Respiratory Cases (DSA and CIS)

Question 1

how is the diagnosis of acute otitis media made (3 things)

Answer 1

acute onset of symptoms

evidence of middle ear effusion

signs and symptoms of middle ear inflammation

Question 2

AOM that is recurring or that has treatment failure often is most likely associated with what?

Answer 2

S. pneumonia

Question 3

how do you treat initial episodes of nonsevere AOM

Answer 3

high dose Amoxicillin

Question 4

what do you use pharm wise for initial therapy in pt’s with SEVERE AOM

Answer 4

amoxicillin-clavulanate

Question 5

when are tympanostomy tubes appropriate?

Answer 5

children who have persistent OME as well as for those who have risk factors for developmental delay or evidence of damage to the middle ear

Question 6

what is the difference b/w AOM and OME

Answer 6

OME describes the presence of middle ear effusion without signs or symtpoms of infection

AOM = acute otitis media
infection of the middle ear with acute onset of signs and symptoms, MEE, and signs and acute symtpoms of middle ear inflammation

Question 7

what is treatment failure AOM

Answer 7

lack of improvement within 48-72 hrs after initiation of antibiotic therapy

Question 8

what is recurrent AOM

Answer 8

3 or more AOM episodes occurring in the previous 6 months or four or more AOM episodes in the preceding 12 months

Question 9

what is the initial mechanism that triggers otitis media

Answer 9

impaired eustachian tube function such as occurs during

ACUTE:
URI, Gastroesophageal reflux, allergic rhinits

chronic:

• craniofacial anomalies (Cleft palate)
• shorter eustachian tubes of younger children

Question 10

what is the most important predictor of AOM complicating a URI

Answer 10

Young age

Question 11

what are the most common viruses involved in AOM

Answer 11

RSV

parainfluenza

influenza (A and B)

coronavirus

Question 12

what are the most common bacterial infections associated with AOM

Answer 12

strep pneumoniae

H. influenzae

Moraxella Catarrhalis

S. pyogenes

Question 13

what is tympanometry

Answer 13

measures the compliance of the TM

put the device in the ear and make air tight seal

the device transmits sound waves reflecting off theTM

energy reflected by these sounds waves is a measure of TM compliance

B curve- flat, meaning poor or no mobility and is usually associated with MEE (OME or AOM)

C- curve- near normal compliance, but the peak shifted towards negative pressures due to increasing negative pressures in the middle ear, generally a precursor to an effusion

Question 14

which children are candidates for watchful waiting and skippin the antibiotics unless the pt worsens?

Answer 14

otherwise healthy children 6 months to 2 years of age with nonsevere illness at presentation and an uncertain diagnosis

AND

children 2 years of age and older without severe symptoms at presentation
OR
with uncertain diagnosis

Question 15

how does OMT help with AOM?

Answer 15

a standard OMT protocol administered adjunctively with standard care for pt’s with AOM resulted in faster resolution of MEE at 2 weeks than standard care alone

Question 16

what is the galbreath technique

Answer 16

simple mandibular manipulation that helps the middle ear drain and leads to quicker resolution of the problem

manipulating the mandible –> the physician increases blood flow to and through the region by alternately compressing and releasing the pterygoid plexus of veins and lymphatics in the region

with the pt sitting in the physicians lap, the pt’s “bad” ear is away from the physician and the doc uses his opposite hand (so if the pt’s right ear, then use docs left hand) and apply a downward and transverse force on the mandible that crosses the face

Question 17

what is the difference b/w respiration and breathing ?

Answer 17

breathing –> move air from outside the body into the lungs, exchange oxygen in the air for carbon dioxide in the blood stream, and then exhale the air

respiration–> provide for a similar exchange of these gases at the cellular level

Question 18

which dominates in the lungs:

parasympathetic or sympathetic

Answer 18

parasympathetic

Question 19

facilitation level of lungs

Answer 19

T1-6

Question 20

chapman’s point for heart

Answer 20

(myocardium)
Anterior:
2nd ICS close to the sternum on the right?

Posterior:
intertransverse space midway b/w spinous and transverse process of the 2nd and 3rd thoracic vertebrae

Question 21

upper lung chapman’s points

Answer 21

3rd ICS (b/w 3rd and 4th ribs) close to sternum anteriorly

posterior:
intertransverse space ,midway b/w spinous and transverse process of the 3rd and 4th thoracic vertebrae

Question 22

lower lung chapman’s point

Answer 22

Posterior:
intertransverse space ,midway b/w spinous and transverse process of the 4th and 5th vertebrae

Anterior 
4th ICS (b/w 4th and 5th ribs)

Question 23

what are the hypersympathetic effects in the lung?

Answer 23

dilation of the bronchial tubes

epithelial hyperplasia –> goblet cells in the bronchial epithelium increase = more mucus that is thin watery

Sinus decongestion

Question 24

what is the outcome of having a flat diaphragm

Answer 24

decrease in pressure b/w the thorax and abd cavity–> decreased lymph flow increases congestion of tissues and can decrease CO

Question 25

initial manipulative treatment in pneumonia has what three main goals?

Answer 25

reduce congestion reduce sympathetic hyperactivity to the parenchyma of the lung reduce mechanical impediments to the thoracic cage respiratory motions

Question 26

what are some techniques used for the treatment of pneumonia

Answer 26

rib raising - focus on T1-T6--> helps make a more thin secretion thoracic inlet - MFR thoracolumbar area treatment Diaphragm

Question 27

exhaled rib dysfunction is most frequently caused by what?

Answer 27

coughing

Question 28

treatment of the OA or AA makes patients more comfortable and normalize what?

Answer 28

parasympathetic influence to the lungs through the vagus

Question 29

what is included in the osteopathic manipulation plan for pt's with lower pulmonary dysfunction

Answer 29

cervicals C3-C5 (phrenic n.) sternum T1-T12 and ribs 1-12 thoracolumbar junction Sympathetics: Rib raising T1-6 Chapmans ``` Lymphatics: Thoracic inlet Abd diaphragm Rib raising Lymphatic pumps ``` Parasympathetics: -OA,AA, cranial- vagus

Question 30

T1-2

Answer 30

upper airway, head Superior cervical ganglion- anterior to CV1 and CV2 Stellate ganglion (= inferior cervical and 1st thoracic)

Question 31

T2-6

Answer 31

= bronchioles, lungs

Question 32

Superior cervical ganglion

Answer 32

fused ganglia of C1 through C4 provides postganglionic innervation to the head and neck

Question 33

stellate ganglion

Answer 33

fusion of the inferior cervical sympathetic ganglion with the ganglion of T1 middle cervical and stellate ganglia innervate the heart, lungs, and bronchi

Question 34

where is parasympathetic innervation of the lungs and upper airways from?

Answer 34

vagus

Question 35

Pterygopalatine (Sphenopalatine) ganglia supplies what?

Answer 35

parasympathetic innervation to the sinuses, nose, lacrimal gland, and blood flow to the nasal mucosa. by treating this you reduce congestion

Question 36

what does sympathetic stimulation cause in the airways

Answer 36

Response tends to be more general Mucous glands and blood vessels are heavily innervated by the sympathetic nervous system Smooth muscles are not Stimulation of the sympathetic nerves in the mucous glands increases water secretion and Decreases the viscosity of mucus. Stimulation of the sympathetic system causes Airway relaxation Blood vessel constriction Inhibition of glandular secretion Increased release of water, which lowers the viscosity of mucus

Question 37

what does parasympathetic stimulation in the airways cause

Answer 37

slightly constricted smooth muscle tone in the normal resting lung innervation is greater in the larger airways, and it diminishes toward the smaller conducting airways in the periphery bronchial glands, increases the synthesis of mucus glycoprotein and increases the viscosity of mucus Stimulation of the parasympathetic system leads to Airway constriction Blood vessel dilation Increased glandular secretion Increased synthesis of mucus glycoprotein, which raises the viscosity of mucus

Question 38

what are muscles that work during inspiration

Answer 38

external intercostal

Question 39

what muscles are involved in expiration

Answer 39

internal and innermost intercostals subcostals transversus thoracis

Question 40

what is the effect of kyphosis on mechanical ventilation

Answer 40

Reduction of thoracic kyphotic angles demonstrated a reduced vital capacity, inspiratory capacity, total lung capacity, and lateral expansion (P<0.05). There is also a significant negative correlation between the increased kyphotic angle and inspiratory capacity, vital capacity, and lateral expansion of the thorax.

Question 41

what are anterior chapman's points for

Answer 41

diagnosis

Question 42

posterior chapmans points are for what

Answer 42

treatment

Question 43

bronchus chapmans points

Answer 43

(esophagus and thyroid): between ribs 2 and 3 close to the sternum bronchus: midway between the tip of the transverse process and spinous process of T2 on the posterior aspect of the transverse process

Question 44

nose chapman's

Answer 44

costochondral junction of 1st rib nose: lateral aspect of the transverse process of C1

Question 45

tonsils chapmans

Answer 45

between 1st and 2nd ribs (1st intercostal space) close to the sternum tonsils: posterior surface of C1 transverse process, midway between the nuchal ligament and lateral most aspect of the C1 transverse process

Question 46

sinuses chapmans'

Answer 46

3 ½” from the sternum, on the upper edge of 2nd rib and in the 1st intercostal space sinuses: midway between the tip of the transverse and spinous processes of C2 on the posterior aspect of the transverse process

Question 47

middle ear chapmans

Answer 47

upper edge of the clavicle, just lateral where it crosses the 1st rib middle ear: (otitis media) upper edge of the posterior aspect of the tip of C1 transverse process

Question 48

pharynx chapmans

Answer 48

front of 1st rib ¾-1” medial to where the clavicle crosses the1st rib pharynx: midway between the spinous process and tip of the transverse process of C2, on the posterior aspect of the transverse process

Question 49

larynx chapmans

Answer 49

upper surface of 2nd rib, 2-3” lateral from the sternum larynx: midway between the tip of the transverse process and spinous process of C2 on the posterior aspect of the transverse process

Question 50

tongue chapman's

Answer 50

Tongue – front of 2nd rib cartilage ¾” from the sternum

Question 51

what is the purpose of the galbreath technique

Answer 51

Purpose – to increase blood flow through the pterygoid plexus of veins and lymphatics, drainage of the Eustachian tube, stretching of the peri-pharyngeal muscles and fascia ``` Patient supine (or seated in treating physician’s lap) Affected side down (or away from physician’s treating hand) Grasp mandible of affected side Draw mandible downward and transversely with mild force for 3-5 seconds, repeating for 30-60 seconds ```

Question 52

vomer sits where in the skull? motion? direction of movement?

Answer 52

The vomer is a midline bone that sits above the inter-maxillary (palatine) suture. Its motion is flexion and extension as it is driven by the motion of sphenoid. The vomer moves in a postero-inferior direction during flexion and the opposite motion in extension. It would be particularly obnoxious to palpate the vomer directly (deep to the soft palate). Palpation is done at the cruciate ligament. You can self-treat by placing your thumb pad over the cruciate ligament. Gently resting your head on the thumb and your elbow on the table. Wait for several cycles of flexion and extension for the vomer to be encouraged to resume its usual motion.

Question 53

what is the function of the vertebropleural ligament and restriction of this can cause what!

Answer 53

The function of this “ligament” is to ensure that each lung is equally aerated much like guide ropes on a hot air balloon. ``` Restriction here can limit lung function and C7 motion. ```

Question 54

somatic dysfunction of the thoracolumbar junction (especially flexed segments T10-L2) can cause what

Answer 54

increased sympathetic tone to the adrenal glands which can lead to weakening of the immune system if chronically present. Can also impair toxin excretion via the kidneys and intestines with chronic somatic dysfunction.

Question 55

what are the contraindications in treatment of resp problems in patients

Answer 55

1) No forceful direct treatments (depending on severity of illness) 2) HVLA to the thoracic spine relatively contra-indicated due to initial increase in sympathetic activity 3) Do not overtreat and tire the patient 4) Do not use treatment positions that aggravate patient’s breathing or pain (relative caution) 5) Thoracic pump technique in COPD patients 6) Visceral techniques in the acute phase