Week 11 Acute Respiratory Flashcards
A 5-month-old infant who has a 3-day history of low grade fever, cough, and rhinorrhea has developed respiratory symptoms with audible expiratory wheezes and increased coughing. The infant’s immunizations are up-to-date. The physical exam reveals a respiratory rate of 42 breaths per minute, coarse expiratory wheezing, and prolonged expiration. An oxygen saturation is 96% on room air. What is the recommended treatment for this infant?
A
Order an oral corticosteroid
B. Obtain a viral culture of nasal washings
C. Administer trial of bronchodilators
D
Recommend increased fluids and close follow-up
D. Recommend increased fluids and close follow up
The infant has bronchiolitis and is stable. Increasing fluids and following up closely are indicated as long as oxygen saturations and hydration are normal. Bronchodilator trials are not recommended because of the risk of adverse effects and questionable efficacy. Viral cultures are performed if hospitalization is necessary or when symptoms are severe. Corticosteroid medications are not indicated.
The primary care pediatric nurse practitioner evaluates a child who awoke with a sore throat and high fever after a nap. The child appears anxious and is sitting on the parent’s lap with the neck hyperextended. The physical exam reveals stridor, drooling, nasal flaring, and retractions. What will the nurse practitioner do next?
A Administer a broad spectrum IV antibiotic
B Transport the patient to the hospital via emergency medical services
C Send the child to radiology for a lateral neck radiograph
D Obtain blood and throat cultures and start antibiotic therapy
B. Transport to hospital via EMS
The child has symptoms of epiglottitis and should be transported immediately for emergency treatment via ambulance. All of the other options may be initiated at the hospital once the diagnosis is more certain. If the possibility of epiglottitis is thought to be remote, a lateral neck radiograph may be obtained prior to visualizing the throat. If epiglottitis is suspected, visualizing the throat is contraindicated.
The most common cause of croup is
Croup is most commonly caused by parainfluenza viruses. It can also be caused by influenza, adenovirus, rhinovirus and other respiratory viruses
Question
The nurse practitioner is seeing a 3-year-old male with a sudden onset of a barking cough last night. He appears well and is in no acute distress. His temperature is 100.5 degrees F, but his vital signs are otherwise normal. He has an occasional cough with mild retractions. His lungs are clear and here is no stridor noted at rest. Treatment for this patient includes
A an inhaled bronchodilator.
B a single dose of dexamethasone
C nebulized epinephrine.
D amoxicillin 80–90 mg/kg/day.
Single dose of dexamethasone
This patient has mild croup. Corticosteroids reduce inflammation and can shorten the duration of and improve symptoms. Bronchodilators are indicated for bronchospasm which this patient does not have. Nebulized epinephrine is used in severe croup. Croup is viral, antibiotics are not warranted.
Question
Which of the following patients should be treated with oseltamivir? Select all that apply.
A A 16-year-old healthy male with influenza symptoms for 36 hours
B A 70-year-old male with heart failure who has a positive influenza test and has been ill for 4 days
C An asymptomatic, immunized 7-month-old infant whose brother was diagnosed with influenza yesterday
D A 25-year-old female in her first trimester of pregnancy with a rapid test that is positive for influenza A
B.C.D.
All patients with high risk for complications should be treated with a neuraminidase inhibitor even if greater than 48 hours from onset of symptoms. This includes heart disease and pregnancy. Chemoprophylaxis should be given to high risk patients if exposed within the past 48 hours, even if they are immunized. Children < 5, especially under 2 are considered high risk. If unvaccinated, patients should also receive the inactivated vaccine. CDC and ACOG recommend treatment during pregnancy and 2 weeks postpartum.
The parent of a toddler and a 4-week-old infant tells the primary care pediatric nurse practitioner that the toddler has just been diagnosed with pertussis. What will the nurse practitioner do to prevent disease transmission to the infant?
A Instruct the parent to limit contact between the toddler and the infant
B Order azithromycin 10 mg/kg/day in a single dose daily for 5 days
C Administer the initial diphtheria, pertussis, and tetanus vaccine
D Prescribe erythromycin 10 mg/kg/dose 4 times daily for 14 days
Order azithromycin 10 mg/kg/day in a single dose daily for 5 days
Chemoprophylaxis for pertussis exposure is recommended for all household and close contacts of infected persons regardless of immunization status. Azithromycin is the drug of choice for infants from 1 month to 6 months of age. Administering the vaccine is not indicated since there isn’t sufficient time to develop immunity. Infants under 1 month of age should not receive erythromycin because of the increased risk for pyloric stenosis associated with this drug.
A 19-year-old patient presents with a cough and fever. The nurse practitioner auscultates rales in both lungs that do not clear with cough. The patient reports having a headache and sore throat prior to the onset of coughing. A chest radiograph shows patchy, nonhomogeneous infiltrates. Based on these findings, which organism is the most likely cause of this patient’s pneumonia?
A A virus
B Mycoplasma
C S. pneumoniae
D Tuberculosis
B. Mycoplasma
Atypical pneumonias, such as those caused by mycoplasma, often present with headache and sore throat and will have larger areas of infiltrate on chest radiograph. Viral pneumonias show more diffuse radiographic findings. S. pneumonia will have high fever and cough and distinct areas of infiltration.
A 35-year-old patient with no past medical history is diagnosed with acute bronchitis. What is the focus for the management of this patient?
A Trimethoprim-sulfamethoxazole therapy
B Azithromycin therapy
C Supportive care
D Short-acting beta agonist
C Supportive Care
The mainstay of treatment in acute bronchitis is directed toward symptom reduction and supportive care. Data suggest that 85% of patients diagnosed with acute bronchitis will improve without specific treatment. Trimethoprim-sulfamethoxazole is prescribed for pertussis when macrolides are not an option. Antibiotic therapy is not effective in treating viral acute bronchitis. SABA’s are not helpful in bronchitis, unless the patient has underlying asthma or bronchospasm.
A 4-year-old child is diagnosed with community-acquired pneumonia and will be treated as an outpatient. Which antibiotic will the primary care pediatric nurse practitioner prescribe?
A Azithromycin
B Amoxicillin
C Ceftriaxone
D Oseltamivir
Amoxicillin
Amoxicillin is given to young children with community-acquired pneumonia. Azithromycin is used to treat atypical pneumonia, which is more common in school age and adolescents. Ceftriaxone is used for inpatient treatment. Oseltamivir is used for viral pneumonia due to influenza.
A patient presenting to primary care with pleuritic chest pain has a Wells score of 1. Based on this score alone, what is an appropriate next step?
A Refer the patient for a chest tomography angiography (CTA)
B Order a D-dimer
C Rule out pulmonary embolism and investigate other causes
D Activate emergency response services to transport the patient to the hospital
B Order a D-dimer
A Wells score of less than 2 indicates low risk or low probability for PE. D-dimer should be performed to rule out a PE and if positive, the patient should then be referred for a CTA. If the d-dimer is negative, PE can be ruled out. CTA should be performed on patient with a high probability. Patients who are clinically unstable should be immediately referred to the emergency department which is not determined by the the Wells score, but by exam findings. Management of patients should not be based on the Wells score alone, but also your clinical judgement.
Exam findings in a patient with a spontaneous pneumothorax include
A pleural friction rub.
B hyper-resonance to percussion
C increased tactile fremitus.
D positive egophany.
B hyper-resonance to percussion
Exam findings with pneumothorax include decreased or absent breath sounds, hyper-resonance to percussion, decreased lung expansion and decreased tactile fremitus. Pleurisy and less commonly pneumonia or PE can cause a friction rub. Positive egophany occurs when there is a consolidation such as pneumonia
Which of the following best describes the symptoms associated with a pulmonary embolism (PE)?
A Increased heart rate and a sharp pleuritic chest pain
B Shortness of breath and stridor
C Burning substernal chest pain and nausea
D Chest tightness radiating into the left arm
A Increased heart rate and a sharp pleuritic chest pain
Symptoms of PE are pleuritic chest pain, tachycardia, cough, shortness of breath, fever, leg pain. Chest burning and nausea is more suggestive of acid reflex. Chest tightness radiating is more suggestive of angina. Shortness of breath and stridor suggest an upper airway etiology
What is included in the initial diagnostic work up for a suspected pneumothorax?
A Chest CT scan
B Chest x-ray
C Needle aspiration test
D Ventilation perfusion scan
B Chest x-ray
What age range is croup common?
What age does croup peak incidence?
6 to 36 months
Peak: 2 years
What is a common cause of croup?
Parainfluenza virus 70% of all cases
others: RSV, flu A, adenovirus, measles, metapneumovirus
Inspiratory stridor is caused by pathology _______ the level of the vocal cords,
while expiratory stridor is caused by pathology _____ the level of the vocal cords
Biphasic stridor is indicative of ____ lesion
Inspiratory stridor is caused by pathology AT or ABOVE the level of the vocal cords (d/t collapse of upper airway soft tissue with negative pressure of inspiration)
while expiratory stridor is caused by pathology BELOW the level of the vocal cords (d/t decreased airway diameter)
Biphasic stridor is indicative of fixed lesion
What is the Westley croup severity scoring system? #5
Level of consciousness:
Cyanosis
Stridor
Air entry
Retractions
What is the score correlation for Westley croup severity score with
Mild
Moderate
Severe
Impending respiratory failure
mild <2
moderate 3 to 7
Severe: 8 to 11
Impending failure >12
What is the description and treatment of mild croup?
- Occasional barky cough
- no stridor at rest
- mild/no retractions
Treatment
- Home: symptom care, antipyretics mist, fluids
- Outpatient: dexamethasone orallly x1
What is the description and treatment for moderate croup?
score 3 to 7
- frequent barky cough
- stridor at rest
- mild-mod retractions
- no/little distress or agitation
Treatment
- Oral dexamethasone x1
- nebulized epinephrine (evaluate 3 hours later)
- F/U in 24 hrs
- hospitalization if tx does not work
What would you expect to be the cause of biphasic stridor?
What test would you order to diagnose this?
Fixed obstruction
Barium swallow
What is the second most common cause of inspiration stridor?
Congenital stridor
Causes include:
- vocal cord paralysis from neuro disease or trauma
- Subglottic hemangioma
What are physical exam findings with the flu?
- Ill appearing
- Erythematous oropharynx
- cough
- LS normal
- could have coexisting PNA, COPD, asthma
NO dyspnea, if seen = complication or covid 19
What flu treatment option should be avoided in asthma patients?
Zanamivir
Who can use Oseltamivir (Tamiflu)
as young as 2 weeks
Active against flu A and B
Who is approved to use Zanamivir (Relenza)?
7+ years old
Inhaled powder
Not for people with underlying airway disease
What would you prescribe for CAP in a person with NO comorbidities or recent use of antimicrobial agents?
Macrolide or Doxycycline
What would you prescribe for a person with CAP WITH comorbidities or recent use of antimicrobial agents?
Respiratory Fluroquinolone (Levofloxacin)
or
Augmentin/high dose amoxicillin AND macrolide
Who are your patients that are high risk for MRSA CAP? 5
How would you treat these patients 3
- antibiotic use last 90 days
- Recent hospitalization
- MRSA isolates >20%
- Active glucocorticoid therapy
- Active Influenza
Treatment
- Vancomycin
- Doxycyline
- Linezolid
What patients are at high risk for Pseudomonas?
How would you treat someone with Pseudomonas aeruginosa CAP? 5
- COPD
- CF
- Bronchiectasis
Treatment
*2 antipseudomonal drugs initiated*
- Pip/Taz
- Cefepime
- Ceftazidime
- Meropenem
- Imipenem/Cilastatin
What is the clinical diagnosis for pneumonia?
What patients should have a CXR?
Clinical diagnosis
- fever
- productive cough
- localized findings on lung auscultation
No CXR needed for patients treated outpatient with no signs of respiratory distress
CXR
- Admitted to hospital to eval infiltrates & effusions
- respiratory distress
What makes bacterial pneumo different than viral pna?
What is most likely bacterial cause of PNA in peds?
Bacterial has…
- sudden onset
- absence of URI symptoms ( ex: conjunctivitis, rhinorrhea)
- Localized findings on auscultation
Cause
- strep pneumo
