9
Q
For Rescue only
Not to be used alone, except for < 5 years of age.
Albuterol
Levalbuterol
Used in Combination therapy (long-acting, LABAs)
Salmeterol (Serevent)
Formoterol (Foradil)
A
Beta 2 Agonists
For Rescue only (short-acting, SABAs).
10
Q
Acute infection of lower RR tract in infants and young children (common in infant hospitalization)
Agent: RSV, Rhino, adeno, corona
A
Bronchiolitis (self limiting, most mild)
11
Q
Dehydration , feeding, lethargy → impending RR failure
Decrease UO
A
Bronchiolitis
12
Q
How to manage/ tx bronchiolitis?
A
Improves itself, most mild and managed at home
Supportive- antipyretics, hydration, bulb syringe
13
Q
TOXIC appearance
Otitis media, nasal congestion, tons secretions, tachypnea, increase WOB, wheezing, rhonchi, delayed cap refill, displaced spleen and liver d/t lung expansion
A
bronchiolitis
14
Q
Inflammation of the trachea and bronchi/ lower tract by definition , caused by viruses or lung irritation
Risk Factors:
Occupational - exposure to irritants
Smoking
A
Bronchitis- URI
15
Q
Cough-may or may not have sputum lasting longer than 7 days
Retrosternal pain- behind the sternum—> “chest cold”
Nasal discharge
Sore throat
Low grade fever
Reduction in FEV1
A
Bronchitis
16
Q
What to consider in adult with hacking cough lasting > 2 weeks?
A
consider B. Pertussis
over Bronchitis
17
Q
Cough and sputum on most days for 3 months of year, two consecutive years
A
Chronic Bronchitis
18
Q
How to Tx/ manage Bronchitis?
Cough ____
A
What is the cause? Sx treatment- 80% improvement without
Cough: dextromethorphan/ benzonotate
Severe cough (bedtime: codine or hyd
Antipyretics
Cough suppressant is controversial- you want to be able to get the sputum out, not suppress it
Bronchodilator - doesn’t help w cough (unless has asthma)
NO ANTIBIOTIC- not likely bacterial - if it is, macrolides (first line)
Stop smoking
19
Q
Illness of larynx, trachea and bronchi → stridor and barking, Inflammation of UR tract
Risk Factors:
18m-2 y.o
History of past infection - can cause recurrent spasmodic
Worse at night (runs course 3-5 days) Clinical Manifestations: Rhinorrhea Barking cough Fever Accessory muscle use
A
Croup
20
Q
WestleyCroup scoring system
A
*Less than 3 - mild
3-6 -moderate
>6 - severe
21
Q
PE:
Dyspnea
Tachypnea
Retractions
Stridor - (stridor at rest- foreign body)
Wheezing and rales may be heard if there is additional lower airway involvement.
A
Croup
22
Q
Croup Differentials?
How to manage?
A
Differentials:
- FB aspiration (if stridor on rest)
- Epiglottitis (if drooling)
Management: Racemic epi (Causes vasoconstriction diminishing edema) Corticosteroids Humidifier in mild cases Antipyretic Oral hydration
23
Q
the maximum rate that person can exhale in a short, maximal expiratory effort after a full inspiration
A
Peak Flow
24
Q
Most common cause of Bronchiolitis
A
RSV
25
Well-controlled with as-needed reliever medication alone or with low-intensity controller treatment such as low-dose inhaled corticosteroids (ICSs), leukotriene receptor antagonists, or
chromones
Mild asthma
26
Well-controlled with low-dose ICS/long-acting beta2-agonists
| LABA
Moderate Asthma
27
Requires high-dose ICS/LABA to prevent it from becoming
uncontrolled, or asthma that remains uncontrolled despite this
treatment
Severe asthma
28
GINA no longer recommends ______ for first-line use in asthma except in children
aged under 5 years (where evidence is lacking) and where a trial of ICS should be
used in those not responding to as-needed
SABAs
29
for as-needed relief of symptoms, GINA’s preferred choice of reliever is _____ for adults and adolescents over the age of 12 and _____ taken as needed together with a ____ in children aged 6–11 years
ICSs in combination with formoterol for adults and adolescents over the age of 12
ICS taken as needed together with a SABA in children aged 6–11 years
30
long-acting bronchodilator with rapid action
ICS-formoterol
31
For Rescue only (short-acting, SABAs).
| • Not to be used alone, except for < 5 years of age.
Beta2 Agonists
• Albuterol
• Levalbuterol
32
Used in Combination asthma therapy (long-acting, LABAs)
Beta2 Agonists
• Salmeterol (Serevent)
• Formoterol (Foradil)
33
Exercised Induced Asthma tx
* Warm up
* Scarf over mouth in cold
* SABA 2 puffs 5 mins before exercise
* LABA
34
Acute Exacerbation Management for > 12 years
```
• Oral steroid burst 3-10 days
• Prednisone up to 60mg AM
• Methylprednisolone 40-60mg AM
• Medrol dosepak 4mg tablets (84mg total
divided over 6 days = inadequate dosing)
```
35
Acute Exacerbation Management for ages 6-11
• Chewable Montelukast (Singulair)
• Nebulizer for ICS until able to use inhaler
• Budesonide 0.25mg/2mL to 1mg/day; may
divide into BID
36
asthma exacerbation Ages 1-11
```
• Nebulizer with albuterol or albuterol syrup
or inhaler
• Oral steroid burst: maximum 60mg/day
• Liquid prednisolone: 1-2mg/kg/day QAM x
3-10 days
• Pediapred 5mg/5mL (contains sorbitol)
• Orapred 15mg/5mL (contains sorbitol)
• Prelone 15mg/5mL (contains 5% alcohol)
```
37
Bacteria infection of RR tract that this cause by strains of gram + c, humans are only reservoir
Diphtheria
38
Thick grey pseudomembrane. In nasopharyngeal, pharynx, trachea that bleeds when removed
Blood nasal discharge
Sore throat
Neck swelling with cervical Aden it is (bull neck)
Cutaneous lesions (non-healing ulcers with dirty grey membranes
Diphtheria
39
Diagnostics for Diphtheria
Culture from nose, throat or lesions
40
Diphtheria Differentials
Acute step pharyngitis
Mono
Nasal foreign body/ purulent rhino- nasal diphtheria, epiglottis, laryngeal diphtheria, viral croup
41
how to manage / tx diphtheria
Children: hospital for tracheostomy
Anti-serum - scratch test prior d/.t allergies + Abx
Erythromycin oral for 14 dats, PCN G 14 days IM or IV,
Supportive care
Droplet precautions until 2 - cultures
Immunization after recovery
42
Sudden swelling of the epiglottis, which worsens rapidly (w/i hours) → death
Airway obstruction, mucous plugging
Epiglottitis
43
```
Tripod
Retractions, cyanosis (late sign)
Abrupt onset of fever, irritability
***Muffled voice***
Severe sore throat , dysphagia
***Drooling***
Increased respiratory distress.
cough and the hoarseness are generally absent… considered late symptoms
```
Epiglottitis
44
- Inspiratory stridor
- Drooling, muffled voice and high fever
- Respiratory obstruction
- Tripod position- Hyperflexion of the neck
Epiglottitis
* Do not examine the throat as it can cause spasms and worsen obstruction *
45
Diagnostics for Epiglottitis
History and observation- ICU and airway mgmt
CBC- increase WBC (left shift)
Blood cultures
Lateral neck radiograph before examining the patient. If positive it will show the “thumb sign”.
Following intubation, epiglottis culture is performed
46
management for Epiglottitis
*Goal is to establish the airway and start appropriate antibiotics*
Droplet isolation first 24 hours, upright until airway secure
47
Antibiotics to tx Epiglottitis
Antibiotic- Gram +. H fl (B) cephalosporins (cefotaxime or ceftriaxone), Amp/sub
Cephalosporin allergies: Amp/Sub, Levofloxacin
7-10days
Very transmissible. Susceptible children should take prophylaxis with Rifampin
48
Swallowed- where is it?
| coughing, wheezing
Larynx
49
Swallowed- where is it?
| Brassy cough, dyspnea, cyanosis
Trachea
50
Swallowed- where is it?
| R lung aspiration
Bronchiole
51
Respiratory illness with PROLONGED coughing; children>adults, highly contagious
Risk Factors:
*unvaccinated infants
Pertussis
52
Adults- cough worse at night, gagging and vomiting, WHOOPING COUGH,
DEADLY TO NEWBORNS- Tdap for pregnant moms
1-2 weeks symptoms
Pertussis
53
phase of pertussis ?
low grade fever, rhinorrhea, mild cough, excessive lacrimation, and conjunctivitis (Highly spreadable ) 1-2 weeks of UR sx
Catarrhal phase of pertussis
54
phase of pertussis?
Increased mucous, paroxysmal cough, cyanosis vomiting, exhaustion (whoop)
Adults: 2-3 weeks cough * hallmark symptoms*
Paroxysmal
55
phase of pertussis?
Decease in cough, less persistent, slow recovery. Symptoms wane.
1-2 weeks or months
Convalescent
56
what sx is not seen in pertussis and thus if present means you should look for another reason
Fever
57
Diagnostics for pertussis
PCR Swab
Nasopharyngeal secretion culture (gold standard but can take too long)
Toxin IgG
CBC- 18k WBC, lymphocyte count (lymphocytosis in infants and children who are in the paroxysmal phase)
CXR- interstitial edema, atelectasis, perihilar infiltrates
58
pertussis Differentials
RSV, adenovirus, influenza, gastro-esophageal reflux, CF, aspiration pneumonia, asthma, FB aspiration
59
Treatment for pertussus
(hospital if severe)
Antibiotics( Macrolide-1st line- azithromycin ) TMP-SMX is alternative
Bactrim is alternative to macrolide if > 2 months old
Must give early in disease process for it to be effective
Erythromycin in < 1 month olds can cause pyloric stenosis
60
preferred for pertussis prophylaxis for babies < 1 month
Azithromycin
61
Increased amount of fluid in pleural space- IS IT WORSE WITH INSPIRATION?
Pleurisy(symptom)/Pleural Effusion
62
Inflammation in the pleural space: causes pain as layers rub together form swelling- viral most common; not a dx, but a symptom of numerous localized and systemic disease processes
Risk Factors:
Trauma
Systemic disease- SLE, sarcoidosis
Pleurisy ( symptom)/Pleural Effusion
63
Pain over affected chest area, usually lower portion of test
Painful with deep inhalation- sharp/ stabbing pain
coughing / sneezing- worse, toughing
R/O MI !!!!!!
They may lay on affected side to decrease lung expansion
Pleurisy
64
Guarded near area, palpation is tender, friction rub with auscultation
Fevers, chills, productive cough (PNA), joint pain/ rash (inflammatory issues or connective tissues disorder)
Tenderness to palpation - directly over site of inflammation
Percussion- dull if there is consolidation or pleural effusion
Pleurisy/ Pleural Effusion
65
diagnostics for Pleurisy/ Pleural Effusion
differentials?
tics
No dx but can help r/o
CXR
CBC- high leuk with shift to left; leukoPENIA= viral or SLE, CT or thora is severe , Thoracentesis
66
managing Pleurisy/ Pleural Effusion
```
Most are viral- sx mgmt
Steroids- SLE helps with inflammation
NSAIDS- pain
Treat underlying - refer
Severe- Refer
```
67
(most common in outpatient and inpatient ) - 8th leading cause of death , 1st among infection related death
CAP (community-acquired pneumonia)
68
what is the typical pathogen for pneumonia in 4m- 18 years
S pna (typical)
69
```
Sudden onset
Chills common
Cough
Purulent sputum
pleuritic pain
focal crackles
wheezes are rare
air space-filling on CXR infiltrate
commonly from S Pneumoniae
```
Typical Pneumonia
70
```
Slower onset (days)
chills are rare
prominent cough
dry sputum
musculoskeletal pain
diffuse crackles
occasional wheeze
diffuse & interstitial CXR infiltrate
commonly from M. pneumoniae
```
Atypical Pneumonia
71
Those at risk of Drug-resistant pneumococci
over 65, children in daycare, beta-lactam therapy in last 90 days, ETOH disorder, immunosuppression
72
Gold standard for pneumonia dx
CXR
73
What to give pt ... No Abx in 3 months and outpatient CAP:
Non-ICU:
ICU:
Macrolide (p 509) or doxycycline
Non-ICU:L Fluroquinolone or B lactam
ICU: B lactam + azithromycin a fluoroquinolone
74
How to tx MRSA pt with CAP (community acquired pneumonia)?
amoxicillin/ doxycycline, or azithromycin
75
What to watch out for Macrolides (-mycin drugs) / fluoroquinolones (-floxacin drugs)?
AE: QT prolong
Fluro: tendonitis, rupture, peripheral neuropathy, AAA
Macrolide: rate >25% resistance then it NOT a good option - combo therapy
Comorbidities
76
Drug that can cause fetal demise (new)
Bacterial protein synthesis inhibitor (strep pneumoniae, MSSA, H influenzae, legionella, mycoplasma, and chlamydia pneumoniae)
QT prolongation* and can affect CYP drugs
Lefamulin
used to tx pneumonia
77
Fluoroquinolone- also works with gram negative pathogens
| Risk of AAA, Tendonitis/ rupture
Delfoxacin
used to tx pneumonia
78
Caused by a virus. Causes common cold symptoms. More severe in infants and old adults. The infection starts at the nasopharynx and progresses towards the lower respiratory tract. It causes edema and necrosis of the epithelial cells which results in airway obstruction/trapping.
Risk Factors:
November-April
Prematurity, smoke exposure
RSV
79
Clinical Manifestations: Rinorrhea, otitis media with or without effusion, dehydration, conjunctivitis, respiratory distress (tahcy), barrel chest and displaced liver and spleen (lungs displacement)
PE: Nasal secretion, cough, fever and lower respiratory infection symptoms. More severe infection presents with apnea, severe cough with possible cyanotic episodes, and poor oral intake. (sx may last up to 3 weeks)
RSV
80
Dx for RSV
Viral testing not recommended (takes 5 days) unless severe case or patient is immunosuppressed. Rapid nasopharyngeal specimens can be used as diagnostic if indicated. Blood cultures not indicated as concurrent bacterial infection with RSV is not common
81
How to manage RSV?
| what is not recommended?
Supportive, hydration, Pulse ox, CPAP in severe cases
NOT recommended: bronchodilators, antibiotics steroids, nebs (also for bronchiolitis)
Ribavirin (antiviral) not recommended unless immunocompromised with severe RSV
82
Infection of the trachea causing airway inflammation and obstruction- life-threatening
caused by epithelial damage from viral infection and/or mechanical trauma in the trachea at the level of the cricoid cartilage = damaged tissue that's more susceptible to bacterial superinfections.
Tracheitis
83
mucosal damage is characterized by subglottic edema, purulent secretions, and a pseudomembrane
= airway obstruction or even toxic shock syndrome
hyperpyrexia, a brassy cough, noisy respirations, lethargy, dyspnea, rapid progression of airway occlusion, and the presence of upper airway infection or croup
Tracheitis
84
Toxic appearance, anxiety, agitation, lethargy, pallor, cyanosis, severe stridor, sx of pneumonia
Tracheitis
85
The gold standard for microbiologic diagnosis of Tracheitis?
Tracheal bacterial cultures
86
How to manage trachitis?
Airway! -> Emergency Transport
Antibiotic therapy is based on gram stain and culture results
87
how do foreign bodies in various locations of the respiratory tract present?
- larynx, trachea, bronchioles
started suddenly, was gagging or choking,
Larynx= unilateral wheeze
Trachea= brassy cough, echoing wheeze, cyanosis
Bronchioles= (usually on the right side)
88
Reduced in obstructive lung disease
FEV1
89
abnormality in ___ often indicates restrictive lung condition
FVC
90
represents the % of lung capacity one is able to exhale in 1 sec, if low/ abnormal = obstruction
what is abnormal for adults/ kids?
FV1/FVC Ratio
```
Adults = Gold critiera <70% is abnormal
Kids= <85%
```
91
For Rescue only (short-acting, SABAs).
Not to be used alone, except for < 5 years of age.
Albuterol
Levalbuterol
Used in Combination therapy (long-acting, LABAs)
Salmeterol (Serevent)
Formoterol (Foradil)
Beta 2 Agonists
92
scratching sound/ loud creek- at the end of inspiration, stops when hold breath
Friction rub
