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Flashcards in Respirology Deck (42):
1

What are the causes of dyspnea in children?

Respiratory
- Upper tract
   >> Croup
   >> Acute epiglottitis
   >> Bacterial tracheitis
   >> Foreign body
   >> Retropharyngeal abscess
   >> Laryngeal angioedema
- Lower tract
   >> Pneumonia
   >> Bronchiolitis
   >> Atelectasis/lung collapse
   >> Asthma
- Pleura
   >> Pneumothorax
   >> Pleural effusion
   >> Empyema

Cardiovascular
- Congestive heart failure
- Cardiac tamponade
- Pulmonary edema
- Pulmonary effusion

Others
- Increased ICP
- Ascites
- Scoliosis

2

What is the common age at presentation for croup?

<6 years during fall and winter

- Peak age: 7 months - 3 years

3

What is the common age of presentation for acute epiglottitis?

2-6 years

- Usually older than those with croup

4

What are the major causative organisms for croup?

- Parainfluenza
- Influenza A and B
- RSV
- Adenovirus

5

What are the major causative organisms for acute epiglotittis?

- Hemophilus influenzae
- B-hemolytic streptococcus

   >> Group A strep (pyogenes)
   >> Group B strep (agalactiae)

6

What is the typical clinical presentation for croup?

- Common prodrome with coryzal symptoms
- Hoarse voice
- Barking cough
- Stridor

>> WORSE AT NIGHT

7

What is the typical clinical presentation for acute epiglottitis?

- Toxic appearance
- Rapid progression
- 4Ds of epiglottitis
   >> Dyspnea
   >> Dysphagia
   >> Dysphonia
   >> Drooling
- Tripod position/sniffing dog position
- High grade fever >39C

8

What is the management for croup?

- Adequate hydration and close monitoring
- Nebulized racemic epinephrine
- Systemic/oral steroids (dexamethasone)
- Intubation if severe
- Hospitalize if:
   >> Poor response to steroids after 4 hours
   >> Persistent stridor at restm

9

What are the three cardinal features for Pierre-Robin sequence?

- Cleft palate
- Micrognathia
- Glossoptosis

10

What are some signs of airway obstruction in children?

- Stridor
   >> Inspiratory VS. expiratory
   >> Body position
         :: Prone: subglottic hemangioma, double aortic arch
         :: Supine: laryngomalacia, glossoptosis
   >> Site of stenosis
         :: Vocal cords or above: inspiratory
         :: Subglottis and extrathoracic trachea: biphasic
         :: Distant tracheobronchial tree: expiratory
- Respiratory distress
   >> Tachycardia
   >> Tachypnea
   >> Nasal flaring
   >> Expiratory grunting
   >> Insucking: suprasternal, intercostal and subcostal
   >> Use of accessory muscles of respiration
   >> Cyanosis
- Feeding difficulties and aspiration
   >> Supraglottic lesion
   >> Laryngomalacia
   >> Vocal cord paralysis
   >> Laryngeal cleft --> aspiration pneumonia
   >> Tracheoesophageal fistula

11

What are the causes of airway problems/obstruction in neonates?

RMB: NEONATES ARE OBLIGATE NOSE BREATHERS

Extralaryngeal
- Choanal atresia
- Nasopharyngeal dermoid/glioma/encephalocele
- Glossoptosis
   >> Pierre Robin sequence
   >> Down syndrome
   >> Lymphatic malformation
   >> Hemangioma

Laryngeal
- Laryngomalacia
- Laryngocele
- Vocal cord palsy
   >> Trauma
   >> Arnold-Chiari malformation
- Glottic web
- Subglottic stenosis
- Laryngeal cleft

Tracheal
- TE fistula
- Tracheomalacia
- Vascular rings

12

What are the causes of airway problems/obstruction in infants?

Congenital
- Laryngomalacia
- Vascular
   >> Subglottic hemangioma
   >> Subclavian artery compression
   >> Double aortic arch
- Laryngeal papilloma

Acquired
- Sudden onset
   >> Croup
   >> Bacterial tracheitis
   >> Epiglottitis
   >> Foreign body aspiration
   >> Caustic ingestion
- Post-intubation
   >> Subglottic stenosis
   >> Tracheal granulation
- Tracheomalacia
   >> Post-tracheostomy
   >> Post-TEF repair

13

What are the causes of airway problems/obstruction in older children/adolescents?

Congenital
- Lingual thyroid/tonsil

Acquired
- Infection
   >> Ludwig's angiona
   >> Peritonsillar abscess
   >> Retropharyngeal abscess
- Trauma
   >> Facial fracture
   >> Burns and lacerations
   >> Post-intubation
- Neoplastic
   >> SCC in adults
   >> Retropharyngeal: lymphoma, neuroblastoma
   >> Nasopharyngeal: carcinoma, rhabdomyosarcoma
- Allergy
   >> Angioneurotic edema
   >> Polyps: allergic rhinitis, asthma, cystic fibrosis

14

What should one rule out in a patient with suspected croup?

- Bacterial tracheitis
- Acute epiglottitis
- Foreign body aspiration
- Subglottic stenosis

15

What should one think of in recurrent croup?

Subglottic stenosis

16

What is the management for acute epiglottitis?

- Immediate intubation/secure airway
- DO NOT EXAMINE THE THROAT
- DO NOT LIE THE PATIENT DOWN
- ABC + IV access with hydration
- IV antibiotics: cefuroxime, cefotaxime, ceftriaxone

>> Watch out for meningitis

17

What is the management for subglottic stenosis?

Soft stenosis
- Divide tissue with knife or laser
- Dilate with balloon
- +/- steroids

Firm stenosis
- Laryngotracheoplasty

18

What are the presenting features of laryngomalacia?

- Chronic high-pitched inspiratory stridor
   >> From 1-2 weeks of life
   >> More pronounced when supine
- If severe
   >> Cyanosis
   >> Feeding problems
   >> Failure to thrive

19

What is the management of laryngomalacia?

1. Conservative/observation
   - Spontaneously subside by 12-18 months in 90%
2. Surgery
   - For severe cases
   - Division of the aryepiglottic folds (supraglottoplasty)

20

What is Ludwig's angina?

Potentially life-threatening connective tissue infection at the floor of the mouth in the submandibular and sublingual space

21

What are the causes of wheezing in a child?

Common causes
- Asthma
- Bronchiolitis
- Pneumonia
- Recurrent aspiration

Less common causes
- Foreign body aspiration
- Bronchopulmonary dysplasia
- Cystic fibrosis

Rare
- Congestive heart failure
- Mediastinal mass
- Tracheobronchial abnormalities
- Bronchiolitis obliterans
- Ciliary dyskinesia

22

What are the possible causes of respiratory distress in a newborn?

Maternal causes
- Gestational diabetes/known DM
- Maternal myasthenia gravis
- Drugs/opiates/anesthesia

Obstetric causes
- Antepartum hemorrhage leading to shock
- Birth injury/hypoxic-ischemic encephalopathy

Fetal causes
- Respiratory
   >> Respiratory distress syndrome
   >> Apnea of prematurity
   >> Transient tachypnea of newborn
   >> Meconium aspiration syndrome
   >> Pneumonia
   >> Pneumothorax
   >> Pleural effusion
   >> Pulmonary hypoplasia
   >> Chest deformities
- Cardiac causes
   >> Congenital heart diseases
   >> Cyanotic VS. noncyanotic
- Severe anemia
   >> Erythroblastosis fetalis
   >> Secondary hydrops fetalis
- Others
   >> Sepsis
   >> CNS depression
   >> Potter's sequence
   >> Hypoglycemia
   >> Hypothermia

23

What are the common organisms for pneumonia according to age groups?

Neonates
- Bacterial
   >> GBS
   >> E. coli
   >> Listeria
   >> Mycoplasma hominis
   >> Ureaplasma urealyticum
- Viral
   >> CMV
   >> Herpesviridae
   >> Enterovirus

1-3 months
- Bacterial
   >> Staphylococcus aureus
   >> Hemophilus influenzae
   >> Streptococcus pneumoniae
   >> Chlamydia trachomatis
   >> Ureaplasma
- Viral
   >> RSV
   >> CMV
   >> Influenza virus
   >> Parainfluenza virus

3 months - 6 years
- Bacterial
   >> Streptococcus pneumoniae
   >> Mycoplasma pneumoniae
   >> Hemophilus influenzae
   >> Group A streptococcus
   >> Staphylococcus aureus
   >> TB
- Viral
   >> RSV
   >> Adenovirus
   >> Influenza virus

> 5 years
- Bacterial
   >> Mycoplasma pneumoniae
   >> Streptococcus pneumoniae
   >> Hemophilus influenzae
   >> Staphylococcus aureus
   >> Chlamydia pneumoniae
   >> TB
- Virus
   >> Influenza
   >> Varicella
   >> Adenovirus

24

What is the management for a child with pneumonia?

Supportive and monitoring

- Hydration
- Antipyretics
- Humidified O2

Antibiotics
- By age group
- Neonates: IV ampicillin + gentamicin +/- erythromycin
- 1-3 months: IV ampicillin +/- clarithromycin/doxycycline
- 3 months - 5 years: PO/IV penicillin/cefuroxime
- >5 years: erythromycin/clarithromycin/doxycycline +/- penicillin/cefuroxime

25

What is the typical age of presentation for bronchiolitis?

First 2 years of life

- Peak at 6 months
- Winter or early spring

26

What are the indications for hospitalization in bronchiolitis?

- Young infants
- Chronic diseases
   >> Chronic lung disease
   >> Hemodynamically significant cardiac disease
   >> Neuromuscular problem
   >> Immunocompromised
- Significant feeding problems
- Hypoxia: SpO2 60 breaths/minute
- Social problems: inadequate care at home

27

What is the mainstay management for bronchiolitis?

Supportive

- O2 supplement
- Oral/IV hydration
- Antipyretics for fever +/- intubation and ventilation as needed

>> Monthly palivizumab for high risk groups as prophylaxis

28

What are the presenting signs of cystic fibrosis?

CF PANCREAS

C: Chronic cough
F: Failure to thrive
P: Pancreatic insufficiency
A: Alkalosis
N: Nasal polyps
C: Clubbing of the finger
R: Rectal prolapse
E: Electrolytes increase in sweat (sweat test positive)
A: Absence of vas deferens
S: Sputum with staphylococcus or pseudomonas

29

What are the four parameters to use to assess long-term asthma control?

1. Daytime symptoms >= 2/week?
2. Night-waking due to asthma?
3. Reliever need >=2/week?
4. Activity limitation due to asthma?

0 = well-controlled
1-2 = poorly controlled
3-4 = uncontrolled

30

What is the management for an acute asthma attack?

Supportive
- Hydration
- Oxygen supplemment

Pharmacotherapy
1. Reliever therapy: short-acting b2 agonists
2. Ipratropium if severe
3. Inhaled or systemic corticosteroids

>> Discharge patient if asymptomatic for 2-4 hours after the last dose of b2 agonist

31

How is asthma different from bronchiolitis clinically?

- Positive family history
- Recurrent wheezing episodes
- Response to bronchodilators

32

What are the main goals of treatment for asthma?

- Education and avoid allergens
- Improve bronchodilation/prevent bronchospasms
- Decrease inflammation

33

How do we quantify the severity of an acute asthmatic attack?

Inpsection and physical examination
- Alertness
- Accessory muscle use
- Colour: ?cyanosis
- Respiratory effort
- Ability to talk in sentences
- Pulsus paradoxus
- Wheezing or absence on auscultation

Parameters
- Respiratory rate at rest
- PEFR
- O2 saturation
- PCO2

34

What findings will an ABG reflect during an acute asthmatic attack?

HYPOCAPNIA
>> Maybe hypoxemia
>> Hypercapnia is a serious sign.

35

What are the indications for hospitalization of an acute asthmatic attack?

1. Pre-treatment O2 saturation <92%
2. Past history of life-threatening asthma
3. Unable to stabilize with masks Q4H
4. Concern over environmental issues or childcare at home

36

What is the mode of inheritance in cystic fibrosis?

Autosomal recessive

37

What is bronchiectasis?

Abnormal and permanent distortion of one or more of the bronchi or airways, often secondary to an infectious process

Chronic wet cough that is unresponsive to antibiotic treatment may indicate bronchiectasis in children

38

What are the common presenting features of bronchiectasis?

History
- Look for any previous infections
   >> Klebsiella
   >> Staphylococcus aureus
   >> Mycobacterium TB
   >> Mycoplasma pneumoniae
   >> Mycobacterium avium complex (MAC)
- Look for other risk factors
   >> Cystic fibrosis
   >> Connective tissue disorders
   >> AAT deficiency
   >> Autosomal dominant polycystic kidney
   >> Aspiration
   >> Immunodeficiency
- Cough and daily mucopurulent sputum production, often lasting moths and years
- Blood-streaked sputum from airway damage associated with acute infection
- Dyspnea, pleuritic chest pain, wheezing
- Fever, fatigue and weight loss

Physical Examination
- Digital clubbing
- Cyanosis/polycythemia
- Nasal polyps
- Weight loss
- Auscultation: crackles, rhonchi, scattered wheezing and inspiratory squeaks
- Resolution of crackles after coughing is a sign for bronchiectasis

39

What is the standard test for diagonsing bronchiectasis?

High-resolution computed tomography (HRCT)

40

What kind of deficiency should one look for in a patient with bronchiectasis?

Vitamin D deficiency

41

What is the mainstay therapy for bronchiectasis?

- Antibiotics
- Chest physiotherapy +/- bronchodilators +/- corticosteroids
- +/- surgical therapies: resection of bronchiectatic sites

42

What are the side effects of TB drugs?

Isoniazid
- Hepatotoxicity
- Hepatitis
- Drug-induced SLE
- Peripheral neuropathy

Rifampicin
- Hepatotoxicity
- P450 enzyme induction
- Orange tears, saliva and urine

Pyrazinamide
- Hepatotoxicity (more hepatotoxic drug of all TB drugs)
- Gout
- Gastric irritation

Ethambutol
- Loss of central and colour vision