1
Q
What is CF (genetics, mechanism, clinical features)?
How do you diagnose it?
Management?
A
Genetics: gene that codes for the CFTR protein (majority are ΔF508) Inheritance: Autosomal Recessive
- Mechanism:
- CFTR dysfunction = ↓Cl secretion and ↑Na absorption → dehydrated/viscous mucus
- Clinical Features (I’m CF Pancreas)
- Infertility
- Meconium ileus
- Cough
- Failure to thrive
- Pancreatic insufficiency
- Asthma (refractory)
- Nasal polyps
- Clubbing
- Rectal prolapse
- Electrolyte abnormalities (metabolic alkalosis, ↓Na, ↓Cl, ↓K)
- Atypical organisms from sputum
- Sludge (cholelithiasis/cystitis, pancreatitis, sinusitis)
- Respiratory*: bronchiectasis, pneumothorax, respiratory failure
- Gastrointestional*: DIOS, intussusception, biliary cirrhosis, hepatic steatosis, GERD, inguinal hernia, steatorrhea, fat-soluble vitamin deficiency (A, D, E, K)
Delayed puberty, hypertrophic osteoarthropathy/arthritis, amyloidosis, aquagenic palmoplantar keratoderma (skin wrinkling), hypoproteinemia
Diagnosis:
- Requires either (1 of):
- Clinical features
- Sibling with CF
- positive NBS
- AND (1 of):
- Elevated sweat chloride
- Abnormal nasal potential difference
- Identification of 2 disease-causing CF mutations
Management:
- Suppressive antibiotic therapy
- Mucociliary clearance (chest PT)
- Inhaled mucolytics (DNase if >6yo)
- Bronchodilators
- Inhaled 3%NaCl
- Antiinflammatory: NSAIDs and macrolides (3x/wk)
- Nutrition: enzyme replacement, vitamin supplements, high-fat, high protein diet, MCTs added
- Insulin PRN
- Ursodiol to prevent/treat liver disease
- CFTR modulators
- Lung transplant
2
Q
List 2 features that would make you concerned for a diagnosis of Primary Ciliary Dyskinesia.
What is the diagnostic test for PCD?
A
Having ≥2 of the following should prompt investigations for PCD:
- Unexplained neonatal respiratory distress in a term infant
- Year-round daily cough starting <6mo
- Year-round daily nasal congestion starting <6mo
- Organ laterality defect
Diagnostic test:
- Electron microscopy of ciliary ultrastructure → Recognized ciliary ultrastructural defect
- Genetic testing → biallellic pathogenic variants in PCD-associated gene
- Contributory: Nasal nitric oxide measurement (must be available in centre, cooperative patient ≥5yo [capable of performing maneuver] and if CF is excluded) → Low nNo level
3
Q
Define Asthma
A
Asthma is:
- paroxysmal or persistent symptoms (SOB, chest tightness, wheeze, sputum production and cough) associated with variable airflow limitation and airway hyperresponsiveness (endo/exogenous stimuli)
- Inflammation and it’s effects on airway structure are the mechanisms for development and persistence of asthma.
4
Q
List 5 alternative diagnoses to a child you suspect has asthma.
A
- Cystic fibrosis
- Foreign body aspiration
- Chronic aspiration
- Primary Ciliary Dyskinesia
- Infectious adenopathy (TB, fungal)
- Pulmonary infections (viral bronchiolitis, pneumonia)
- CLD of prematurity
- Rare interstitial lung disease
- Congestive Heart Failure (CHF)
- GERD
- Allergic reaction
- Large airway obstruction
- Extrinsic - tumour (mediastinal mass), vascular ring
- Intrinsic - laryngeal web, tracheoesophageal fistula (TEF)
- Wall abnormality - CNS disorder
5
Q
List 5 indications of asthma control in school-aged children
Describe the differences in monitoring control for “preschool” children (1-5yo)
A
- Daytime symptoms <4 days/week
- Nighttime symptoms <1 night/week
- Normal physical activity
- Mild, infrequent exacerbations
- No absence from school/work
- Requiring <4 doses/week of SABA (no longer excludes pre-exercise beta-agonist use)
- FEV1 or PEF is ≥90% personal best
Differences
- Persistent symptoms:
- Daytime symptoms ≥8 days/month
- SABA use ≥8 days/month
- ≥1 night awakening due to symptoms/month
- Severe exacerbations (requiring rescue corticosteroids or hospital admission
Same
- Absence from usual activities due to asthma symptoms
- No exercise limitation
6
Q
What is your initial management for a preschool child (1-5yo)?
Describe the progression for escalation of management.
A
Initial
- Start management if:
- No red flags for alternative diagnosis AND
- ≥1 document asthma-like exacerbation OR
- ≥2 episodes asthma-like symptoms AND no documented signs of obstruction or improvement to therapy
- Asthma education (environmental control + action plan)
- Current signs of obstruction (wheeze, initial ↓AEBB→↑RR→ prolonged expiration→accessory muscle use→hypoxemia →altered LOC)
- Mild intermittent symptoms
- SABA PRN
- Persistent symptoms OR moderate/severe exacerbations (hospital or requiring corticosteroids)
- Low-dose ICS + SABA PRN
- Mild intermittent symptoms
- No signs of obstruction
- Monitor and reassess when symptomatic
- +/- SABA PRN x 3mos,
- If documented signs of airflow obstruction AND convincing response to SABA = ASTHMA
- If unclear, stop trial, if deterioration = ASTHMA
- +/- SABA PRN x 3mos,
- Monitor and reassess when symptomatic
- If frequent symptoms OR ≥1 moderate/severe exacerbation
- MEDIUM dose ICS x 3 mos + R/A at 6wks AND 3 mos, if clear improvement = ASTHMA
- If unclear improvement, stop challenge - if deteriorates = ASTHMA
- MEDIUM dose ICS x 3 mos + R/A at 6wks AND 3 mos, if clear improvement = ASTHMA
GET INFLUENZA VACCINATION
Escalation
If initially mild → low dose ICS → Medium dose ICS → asthma specialist (add LABA/LTRA)
7
Q
How do you diagnose asthma in preschoolers (1-5yo) vs school-aged children/teenagers?
A
Preschool
- Documentation of signs/symptoms of airflow obstruction
- Reversibility of obstruction (improvement of these symptoms with asthma therapy [SABA +/-)
- No clinical suspicion of an alternative diagnosis
Recurrent (≥2) asthma-like exacerbations
School-aged/Teens
- Clinical symptoms + Objective evidence (below)
- Spirometry: obstruction (↓FEV1/FVC) + bronchodilator response (↑FEV1 by ≥12%)
- Peak flow: ↑≥20% following SABA
- Methacholine
- +ve = <4mg/mL
- Borderline = 4-16mg/mL
- Negative = >16mg/mL
8
Q
List 3 reasons for referring a preschool (1-5yo) asthmatic to a respirologist or specialist
A
- Diagnostic uncertainty or suspicion of comorbidity
- ≥2 exacerbations needing rescue PO CS or hospitalization or frequent symptoms (≥8 days/month) despite moderate (200 -250µg) daily doses ICS
- Life-threatening event (ICU admission)
- Need for allergy testing
- Other considerations
- Parental anxiety
- Need for Reassurance
- Additional education
9
Q
What is the most frequent cause of Recurrent Cough?
A
Recurrent URTIs with postnasal drip
10
Q
List 4 causes of stridor
A
- Infection*: Tracheitis, croup
- Intrinsic:* Laryngomalacia, Tracheal Stenosis
- Extrinsic:* Vascular Ring, Tumour
Other: Foreign body
11
Q
What type of spacer is indicated for 1-3yo, 4-5yo
A
12
Q
Describe the pyramidal progression of asthma management for school aged children.
A
- Confirm diagnosis
- Environmental Controls, Education and Written Action Plan
6-11yo: SABA PRN→Low ICS→↑Med ICS→add LABA/LTRA
≥12yo: SARA PRN→Low ICS→add LABA →Add LTRA→Med ICS +LTRA+LABA
13
Q
What are indications that a child may have asthma later in life?
A
Modified Asthma Predictive Index (mAPI)
- For patients ≤3yo
- MUST HAVE
- ≥3 episodes of wheezing/year
- 1 MAJOR or 2 MINOR criteria
MAJOR
- Parental Asthma (dx by MD)
- Eczema (dx by MD at 2 or 3)
MINOR
- Allergic rhinitis (dx by MD at 2 or 3)
- Wheezing apart from colds
- Eosinophilia (≥4%)
14
Q
What are the most common organisms seen in a baby, toddler and school-aged child with cystic fibrosis?
A
Baby: Staphylococcus aureus
Toddler: Haemophilus influenzae
School-aged child: Pseudomonas aeruginosa, Klebsiella pneumoniae, Stenotrophomonas maltophilia, Burkholderia cepacia
15
Q
How can parents minimize transmission of RV to their infants?
A
- Hand hygiene
- Avoid contact of high-risk children with people with respiratory tract infections
- Breastfeeding
- Avoidance of cigarette smoke
16
Q
What are the indications for RSV prophylaxis?
A
<6mo at start of season
- <30wks GA WITHOUT CLD
- <36wks GA in remote communities
- Term Inuit infants living in communities with documented persistent high rates of RSV hospitalization
<12mo at start of season
- HD-significant CHD or CLD (need for O2 at 36wks GA)
- Consider for those <24mo on home O2, severely immunocompromised or prolonged hospitalization for severe pulmonary disease
If they get an RSV infection, stop the immunizations.
If being discharged home for first time during RSV season, give first dose before discharge.
17
Q
What are 2 risk factors for severe RSV?
A
18
Q
Describe features of vocal cord dysfunction
A
Intermittent stridor (with wheezing) that accompanies physical activity and is not responsive to asthma therapies.
Investigated with laryngoscopy during exercise challenge test if symptoms are successfully elicited. (would cause a truncated loop on spirometry)
Management: SLP and behaviour modification can be therapeutic
19
Q
List 4 indications for hospitalization of a child with RSV infection
A
- Risk for progression to severe disease
- Respiratory status - tachypnea (RR>70), ↑WOB, O2 required, cyanosis or history of apnea
- Ability to maintain adequate hydration
- Family’s ability to cope at home
- Infant at risk of severe disease
- Prematurity <35wks
- Age <3mo
- HD-CHD
- Immunodeficiency
20
Q
List 2 indications for discharge from hospital with bronchiolitis.
A
- Improvement of breathing and tachypnea
- Maintaining SpO2 >90% without O2 or stable for home oxygen therapy
- Adequate PO feeding
- Education provided and appropriate follow-up arranged
21
Q
What 2 treatments for bronchiolitis are recommended by CPS?
Which have equivocal evidence?
What treatments should be considered if there is no improvement?
A
Recommended: Hydration, oxygen
Equivocal: Epi nebs, nasal suctiniong, combined Epi/dex
No improvement: humidified, heated, high-flow nasal oxygen (HHHFN), nebulized epinephrine
If high-risk in acute phase of illness, place continuous SpO2 on. Low-risk children to have intermittent monitoring or spot checks.
22
Q
When is a CXR indicated with bronchiolitis?
A
- Diagnosis of bronchiolitis is unclear
- Rate of improvement is not as expected
- Severity of disease raises other diagnostic possibilities, such as pneumonia
23
Q
A
24
Q
In a pleural effusion, what 3 findings are expected in an empyema
A
LIGHT’S CRITERIA
Transudate (pleural fluid) - MUST FULFILL ALL CRITERIA
- Serum Protein <0.5
- Serum LDH <0.6
- Pleural fluid LDH <2/3 ULN
Exudate - MUST FULFILL ≥1 CRITERIA
- Serum Protein ≥0.5
- Serum LDH ≥0.6
- Pleural fluid LDH >2/3 ULN
25
What are the most common triggers of an asthma exacerbation in the paediatric population?
Viral respiratory tract infections
Exposures to allergens
Suboptimal control of asthma as a baseline
26
Describe the objectives of management of an asthma exacerbation in the ED
1. Immediate and objective assessment of severity → PRAM
* SpO2
* Risk of ICU/death
* Spirometry [if able]
2. Prompt and effective medical intervention to decrease respiratory distress and improve oxygenation
* Supplemental O2
* SABA MDI w/spacer *[\<20kg: 5 puffs; \>20kg: 10 puffs; nebs 5mg in 2mL NS x 3; continuous 0.3mg/kg/h in 4mL NS]*
* SE: ↑HR, ↑glucose, ↓K; if continuous, arrhythmia
* Inhaled anticholinergic *(ipratropium bromide-Atrovent) [\<20kg: 3 puffs/neb 0.25mg; \>20kg: 6 puffs/neb 0.5mg]*
* Corticosteroids
3. Assess treatment response
* If poor:
* MgSO4 (25-50mg/kg [max 2g]IV over 20min
* SE: ↓BP
* Heliox
* Intubate
* ICU: IV aminophylline
* Consider other modalities of treatment→anaphylaxis
4. Appropriate disposition after ED management
5. Arrange proper follow-up
* Corticosteroids x 3-5 days
* Review ICS dosing and adjust PRN, start if not taking
* SABA q4h until resolved → PRN
* Give written asthma action plan
* Review techniques of spacer maintenance and use
* F/U PCP, asthma clinic within 2-4 weeks
* If ICU → asthma specialist (allergist or respirologist)
27
List 2 risk factors for ICU admission/death in an asthmatic patient
1. Previous life-threatening events
2. Admissions to ICU
3. Intubation
4. Deterioration while already on systemic steroids
28
List 2 indications for admission to hospital in an asthma exacerbation.
List 2 indications for discharge for this patient.
**Admission**
1. Ongoing supplemental O2 requirement
2. Persistently ↑WOB
3. SABA needed \>q4h after 4-8h treatment
4. Deterioration on systemic steroids
5. Distance from home, comorbid conditions (anaphylaxis)
**Discharged**
1. SABA PRN
2. SpO2 of 94% on RA
3. Minimal or no signs of respiratory distress
4. Improved air entry
29
List 5 conditions associated with false-positive sweat chloride results.
List 3 conditions associated with false-negative sweat chloride results
**False-positive**
* Eczema (atopic dermatitis)
* Ectodermal dysplasia
* Anorexia nervosa
* Malnutrition/FTT/deprivation
* CAH
* G6PD
* Hypothyroidism
* Klinefelter
* Adrenal insufficiency
* Nephrogenic DI
**False-Negative**
* Dilution
* Malnutrition
* Edema
* Insufficient sweat quanitity
* Hyponatremia
* CFTR mutation with preserved sweat duct function
30
List 3 genetic disorders or syndromes associated with Obstructive Sleep Apnea
List 5 medical conditions that can be associated with OSA.
1. Midface hypoplasia (Trisomy 21, Crouzon, Apert syndrome)
2. Mandibular hypoplasia (Treacher Collins, Cornelia de Lange syndrome)
3. Achondroplasia
4. MPSI/II
**MEDICAL CONDITIONS**
1. Upper airway obstruction (chronic allergic rhinitis, GERD with pharyngeal reactive edema, nasal septal deviation)
2. Reduced upper airway tone (muscular dystrophy, hypotonic cerebral palsy, hypothyroidism)
3. Reduced central ventilatory drive (Chiari malformation, rapid-onset obesity with hypothalamic dysfunction/autonomic dysregulation)
4. Meningomyelocele
5. Obesity
31
List 5 daytime symptoms of OSA.
1. Morning headaches
2. Secondary enuresis
3. Daytime somnolence + difficulty with morning waking
4. Mood changes (depression, anxiety, irritability,)
5. Behavioural issues (increased somatic complaints, aggression, impulsivity, hyperactivity, oppositional and conduct problems)
6. Mouth breathing and dry mouth
7. Difficulty swallowing
8. Poor appetite
9. Hyponasal speech
10. Chronic nasal congestion or rhinorrhea
32
What is the gold standard test for diagnosis of OSA.
If not available, describe alternative testing options.
What is the AHI cutoff value for OSA (children/adolescent)?
Overnight Polysomnogram
**ALTERNATIVE TESTING**
* Nocturnal oximetry
**AHI CUT OFF**
* Children ≤12: AHI ≥1.5
* Adolescents \>12: AHI ≥5
33
Describe the options for management of OSA.
1st line: tonsillectomy
* if contraindicated: nasal CS
If overweight/obese: weight loss
If ongoing symptoms after T&A: CPAP
Other:
* Positional therapy (attach firm object [tennis ball] to back of sleep garment to prevent sleeping in supine position
* Aggressive treatment of risk factors: GERD, allergies, asthma
* LTRAs if upper airway inflammation present
34
Identify this abnormality
**CPAM (Congenital pulmonary airway malformation)**
## Footnote
Previously called CCAM (congenital cystic adenomatoid malformation)
Management: resection if symptomatic, mass effect, infection or concern of malignant potential
35
Identify this abnormality
**Congenital lobar emphysema**
## Footnote
Affects upper\>lower
Caused by intrinsic or extrinsic obstruction to lobar bronchus
Management: clinical observation with serial XRs
if any kind of compression, infections or wheezing it may be resected
36
Identify this abnormality
**Pulmonary sequestration**
## Footnote
Can be associated with CHF, recurrent infections
Aberrant arterial supply.
No communication with functional airways
Extralobar sequestrations are associated with CDH
**Need CTA to diagnose** - CT without contrast not helpful
Management: if frequent infections - require resection after adequate Abx, all should be resected once identified
37
What are 4 long-term consequences of OSA?
1. Cor pulmonale
2. Neurocognitive impairment
3. Behavioural problems
4. Failure to Thrive
38
What are the first choice antimicrobials for a CF exacerbation in a teenager?
Tobramycin
Ceftazidime
39
You are seeing a teenager with cystic fibrosis. He’s been complaining of worsening cough, chest pain, and increased sputum production. His IgE is noted to be elevated with increased eosinophils on differential.
What is the most likely diagnosis?
What is your treatment?
**ABPA (allergic bronchopulmonary aspergillosis)**
## Footnote
Extended course of systemic corticosteroids
Oral antifungal agents (itraconazole or voriconzole)
40
What 4 things in the medical history of an asthmatic put them at increased risk for anesthetic?
1. Hospital admission within the previous year
2. ED care in the past 6 months
3. Previous ICU admission
4. Previous IV systemic corticosteroids
41
What are 3 conditions that predispose causes of bronchiectasis?
1. Cystic fibrosis
2. Primary Ciliary Dyskinesia
3. ABPA (allergic bronchopulmonary aspergillosis)
4. Recurrent pneumonia
5. Bronchiolitis obliterans
6. Immunodeficiency (HIV, hypogammaglobulinemia, CVID)
42
What is the most common cause of uncomplicated bacterial pneumonia?
What is the most common cause of an empyema? What other pathogens are commonly seen?
*Streptococcus pneumoniae* (for both)
Empyema (other pathogens): *Staph aureus, GAS*
43
List 3 physical examination findings seen with pneumonic consolidation
1. Dullness to percussion
2. Increased tactile fremitus
3. Reduced normal vesicular breath sounds
4. Increased bronchial breath sounds
44
List 3 indications for hospitalization with pneumonia
1. Inadequate oral intake
2. Intolerant to oral therapy
3. Severe illness or respiratory compromise
4. Complicated pneumonia
5. \<6mo
45
**Describe the recommended antimicrobials for uncomplicated pneumonia in the following scenarios:**
* Stable (outpatient/hospital)
* Unstable
* Presence of multilobar disease or pneumatocele
**What is the recommended duration of management in the following scenarios?:**
* Outpatient
* Hospitalized
* Empyema
**Stable**:
* *Outpatient:* Amoxicillin 40-90mg/kg/day divided TID **x 5 days**
* *Hospital:* Ampicillin 200mg/kg/day divided q6h **x 7-10 days**
**Unstable:** 3rd gen cephalosporin (Ceftriaxone or Cefotaxime) *better H influenzae coverage and high-level PCN-resistant pneumococcus*
**Multilobar disease/pneumatocele**: 3rd gen cephalosporin (Ceftriaxone or Cefotaxime) AND Vancomycin
**Empyema =** 2-4 weeks
Step-down once afebrile, improving and otherwise ready for hospital discharge.
CXR takes 4-6 weeks to resolve
46
Describe your management for an uncomplicated pneumonia that is not responding to treatment within 48-72h.
List 3 alternative diagnoses
**Management:**
47
What makes a pneumonia complicated?
1. 48-72h antibiotics without clinical improvement
2. Persistent or worsening respiratory distress and/or hypoxia
3. New clinical findings of a pleural effusion
48
Describe the recommended investigations for an empyema.
CXR
49
What is the recommended treatment of a complicated pneumonia?
When should you transition to oral antimicrobials? Which one?
* Monitor for clinical improvement (normal for fevers to persist \>72h on appropriate therapy, not treatment failure if improving clinically)
* Start Ampicillin or 3rd gen cephalosporin (Ceftriaxone or Cefotaxime) depending on antibiogram
* Add Vancomycin if MRSA suspected
* If moderate-severe respiratory distress → Pleural drainage
* Best evidence for VATS, early thoracotomy or small-bore percutaneous CT placement w/fibrinolytics
* TPA 4mg in 30-50mL NS daily x 3 days
**Step down:** once clinically improving, drainge completed AND off oxygen
* Cultures negative → Amoxicillin
* *MRSA or H influenzae* (suspected or proven) → Clavulin
Follow after discharge until clinically recovered and CXR has returned to near normal (can take several months)
* **order repeat CXR in 2-3 months** **for initial assessment**
50
What is the expected prognosis of a complicated pneumonia?
51
What clinical conditions are potentially responsive to humidified heated high-flow nasal cannula oxygen therapy?
Name 2 contraindications to HHHFNC oxygen therapy
1. Obstructive sleep apnea
2. Bronchiolitis
3. Asthma
4. Pneumonia or pneumonitis
5. Heart failure (reduces systemic afterload/preload)
**CONTRAINDICATIONS**
* Nasal obstruction
* Epistaxis
* Severe upper airway obstruction
52
List 4 complications or considerations for humidified heated high-flow nasal cannula oxygen therapy
1. Sudden discontinuation → rapid deterioration in HD and respiratory status
53
Describe how to start humidified heated high-flow oxygen therapy
* Start 1-2L/kg/min and increase PRN to minimize WOB (max 2L/kg/min - 50-60L/min in adults), wean as WOB improves
* Start FiO2 at 50% and titrate up or down PRN to maintain SpO2 94-98%, wean and transition to low-flow once tolerating lower rate
54
Name 4 risk factors for inhalant abuse
1. Homelessness
2. School dropout
3. Incarcerated
4. Physical, sexual abuse or neglect
5. Indigenous
* Additional risk factors:
* Health disparities
* Reduced access to services
* Socioeconomic factors
6. Rural, isolated community
7. Reduced community support
8. Poor self-esteem
9. Suicidality
10. Psychiatric conditions, substance abuse
11. FMHx substance abuse or peers abusing substances
55
List 2 short-term complications and 4 long-term complications of inhalant abuse
**SHORT-TERM**
* Respiratory arrest → CNS depression
* "Sudden sniffing death syndrome"→ disruption of myocardial electrical propogation → arrhythmia
* Death/injuries from dangerous behaviour
* Aspiration or suffocation while "bagging"
* Freezing + burning face and upper aerodigestive tract
**LONG-TERM**
* Renal tubular acidosis
* Cardiomyopathy
* Hepatitis
* Poor school performance
* Menstrual disorders
* Criminal behaviour
* Spontaneous abortions
* Preeclampsia
* "Fetal solvent syndrome" →microcephaly, cognitive impairments
* Cortical atrophy
* Brainstem dysfunction
* Dyspnea, emphysema-like abnormalities
* *_Hydrocarbons:_* Bone marrow toxicity
* *_Volatile nitrites_*: Immune impairment (replication of HIV, Kaposi's sarcoma)
56
When screening for abuse with the CRAFFT screening tool, what factors are being assessed?
**C**ar driven by someone "high" or had used drugs → been in one?
**R**elax → do you use alcohol or drugs to relax, feel better about yourself or fit in?
**A**lone → using alcohol or drugs by yourself
**F**orget → do you ever forget things you did while using alcohol or drugs
**F**riends or **F**amily → do they tell you to cut down on your use
**T**rouble → have you gotten into trouble with use
≥2 indicates potential for substance abuse problem
57
You discover your patient has been abusing inhalants when completing your history in the ED. How will you manage them?
* Monitor for hypotension
* Complete neurological examination
* Avoid sympathomimetics
* Assess liver, kidney and heart for damage
* Antiarrhythmics or beta-blockers to stabilize myocardium
58
What intervention is effective with reducing alcohol, marijuana and tobacco use but is NOT HELPFUL for inhalant abuse?
Office-based brief interventions (5-10 min session)
Best Prevention of Inhalant abuse
* Reduce social acceptability
* Evidence-based in-school primary prevention (before use)
* Reduce social factors, such as social determinants of health
59
Who is at highest risk of severe disease in bronchiolitis?
What factors are likely to influence admission?
60
What is a bronchogenic cyst?
* Piece of bronchial tissue separate from the developing airway resulting in an epithelium-lined sac that contains cartilage in the wall
* Usually no connection between the bronchogenic cyst and the normal airway
* Presentation:
* Most remain asymptomatic --\> incidental detection later in life
* If there is a connection:
* Can develop recurrent or chronic infections of the cyst
* If peritracheal lesion, it can stridor/ airway narrowing
* Feeding difficulties if compress esophagus
* Evaluation:
* CXR - usually fluid filled, but if communication can have air-fluid level
* Barium esophagram
* CT scan
* Treatment:
* Surgical removal if Sx
61
What is the most sensitive PFT for small airways disease: a) FEV1 b) FEV1/FVC c) FEF 25-75 d) peak flow velocity
c) FEF 25-75 ● FEF 25-75: mean expiratory flow in middle half of FVC maneuver o Reflects flow through small airways (\< 2mm diameter)
62
A 15 year old boy with recurrent pneumonia. RML x3, RLL, LLL in the past. Next test: a) Quantitative immunoglobulins b) Pulmonary function tests c) Lung scan
a) Quantitative immunoglobulins Recurrent Pneumonia= 2 or more episodes in single year or 3 or more episodes ever (with CXR clearing between occurrences) - think primary immune deficiency \*if recurrent in same lobe suspect structural abnormality
63
14 year old boy with Duchenne’s, who is in a wheelchair, has recently seen his FVC fall from 30% to 21% predicted. What symptom will he most likely complain of? a) Headache early in morning b) Headaches in the afternoon c) Tingling of his fingers d) Dyspnea with exertion
a) Headache early in morning - Nocturnal hypoventilation (early sign of muscle weakness) - morning headache, daytime fatigue
64
A 12 year old presents to your office with a history of quickly fatiguing with exercise. Her physical exam is unremarkable in your office. You send her for PFTs. What would you expect the results to be if her trouble was related to deconditioning? What if it was related to asthma? What about restrictive lung disease? a. Fill in a table with normal, increased or decreased for the following PFTs: FEV1/FVC, MMEF25-75 and RV/TLC (rows for asthma and deconditioning).
Asthma: FEV1/FVC decreased - MMEF25-75 decreased - RV/TLC increased Deconditioning: FEV1/FVC normal - MMEF25-75 normal - RV/TLC normal Restrictive: FEV1/FVC normal/increased - MMEF25-75 normal - RV/TLC normal/increased
65
Newborn has significant respiratory distress and CXR that is consistent with pneumonia. She is ventilated with PIP 36, PEEP 5 rate 60 bpm, FiO2 1.0, she is not saturating very well. What is the likely diagnosis? What intervention should you start now?
1. PPHN 2. iNO
66
You see a 6 year old girl with a history of a productive cough and persistent otitis media. On physical exam, you note cobblestoning of the oropharynx. What is the most appropriate diagnostic test: a. Immunoglobulins b. CT chest c. tracheal aspirate d. bronchial biopsy e. call a psychic hotline
a. Immunoglobulins - primary immune deficiency (chronic cough and otitis media) - cobblestoning more related to GERD/postnasal drip
67
8 year old girl with cough at night and with exertion for the past three months. PFTs are all normal. What would you do next: A) CXR B) Treat with b2 agonist C) Methacoline challenge D) PH probe
C) Methacoline challenge - very specific for asthma
68
7 year old with sore throat in the mornings, bad breath, chronic cough with abdominal pain for 2 weeks. Her cough is worse with activity. What test will give you the diagnosis? a) Throat swab b) Pulmonary function tests with methacholine challenge c) pH probe d) Upper GI series
c) pH probe pH monitoring- quantitative and sensitive documentation of acid reflux episodes (pathologic)- insufficient to prove/disprove diagnosis of GERD, can’t measure non-acid reflux- better for acid suppression during treatment, apneas and atypical presentations (cough, stridor, asthma)
69
6y F with chronic cough x 8 mos. Occurs unrelated to illness. It is a harsh cough during the day that decreases at night. Previous unsuccessful treatment for croup x 4 What is the likely diagnosis? a. Athma b. Post-viral cough c. Habit cough d. Vascular ring
c. Habit cough
70
A 1 year old child has a cough, and mom wants to know if she can use an over-the- counter cough preparation for him/her. What do you tell her?
No safe cough medications for kids under 6 - no studies show significant benefit, and there is risk of serious side effects with over the counter cold medications
71
A child is seen at 4 weeks of age in your office. They have had viral URTI symptoms for a week and now have cough and tachypnea. There is no increased work of breathing or wheezing. On CXR there is patchy atelectasis and interstitial infiltrates. What is the most likely etiology: a. Ureaplasma urealyticum b. Chlamydia pneumonia c. RSV
b. Chlamydia pneumonia - young infants, afebrile illness, insidious onset between 1-3m - repetitive cough “staccato”, tachypnea, rales in afebrile 1 month old is characteristic - absence of fever and wheezing helps distinguish from RSV
72
A 2 year old child is transferred to your center after 12 hours in a peripheral centre being treated for croup. They have had an acute onset of stridor and a barking cough after 1-2 days of viral URTI symptoms. There has been minimal response to 2 doses of neb racemic epinephrine and 2 doses of corticosteroid. On arrival the child is anxious, stidorous and has increased work of breathing. What is the next step in your management process: a. Orotracheal intubation b. Heliox c. IV ventolin
a. Orotracheal intubation - think bacterial tracheitis in kid with croup who is not responding to croup treatment - tx: vanco or cloned and cefotax or ceftriaxone
73
3 mo with recurrent URTI. Has had on + off stridor since birth. On exam looks well, afebrile, VSS, intermittent stridor on inspiration. Most likely diagnosis? a. Laryngomalacia b. Viral croup c. Laryngeal web d. Vascular ring
a. Laryngomalacia o Sx at 1-2 weeks and increase up to 6m (vs vascular ring where symptoms present at about 3 months)
74
A 4-year-old child has a chest x-ray done for a different reason, but it shows an asymptomatic solid circular lesion in the anterior mediastinum: a) ganglioneuroma b) neuroblastoma c) lymphoma d) teratoma e) metastasis from a Wilms' tumor
ANSWER: d) teratoma (more rare but anterior ONLY, in adults asymptomatic; missing kids info) a) ganglioneuroma (posterior) b) neuroblastoma (posterior) c) lymphoma (can be anterior or other areas of mediastinum); non-Hodgkin or Hodgkin’s; but typically older age peak incidence e) metastasis (not common site for mets)
75
Newborn with respiratory distress and cystic lesion in LUL with tracheal deviation. What is the most likely diagnosis: 1. CCAM 2. Pulmonary sequestration 3. Pneumonia
1. CCAM congenital pulmonary airway malformation (CPAM) o Sx- asymptomatic, resp distress, resp infections, pneumo, hydrops, hypoplasia of other lobes, chest pain, mediastinal shift away o Ix- CT scan (even if asymptomatic) o Rx- resection by 1 year (malignant potential)
76
In asthma, bronchiolar hyperresponsiveness: a. Is present even if spirometry is normal b. Decreases with a URI c. Is not a sensitive test for the diagnosis of asthma d. Is not inherited
a. Is present even if spirometry is normal
77
3-year-old with asthma exacerbation in moderate respiratory distress. Can speak in sentences. Tachypneic and wheezing. Which test would you do: a) chest x-ray b) arterial blood gas c) spirometry (FVC, FEV 1 ) d) O 2 saturation by pulse oximetry e) flow, end tidal CO 2
d) O 2 saturation by pulse oximetry
78
5 year old with asthma. Treated with ventolin overnight and Q 30 this morning. Aminophyline added this morning to help improve oxygenation. Child complaining of nausea and weakness. You should check: A) serum sodium B) serum glucose C) serum potassium D) serum magnesium
C) serum potassium hypokalemia o Symptoms: nausea (GI decreased peristalsis), neuromuscular excitability (hyporeflexia, paralysis), arrhythmias
79
You are called about an asthmatic with a unilateral pneumothorax. In arranging medical air transport to your Intensive Care Unit, you suggest: a) insert a chest tube on the affected side b) insert a chest tube if the pneumothorax is greater than 10% c) insert a chest tube only if the patient requires intubation d) insert a needle into the 2nd intercostal space, midclavicular line e) transfer without intervention
a) insert a chest tube on the affected side
80
Which is true regarding asthma management: a) beta-2 agonists act primarily on small airways b) systemic beta-2 agonists work better than inhaled c) steroids increase the responsiveness to beta-2 agonists d) Cromolyn is useful in the acute phase of asthma
c) steroids increase the responsiveness to beta-2 agonists
81
Patient on budesonide 200 mcg bid for five years for poorly controlled asthma. Best to monitor? a. No investigations b. Height velocity c. Cortisol levels
b. Height velocity
82
A 6-year-old asthmatic has been receiving 400 mcg of budesonide 4 times daily for the past 2 months with no improvement. His cough is worse at night. Physical examination is normal. His inhalation technique is adequate. What next: a) increase budesonide to 600 mcg 4 times daily b) add oral prednisone for 5 days c) add sodium cromolyn d) add theophyline e) add a long-acting beta-2 adrenergic medication
e) add a long-acting beta-2 adrenergic medication ● Add-On Therapy to ICS if symptomatic or experiencing significant AE despite optimal use of moderate dose inhaled steroids o (1) consider increasing steroid dose o (2) add long-acting beta two agonist (if min. 4 y.o.) ▪ combined meds= Advair (fluticasone + Salmeterol), symbicort (budesonide + formoterol), zenhale (mometasone + formoterol)
83
The following is true about MDI's in adolescents with asthma a. pinch nose when using MDI b. dispense medication at beginning of exhalation c. hold breath for 3 seconds after puff d. take medication in slowly through the whole of inspiration e. hold MDI in mouth
d. take medication in slowly through the whole of inspiration - consider put in mouth depending on how question is phrased - should hold breath for 10 seconds after inhalation - with spacer: slow (5 sec) inhalation with 5-10sec breath-hold OR regular breathing for 30 seconds (5-10 breaths)
84
Teenager with an MDI for asthma without aerochamber. Method of proper administration: A) put in mouth B) hold breath for 3 secs with inhalation C) hold breath for duration of inhalation D) hold nose during inhalation
A) put in mouth
85
Indication that asthma is in poor control: a. 2 ventolins per week pre-exercise b. 2 ventolins per week for symptomatic wheeze c. 2 ventolins per week for night-time cough d. 2 ventolins per month with colds
c. 2 ventolins per week for night-time cough - well controlled: daytime symptoms max twice per week with no night time symptoms - very poorly controlled: more than 1 night per week
86
What is the best indicator for mortality in asthma a) previous intubation b) previous oral steroids c) family history d) history of atopy
a) previous intubation
87
Which of the following is correct with respect to the use of a spacer with an MDI: 1. Decreases spray effect 2. Increases oral deposition 3. Decreases bronchial deposition 4. Usually requires a normal tidal volume 5. Does not require coordination
5. Does not require coordination
88
Asthma Question re: atopy. What is an indication of bad control? What should be monitored in chronic asthma for control?
1. bad control: any night time symptoms, limitations of activity, 2+ exacerbations per 6 months, daytime symptoms more than twice weekly 2. monitor PFTs, ventolin usage, ED visits and hospitalizations
89
A 6 year old boy has been on moderate dose inhaled corticosteroids continuously for his asthma. His mother is concerned about his final adult height. What do you tell her about the current literature in the area: a. He will be slightly shorter than his expected adult height b. There will be no effect on his adult height
a. He will be slightly shorter than his expected adult height
90
8 yo with BMI 25, SOB with exertion. Dad with allergic rhinitis. Patient has mild eczema. PFTs show. FVC 80%, FEV1 84% → 87% with bronchodilator and FVC to 85%. What is the treatment? a. BID fluticasone b. Salbutamol prior to exercise c. Montelukast d. Physical training
d. Physical training - BMI 25 super obese for an 8 year old - normal PFTs and no bronchodilator response (response is 12% increase)
91
Which of the following is the most helpful measure to decrease risk of asthma? a. dust mite covers b. elimination of environmental smoke exposure c. removing pets from the home d. breastfeeding
d. breastfeeding - all of them except removing pets will decrease risk of asthma (exposure to pets is protective against asthma) - choosing BF over elimination of smoke because the therapeutic effect comes from long standing avoidance of cigarette smoke even prenatally
92
Teen with asthma. Still symptomatic on inhaled fluticasone 125 mcg BID and monteleukast. Uses ventolin QID. Best treatment to address acute and chronic symptoms. a. Salmeterol and fluticasone b. Formoterol and budesonide c. Salmeterol and ciclesonide
b. Formoterol and budesonide “in adult patients who are poorly controlled the use of budesonide/formoterol in a single inhaler as a rescue medication instead of a SABA in addition to its regular use as a controller therapy has been shown to be effective"
93
Teenager with history of asthma. She is currently on Fluticasone 125 mcg bid. She has been needing to use her Ventolin puffers, two to three times a week in the day time over the past while. What four suggestions could you make for her management?
- review proper puffer technique including use of aerochamber and ensure patient compliance with medication - eliminate environmental exposures - no tobacco smoke (first or second hand) - allergens (pets, dust mites, mold) - wood burning stoves, strong chemical odours, dust - could increase to medium dose ICS - could add LABA (formoterol) - could add LTRA (montelukast) - if significant allergic component could use omalizumab
94
4 year old with asthma on inhaled steroids. Name 2 mechanisms of delivery of asthma medication.
- multiple dose inhaler - DPI (dry powder inhaler) device (diskus, flexhaler autohaler, twisthaler) - nebulized solution
95
Child in status asthmaticus who has been given inhaled beta agonists, ipratroprium bromide and iv steroids. Heʼs still in trouble. What are FOUR other medications that can be tried?
1. IV magnesium sulphate 2. IV ventolin 3. IV aminophylline 4. heliox
96
An 18-year-old male presents with left sided chest pain that radiates to his shoulder. There is a pneumothorax visible on chest x-ray. What is the most likely explanation: a) idiopathic b) cocaine abuse c) status asthmaticus d) emphysematous bleb e) previously undiagnosed Marfan syndrome
a) idiopathic Most common cause of spontaneous= Primary idiopathic: usually resulting from sub pleural blebs.
97
17 yr old male found to have pneumothorax on CXR. He had been at a party that night. What is the number one cause of pneumothorax? a) Spontaneous b) Cocaine c) Status asthmaticus d) Undiagnosed Marfan syndrome
a) Spontaneous
98
Teen with tension pneumothorax, where do you put the needle? a. needle over 3rd rib, in the second intercostal space at the midclavicular line b. needle over 5th rib, in the fourth intercostal space midclavicular line c. Needle in 2nd IC space, anterior axillary line
a. needle over 3rd rib, in the second intercostal space at the midclavicular line - OR 4th ICS in anterior axillary line
99
Teen with ARDS. What is the most likely: 1. increased pulmonary airway resistance 2. decreased compliance 3. decreased elastic recoil 4. hyperinflation
2. decreased compliance
100
15 y/o status post therapeutic abortion. Sudden onset of respiratory distress. On exam, bilateral crackles. She is coughing blood. What is the best test: 1. ECG 2. Pulmonary angiography 3. CXR 4. Pulmonary V/Q scan 5. Leg dopplers 6. CT chest
2. Pulmonary angiography - gold standard - spiral CT with contrast could also be an option, but not normal CT chest - has a PE (pregnancy is risk factor)
101
2-year-old with persistent wheezing localized to the RLL x 8 weeks. Unable to obtain inspiratory and expiratory films. Next test: a) lateral decubitus chest x-ray b) CT chest c) MRI chest d) nuclear lung scan e) bronchoscopy
a) lateral decubitus chest x-ray ▪ Side with FB will not deflate when placed in dependent position (i.e. if right side has foreign body, put right side down and right side will not deflate as expected o If high degree of suspicion, bronch should be performed despite (-) results. ▪ And if (+) Hx and convinced can go right to bronch.
102
Infant has problem of vomiting with feeds and chronically wheezy. Upper GI shows indentation of upper esophagus. What are two diagnoses you consider?
- vascular ring - pulmonary artery sling - these 2 specifically say in Nelson’s that they are associated with esophageal indentation, wheeze and vomiting
103
Wheezing toddler with URTI symptoms. Which is a proven therapy? a. O2 b. racemic epi c. iv steroids d. bronchodilators
a. O2 (for bronchiolitis)
104
Proven therapy in a kid with recurrent viral wheezing? a. Ventolin b. Fluticasone X 3 weeks
a. Ventolin
105
teenage elite female athlete is having episodes of shortness of breath, chest tightness and wheezing with exercise. She has had an oxygen sat during the episode of 100%, a negative bronchodilator challenge and a negative CXR. What is the most likely cause of her condition? What is the best management of this?
Paradoxical vocal cord dysfunction - speech therapy and behaviour modification are therapeutic - symptoms include throat tightness, dyspnea, wheeze, chest tightness, cough - no response to bronchodilators - CXR is normal - PFTs are normal aside from the inspiratory flow loop
106
What is the management of exercise induced asthma?
Note re exercise induced asthma: - diagnosis of EIA can be confirmed by 15% decrease in FEV1 5-10 minutes after an exercise test (non asthmatic people increase their FEV1 in response to exercise) - SABA 15 minutes prior to exercise - warm up and cool down - avoid exercising in cool, dry environments
107
Kid with wheeze 5-6 yrs old. You have dx asthma. Unresponsive to therapy, steroid, laba, leukotriene inhibitor. Has dyspnea and wheeze. List 4 alternative diagnosis to asthma in your ddx.
- allergic rhinitis/sinusitis - foreign body aspiration - laryngeal web, cyst or stenosis - vocal cord dysfunction/paralysis - TEF - vascular ring, sling or external mass compressing airway - viral bronchiolitis - GERD - bronchiectasis (CF)
108
A 3 month old child had a TEF repaired in the first few weeks of life. He now presents in your office with stridor. List 3 causes of his stridor.
- refistulization (recurrence of TEF) - stricture - GERD
109
A child is noted to have nasal polyps. Next step: a) referral for surgical excision b) intranasal corticosteroids c) oral antihistamines d) oral decongestants e) arrange a sweat chloride
e) arrange a sweat chloride
110
14 year old with CF has sudden onset of severe left chest pain over for the past three hours. The pain is now involving the left shoulder. Some respiratory distress. Mother notes that he has been well, but did miss physio that week. Most likely diagnosis is: a. RLL pneumonia b. pneumothorax c. pleural effusion
b. pneumothorax
111
Teen boy with CF has had 2 days of gradually increasing pleuritic chest pain. What is the most likely cause? a. Infective exacerbation b. Pneumothorax c. Pleurodynia
b. Pneumothorax
112
In a child with cystic fibrosis, which of the following findings would have the worst prognostic implications: a. liver disease b. hemoptysis c. malnutrition d. pneumothorax e. pancreatitis
ANSWER: c. malnutrition \*a. liver disease (third most common cause of death in CF after resp failure and transplant complications) - other prognostic factors: o Gender (F slightly worse) o Type of infection (Burkholderia cepacia leads to early deterioration) o FeV1 o CF related DM associated with poor prognosis
113
What clinical situation predisposes to the worst outcome for cystic fibrosis? a) malnutrition b) liver disease
a) malnutrition
114
What can cause a false negative sweat chloride test? 1. Low albumin 2. Low magnesium 3. Low phosphate 4. Low chloride
1. Low albumin - other false negatives: meconium ileus, dilution, malnutrition, edema, insufficient sweat quantity, hyponatremia, hypoproteinemia
115
Girl with rectal prolapse x 2 reduced easily in the ER. What do you do? a. reassure mom b. observe and follow in 3 months c. sweat chloride d. barium enema
c. sweat chloride
116
3 month old boy comes in for routine newborn care. The mother describes symptoms of URTI and mentions that when he has coughed on two recent occasions, she has noticed a swelling protruding from his anus [picture of rectal prolapse]. List the most likely underlying etiology .
- most cases are idiopathic - rule out underlying conditions including CF and sacral nerve root lesions
117
16 yo female with CF and complaints of chest pain, cough that produces a rust colored sputum. What is the most likely diagnosis (1 line). List 2 investigations to confirm diagnosis. What is your treatment?
1. ABPA - allergic bronchopulmonary aspergillosis 2. dx: sputum culture for aspergillus - assessment of sputum for elevated IgE antibodies - elevated serum IgE 3. oral corticosteroids first line - may need antifungals, but goal is to control the allergic reaction to the fungus, not treat the fungus
118
List 3 organisms that colonize airway of patients with CF
- staph aureus - hemophilus influenza - pseudomonas - MRSA - stenotrophomonas maltophilia - burkholderia cepaciae - aspergillus
119
You are unable to obtain a sweat sample in a neonate. List 3 other ways to confirm the diagnosis of CF.
- genetic testing - identifying 2 CFTR mutations - fecal elastase testing (pancreatic insufficiency) - positive newborn screen
120
Kid with CF. Reduced PFT by 30%. Maxed out on salbutamol. Give four interventions to improve his lung function
- chest physiotherapy - human recombinant DNase (dornase) - nebulized hypertonic saline - routine aerobic exercise - ensure adequate nutrition - antibiotic therapy - inhaled corticosteroids - voluntary cough and forced expiratory maneuver (in-ex sufflator)
121
A chest tube was inserted into a child with empyema and whiteout of the left lung field. 12 hours after the chest tube insertion, a repeat CXR shows persistent pleural air. The chest tube system is patent. List 3 causes of the persistent pleural air
- bronchopleural fistula - necrotizing pneumonia - equipment failure
122
A 16-month-old ex-prem with BPD presents with fever (39.4), cough, rhinorrhea, and dyspnea. On exam, febrile, RR 40, no wheeze, but decreased air entry over LLL. There have been several other infants in the community who have been recently admitted to hospital and found to have RSV. What would be your management of this infant: a) outpatient Ventolin q4h b) outpatient Pulmicort c) outpatient antibiotics d) admit for treatment with Ribavirin e) admit for blood culture, IV antibiotics, and tests for RSV
e) admit for blood culture, IV antibiotics, and tests for RSV - or maybe outpatient antibiotics depending on clinical picture, but err on side of caution given BPD
123
4-month-old ex-prem with RSV. pH 7.31, pCO 2 60, pO 2 94. Best management: a) humidified oxygen and careful monitoring b) intubate and ventilate c) RSV immune globulin d) steroids e) antibiotics
a) humidified oxygen and careful monitoring
124
A 2 month old child is seen with a 3-4 day history of viral URTI symptoms, now has progressively increasing work of breathing. RR is 65, O2sat is 91% on room air. On auscultation there is diffuse wheezing. Of the following treatment modalities, which has been proven effective in this disorder: a. Neb ventolin b. Neb racemic epinephrine c. Corticosteroids d. O2
d. O2
125
Baby with severe bronchiolitis, wheezing, severe retractions, lethargy. HR 160, RR 12, Sats 82% what is the next step. a. Give racemic epi b. Give salbutamol c. Give steroids d. Bag-mask ventilation
d. Bag-mask ventilation
126
B) How does palivizumab minimize risk and by what mechanism does it work?
decreases hospitalization risk but does not decrease severity of infection in those who get RSV despite prophylaxis; works by conveying passive immunity
127
List a couple of babies who should get palivizumab
1. Clinically significant CHD or CLD (on bronchodilator, steroids, diuretics or supplemental O2) and \<12 months of age at start of RSV season 2. prems without CLD born before 30+0 weeks who are less than 6 months old at start of RSV season (can offer it but it's not essential) 3. infants born before 36+0 weeks, less than 6 months old at start of RSV season who would need medevac for hospitalization
128
A patient with recurrent pneumonia, sinusitis, bronchiectasis in RML. One should investigate for all of the following except: 1. CF 2. Alpha-1-antitrypsin deficiency 3. Ciliary dyskinesia 4. Hypogammaglobulinemia 5. CGD
2. Alpha-1-antitrypsin deficiency - CF, PCD and immunodeficiencies can all cause bronchiectasis - alpha-1 antitrypsin causes liver disease in kids, lung disease not usually seen until 20s
129
14 yo boy with recurrent wheezing. CXR shows bronchiectasis. Most likely diagnosis?
CF (most common cause of bronchiectasis in industrialized nations)
130
Bronchiectasis and recurrent wheezing in a 14 year old boy. What are 3 causes
1. CF 2. primary ciliary dyskinesia 3. humoral immune deficiency 4. recurrent pulmonary infection/infection with pertussis, measles or TB
131
A 3-year-old boy comes for a regular checkup. He attends day care and he always seems to get “colds”. He does not eat well and his weight gain has been poor. He snores, and usually wakes up several times during the night. You notice that he cannot breathe through his nose and that his tonsils are large. Most appropriate investigation: a) chest x-ray b) lateral view of the nasopharynx c) overnight oxygen saturation recording d) morning capillary blood gas analysis e) electrocardiogram
c) overnight oxygen saturation recording - poor man's oximetry
132
Parents are worried about their 9 year old daughter; she has been snoring a lot and having episodes overnight where she stops breathing. Polysomnography was done and shows episodes of significant, severe central apnea. What to do? a) consult ENT b) MRI brain c) brainstem evoked auditory potentials d) pH probe e) CPAP overnight
b) MRI brain
133
Which of the following is treatment for obstructive sleep apnea? 1. CPAP 2. T & A 3. BiPAP 4. Nasal O2
2. T & A TA hypertrophy the most common cause of obstructive sleep apnea
134
You are seeing a 6 year old boy in your office. His mother is concerned that he snores, and occasionally seems to pause in his breathing while he is asleep. a. What is the most common reason for obstructive sleep apnea in children?
a. adenotonsillar hypertrophy
135
Name 2 severe complications of OSA
- pulmonary hypertension, systemic hypertension, right sided heart failure
136
List 4 daytime symptoms of obstructive sleep apnea.
- mouth breathing - chronic nasal congestion - hyponasal speech - morning headache - poor appetite - secondary enuresis - decreased mood, behavioural difficulties (irritability, aggression, impulsivity), impaired learning and academic function - daytime sleepiness
137
5 things you would tell a boy to improve his sleep hygiene
- consistent bedtime - consistent waking time - age appropriate number of hours in bed per night - sleep in a quiet, dark place - avoid hunger and eating prior to bed - avoid caffeine, alcohol and nicotine - relaxation techniques before bed - no screens before bed - read a book before bed - exercise in the day but not within 2 hours of bedtime
138
3 yo with CP with recurrent symptoms of aspiration. Admitted with pneumonia, abscess and pleural effusion. What would be your choice of antibiotics. a) Vanco & Amp b) Amp & gent c) Clinda & Gent d) Azithro e) Cefuroxime
c) Clinda (staph, strep and anaerobic coverage) & Gent (if gram negative suspected) OR pip/tazo or amox/clav
139
3 year old with cerebral palsy chokes with feeds on past history. Currently presents with fever, increased respiratory rate and chest X-ray shows an air bubble on left chest, surrounded by consolidation with a pleural effusion. What is the diagnosis? a) Lung Abscess b) Pulmonary sequestration c) Diaphragmatic hernia
a) Lung Abscess
140
Child with CP has recurrent choking episodes. Presents with LLL pneumonia and air fluid level and significant pleural effusion. What is the investigation to help with management. a. Sputum cultures b. Blood culture c. Pleural fluid culture d. Bronchoscopy and culture
c. Pleural fluid culture
141
A child presents to the emergency room with shortness of breath and wheezing. This occurred suddenly after playing with older sibling. What should be the next management step after a CXR? a) Bronchoscopy b) Ventolin via nebulizer c) Racemic epinephrine
a) Bronchoscopy - foreign body
142
The reason that oxygen-helium mixtures are used in airway diseases: a. reduces pulmonary airway resistance b. reduces small airway inflammation c. reduces peribronchial inflammation
a. reduces pulmonary airway resistance - decreases turbulence of flow
143
How does helium work in a ventilated patient?
● 60-80% helium + 20-40% oxygen ● reaches lower airway more easily because lower resistance/turbulent flow o lowered gas density= laminar flow overcomes airway obstruction
144
What statement is not true regarding Intal (sodium chromoglycate/cromolyn): a. no bronchodilator effect b. mast cell stabilizer c. not used in children less than 5 years old d. good for exercise induced asthma e. prevents late onset allergic effect
c. not used in children less than 5 years old (false- must be min. 2 y.o.) - can be used for prevention of exercise induced asthma or allergen induced bronchospasm (but is not a bronchodilator so do not use in acute exacerbation) - prevents mast cell release
145
12 month old M with pneumonia and toxic. How to treat? a) IV Cefuroxime and po erythromycin b) IV Ampicillin
b) IV Ampicillin
146
5½-year-old child with a recent upper respiratory tract infection, now has respiratory distress and BP 150/110. Most likely: a) anxiety b) pneumonia c) myocarditis d) Henoch-Schonlein purpura e) post-streptococcal glomerulonephritis
e) post-streptococcal glomerulonephritis
147
Child with eczema and recurrent pneumonia. Hepatomegaly, petechiae, otitis media and low platelets. What do you expect? a. elevated IgA and IgE b. immune response to polysaccharide vaccine c. oral Candida d. abnormal mitogen proliferation
a. elevated IgA and IgE (low IgM and IgG) Wiskott-Aldrich syndrome: atopic dermatitis, thrombocytopenic purpura w/ normal-appearing megakaryocytes but small defective platelets, and undue susceptibility to infection - have poor response to polysac vaccines
148
Alpha-1 antitrypsin. Most likely presentation in children? a) jaundice b) emphysema c) bronchiectasis d) pneumonia
a) jaundice Typical presentation in kids: - neonatal cholestasis - later-onset childhood cirrhosis Dx: - serum immunoassay shows low level of alpha-1 antitrypsin
149
Child with recurrent OM, sinusitis, and dextrocardia. a.) Diagnosis? b.) Test to confirm diagnosis.
a) Primary ciliary dyskinesia (with Kartagener triad): - Triad: - Situs inversus totalis - Chronic sinusitis and otitis (Clinical feature that distinguishes it from CF) - Bronchiectasis b) - curettage from nasal epithelium or endobronchial brushing to obtain suitable specimen for transmission electron microscopy
150
List specific etiologies for specific ‘types’ of cough: 1) wheezy cough, 2) throat clearing, 3) wet productive cough, 4) cough/choking with feeds, 5) barky cough, 6) honking cough, 7) dry cough, 8) progressive cough, 9) sudden onset
151
List syndromes associated with Laryngeal clefts
VACTERL, CHARGE, Opitz Frias, midline defects
152
What are factors in the Modified Asthma Predictive Index?
1 Major Criteria:
* parental asthma
* doctor diagnosed eczema
* sensitization to areoallergen
OR
2 Minor Criteria:
* wheezing in between episodes
* peripheral eosinophilia
* sensitization to food allergens
AND
\>3 wheezing episodes
RC Study Cards
flashcards
Decks in class (23)
# Cards
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Acute Care270
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Adolescent/Gyne98
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Allergy/Immunology70
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Cardiology136
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CYPT and Ethics64
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Dermatology70
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Endocrinology161
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ENT/Ophtho/Gen Surg149
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Gen Paeds0
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Genetics179
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GI/Nutrition146
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Heme/Onc106
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Infectious Disease271
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Metabolics27
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MSK/Ortho/Rheumatology138
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Nephrology/Urology154
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Neurology110
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NICU233
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Pharm and Critical Appraisal57
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Psych/Development200
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Respirology152
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ADHD13
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Syndromes102
