Pulmonary

Question 1

Bronchiolitis

Answer 1

• Lower resp track infection, viral, usually rsv or influenza, Starts as URI -> progresses
• CXR: peribronchial thickening, bronchial wall thickening, hyperexpansion, patchy atelectasis
• Supportive care - not recommending using bronchodilators, rac epi or corticosteroids

Question 2

Croup

Answer 2

• Infection of subglottic airway, larynx, trachea, bronchi
• Common causes - para flu t1 and t2
• Mucosal airway edema ->epithelial necrosis -> decreased airway diameter and increased air resistance
• Barky cough, worse at night
• XR: lateral neck film with “steeple sign”***
• Humidified or cool mist, rac epi, heliox
• dexamethasone 0.6mg/kg IV/IM x1*

Question 3

Asthma

Answer 3

• Chronic reversible disorder resulting in inflammation, bronchoconstriction, airway hype-responsiveness
• Triggers: extrinsic (allergic), intrinsic (infection, viral more likely), exercise induced

Question 4

Status asthmaticus

Answer 4

• Progressively worsening bronchospasm/ airway flow obstruction unresponsive to standard therapy
• Cough, esp at night that wakes child up, Pulsus paradoxus (mod/severe) r/t lower airway obstruction, Fever if associated with infectious trigger
• CXR: hyperinflation, flattened diaphragms, peribronchial thickening, narrowed cardiac silhouette -> air-trapping
• **anticipate hypocarbia/ respiratory alkalosis when compensating -> normal or rising CO2 measurement shows unable to compensate
• Mgmnt: supplemental O2, inhaled beta agonists (albuterol, levalbuterol - bronchial smooth muscle relaxation, reduce histamine release), corticosteroids (decrease inflammation), anticholinergic (atrovent - bronchodilation), magnesium sulfate (smooth muscle relaxation … hypotension), heliox (low density gas, facilitates oxygen delivery), invasive ventilation (allow permissive hypercapnia)
• *ketamine for induction –> bronchodilator effects**

Question 5

Pertussis

Answer 5

-Bordatella pertussis - grm neg coccobacillus, toxin mediated disease (paralyzed cilia, causes inflammation), aerosolized droplets, v contagious, high risk when starting vaccinations
-3 stages: catarrhal, paroxysmal (cough at night, paroxysmal coughing spams, young infants present with apnea**), convalescence
-Diagnosis: DFA, PCR, CBC (leukocytosis, lymphocyte predominance)
-ABX: erythromycin (avoid in infants <1mo r/t hypertrophic, pyloric stenosis), clarithromycin, azithromycin ***
Post exposure antimicrobial prophylaxis for all persons within 21d of exposure

Question 6

Epiglottis

Answer 6

• H. Influenzae, staph aureus, strep pneumo
• severe inflammation of epiglottis, may obstruct breathing - sudden onset of symptoms, difficulty swallowing, drooling, dysphasia, tripod position
• XR: enlarged epiglottis and distended hypopharynx “thumbprint sign”**
• Avoid noxious stimuli, humidified O2, IVF, systemic steroids, abx (3rd gen cephalosporin plus vancomycin)

Question 7

Retropharyngeal abscess

Answer 7

• Strep pyogenes, staph aureus, h flu
• follows trauma or infection, ages 1-5yr
• sore throat, fever, dysphagia, trismus, leukocytosis
• CT scan with IV contrast
• surgical drainage, broad spectrum ABX

Question 8

Peritonsillar abscess

Answer 8

• local cellulitis progresses to abscess, older children/adolescents
• strep pyogenes, staph aureus, h flu
• swollen tonsils with uvula deviation (may obstruct airway), leukocytosis, threat culture for group a strep
• CT scan with IV contrast
• surgical drainage, ABX (ampicillin-sulbactam, clindamycin, vancomycin)**

Question 9

Obstructive sleep apnea

Answer 9

• cessation of airflow
• d/t hypertrophy of tonsils +- adenoids, craniofacial abnormalities, neurological abnormalities, decreased muscle tone, genetic disorders
• snoring, restless sleep, morning headaches (from chronic CO2 retention), pulmonary hypertension, cor pulmonale / right sided heart failure
• tx: tonsillectomy, adenoidectomy, cpap, bipap

Question 10

Tracheomalacia

Answer 10

• upper airway lacking cartilaginous rigidity (floppy), associated with feeding problems, expiratory stridor and cough, worse with agitation, harsh and barky cough, decreased symptoms when prone
• direct visualization when awake with flexible bronchoscope for airway collapse
• observation in most cases, resolution before 18months in most cases

Question 11

Acutely respiratory distress syndrome (ARDS)

Answer 11

• injury to alveolar capillary membrane
• stages: exudative (injury to alveolar capillary barrier, increased pulmonary congestion, pulmonary edema, depletion of surfactant), proliferative (healing begins), fibrotic (remodeling, fibrotic scarring) –> leads to pulmonary hypertension, bronchoconstriction, hypovolemia, increased pulmonary vascular resistance
• ABG with PaO2/FiO2 ration <200 (predicts shunt), CXR with bilateral infiltrates
• Mgmnt: supportive care, ventilation (permissive hypercapnia, low tidal volumes, avoid PIP >30)

Question 12

Cystic fibrosis

Answer 12

• autosomal recessive multi system disorder
• abnormal protein impairs movement of salt and water across epithelial walls in exocrine glands–> sticky secretions
• meconium ileus, cholestatic jaundice, nasal polyps, pancreatic insufficiency, chronic metabolic alkalosis
• Mgmnt: airway clearance techniques, high calorie unrestricted fat diet, pancreatic enzymes

Question 13

Pulmonary embolism

Answer 13

• materials traveling in blood stream become lodged in pulmonary artery bed, thromboembolism most common
• decreased perfusion to affected alveolar units distal to emboli -> increased alveolar dead space -> impaired ability to eliminate CO2 -> ventilation/perfusion mismatch
• pleuritic chest pain, sense of doom, elevated d dimers**
• VQ scan, helical CT scan (useful if other lung disease present), evaluate for DVT
• Mgmnt: anticoagulation, thrombolysis, thrombectomy

Question 14

Tracheoesophageal fistula

Answer 14

• congenital or acquired communication between trachea and esophagus
• associated GU defects (horseshoe kidney, polycystic kidney), GI defects (imperforated anus, duodenal atresia, malrotation), MSK defects, VATER syndrome (vertebral/vascular, anal atresia, tracheoesophageal fistula, esophageal atresia, renal or radial anomalies)
• symptoms worse with feeding
• pre-op: reduce risk of aspiration (continuous auctioning and gastric decompression) –> operative repair

Question 15

ABG interpretation

Answer 15

Normal Values

• pH: 7.35-7.45
• CO2: 35-45
• HCO3: 22-26
• PaO2: 80-100

-measurement of oxygenation, ventilation, acid/base status

Question 16

Respiratory acidosis

Answer 16

-CO2 retention: hypoventilation, CNS depression, trauma, COPD

Question 17

Respiratory alkalosis

Answer 17

-excess CO2 loss: hyperventilation, anxiety, pain, fever, excessive ventilatory support

Question 18

Metabolic acidosis

Answer 18

• increased acids: diabetic ketoacidosis, renal failure, lactic acidosis
• loss of base: diarrhea***

Question 19

Metabolic alkalosis

Answer 19

• excess base: excess antacids, citrate in blood transfusions, sodium bicarbonate administration
• loss of acids: vomiting***, NG suctioning

Question 20

Non-invasive ventilation

Answer 20

• positive pressure ventilation increases surface area available to participate in gas exchange, can stent open upper airways
• continuous positive airway pressure (CPAP): one set pressure throughout respiratory cycle
• bilevel positive airway pressure (BiPAP): higher pressure during inspiration, lower pressure in between respirations, keeps lungs open for entire respiratory cycle, can be timed or spontaneous

Question 21

Invasive ventilation

Answer 21

• provide positive pressure and oxygenation, override work of breathing, monitor with capnography
• pressure support only: no rate, two leaves of pressure (one for inspiration and one for end of expiration and in between breaths)
• pressure control pressure support: set pressure with each breath, volume of breath depends of lung compliance
• volume control pressure support: set volume with each breath –> high pressure to achieve set volume indicate poor lung compliance

Question 22

Invasive ventilator adjustments to eliminate more CO2

Answer 22

• increase rate (blow off more CO2)
• increase pressure control (increase size of breath delivered)
• increase tidal volume (increase size of breath delivered)
• decrease inspiratory time (shorter time for inspiration allows more time for expiration)

Question 23

Invasive ventilator adjustments to increase oxygenation

Answer 23

• increase FiO2
• increase positive end expiratory pressure (PEEP)
• increase inspiratory time (increases mean airway pressure)