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Board Review You take my breath away:

Board Review You take my breath away:. Jillian Parekh, MD February 2, 2010. Asthma – random facts. Mortality of asthma is on the rise Until puberty it is more common in males MDIs (if used properly) are as effective as nebulizers In mild asthma, 60% will outgrow

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Board Review You take my breath away:

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  1. Board ReviewYou take my breath away: Jillian Parekh, MD February 2, 2010

  2. Asthma – random facts • Mortality of asthma is on the rise • Until puberty it is more common in males • MDIs (if used properly) are as effective as nebulizers • In mild asthma, 60% will outgrow • In severe asthma, 30% will outgrow • No evidence for Levalbuterol over Albuterol • 80% asthmatics have immediate type allergy skin tests

  3. An 11 y/o F p/w 6 mos of coughing, wheezing and chest tightness. Usually has these sx 3 times/week during the day, but also wakes up at night once a month with the same sx. Sx have improved when she has used her mom’s beta-2-agonist. Her parents are worried b/c she sometimes has to miss school b/c of her sx. BASED ON FREQUENCY OF SX, BEST CATEGORIZATION OF HER ASTHMA IS: A. Exercise induced asthma B. Mild intermittent asthma C. Mild Persistent asthma D. Moderate persistent asthma E. Severe persistent asthma

  4. Answer: A. Exercise induced asthma B. Mild intermittent asthma C. Mild Persistent asthma D. Moderate persistent asthma E. Severe persistent asthma

  5. Classification • Intermittent: • Symptoms < 2 x / week • Night time symptoms < 2 x / month • Albuterol < 2 x / week • No interference with normal activity • (Lung function > 85%) • Only class you treat with bronchodilators alone

  6. Mild Persistent • General symptoms > 2 x / week • Night time symptoms > 2 x / month • Albuterol use > 2 x / week • Minor limitation in activity • (Lung function >80%) • Low dose ICS OR • Leukotriene inhibitor

  7. Moderate Persistent: • Daily symptoms • Night time symptoms > 1 x / week, but not daily • Albuterol daily • Some limitation in activity • (Lung function 75-80%) • Low dose ICS + LABA / Leukotriene inhibitor • Medium dose ICS

  8. Severe Persistent: • general symptoms throughout the day • night symptoms every night • Albuterol several times/day • Extreme limitation in activity • (Lung function <75%) • Medium dose ICS + LABA / Leukotriene

  9. Exacerbations • Mild: decrease in pulmonary fxn, but > than 50% predicted • Manage with Albuterol • Don’t fall for trap to order abx for asthmatic w/ fever and cough (viral, viral, viral, viral)! • Moderate and Severe: PFT < than 50% of predicted • No role for mucolytics and chest PT as part of routine care for asthma exacerbations

  10. Exercise Induced Asthma • Coughing and wheezing 5 mins after exercising with gradual improvement within 15 mins of rest • Cold, dry air is the worst • Results from poor control and management • Encourage exercise • Other causes of poor exercise tolerance • Cardiac • anemia • Muscle weakness • Poor conditioning

  11. Prognosis • Risk factors for persistent asthma: • Onset before age 3 • IgE elevation • FMH asthma • Peripheral Eosinophilia

  12. A 14 y/o M presents to the ED with a severe asthma exacerbation and resp failure. Despite intubation and aggressive resuscitation, he develops severe acidosis, pulmonary edema and hypoxic encephalopathy. His condition worsens over the next week and the parents decide to withdraw care. OF THE FOLLOWING, THE RISK FACTOR MOST ASSOCIATED WITH FATAL ASTHMA IS: Caucasian Race High SES Poor perception of symptoms Sensitivity to house dust mites Use of daily low-dose inhaled corticosteroids.

  13. Answer: • Caucasian Race • High SES • Poor perception of symptoms • Sensitivity to house dust mites • Use of daily low-dose inhaled corticosteroids

  14. Explanation: • Risk Factors for Asthma Deaths: • H/o sudden severe exacerbations • Prior intubation • Prior PICU admit • 2+ asthma admits in last year • 3+ ED visits in past year • ED or admission in past month • Use of > 2 canisters Albuterol/month • Current use of systemic steroids or recent withdrawal • Difficulty perceiving airflow obstruction and its severity • Co-morbidities that affect cardiopulm systems • Serious psych disease or psychosocial problems • Low SES and urban residence • Illicit drug use

  15. A 2 y/o M is brought to ED with moderate resp distress. He is an ex 25 weeker with h/o BPD. +rhinorrhea and cough x 2 days, this morning he developed rtx and wheezing that was unresponsive to Albuterol. Usual meds are Albuterol and oxygen at 1L/min to keep O2 sat > 93%. HR: 160, RR: 60, O2: 82%. You place him on 100% O2 via non-rebreather mask, and get an ABG: 7.35, PCO2:70, O2: 225, HCO3:35. The nurse then calls you because patient is apneic. OF THE FOLLOWING THE MOST LIKELY EXPLANATION FOR HIS SUDDEN DETORIORATION IS: Acute pulmonary embolus with increased AA gradient Elimination of respiratory drive by correction of chronic hypoxemia Respiratory muscle fatigue due to acute metabolic acidosis Severe bronchospasm with acute respiratory acidosis Spontaneous pneumothorax with acute hypoxemia

  16. Answer: • Acute pulmonary embolus with increased AA gradient • Elimination of respiratory drive by correction of chronic hypoxemia • Respiratory muscle fatigue due to acute metabolic acidosis • Severe bronchospasm with acute respiratory acidosis • Spontaneous pneumothorax with acute hypoxemia

  17. Explanation: • RESPIRATORY DRIVE of many CRF patients is dependent on hypoxemia and correction of hypoxia can lead to respiratory arrest • ABG in chronic resp failure includes a near normal pH, increased PC02, decreased P02 and elevated serum bicarb. Can also have polycythemia and pulm HTN with RVH due to chronic hypoxemia. • CRF patients can benefit from O2 to maintain sats between 90-95% as to limit the consequences of chronic hypoxemia or to treat acute decompensations.

  18. Hypercapnia • Low PCO2 with acute asthma: • Tachypnea • High PCO2 • C02 retention and fatigue = BAD • Signs of hypercapnia: flushing, mental status change, headache, tachycardia

  19. Other causes of wheezing • Aspiration • BPD / CLD • Foreign body Aspiration • Vascular rings/anatomic anomalies • Bronchiolitis

  20. You are seeing a 2 m/o M who has Trisomy 21 for WCC. The boy’s mother expresses concern that the infant has been having “noisy breathing” x 2-3 weeks. No feeding difficulties and is exclusively breast fed. According to mom, the noise, which occurs on inspiration, is louder when the infant is supine and crying. He was born via NSVD, no forceps, Apgars of 8, 9. His vitals are appropriate for age, but you hear an audible noise during inspiration. OF THE FOLLOWING, THE MOST LIKELY EXPLANATION FOR THE INFANT’S RESP SX IS: Laryngomalacia Subglottic tracheal web Tracheomalacia Vascular Ring Vocal Cord paralysis

  21. Answer: • Laryngomalacia • Subglottic tracheal web • Tracheomalacia • Vascular Ring • Vocal Cord paralysis

  22. Explanation: • Disorders at level of and above the vocal cords result in a harsh, inspiratory noise– STRIDOR. • Lesions inferior to the vocal cords usually result in wheezing – high pitched expiratory sound. • Laryngomalacia is most common congenital laryngeal abnormality causing stridor. Usually are symptomatic at 1-2 months. Stridor worsens in supine position and with crying or URI. Usually improves by 2 y/o (severe cases may require surgical correction). • Tracheomalacia presents with wheezing. • Laryngeal web usually presents with stridor at birth (failure of embryonal airway to recanalize). • Vascular ring p/w recurrent wheezing. • Vocal cord paralysis p/w stridor, but also usually associated with weak cry, feeding problems (coughing and choking).

  23. A 2 y/o F has a choking episode in the waiting room of your office while eating peanuts. When you evaluate her she appears well, coughing has resolved, her RR is 24 and her 02 sat is 97%. Her lung exam reveals coarse rhonchi at both lung bases with an end expiratory wheeze in the RML. AP, lateral and decub Xrays appear normal. OF THE FOLLOWING, THE NEXT MOST APPROPRIATE STEP IN THE EVAL OF THIS PATIENT IS: CT of the chest Flexible laryngoscopy Fluoroscopy of the chest No further evaluation Rigid bronchoscopy

  24. Answer: • CT of the chest • Flexible laryngoscopy • Fluoroscopy of the chest • No further evaluation • Rigid bronchoscopy

  25. Explanation: • Whenever FB is certain or high index of suspicion – rigid bronchoscopy should be performed emergently. Serves as diagnosis and treatment. • Toy balloons (gloves) are the objects most commonly involved in fatal childhood FB aspiration. • Most FBs are radiolucent, but initial evaluation should be Xrays. Can show signs of air trapping (unilateral hyperinflation, atelactasis, or mediastinal shift). Will be normal in 27-65%. • Flexible laryngoscopy is not useful b/c a bronchial FB can’t be seen.

  26. Foreign Body • Infants/Toddlers/MR • Infants usually aspirate food • Toddlers usually “objects” • Manifest within 24 hours usually – sudden onset • TRIAD: • Cough (unlabored breathing w/ intermittent non productive cough) • Wheeze (localized and fixed) • Decreased BS

  27. A 2 year old M is brought to your office bc of night time cough. According to mom, several times over the past few months he has awakened with a barking, nonproductive cough that improves by the next morning. She denies fever and rhinorrhea with the episodes. Lungs are normal on exam. OF THE FOLLOWING, THE CLNINCAL FEATURE THAT IS MOST SUGGESTIVE OF SPASMODIC CROUP RATHER THAN RECURRENT LARYNGOTRACHEOBRONCHITIS IN THIS BOY IS: Age of the patient Barking nature of the cough Lack of rhinorrhea and fever Nonproductive nature of the cough Normal findings on PE

  28. Answer: • Age of the patient • Barking nature of the cough • Lack of rhinorrhea and fever • Nonproductive nature of the cough • Normal findings on PE

  29. Explanation: • Croup is the most common cause of acute upper airway obstruction in children. • Spasmodic croup is similar to acute croup in that the cough is often “barking” and nonproductive. Allergic and psychological factors are believed to be primarily responsible for spasmodic croup. Classically, not associated with infectious sx.

  30. Croup • Most common bugs are: • RSV • Influenza • Parainfluenza • Will describe inspiratory stridor or a biphasic stridor.

  31. You are working with a medical student in clinic. His first case is a 4 m/o M who has had 4 days of rhinorrhea, coughing, and tachypnea. On PE: infant is fussy, T: 99.2, HR: 110, RR: 60, 92% on RA. On auscultation, expiratory wheezes are audible in all lung fields. You discuss the DDx and ask the med student what he knows about RSV. • OF THE FOLLOWING, THE MOST ACCURATE STATEMENT REGARDING RSV IS : • Household pets can be colonized with RSV and may act as reservoirs for transmission to family members. • Most chest X-rays of infants hospitalized for RSV bronchiolitis appear normal. • Most infants who develop RSV bronchiolitis require admission. • Recurrent wheezing may occur for several years after mild or severe RSV bronchiolitis. • The initial RSV infection usually occurs in school-age children

  32. Answer: • Household pets can be colonized with RSV and may act as reservoirs for transmission to family members. • Most chest Xrays of infants hospitalized for RSV bronchiolitis appear normal. • Most infants who develop RSV bronchiolitis require admission. • Recurrent wheezing may occur for several years after mild or severe RSV bronchiolitis. • The initial RSV infection usually occurs in school-age children

  33. Explanation: • RSV is the most common pathogen causing lower airway disease in infants and toddlers. • Recurrent wheezing after RSV may occur for months to years in 33%-50% of affected children. Males are at higher risk for recurrent wheezing, or later diagnosis of asthma. • Transmission is via human-human contact. • Chest Xrays are normal in ~10% (peribronchial thickening or interstitial pneumonia) • Most infants can be treated as outpatients. • Initial infection is almost universal by age 2, so primary infection in school-aged children is rare.

  34. Bronchiolitis • Usually between age 2-7 mos (but up to 2 y/o) • Obstruction of the small airways secondary to virus, often RSV (paromyxovirus is 2nd leading cause) • 50% of infants with severe RSV will develop recurrent wheezing • CXR findings are non focal: hyperinflation and patchy infiltrates • Prevention of spread: HAND WASHING (not wearing a mask) • Treatment is symptomatic • Albuterol or prednisone as warranted • Admission criteria: • Reliability of parents • Duration of sx • Underlying medical conditions • Less than 3 mos, low 02 sats, poor feeding, dehydration

  35. Chronic Cough • Initial screen: • Routine CXR • PPD • Sweat test • Cough suppressants in children have no benefit over placebo • Psychogenic cough: loud, brassy barking/honking. Can be produced on command. Disappears during sleep.

  36. During the health supervision visit of a 2 y/o M who is new to your clinic, you note a productive cough that his mother says has been present for several months. His weight is below the 5%. Fine crackles are present in his lungs b/l, he has mild clubbing of the fingers. The remainder of his exam is unremarkable. CXR reveals poorly defined bronchovascular markings and a few cystic spaces b/l. You then order a chest CT, which reveals diffuse bronchiectasis. • OF THE FOLLOWING THE MOST LIKELY DIAGNOSIS IS: • Allergic bronchopulmonary aspergillosis • Cystic Fibrosis • Foreign body aspiration • Mycobacterium tuberculosis infection • Primary ciliary dyskinesia

  37. Answer: • Allergic bronchopulmonary aspergillosis • Cystic Fibrosis • Foreign body aspiration • Mycobacterium tuberculosis infection • Primary ciliary dyskinesia

  38. Explanation: • The most common cause of bronchiectasis in children is cystic fibrosis. • Bronchiectasis is characterized by abnormal dilatation of the bronchi and bronchioles. • In CF, recurrent infections and inflammation cause chronic obstruction and hypertrophy of the wall of the bronchi. • Changes in the bronchial tree are irreversible.

  39. Cystic Fibrosis • Sweat test is gold standard: 60 mEq or greater is diagnostic • Often see low albumin/sodium, FTT and pseudomonas infxn • AR genetics (carriers show no signs) • Treat flares with Aminoglycoside + Piperacillin (pseudomonas) • Staph infxn early in life • Pseudomonas later in life • Carrier rate is 1/25 (know this) • Like to ask “what are the odds”…Go to p. 411.

  40. CF in infancy • In infants: GI sx > Resp sx • Vit E defcy hemolytic anemia • Vit K defcy  prolonged prothrombin time • Anemia • Hypoproteinemia • Steatorrhea • Recurrent pulmonary sx

  41. Tuberculosis • Most children will be asymptomatic • + PPD, - CXR = LTBI • INH x 9 months • Rifampin x 9 months (if resistant) • + PPD, + CXR = Active disease • Most common CXR finding: hilar adenopathy • 2 months of RIP THEN • 4 months of INH + Rifampin OR • 9 months of INH + Rifampin • Extrapulmonary TB: • Meningitis – treat with RIP + streptomycin x 2 mos, then 10 mos of RI, steroids used too. • Adenitis • Pleuritis • Disseminated (Miliary Disease)

  42. ALTE • A = • APPARENT • Ceases to breathe • Cyanosis or pallor • Becomes unresponsive • Ressucitated successfully • Admit for observation (based on hx, physical will be normal) • Remember NALS • Neuro • Abuse/Trauma • Lung (infxn, aspiration, apnea, GER) • Sugar (hypoglycemia, metabolic)

  43. SIDS • Risk factors: • Sleeping on tummy • Co-sleeping • Low SES • Smoking • Cold Weather (bundling?) • Young parents • Risk for SIDS peaks at 2-3 mos, decreases after 6 months.

  44. An infant who was born at 26 weeks gestation, weighing 700 grams, is nearing 37 weeks corrected age. He is receiving nasal cannula oxygen (0.2 L /min) and being treated with diuretics for CLD. He has no intracranial hemorrhage and is growing well on enteral feedings via a NG tube. Attempts at oral feeding have been unsuccessful because of frequent oxygen desaturation, bradycardia, and concerns over the inability to coordinate sucking-swallowing. The mother asks why you are continuing to feed her son via a feeding tube. • OF THE FOLLOWING, THE CONDITION THAT BEST EXPLAINS WHY HER SON HAS A FEEDING PROBLEM IS: • Apnea of prematurity • Chronic Lung Disease • Gastroesophageal reflux • Necrotizing enterocolitis • Tracheoesophageal fistula

  45. Answer: • Apnea of prematurity • Chronic Lung Disease • Gastroesophageal reflux • Necrotizing enterocolitis • Tracheoesophageal fistula

  46. Explanation: • Infant described has problems coordinating breathing with sucking and swallowing. • No apnea of prematurity described. • GER usually occurs after a feeding, not during it. • NEC would show more decompensation with acute abdomen. • TEF is associated with resp distress and secretion control problems in between feeds.

  47. Neonatal Pulmonary • Central Apnea • No respiratory effort bc no signal from CNS • Obstructive Apnea • Upper airway occlusion stops airflow • Periodic Breathing • < 20 seconds, no associated brady or cyanosis • Remember association b/w anemia and apnea of prematurity

  48. A 4 y/o child who was struck by a car is unconscious and has a shallow respiratory rate of 6 breaths/min on arrival at the ED. You begin BVM ventilation and prepare to intubate the child. The respiratory therapist asks you what size ET tube you would like. • OF THE FOLLOWING, THE CORRECT ET TUBE IS: • 4.5 mm cuffed • 5.0 mm cuffed • 5.5 mm cuffed • 5.0 mm uncuffed • 5.5 mm uncuffed

  49. Answer: • 4.5 mm cuffed • 5.0 mm cuffed • 5.5 mm cuffed • 5.0 mm uncuffed • 5.5 mm uncuffed

  50. Explanation: • Estimate of ETT size: • Diameter of child’s 5th finger • Age/4 + 4 = uncuffed size • Age/4 + 3 = cuffed size • Usually should prepare ETTs one size larger and one size smaller, as above are only estimations. • Cuffed tubes tend not to be used b/c of concern for high cuff pressure causing ischemic tracheal necrosis. • For inpatients with monitored use – cuffed tubes are safe and sometimes necessary to prevent air leak.

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