Respirology Flashcards
1
Q
7 year old girl with persistent cough, wheeze, nighttime cough, worse with activity. FEV1/FVC is 75%, bronchodilator increases her FEV1 by 15%. What do you recommend?
A. Inhaled corticosteroid with SABA PRN
B. Avoid the activities that trigger the symptoms
A
Inhaled corticosteroids with SABA PRN
Has a diagnosis of asthma: FEV1/FVC < 0.8-0.9
Increased FEV1 by >=12% with bronchodilator
It is uncontrolled: nighttime cough
Needs to be on controller ICS
Would also need to avoid activities that trigger Sx, but this is not enough
2
Q
16 year old competitive hockey player who had a history of asthma that was asymptomatic for 7 years. Has been having exercise induced symptoms and he’s using ventolin 6x/week before and during games. PFTs show normal FEV1 and FEV1/FVC but he has a positive methacholine challenge. What do you recommend?
A. Low dose inhaled corticosteroid
B. Stop playing high level hockey
C. 5 day course of oral corticosteroids
D. LABA in the morning on the days of the games
A
Low dose inhaled corticosteroids
Has poor control: Ventolin >4X/wk
(Exercise induced Sx)
- Regular need for a reliever to prevent or treat exercise-induced symptoms indicates suboptimal control and should be included in the weekly limit.
Other answers:
- All triggers should be avoided except exercise should not be discouraged
- LABA to be added to ICS if not full control
- Reserve oral steroids for when fail to respond to SABASs
3
Q
What is the most likely side effect of inhaled steroids? A. Decreased linear growth. B. Immunosuppression C. Moon facies D. Hypertension
A
Decreased linear growth
Regular use of ICS at low or medium daily doses is assoc’d with mean reduction of final adult height by 1.2cm
(0.5cm/yr in linear growth velocity, 0.6cm change from baseline height during 1y treatment period)
4
Q
You are seeing an adolescent male with a history of asthma. He is complaining of worsening asthma symptoms despite compliance with his inhalers. He admits that his group of friends has recently starting vaping and dripping. You advise:
A. Advise him not to be around his friends when they are dripping
B. Advise him there is no harm in the use of e-cigarette products
C. Advise him to not be around his friends when they are using e-cigarette products
D. Advise him not be around his friends when they use e-cigarette products with nicotine
E. He should tell his friends to stop vaping
A
Advise him not to be around his friends when they are using e-cigarette products
- e-cigarettes produce fine particulates greater than conventional cigarettes. Impair resp function. Worsen pre-existing breathing problems (asthma, bronchitis)
5
Q
A 7 year old boy with asthma is using ventolin. On your follow up visit, you find out that he uses his ventolin 2 puffs, 3-4 times per week, and has had 2 courses of systemic steroids in the last year. What should be your next course of action?
A. Increase ventolin dose to 4 puffs as needed
B. Add inhaled corticosteroid
C. Add oral prednisone
A
Add inhaled corticosteroid
6
Q
Severe asthmatic, tried multiple doses beta agonist and IV steroids with no response what should you do next?
A. One dose of MgSO4
B. INH heliox
C. Aminophylline infusion
A
One dose of MgSO4
7
Q
Kid has eczema and has cough with exercise relieved an hour later. Normal FEV. Normal PFT. What do you do to get the diagnosis?
A. Methacholine challenge
B. Exercise with spirometry
A
Methacholine challenge b/c more sensitive
CTS guidelines say you can do either one
Exercise testing - tester dependent
Do methacholine challenge when patients fail traditional PFT testing, but symptoms are highly suggestive of asthma. Test causes bronchoconstriction
8
Q
Kid w viral wheezing, worse w URTI
A. Give steroids + ventolin in winter + fall time
A
Give steroids + ventolin in winter and fall time
If preschooler who is not currently wheezing with >=2 episodes of asthma-like Sx, do therapeutic trials;
- mild, infreq Sx: SABA PRN
- mod-severe, freq Sx (>8X/mo): medium dose ICS x3mo + SABA PRN
If school aged child: make the Dx with PFTs
If mild asthma Sx: start low dose ICS + SABA PRN
9
Q
Teenager with exercise induced wheezing. Spirometry normal. What is next step?
A. Methacholine challenge
B. Spirometry during exercise
A
Methacholine challenge
10
Q
Child with wheezing during exercise. No significant reversibility (80 to 85%) PFTs given. How to further investigate?
A. Exercise challenge
B. Methacholine test?
A
Methacholin challenge
11
Q
Teenager with asthma. Using lots of ventolin. What to do next?
A. Verify technique
A
Verify technique
Reasons for poor control:
- Wrong diagnosis
- Wrong technique
- Poor adherence
- Ongoing exposure to triggers + comorbidities
- Wrong dose
12
Q
Recurrent wheezing with urti, how to treat?
A. Fluticasone
B. Salbutamol
A
Depends on what they were on before.
CTS Guidelines: all individuals with asthma should have access to a fast acting bronchodilator for use as needed to treat acute Sx
If preschooler with mild Sx: SABA PRN
If preschooler with moderate Sx (>2 exacerbations): trial of medium dose ICS + SABA PRN
If child >=6yo: do PFTs to diagnose
Consider start ICS
13
Q
Teen with asthma. Still symptomatic on inhaled fluticasone 125 mcg BID and monteleukast. Uses ventolin QID. Best treatment to address acute and chronic symptoms.
A. Salmeterol and fluticasone (Advair)
B. Formoterol and budesonide (Symbicort)
C. Salmeterol and ciclethisone (sp) (dont know what this is)
A
Formoterol + budesonide (Symbicort)
Teen on Low dose ICS+LTRA. Add LABA
Both Advair + Symbicort are ICS + LABA
- Symbicort: >=12yo (>=6yo practically)
- Advair: >=4yo
But SMART = Symbicort for maintenance and acute relief therapy
- RCT that looked at symbicort vs Advair in >=16yo
- Symbicort has more evidence for potential to use as reliever medication in addition to maintenance
14
Q
15 yo boy with poorly controlled chronic asthma. Fluticasone 125 mcg bid, on leukotriene antagonist, and still requires 2 ventolin puffs a day. What management should we do now?
A. Fluticasone and salmeterol → Advair
B. Budesonide and formoterol → Symbicort
C. Ciclesonide and salbuterol → not appropiate b/c salbuterol is a SABA
D. Budesonide + ipatropium bromide + salmeterol
A
Budesonide + fomoterol
> =12yo. Fluticasone low dose, LTRA. Add LABA
Both Advair + Symbicort are ICS + LABA
- Symbicort: >=12yo (>=6yo practically)
- Advair: >=4yo
But SMART = Symbicort for maintenance and acute relief therapy
- RCT that looked at symbicort vs Advair in >=16yo
- Symbicort has more evidence for potential to use as reliever medication in addition to maintenance
15
Q
Proven therapy in a kid with recurrent viral wheezing?
A. Ventolin
B. Fluticisone X 3 weeks
A
Ventolin
16
Q
2 yo child with recurrent viral wheezing. What is proven therapy?
A. Ventolin PRN
B. Prednisone 5 days
C. Fluticasone 3 weeks
A
Ventolin PRN
Preschool with recurrent (>=2) episodes of asthma-like Sx
If currently wheezing
- Start therapeutic trial of either SABA (if mild exacerbation) or SABA + OCS (if moderate to severe exacerbation)
- Direct observation of improvement by MD or trained HCP confirms asthma Dx
If currently NO wheezing
- If has freq Sx (>=8d/mo w asthma-like Sx) or >=1 mod-severe asthma-like exacerbation: therapeutic trial of medium dose ICS for 3mo with PRN SABA
- If <8d/mo of Sx or mild asthma-like Sx or mild asthma-like exacerbation (last hrs to a few days, no rescue OCS or hospital admission): therapeutic trial of PRNA SABA x3mo
Other answers:
- Prednisone can potentially help with an exacerbation, but not for asthma control
- Medium dose fluticasone should be trialed for 3mo, not 3wks
17
Q
What is the best measure to decrease the likelihood of asthma in child?
A. Breastfeeding
B. Avoid second hand smoke
C. Elimination of environmental allergens
A
Breastfeeding
18
Q
Adolescent female receives inhaler fluticasone BID and ventolin via MDI spacer TID. Her PFT shows FEV1 65% and improves by 20% with bronchodilators. What should be done now?
A. Check technique and compliance
B. Increase inhaled corticosteroid dose
A
Check technique and compliance
CTS guidelines: Need to check before increasing along the pyramid: 1. Sx control 2. Correct diagnosis via spirometry/PEF 3. Correct inhaler technique 4. Adherence 5. Persistent exposure to triggers 6. Comorbidities
19
Q
What will predict the persistence of asthma in adulthood?
A. Severe RSV pneumonia with intubation
B. Allergic rhinitis
A
Allergic rhinitis
Atopic wheezers are more likely to have persistent Sx into adulthood
CPS Position Statement on Asthma in Preschoolers:
Wheezing in early childhood associated with decreased lung function at 6yo (FEV1 is 10% lower than healthy peers) that generally persists until adulthood
20
Q
Which of the following is the most helpful measure to decrease risk of asthma?
A. Dust mite covers
B. Elimination of environmental smoke exposure
C. Removing pets from the home
D. Breastfeeding
A
Eliminate smoke exposure
Nelsons; avoidance of environmental tobacco smoke (beginning prenatally), prolonged breastfeeding (>4 months), an active lifestyle and healthy diet - might reduce the likelihood of asthma development
21
Q
Child with BMI 25. Cough and shortness of breath with gym class. Dad had allergic rhinitis and boy has history of mild eczema. FVC 80%. With inhaler, FEV1 increases to 87% and FVC to 85%. Treatment? A. Salbutamol prior to exercise B. Steroid inhaler C. Needs conditioning D. Steroids PO
A
? Needs conditions
Not sure what the pre-bronchodilator FEV1 was
Consider methacholine or exercise challenge test
22
Q
Teen with asthma , what would be an indicator of poor control:
A. Using ventolin 2/week for wheezing
B. Using ventolin 2/week for exercise
C. Using ventolin 2/week for night cough
D. Using ventolin with upper respiratory tract infections
A
Ventolin 2x/wk for night cough
23
Q
Poor control of asthma
A. Use of ventolin 2 days/wk
B. Use of ventolin 2 nights/wk
A
Use of ventolin 2 nights/wk
24
Q
8 yo with BMI 25, SOB with exertion. Dad with allergic rhinitis. Patient has mild eczema. PFTs show. FVC 80%, FEV1 84% → 87% with bronchodilator and FVC to 85%. What is the treatment? A. BID fluticasone B. Salbutamol prior to exercise C. Montelukast D. Physical training
A
Physical training
Does not meet asthma criteria
Calculation for change in FEV1 with bronchodilator: (87 - 84)/84 * 100 = 3.5% increase
25
```
What is the best indicator for mortality in asthma
A. Previous intubation
B. Previous oral steroids
C. Family history
D. History of atopy
```
Previous intubation
What are RFs for ICU admission and death?
1. Previous life-threatening events
2. Admissions to ICU
3. Intubation
4. Deterioration while already on systemic steroids
What are RFs for asthma morbidity + mortality (Nelson's)
A. Biologic
1. Previous severe asthma exacerbation (ICU admission, intubation for asthma)
2. Sudden asphyxia episodes (resp failure, arrest)
3. >=2 hospitalizations for asthma in past year
4. >=3 ED visits for asthma in past year
5. Using >2 canisters of SABA/mo
B. Environmental
1. Environmental tobacco smoke exposure
2. Allergen exposure
3. Air pollution exposure
C. Economic + Psychosocial
1. Poverty
2. Crowding
3. Low SES
4. Poor access to medical care
5. Poor perception of asthma Sx
26
6 year old girl with otitis media and sinusitis, found to have bilateral wheezes and crackles on exam as well as clubbing. She also has cobblestoning of the posterior oropharynx. Sweat chloride is negative. Which of the following tests would reveal the diagnosis?
A. CT sinuses
B. Electron microscopy of respiratory mucosa
C. Immunoglobulins
D. Alpha 1 anti-trypsin levels (serum)
? electron microscopy of respiratory mucosa
Primary ciliary dyskinesia
Note: cobbelstoning of posterior pharynx mucosa = allergic rhinitis
27
```
A child comes in with wheezing for the last few weeks. It started after playing at a friend’s house. She has not responded to corticosteroids or antibiotics. Her CXR is normal and she is not in respiratory distress. What is the next best management.
A. Bronchoscopy
B. Racemic epinephrine
C. Ventolin and steroids
D. Chest CT
E. Neck X-ray
```
Bronchoscopy to r/o foreign body
* *History is the most important factor in determining need for bronchoscopy
- Never ignore positive Hx (choking/coughing followed by wheezing)
28
Bronchiectasis-5 yo with productive cough day and night, wheeze, crackles, clubbing, how will you get the diagnosis?
A. Immunoglobulins
B. A1AT
C. Biopsy and microscopy → assuming nasal cilliary Bx
D. CT sinuses
Electron microscopy of nasal ciliary Bx
Note in this case, if CF was an option, would consider sweat chloride
29
Patient presents with diffuse wheezing and crackles. He is well grown. He has had a negative sweat chloride. What test would help with his diagnosis?
A. CT chest
B. Ig
C. Bronchoscopy with tracheal mucosal biopsy
Bronchoscopy with tracheal mucosal biopsy
Transmission electron microscopy is gold standard
Can get sample from NP or endobronchial
30
15 year old girl with SOB, no wheeze and no response to puffers. What would give you the strongest support for vocal cord dysfunction?
A. Normal oxygen saturation
B. Vocal cord abduction with inspiration
C. Truncated inspiratory loop on spirometry
D. Normal chest xray
Truncated inspiratory loop
Vocal cord abduction with inspiration is NORMAL
VCD: inappropriate and involuntary ADDuction of vocal cords during inspiration + sometimes during expiration
31
```
3 week old baby, admitted with bronchiolitis. Mildly tachypneic, and retractions on exam. Requiring O2 0.5L/min. Day 2 of admission, febrile 39C. Exam otherwise unchanged. What is cause for fever?
A. GBS
B. Strep pneumo
C. GAS
D. RSV
```
RSV
32
```
6 m.o baby with bronchiolitis symptoms. What is the best evidence supporting treatment:
A. Oral dexamethasone
B. Oxygen
C. Nebulized epinephrine
D. Nebulized salbutamol
```
Oxygen
33
It is the beginning of RSV season; who qualifies for RSV prophylaxis?
A. 2mo with cystic fibrosis
B. 4 mo ex 31+6 wk without chronic lung disease
C. 9 mo ex 33+6 wk with chronic lung disease requiring home O2
D. 15 mo old with congenital heart disease, now corrected
9mo ex 33+6wk GA with CLD requiring home O2
Because <12mo at start of RSV season with CLD requiring home O2
```
Other indications:
2. <12mo with hemodynamically significant CHD
(O2 diuretics, bronchodilators, O2)
3. <6mo and <30wk
4. <6mo and <36wk in remote area
5. <6mo and term Inuit in remote area
6. Consider in <24mo
a) Home O2 (or just weaned off in past 3mo)
b) Prolonged hospitalization for resp illness
c)T21
d) CF
e) Severely immunocompromised
```
34
```
A 2 month old child is seen with a 3-4 day history of viral URTI symptoms. Now, has progressively increasing work of breathing. RR is 65, O2 sat is 91% on room air. On auscultation there is diffuse wheezing. Of the following treatment modalities, which has been proven effective in this disorder?
A. Oxygen plus nebulized Ventolin
B. Oxygen plus nebulized epinephrine
C. Oxygen plus corticosteroids
D. Humidified oxygen alone
```
Humidified O2 alone
RSV bronchiolitis
35
```
Wheezing toddler with URTI symptoms. Which is a proven therapy?
A. O2
B. Racemic epi
C. IV steroids
D. Bronchodilators
```
O2
36
```
A one-month old baby presents with tachypnea, fever and a CXR showing bilateral interstitial infiltrates. There is significant wheezing on physical examination. O2 sats are 91%. Which therapy has been shown by evidence to give definite benefit?
A. Salbutamol
B. Racemic epinephrine
C. Oxygen
D. Prednisone
```
Oxygen
37
```
4 year old with CF, most likely deficiency:
A. Iron
B. Calcium
C. Vitamin D
D. Zinc
```
Vitamin D
Pancreatic insufficiency = fat soluble vitamins = ADEK
Vit A = eyes (night blindness, dryness of cornea + conjunctiva), follicular hyperkeratosis
Vit D = nutritional rickets, osteopenia, osteoporosis
Vit E = peripheral neuropathy, myopathy, hemolysis
Vit K = coagulopathy
38
```
Young child with 2 episodes of rectal prolapse.
A. Manometry
B. Rectal bx
C. Sweat chloride
D. Barium enema
```
Sweat chloride
Due to steatorrhea, malnutrition, repetitive cough.
Usually improves with adequate pancreatic enzyme replacement, stool softener.
39
Rectal prolapse x 2 that is easily managed in the ER. What test do you do now?
A. Sweat chloride
B. Reassure
Sweat chloride
Due to steatorrhea, malnutrition, repetitive cough
Usually improves with adequate pancreatic enzyme replacement, stool softener
40
```
Teen with cystic fibrosis has worsened cough, sputum, drop in PFT. What is the most appropriate antibiotics to start?
A. Ceftaz + tobra
B. Clox and tobra
C. Clox and ceftaz
D. PO cipro
```
Ceftaz+Tobra = pseudomonas coverage
- If progressive or persistent SSx despite intensive home measures, need IV ABx for at least 14d (usually improve within 7d)
- In general, pseudomonas requires 2 drug Tx
- If worried about MRSA, need Vanco
- Note: if MSSA + pseudo then choose [pip taz or mero]+tobra b/c ceftaz isn't great for staph aureus
Staph aureus - early
H influenza - early
Pseudomonas - late child/adol
Burkholderia cepacia
Stenotrophomonas
41
```
CF kid w green sputum, what do you tx w?
A. Ceftaz and tobra IV
B. Ceftaz and clox
C. Clox and tobra IV
D. Vancomycin
```
Ceftaz + tobra IV
= pseudomonas coverage, which requires 2 drug therapy
If worried about MRSA, need vanco.
Note: If MSSA + pseudo: choose [piptaz or mero]+tobra b/c ceftaz isn't great for staph aureus
If progressive or persistent SSx despite intensive home therapy, then need IV ABx x14d (usually improve by 7d)
```
Staph aureus - early
H influ - early
Pseudomonas - late child/adol
Burkholderia cepacia
Stenotrophomonas
```
42
Child with FTT and diarrhea, suspected of having CF. His CF sweat test was negative. Which of the following can cause a false negative sweat test?
A. Hypoalbuminemia
B. Hypothyroidism
Hypoalbuminemia
Positive sweat test if >60
DDx for FN sweat test:
1. Malnutrition
2. Edema
3. Insufficienct sweat quantity
4. Hyponatremia
DDx for FP sweat test
1. Adrenal insufficiency
2. anorexia nervosa
3. eczema
4. Malnutrition
5. Hypothyroidism
43
False negatives for sweat chloride
A. Hypoalbuminemia
B. Hyponatremia
C. Hypercalcemia
Hypoalbuminemia
Positive sweat test if >60
DDx for FN sweat test
1. Malnutrition
2. Edema
3. Insufficient sweat quantity
4. Hyponatremia
DDx for FP sweat test
1. Adrenal insufficiency
2. Anorexia nervosa
3. Malnutrition
4. Hypothyroidism
5. Eczema
44
```
What would cause false negative sweat chloride test?
A. Atopic dermatitis
B. Low albumin
C. Adrenal insufficiency
D. Hypothyroidism
```
Low albumin
Positive sweat test if >60
The rest can cause false POS for sweat test:
1. Adrenal insufficiency
2. Anorexia nervosa
3. Malnutrition
4. Hypothyroidism
5. Eczema
45
```
14 year old boy with cystic fibrosis has a two day history of pleuritic chest pain. What is the likely cause
A. Infective exacerbation
B. Pulmonary embolism
C. Pneumothorax
D. Pleurodynia
```
Infectious exacerbation
PTX in <1% of children with CF
Pleurodynia = sudden stabbing chest pain or abdo pain, often Coxsackie B. Fever, malaise, H/A.
CXR usually normal
Assoc'd with meningitis, orchitis, myocarditis, pericarditis
46
What would be the most important prognostic indicator in cystic fibrosis
A. Pneumothorax
B. Hemothorax
C. Malnutrition
Pneumothorax
47
```
Kid with recurrent sinopulmonary infections. CXR suggests RML bronchiectasis. Which test NOT to order?
A. Alpha-1-antitrypsin
B. Ciliary biopsy
C. CT chest
D. Immunoglobulins
```
Do not order alpha-1-antirypsin
A1AT deficiency
- Little or no detectable lung disease during childhood
- usually normal physical exam
- Can have jaundice, acholic stools, hepatomegaly in first week of life
- A1AT serum immunoassay to measure levels
- Tx: IV replacement of A1AT enzyme derived from pooled human plasma
CT chest to better characterize bronchiectasis + look for situs inversus
Ciliary biopsy for PCD
Immunoglobulins for hypogammaglobulinemia in context of recurrent sinopulmonary infections
48
```
A patient with recurrent pneumonia, sinusitis, bronchiectasis in the RML. One should investigate for all of the following except:
A. CF
B. Alpha-1-antitrypsin deficiency
C. Ciliary dyskinesia
D. Hypogammaglobulinemia
```
Alpha-1-antitrypsin deficiency
A1AT deficiency
- Rarely presents with lung disease in childhood. Smoking is bad
- Usually normal physical exam
- Can have jaundice, acholic stools, hepatomegaly in first week of life, usually clears by 2-4mo
- ATA1 serum immunoassay to measure levels
- Tx: IV replacement of A1AT enzyme derived from pooled human plasma
CT chest to better characterize bronchiectasis + look for situs inversus
Ciliary biopsy for PCD
Immunoglobuins for hypogammaglobulinemia in context of recurrent sinopulmonary infections
49
```
Which of the following indicates the worst prognosis in CF?
A. Liver disease
B. Malnutrition
C. Pneumothorax
D. Hemoptysis
```
Pneumothorax
Hemoptysis can be quite common. Usually reflects airway wall erosion secondary to infection.
<20mL (small-volume) isn't panic worthy. Means need to intensify ABx + chest PT
Admit if hemoptysis persistent or increases in severity
Massive hemoptysis is >=250mL in 24H
May need bronchial artery embolization
50
```
2 month old child is found to have respiratory distress and focal right sided crackles on exam. A CXR was done showing a defect of the right diaphragm - CDH vs eventration. What is your next step?
A. MRI Chest
B. CT Chest
C. Diaphragm fluoroscopy
D. Exploratory OR - ??
```
Diaphragm fluroscopy
(I would choose U/S if this was an option)
Normal movement of diaphragm
- contracts + decreases with insp
- relaxes + increases with exp
CDH
- 90% posterolateral, 90% on left
- pulmonary hypoplasia + intestinal malrotation
- Do CXR with NG to confirm Dx
- No PPV
- Will need surgical repair, timing controversial
- 70% survival
Eventration
- thinned diaphragmatic muscle -> abnormal elevation of hemidiaphragm -> paradoxical motion of affected diaphragm
- most are asymptomatic + don't require repair
51
```
Newborn with respiratory distress and cystic lesion in LUL with tracheal deviation. What is the most likely diagnosis:
A. CCAM
B. Pulmonary sequestration
C. Pneumonia
D. Congenital lobar emphysema
```
CCAM b/c cystic
CPAM
- 1 lobe (can be any)
- connects to tracheobronchial tree
- arterial supply + venous drainage from pulmonary circulation
- often antentally Dx
- newborn to early infancy
- resp distress, recurrent infxns, PTX
- All should get CXR: cystic mass
- mediastinal shift AWAY from lesion
- Then CT/MRI + contrast to confirm Dx + further evaluate
- Surgical excision is curative, good prognosis
- Overall survival rate >95%
CLE
- most common neonatal cystic lung malformation
- Progressive lobar hyperinflammation d/t airway obstruction (intrinsic or extrinsic)
- LUL 50%
- Usu aSx in neonatal period, 50% by 1mo, almost all by 6mo
- Progressive resp distress, +/- wheezing
- CXR: distension of affected lung. compression + atelectasis of contralateral lung.
- mediastinal shift AWAY from lesion
- majority are Sx + require early resection
- if aSx, conservative mgmt b/c rarely dvlp complication
Bronchopulmonary sequestration
- Nonfunctioning mass of lung tissue
- NO connections with tracheobronchial tree
- Arterial supply from systemic circulation
- intralobar sequestration: located within normal lobe (most often in lower lobes), doesn't have its own visceral pleura
- extralobar sequestration: located outside normal lung, has its own visceral pleura
- left side most often affected
- most newborns aSx
- If Sx, usually resp distress in neonatal period
- Intralobar sequestration usually present with infection
- CXR: uniformly dense mass within thoracic cavity or pulmonary parenchyma
- If Sx, surgical resection
- If ASx (esp extralobar): can observe
52
```
Kid with a tracheostomy desaturates and is cyanotic. The nurse has tried to suction without improvement. What do you do next?
A. Intubate
B. Provide 100% oxygen
C. Change tracheostomy
D. Try suction the tracheostomy yourself
```
ABCs
| Change tracheostomy
53
In empyema, fluid is most likely to show:
A. LDH 300
B. Fluid protein to serum protein > 0.5
C. Glucose 4.8 mmol/L
Fluid protein to serum protein >0.5
Transudate
- intact blood vessels
- imbalance of hydrostatic + oncotic pressures
- heart failure, nephrotic syndrome, cirrhosis, peritoneal dialysis
Exudate
- leaky blood vessels
- fluid moves into pleural space
- infection (parapneumonic, lung abscess), TB, malignancy, autoimmune disease
- pleural fluid prot to serum prot >=0.5
- pleural prot >3g/dL
- pleural fluid LDH to serum LDH >0.6
- pleural fluid LDH >ULN of serum
- neutrophil predominance: bacterial infxn
- lymphocyte predominance: TB, malig, autoimmune, chylothorax
pH is most accurate test to determine if parapneumonic effusion is empyema, exudate, transudate
normal pleural fluid pH similar to blood
<7.3: infection
>7.45: transudate
```
Transudate = pale yellow
Chyle = milky
Purulent = infection
Bloody = malignancy, trauma, infection
Bad odour = anaerobic bacteria
Chocolate brown = amebiasis
```
54
Kid with whiteout hemithorax. Next test?
A. U/S
B. Dx thoracentesis
C. Lateral X-ray
Ultrasound
CPS Statement: complicated pneumonia
- CXR should always be initial imaging modality
- U/S to confirm presence of pleural effusion suspected on CXR
- Consider CT if suspect alt Dx (e.g. malignancy)
55
Child with high fever, and white out on XR. Which investigation?
A. U/S
B. Thoracentesis
C. Lateral decubitus XR
U/S
CPS Statement: complicated pneumonia
- CXR should always be initial imaging modality. only repeat if clinical deterioration
- U/S to confirm presence of pleural effusion suspected on CXR
- Consider CT if suspect alt Dx (e.g. malignancy)
56
Child with cerebral palsy has history of choking with feeds now comes in respiratory distress, drooling, febrile. Chest Xray reveals opacity in LLL with air bubbles. Most likely diagnosis is:
1. Pulmonary abscess
2. Pulmonary sequestration
3. CCAM
4. Empyema
Pulmonary abscess
- often due to aspiration or pneumonia
- aerobic (staph, pseudo, e coli, kleb) + anaerobic
- CXR: lung inflammation, cavity with air fluid level, thick walled (vs. pneumatoceles are thin walled)
- CT chest: location+ size
- Treat 2-3wk of IV, then PO for total 4-6wks
- Cephalosporin (staph) +/- cinda (anaerobes) +/- tobra (gram neg)
- Consider drainage
- Sx improve in 7-10d
- Xray changes resolve in 1-3mo
Pulm sequestration + CCAM more likely to present newborn/infancy.
Empyema: lung injury -> increased cap permeability -> neut/lympho/eos migrate into pleural space -> pus
57
```
Child comes in febrile, coughing, tachypneic, tachycardic and lethargy for few days. O2 sat is 91% room air. CXR shows white out of right lung. Next step is:
A. Diagnostic Thoracentesis|
B. Ultrasound chest
C. CT chest
D. Lateral decubitus film
```
U/S Chest
Of note, I'd want to put in a chest tube ASAP b/c of mod-severe signs of resp distress
58
Patient with CP choking on feeds. CXR shows air bubble with consolidation and pleural effusion in RLL.
A. Abscess
B. Pulmonary sequestration
C. Congenital diaphragmatic hernia
Abscess
59
6 yo child with persistent non-productive cough in the daytime, which settles at night. In your office, she has a hacking cough. What is your diagnosis?
A. Psychogenic cough
B. Habit cough
C. Post-nasal drip cough
Habit cough
60
Obese kid with cough and sob. No significant difference in FEV1 with ventolin. What would you for this patients’ management?
A. Daily inhaled corticosteroid
B. Daily montelukast
C. Physical conditioning
Physical conditioning
61
```
6y F with chronic cough x 8 mos. Occurs unrelated to illness. It is a harsh cough during the day that decreases at night. Previous unsuccessful treatment for croup x 4. What is the likely diagnosis?
A. Asthma
B. Post-viral cough
C. Habit cough
D. Vascular ring
```
Habit cough
Post-viral cough: should be related to illness. Should gradually resolve in 2-4wks w/o therapy. Reassure + observe
Asthma: can see night time Sx
Vascular right: Sx related to tracheal compression (stridor, resp infnx, distress, wheeze, cough), may have esophageal involvement (dysphagia)
Note: Nelson's says that child who coughs for >6wks should be tested for CF regardless of race or ethnicity
62
9 yo presents with third episode of stridor. He is otherwise well. Which of the following investigations would you do?
A. CXR
B. Lateral soft tissue of the neck
C. MRI
D. Bronchoscopy
E. Culture of his oropharyngeal secretions
Bronchoscopy
63
Kid with central apnea, what to do next?
| A. MRI head
MRI head
64
```
14 year old girl with symptoms of obstructive sleep apnea and BMI > 95th percentile. Which of the following tests is MOST likely to reveal an underlying sequela of her disease?
A. Echocardiography
B. Electrocardiogram
C. Creatinine
D. Fundoscopy
```
Echocardiography
| Assess for pulmonary HTN, right sided heart failure, cor pulmonale, systemic hypertention (obese)
65
Child with daytime sleepiness, snores at night. Weight 95th percentile. Best first line management option.
A. T+A
B. CPAP
T+A
66
What is the number one cause of central apnea in an 8 week old infant?
A. Apnea of prematurity
B. RSV
C. Seizures
RSV
Young children with bronchiolitis may develop central apnea but resp distress clearly distinguishes from CCHS
67
Kid with snoring + central apnea on sleep study. Best thing to do?
A. Refer to ENT
B. MRI
MRI
| R/O other causes of central sleep apnea
68
An 8 year old girl presents with parental concern of snoring and stopping breathing overnight. Sleep study reveals multiple episodes of central sleep apnea. What do you do?
A. MRI
B. ENT consult
C. CPAP overnight
MRI
69
```
Greek 6 y/o girl with fever to 40 degrees. WBC 38. Tachnypeic. Pain in the right hypochondrium. Tender in right hypogastrium but no guarding or rebound. What is the diagnosis:
A. Pleurodynia (Bornholm's syndrome)
B. Bacterial pneumonia
C. First presentation of Familial Mediterranean Fever
D. Cholecystitis
-----------------------
6 yo girl with Greek background has severe abdominal pain with fever of 40. Her respiratory rate is 44, HR 160 and BP 100/50. She has RUQ pain on exam but no guarding with muscles. WBC is 40. Her ultrasound of liver is normal. Liver and renal function are normal. What is her diagnosis?
A. First episode of familial
B. Mediterranean fever
C. Pleurodynia (Bornholm’s)
D. Bacterial pneumonia
E. Acute cholecystitis
```
Bacterial pneumonia
RUQ pain but no guarding implies not peritonitis. Serositis is a clinical hallmark of FMF. Also, doesn’t have features of arthritis, erysipelas rash.
No pleurodynia b/c no information on spasmodic/paroxysmal pleuritic pain. Coxsackie B. Fever, malaise, H/A
CXR usually normal
Assoc'd with meningitis, orchitis, myocarditis, pericarditis
No N+V, jaundice to suggest cholecystitis
70
```
Boy with CP with hx aspiration pneumonias with left lower lobe infiltrated with pleural effusion. ??on antibiotics. Which of the following would be most diagnostic?
A. Bronchoscopy and culture
B. Pleural fluid C/S
C. Blood C/S
D. Sputum C/S
```
Pleural fluid C+S?
CPS Statement
- If draining, then do pleural C+S (usu low yield b/c already started on ABx), add pneumococcal PCR to increase yield
- BCx (10% yield)
- Sputum culture occasionally helpful, but difficult to obtain [mixed pathogens usually]
71
```
Child with CP has recurrent choking episodes. Presents with LLL pneumonia and air fluid level and significant pleural effusion. What is the investigation to help with management.
A. Sputum cultures
B. Blood culture
C. Pleural fluid culture
D. Bronchoscopy and culture
```
Pleural fluid culture
Since it's significant pleural effusion, likely warrants drainage. In which case, should get pleural cultures
If recurrent choking episodes, may indicate aspiration pneumonia. If pt can expectorate, may be worthwhile doing sputum Cx to determine what he's growing +/ colonized with
72
The same CP patient with LLL pneumonia and fluid level ?aspiration/abscess. What antibiotics:
A. Ampicillin+gentamicin
B. Clindamycin+gentamicin
C. Cefuroxime
?Cefuroxime
CPS Complicated pneumonia
Ceftoxime or CFTX +/- clinda
Add vanco if suspect/culture-proven MRSA pneumonia
73
```
Child with CP (same kid). What would you treat with?
A. Genta/clinda
B. Azithro
C. Cefuroxime
D. Ampi/genta
```
?Cefuroxime
CPS Complicated pneumonia
Ceftoxime or CFTX +/- clinda
Add vanco if suspect/culture-proven MRSA pneumonia
74
```
17 yr old male found to have pneumothorax on CXR. He had been at a party that night. What is the number one cause of pneumothorax?
A. Spontaneous
B. Cocaine
C. Status asthmaticus
D. Undiagnosed Marfan syndrome
```
Spontaneous
Primary spontaneous: no underlying disease, no trauma
- tall, thin, male teens
- cigarettes, marijuana, cocaine
Secondary spontaneous: underlying lung disorder, no trauma
- pneumonia, asthma, CF
75
```
Teen with ARDS. What is the most likely:
A. Increased pulmonary airway resistance
B. Decreased compliance
C. Decreased elastic recoil
D. Hyperinflation
```
Decreased compliance = hallmark of ARDS
- Loss of FRC, so lost lung volumes, not hyperinflation
- elastic recoil is inversely related to lung compliance (more likely collapse in ARDS with poor compliant lung)
- No perinatal related lung disease
1. Acute onset: w/in 7 d of known clinical insult
2. Origin of edema: resp failure not fully explained by cardiac failure or fluid overload
3. CXR showing new infiltrate consistent with acute pulmonary parenchymal disease
4. Oxygenation problem
- PF ratio = PaO2/FiO2 = indicator of O2 uptake relative to O2 delivery (low value is worse)
- SF ratio = SaO2/FiO2
- OI = (MAP x FiO2)/PaO2 (higher number is worse)
76
A. Name 4 daytime symptoms of obstructive sleep apnea
| B. Name 2 long term consequences
A.
1. Morning H/A
2. Daytime somnolence
3. Fatigue
4. Increased irritability
5. Mouth breathing + dry mouth
6. Chronic nasal congestion/rhinorrhea
B.
1. Poor school performance
2. Pulmonary hypertension
3. Systemic HTN
4. FTT
5. Mood and behavioural changes
77
Complete the following table with either increased, decreased or normal.
```
Asthma vs Severe Scoliosis
FEV1/FVC
FEF 25 - 75
RV/TLC
FVC
```
```
Asthma (obstructive)
FEV1/FVC decreased
FEF 25-75 decreased
RV/TLC increased (if gas trapping)
FVC normal
```
```
Severe Scoliosis (restrictive)
FEV1/FVC normal/increased
FEF 25-75 normal
RV/TLC = increased
FVC = decreased
```
FEF 25-75 = flow through small airways
78
2 year old girl previously healthy, presents to ED with recurrent episodes of respiratory distress and wheeze that started 6 weeks ago. She has been treated with fluticasone and salbutamol inhaled and parents think she is not responded to treatment.
A. What is the most prominent finding on chest x-ray?
B. What is the most important question to ask parents on history?
C. What is your next step in management?
A.
- Foreign body
- If do an insp/exp PA film. Insp looks normal. Exp (bronchial FB obstructs exit of air from obstructed lung -> obstructive emphysema, air trapping + persistent inflation of obstruction lung): distension of affected lobe + hyperlucency, mediastinal shift towards other side.
B. If they witnessed choking/coughing/gagging episode
(negative answer doesn't r/o FB, but cannot ignore positive Hx)
C. Bronchoscopy
79
Teen with CF with weight loss, fatigue, FEV1 decrease 10%, exercise intolerance. Name 5 reasons for her presentation (5)
1. CF exacerbation/pulmonary infection
2. Not using her pancreatic enzymes
3. Poor adherence with antibiotic prophylaxis
4. Poor adherence with chest physiotherapy
5. Malnutrition/disordered eating
6. New onset CF related diabetes
7. Allergic bronchopulmonary aspergillosis
8. Smoking
80
Name 5 indicators of poor asthma control in a 7 yo child (5).
1. Daytime Sx >=4X/wk
2. Night time Sx >=1X/wk
3. School absenteeism
4. Using SABA >=4X/wk
5. Having mod-severe or frequent exacerbations
6. FEV1 or PEF <90% of personal best
7. PEF variation>10-15%
81
2 patients have arrived at the same time in the ED:
Patient 1 – 8yo boy with asthma attack, resp distress and tracheal tug. RR 36 PCO2 28.
Patient 2 – 8yo boy with asthma attack, resp distress and tracheal tug. RR 20 PCO2 38.
(no other info was given) Which patient do you see first? (2 points) Explain your choice (2 points)
Pt 2 because slowing of RR and PCO2 climbing means that he is getting tired and is in impending respiratory failure
82
You are seeing a 15yr old girl with cystic fibrosis in follow up. Over the past 3 months she has had a 5kg weight loss. On spirometry today she is noted to have a 10% in her FEV1 from previous. She reports that she is compliant with nutritional therapies and chest physio. List 5 possible causes for this presentation
1. CF exacerbation/pulmonary infection
2. Allergic bronchopulmonary aspergillosis
3. Poor adherence to antibiotic prophylaxis (i.e. Turboinhaler)
4. Disordered eating/malnutrition
5. Smoking
83
Poor controlled asthma. List 5 items to assure good controlled asthma
1. Remove environmental triggers as much as possible
2. Education about proper inhaler and aerochamber technique
3. Written asthma action plan
4. Immunizations including flu shot
5. Ensure adequate dosing of ICS and adherence
6. Monitor and manage comorbidities
7. Symptom diary
84
A boy (10y) with Duchenne’s muscular dystrophy who is waking up in the morning tired Blood gas showed (7.27/60/?/30).
Interpret the blood gas?
What is the diagnosis?
What treatment is the treatment needed for this condition?
1. Respiratory acidosis
2. OSA
3. CPAP/BiPAP
85
How would the PFT values be altered in someone with asthma.
| Name 3
1. Low FEV1/FVC (<0.8)
2. Bronchodilator response with change of FEV1 >=12%
3. Decreased FEF25-75
4. Decreased or normal FVC
5. Increased RV
6. Increased RV/TLC
86
CF exacerbation – therapy? (compliant teen, FEV fell by 20-30% over 3 months)
Antibiotic therapy - try to cover what they had in the past (Staph aureus, H influ nontypeable, P aeru, B cepacia)
Ceftazidime+Tobra for 2 drug coverage of pseudomonas
Add vanco if concerned about MRSA
Treat for at least 14d
Staph aureus
PO: keflex, clinda, amox clav
IV: ancef, vanco
H influ
PO: amox
IV: amp
P aeru
PO: clinda
IV: tobra, ceftazidime, piptazo, mero
B cepacia
PO: septra
IV; mero
87
Deconditioned vs. Asthma (2 points)
List two diagnostic criteria for ARDS
List 4 daytime symptoms of obstructive sleep apnea.
A. 1. Deconditioned
- doesn't respond to bronchodilator
- exercise induced PFT testing normal
2. Asthma
- responds to bronchodilator
- exercised induced PFT testing with >10-15% decrease in FEV1
B. ARDS
1. Not due to perinatal lung disease
2. Sudden onset (within 7d)
3. Respiratory failure not fully explained by cardiac failure or fluid overload
4. CXR with new infiltrate(s) consistent with acute pulmonary parenchymal disease
5. Hypoxemia
C. OSA
1. AM H/A
2. Daytime somnolence
3. Irritability
4. Poor school performance
88
A chest tube was inserted into a child with empyema and white out of the left lung field. 12 hours after the chest tube insertion, a repeat CXR shows persistent pleural air. The chest tube system is patent. List 3 causes of the persistent pleural air.
1. Tube malposition or dislodgement
2. Bronchopleural fistula (may see bubbling chest drain in child with necrotizing pneumonia)
3. Pneumothorax (spontaneous or iatrogenic)
4. Leak around dressing site in chest tube circuit
89
You are seeing a teenager with cystic fibrosis. He’s been complaining of worsening cough, chest pain, and increased sputum production. His IgE is noted to be elevated with increased eosinophils on differential.
Most likely diagnosis?
Treatment?
Allergic Bronchopulmonary Aspergillosis
Oral corticosteroids (Extended course)
90
A 7 year old boy is referred with possible ADHD. His teacher notices that he is sleepy at school. On exam you notice that he breathes through his mouth.
What are three questions you would like to ask his parents to help with his diagnosis?
```
Screen for sleep disorders
Bedtime problems: difficulty falling asleep or staying asleep
Excessive daytime somnolence
Awakening at night
Regularity and duration of sleep
Snoring
```
91
6 yo well. Intermittent cough x 6 months.
| List three common causes
1. Habit cough
2. Post viral cough
3. Asthma
4. Recurrent URTIs
5. Chronic rhinosinusitis
6. CF
7. Reflux
92
14 year old male with bronchiectasis. List 3 differential diagnosis
1. CF
2. PCD
3. ABPA
4. Chronic aspiration/aspiration of FB
5. Infectious: pertussis, measles, TB
93
Boy with decreased school performance and sleepiness during the day. Height of 120 cm and weight of 28.8 kg
Calculate BMI
How do you interpret this BMI (BMI-for-age chart given)
c. What is the diagnosis you are concerned about?
A. BMI = 28.8/(1.2x1.2) = 20
B. Not sure about this kid's age
C. OSA (in context of obesity)
94
Moderately overweight teen has shortness of breath on exertion. Fill in table of PFTs comparing asthma vs. deconditioned person (RV/TLC, FEF25-75, FEV1/FVC) ***Q
Asthma
FEV1/FVC: decreased
FEF25-75: decreased
RV/TLC: increased (RV high from air trapping, TLC normal)
Deconditioned
FEV1/FVC: normal
FEF25-75: normal
RV/TLC: normal
Restrictive
FEV1/FVC: normal
FEF25-75: normal
RV/TLC: increased (low TLC)
95
22. A) List 3 organisms that colonize airway of patients with CF (unique to patients with CF).
1. Staph aureus
2. Nontypeable H influenza
3. Pseudomonas aeuroginosa
4. Burkholderia cepacia
5. *Stenotrophomonas maltophilia
96
What are 4 clinical signs of inhalant lung injury in a patient who was rescued from a house fire?
1. Stridor
2. Vocal hoarseness
3. Soot in nose or mouth
4. Singed nose hair or eyebrows
5. Coughing up carbonaceous sputum
6. Decreased LOC or confusion, agitation
7. Clinical hypoxemia; SpO2 <94% in air
8. Increased carboxyhemoglobin levels
97
4 year old with asthma on inhaled steroids. Name 2 mechanisms of delivery of asthma medication.
1. MDI
| 2. Nebulization of medication to be inhaled in aerosolized suspension form
