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92 Cards in this Set

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What percentage of patients with mild asthma will outgrow asthma by adulthood? What about severe asthma?
60% and 30%
True or False.
Asthma is more common in girls than boys.
False. Boys > Girls until puberty when it equalizes.
An asthmatic has symptoms less than twice weekly and night symptoms less than twice monthly. What class of asthma is this? How do you treat?
Mild intermittent. Give bronchodilators alone.
An asthmatic has symptoms more than twice weekly and night symptoms more than twice monthly, but has normal baseline PFTs. What class of asthma is this? How do you treat?
Mild persistent. Give bronchodilators + low dose inhaled steroids. Leukotriene inhibitors are second line.
An asthmatic has symptoms more than twice weekly, but not daily and night symptoms more than twice monthly, but not daily. Baseline PFTs are abnormal. What class of asthma is this? How do you treat?
Moderate persistant. Give low dose steroids and long acting bronchodilator.
True or False.
Atelectasis on x-ray of an asthmatic with acute exacerbation is a sign of pneumonia.
False.
How do you define mild asthma exacerbation? How do you treat?
Peak flow >50% expected. Treat with bronchodilators and po steroids. Discharge from ED. Do not give antibiotics.
When do you give levalbuterol as opposed to albuterol for severe asthma exacerbation?
With severe tachycardia, tremor and irritability.
True or False.
Chest PT and inhaled mucolytics should be included in treatment of severe asthma exacerbation.
False. There is no role for these in routine care of severe asthma exacerbation.
A patient with asthma exacerbation has pCO2 that is normal but the patient can not speak full sentences, and is more sleepy. What does this indicate?
Pt is getting fatigued and this is an ominous sign of CO2 retention. Consider increasing ventilation support with non-rebreather or intubation depending on clinical picture.
A 7yo child is brought in because for the past several nights, she has been having a nighttime cough with whitish mucous production. She has no fever, has been previously healthy and has no known new pets or detergents or allergies. What is her likely diagnosis?
Reactive airway disease
Preschool aged asthmatics may have an acute exacerbation without audible wheezing. How do you make a diagnosis of asthma exacerbation?
They might not move enough air to elicit a wheeze. Rely on history, other parts of exam like retractions and nasal flaring and check cxr.
CXR will show hyperinflation and increased peribronchial markings.
What are 6 non-asthma causes of wheezing?
Drinks (aspiration)
Slings (vascular)
Rings (vascular)
and other Things (Foreign body)
BPD
Bronchiolitis
What percentage of asthmatics have positive immediate type allergy skin tests?
80%
What is the best climate to run outdoors for someone with EIA?
hot and humid.
What are four causes of exercise intolerance other than EIA?
Cardiac disease
Anemia
Muscle weakness
Psychological factors and Poor Shape
A 2yo child is brought in for a respiratory infection that is not clearing. She has a localized wheeze and reduced breath sounds over one lung. Her cxr shows mediastinal shift. What is her likely diagnosis?
Foreign body aspiration.
What are 4 risk factors for persistent asthma?
Onset before age 3
Increased IgE
Maternal history of asthma
Eosinophilia
What percent of infants with severe RSV will develop recurring wheezing?
50%
What is the benefit of steroids in prevention of asthma?
they decrease bronchial inflammation and bronchial hyperresponsiveness.
Unlabored breathing + intermittent non-productive cough + right sided expiratory wheeze = ?. How do you confirm diagnosis and treat?
Foreign body aspiration. Check CXR. Confirm with bronchoscopy which can remove the object as well.
What is pulsus paradoxus?
It is where the difference in blood pressure during inspiration and expiration should not be greater than 10; more than 20 suggests pulmonary or cardiac problems.
What is the first step in assessing respiratory distress?
A) Check ABG
B) Check Respiratory Rate and effort
C) Auscultate
D) check for tachycardia and diaphoresis
B) Look for tachypnea, retractions and inability to speak in early phases, but later, when patient is fatigued, ie in failure, you should look for sweating, anxiety and tachycardia.
True or False.
Pulmonary hypertension compromises the ability to reduce carbon dioxide and results in hypercarbia.
False. It reduces oxygenation and causes hypoxemia
What happens at the kidney level in pulmonary hypertension?
The kidneys "see" hypoxemia, so release erythropoetin and thus increase the HCT. This results in increased headaches, joint pain, clots and PE and thrombocytopenia.
Which of the following result in impaired effectiveness of coughing?
A) Vocal cord dysplasia
B) CNS disease
C) Thoracic deformity
D) CP
E) Muscle Weakness
F) All of the above.
F.
A 4yo presents with chronic cough. What tests should be in the initial screening?
Sweat chloride testing
TB skin testing
CXR.
A 6yo presents with chronic cough sweat testing, TB testing and CXR are all normal. What is your next step?
Spirometry.
A 7yo has a loud barking cough. His mother says it is only in the day. She has had to take him home from school for this on multiple occasions but he doesn't have it at home and he sleeps fine. What is the most likely diagnosis?
Psychogenic cough.
An 8yo has fever, night sweats, weight loss and a dry hacky cough. What should be your screening test other than CXR?
TB skin testing.
BE SURE TO REVIEW FLOW VOLUME LOOPS
BE SURE TO REVIEW FLOW VOLUME LOOPS
Chronic cough
Low albumin
low sodium
FTT
Pseudomonas infections
What is your diagnostic test of choice. What is your diagnosis?
Sweat test. It should be <60 if normal. Otherwise this is CF.
If a sibling of someone with CF marries someone from the general population what are the odds of them having a kid with CF?
The caucasian carrier rate is 1/25.
1. both parents must have been Rr
2. the sibling does not have disease, so the rr possibility is out
3. the sibling is either RR or Rr and has 1/3 chance of RR and 2/3 chance of Rr.
4. So the sibling (carrier) x avg joe (carrier) = kid risk equation is:
2/3 x 1/25 x 1/4 = 2/300 = 1/150
What is the gold standard in testing for CF?
Sweat chloride test?
What is the probability of a sibling of a CF patient being a carrier?
2/3
An infant has hypoproteinemia, steatorrhea, anemia, hypokalemic alkalosis and recurrent pulmonary symptoms. What is your diagnosis?
CF
What is are the major vitamin deficiencies in CF? How do they manifest?
Vitamins ADEK
Vitamin A deficiency: eye problems and neuro problems
Vitamin D: bone and muscle problem
Vitamin E: skin and neuro problem
Vitamin K: prolonged PT
What is the treatment for acute CF exacerbation?
aminoglycosides and penicillin/piperacillin
Which bug is responsible for most CF infections early in life?
S. aureus. Pseudomonas is in older kids.
What is cor pulmonale?
Right heart failure or RVH due to pulmonary hypertension or severe upper airway obstruction.
Lower body edema
S3 gallop
hepatomegaly
clubbing
child does not have congenital heart disease.
What is your diagnosis? Is this reversible?
This is cor pulmonale. It is irreversible if it is from pulmonary hypertension but reversible if it is surgically corrected upper airway obstruction.
An ICU patient admitted with respiratory failure and pneumonia initially had some improvement with antibiotics, but is now declining with fever and increased vent dependance again. What do you expect on CT Chest?
Empyema.
Cyanosis and depressed sensorium is a reflection of ?
A) hypoxia
B)hypercarbia
A
Flushing, agitation, headaches is a reflection of ?
A) hypoxia
B)hypercarbia
B
What is the first step in management of a pneumothorax? Is it different for large tension pneumothoroax?
If small pneumothorax, give oxygen
If large tension pneumothorax, get chest tube STAT
A 3 day old ex 32 weeker is having tachycardia, retractions, tachypnea at rest and has FTT. What is the treatment?
The patient is likely hypoxic and in preemies this is likely due to anemia, so give them a PRBC transfusion.
Name 2 causes of complete obstructive apnea. How do you treat them?
1. Severe subglottic stenosis
2. Vocal cord paralysis.
Require tracheostomy.
What is central apnea?
It is apnea where there is no CNS signal. Give caffeine and put on vent.
A patient is post-op after tonsillectomy and adenoidectomy and is experiencing respiratory distress post-operatively. He has a history of severe obstructive apnea. What is the cause of his current respiratory distress?
A) Pulmonary hemorrhage
B) Pulmonary edema
C) Tension pneumothorax
D) hemothorax
E) mucous plug
B
A patient undergoes thoracentesis for pleural effusion after cardiac surgery. The fluid has electrolytes like that in serum. Triglycerides are >110, lymphs are high and protein is greater than 3. What is this fluid?
Chylothorax. See the triglycerides.
What is the distinguishing character of transudate?
TG is low < 50
What is the treatment for a small pneumothorax?
Oxygen and observation. Do not pick intubation.
What is the treatment of a pneumothorax affecting about 15% lung?
Needle aspiration. Do not pick intubation.
True or False.
The degree of pain does not correlate with the extent of pneumothorax.
True
What are the risk factors for SIDS?
Sleeping on tummy, especially on soft bedding
Sleeping with Mummy
Living in the Slummy (low income)
Smoking
Young parents
Cold weather
What is an ALTE?
Infant stops breathing
Infant becomes cyanotic
Infant is nonresponsive
BUT is resuscitated successfully
A 2 month old suddenly becomes limp, cyanotic and apneic. He is revived with mouth to mouth resuscitation. When he is seen in ER, he is normal. What is your management? What are the four classes of possible underlying problems?
Admit for observation and evaluation.
Neuro
Abuse
Lung infection
Sugar is low
When is the highest risk for SIDS? When is a child at low to no risk for SIDS?
Peak at 3-4 mos. Low at 6 months
What are the two most common causes of extrapulmonary causes of cyanosis?
Right to left shunting
Methhemoglobinemia
A child is brought to ED with smoke inhalation. The pulse ox ready 92% on RA. What is your next step?
Give 100% oxygen and check a blood gas with carboxyhemoglobin.
A child has been brought in from his farm house with confusion, lethargy and cyanotic. He has inconsistent pulse ox readings that are around 85% and when the nurse took his blood, she noted it to be brown like chocolate. What is the likely diagnosis?
Methemoglobinemia
True or False.
Septic shock, hypovolemia, and heart failure are all situations in which pulse ox may not be reliable.
True
What is the best measure of pulmonary function in a newborn?
ABG.
What is the least reliable measure of pulmonary function in a newborn?
CBG
What bugs cause croup?
RSV
Influenzae
Parainfluenzae
A child has cough with inspiratory or biphasic stridor. What is your diagnosis?
Croup
What are the two most common causes of bronchiolitis?
RSV and Paramyxovirus
A 6month old comes to the ED in November. She has rhinorrhea, nasal flaring, retractions, tachypnea and pulse ox is 90% on RA. A blood gas is done with PO2 < 65, PCO2 > 40. What do you expect on her CXR?
She has bronchiolitis. You expect hyperinflation and patchy infiltrates.
A 3 week old presents with staccato cough without fever or wheezing. What is the likely diagnosis?
Chlamydia pneumonia.
How do you prevent spread of RSV?
Hand washing
What is the treatment for RSV?
Cool mist hood, albuterol +/- steroids.
True or False.
All kids with RSV should be hospitalized.
False. If patient's family is reliable and patient has no underlying problems, patient is over 3 months of age, and disease is not severe, may discharge from ED.
A 1yo presents with acute onset of coughing and right sided wheeze. You suspect foreign body aspiration. How do you confirm?
A) CXR
B) Inspiratory and Expiratory film
C) Airway fluroscopy.
D) Chest CT
E) EGD
C. this is the safest and most effective way to confirm foreign body aspiration, especially since you can't get a one year old to do B on command.
True or false
Bronchiectasis has permanent dilatation of a small segment of airway along with inflammation.
True
A 2yo has repeated lower respiratory infections where cough is worse with positioning. What test will reveal the diagnosis? What is the diagnosis?
Chest CT will show bronchiectasis.
An infant has recurrent wheezing that increases with feeding and neck flexion. She has no emesis and no fever. What is her likely diagnosis?
Double aortic arch or external compression on trachea.
True or False.
Most kids with TB are asymptomatic but they do have visible Ghon complex on CXR.
False. They don't normally have this finding on CXR.
How do you treat someone with TB positive skin test but negative disease on CXR?
Isoniazid for 9 months
How do you treat someone with TB positive skin test but negative disease on CXR where you know there is resistance to INH.
Give rifampin for 9 months
A child has low grade fever and cough for one month with rales at the bases and hilar adenopathy on CXR. What is the treatment?
This is active TB. You have two options:
1. Give two months of RIP (rifampin, INH, Pyrazidamide) + 4 months of INH and rifampin
OR
2. 9 months INH with rifampin
What are the extrapulmonary signs of TB?
Meningitis
Adenitis
Pleuritis
Disseminated (Milliary TB)

It's all MAPD out!
How do you treat TB meningitis?
STRIPS for 2 months then RI for 10 more months.
Steroids
TB
Rifampin
INH
Pyrazidamide
What is ARDS?
Acute Respiratory Distress Syndrome
Increased alveolar capillary permeability leads to pulmonary edema and respiratory failure.
What is the first procedure in a child who has just suffered blunt trauma to the chest?
Physical exam. ALWAYS AIRWAY FIRST.
What is the first step in caring for a patient rescued from drowning?
External warming of the head and neck
Do all drown patients require admission?
No. Not if they were submerged < 1 minute with no LOC and no need for resuscitation in the field, the patient can be observed at home.
What determines prognosis in a drowning situation?
Duration of asphyxia. This is the time from submersion to the time adequate respiration was restored.
What are the most likely causes of hemoptysis in kids?
1. Infection
2. CF
3. foreign body.
Which of the following are adequate next steps in management of a child with hemoptysis?
A) CBC
B) Coagulation studies
C) ph of emesis
D) CXR
E) Any of the above.
E.
A patient has pneumonia on x-ray. What is the next best test to confirm the diagnosis?
A) Sputum culture
B) Nasalpharyngeal culture
C) Chest CT
D) Blood Culture
E) None of the above.
D. This is helpful, if positive.
If a child is brought to ED after near-drowning and is hypothermic. How do you warm him?
Extracorporeal head and neck warming.
How do you distinguish laryngomalacea and vocal cord paralysis?
Vocal cord paralysis is not positional whereas laryngomalacea is positional.