Pulmonary

Question 0

Examples of obstructive versus restrictive defects?

Answer 0

Asthma, bronchiolitis, foreign body aspiration

Pulmonary edema, scoliosis, pulmonary fibrosis, respiratory muscle weakness

Question 1

Bronchial tree develops when? Sufficient air sacs/vasculature for viability when? Alveoli increase in number until?

Answer 1

16 weeks; 27 weeks; eight years

Question 2

Differential for inspiratory strider?

Expiratory wheezing?

Crackles/rales?

Answer 2

Extrathoracic obstruction – croup, laryngomalacia

Intrathoracic obstruction – asthma, bronchiolitis

Parenchymal disease – pneumonia, pulmonary edema

Question 3

Epiglottitis – Ddx? causes? Features? Laboratory studies? Radiographic findings?

Answer 3

Croup, bacterial tracheitis, retropharyngeal abscess

H. influenzae type B, GABHS

1. Rapidly progressive airway obstruction without prodrome
2. Muffled speech, drooling

Leukocytosis with a left shift and positive blood culture

Thumb sign

Question 4

Supraglottic versus subglottic disorders – examples?

1. Strider?
2. Cough?
3. Voice?
4. Drooling?
5. Fever?
6. Toxicity?
7. Posture?

Answer 4

Epiglottitis, retropharyngeal abscess versus tracheitis, croup

1. Quiet versus loud
2. None versus Barky
3. Muffled versus hoarse
4. Yes versus no
5. High versus low/high
6. Yes versus no (unless tracheitis)
7. Tripod versus normal

Question 5

Epiglottitis secondary to H. influenzae – prophylaxis for who? Drugs?

Answer 5

Rifampin for unimmunized children under four

Question 6

Viral croup – causes? Non-viral cause? Clinical features? Radiologic findings? Management?

Answer 6

Parainfluenza, RSV, adenovirus, influenza; Mycoplasma

1. Prodrome
2. Inspiratory Strider, barky cough, horse voice

Steeple sign (subglottic narrowing) on x-ray

1. Cool mist/food
2. Corticosteroids if stridor at rest
3. Racemic epinephrine if respiratory distress
4. Beta agonist if wheezing

Question 7

Spasmodic croup – cause? Symptoms? Management?

Answer 7

Hypersensitivity reaction

1. Stridor at night
2. Recurrs and resolves without treatment
3. Cool mist/food
4. Corticosteroids if stridor at rest
5. Racemic epinephrine if respiratory distress
6. Beta agonist if wheezing

Question 8

Bacterial tracheitis – causes? Clinical features? Management?

Answer 8

Staph aureus, streptococcus, nontypeable H. influenzae

Abrupt onset with high fever, toxicity, and pus in the trachea

Anti-staphylococcal antibiotics

Question 9

Bronchiolitis – age of typical patient? Causes? Clinical features? CXR? Management?

Answer 9

Children under two

RSV >parainfluenza, adenovirus, rhinovirus, influenza, Mycoplasma

1. Gradual onset with URI symptoms
2. Progression to tachypnea, Respiratory distress, apnea, hepatosplenomegaly

CXR shows hyperinflation with air trapping, patchy infiltrates, atelectasis

1. Primarily supportive
2. Nebulized bronchodilators, steroids, racemic epinephrine
3. Aerosolized ribavirin
4. Palivizumab - RSV monoclonal antibody

Question 10

Causes of pneumonia: 
Most common in all age groups?
1. 0 to 3 months
2. Three months to five years
3. 6+ years

Answer 10

Viruses

1. Congenital infections, postpartum infections (respiratory viruses), afebrile pneumonitis
2. Viruses, strep pneumonia/staph aureus/HIB
3. Mycoplasma, chlamydia, viruses and bacteria

Question 11

Diagnosis of viral pneumonia?

Answer 11

Interstitial infiltrates on chest x-ray and WBC >20 with lymphocytic predominance

Question 12

Common cause of afebrile pneumonia at 1 to 3 months? Clinical features? Management?

Answer 12

Chlamydia

Staccato type cough, eosinophilia

Erythromycin, azithromycin

Question 13

Causes of recurrent pulmonary infiltrates in single lobe of lung?

Answer 13

1. Intraluminal obstruction – foreign body, tumor, mucous plug
2. Extraluminal obstruction – lymph node, malignancy
3. Structural abnormalities – bronchial stenosis, bronchiectasis, congenital abnormalities,

Question 14

Causes of recurrent pulmonary infiltrates in multiple lobes?

Answer 14

1. Aspiration
2. Mucociliary clearance dysfunction – CF, Kartagener’s
3. Bronchopulmonary dysplasia – chronic lung disease
4. Asthma
5. Immunodeficiency
6. Misc - Congenital heart disease, alpha-1-antitrypsin deficiency, sickle cell, hypersensitivity pneumonitis

Question 15

Stages of pertussis?

Answer 15

1. Catarrhal – URI symptoms
2. Paroxysmal – forceful cough with inspiratory whoop (And possible post-tested vomiting)
3. Convalescent – Recovery stage, where paroxysmal cough slowly improves

Question 16

Characteristics findings in pertussis? Diagnosis?

Answer 16

1. Whooping cough
2. Lymphocytosis

Culture/direct fluorescent antibody test

Question 17

Chest x-ray findings of asthma?

Answer 17

1. Hyperinflation
2. Peribronchial thickening
3. Patchy atelectasis

Question 18

Wheezing – differential?

Answer 18

1. Asthma
2. Hypersensitivity reaction
3. Bronchiolitis
4. Pneumonia
5. Aspiration
6. Environmental irritants

Question 19

Theophylline – drug class? Why not used anymore?

Answer 19

Methylxanthine; narrow toxic-therapeutic ratio

Question 20

Classic hallmarks of cystic fibrosis? Structural abnormality? Sinopulmonary infections – bugs?
Finding at birth?
Nutritional deficiency?
Acid/base status?

Answer 20

1. Lungs - Chronic progressive pulmonary insufficiency
2. Pancreas - Pancreatic insufficiency
3. Skin - High sweat electrolytes

Also see:

1. Chronic sinopulmonary disease – nasal polyps, staph aureus/pseudomonas infection
2. G.I. – meconium ileus, pancreatic insufficiency, chronic hepatic disease
3. Nutritional – fat-soluble vitamin deficiencies (decreased pancreatic enzymes)
4. Metabolic – hypoNa/Cl/K metabolic alkalosis

Question 21

Diagnosis of cystic fibrosis?

Answer 21

1. Laboratory evidence – sweat chlorine over 60 OR two CF mutations OR ion transport abnormality across nasal epithelium
2. One or more phenotypic features OR +family hx OR Immunoreactive trypsinogen on newborn screen

Question 22

Chronic lung disease – definition? Commonly occurs in? Causes? Clinical features? ABG findings?Chest x-ray? Management?

Answer 22

Oxygen dependency beyond 28 days of life

Children with hyaline membrane disease or surfactant deficiency syndrome

1. Acute injury – meconium aspiration, infection, mechanical ventilation
2. Oxidants or proteases
3. Abnormally healed lung – fibrosis

Low PaO2, high PaCO2

CXR – hyperinflation, atelectasis, cystic radiodensity

Supplemental oxygen, bronchodilators/diuretics, immunization,

Question 23

Apnea of infancy/prematurity? Periodic breathing?

ALTE?

Answer 23

Cessation of breathing for more than 20 seconds

Breathing pattern with 3+ respiratory pauses lasting over 3 seconds each with less than 20 seconds of normal respiration in between

Apnea, color change, choking, gagging – recovery only with resuscitation

Question 24

Risk factors – SIDS?

Answer 24

1. Belly sleeping 2. Soft bedding, over bundling 3. Prematurity 4. Lack of breast-feeding 5. Maternal smoking, drug