Transcript of January 24, 2011. Always look for clubbing Suprasternal and intercostal retractions may be normal...
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- January 24, 2011
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- Always look for clubbing Suprasternal and intercostal
retractions may be normal following exercise Subcostal retractions
always pathologic Accessory muscles Respiratory alternans-
alternating abdominal and chest expansion Respiratory muscle
fatigue
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- 1-2 months of age Afebrile pneumonitis Congestion, wheezing,
fine diffuse crackles Paroxysmal, staccato cough Inclusion
conjunctivitis in 50% CBC may have eosinophil predominance
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- Which CBC results support the diagnosis of Bordetella
pertussis? A.High white count with lymphocytosis B.High white count
with eosinophilia C.High white count with high bands D.Low white
count
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- 3 Phases Catarrhal Paroxysmal Severe paroxysmal coughing
episodes Followed by cyanosis and apnea Inspiratory whoop
Convalescent Apnea may be presenting sign CXR nonspecific Elevated
WBCs with lymphocytosis
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- Dx with PCR Treat only to reduce spread Macrolide (treat
contacts also) Tdap vaccine Adults 19-64 years old, one Tdap At
least 2 years after Td
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- You diagnose a 4 year old patient with 3 rd episode of
pneumonia. A dense, opaque area has been seen on CXR in same
location all three times. What is most likely diagnosis? APulmonary
Sequestration BBronchogenic cyst CCongenital Cystic Adenomatoid
Malformation DRetained foreign body
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- Think of underlying structural defect!!
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- Bronchopulmonary Sequestration Bronchogenic Cyst Congenital
Cystic Adenomatoid Malformation
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- Portion of lungs perfused by systemic arteries Lacks normal
connection with tracheobronchial tree Intralobar: Most common lower
lobes Anywhere in thorax Extralobar: Subdiaphragmatic or
retroperitoneal Associated with other anomalies
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- Occur any point along the tracheobronchial tree Centrally
located Does not communicate, fluid fill with wall composed of
tissue resembling large airways Typically present 2 nd decade of
life with recurrent wheezing, cough, pneumonia
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- Previously known as Congenital Cystic Adenomatoid Malformation
(CCAM) Hamartomatous lesion Cystic and adenomatous elements Resp
distress, recurrent PNA, asymptomatic Surgical resection is
symptomatic Controversial if asymptomatic
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- A 21year old patient is in the ER for pneumonia, which has been
recurrent. He has also been treated multiple times for chronic
sinusitis. He has required multiple sets of ear tubes for OM, even
as an adolescent. He has been married for a year, and has been
trying unsuccessfully to have a child. On review of systems, he has
had normal growth and development, no bowel or bladder complaints.
On exam: bibasilar crackles and ronchi, nasal discharge, nasal
polyps. CV exam normal. What is the most likely underlying
diagnosis A. Cystic Fibrosis B. Kartagener Syndrome (Primary
ciliary dyskinesia) C. Aquired ciliary dyskinesia D. Lymphocytic
interstitial pneumonitis
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- Triad: situs inversus, sinusitis, bronchiectasis Situs inversus
in only 50% Recurrent OM Nasal polyposis Recurrent Pneumonia
Infertility
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- Far more common May follow LRTI Adeno Mycoplasma RSV Influenza
Need bx of resp epithelium for confirmation
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- Potentially fatal Associated with: Cardiac dz
Glomerulonephritis (Goodpasture syndrome) Infantile
hypersensitivity to cows milk Collagen vascular diseases
Idiopathic
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- Dyspnea, cough, hemoptysis, cyanosis, fever, iron-def anemia
Hematemasis or melena May develop jaundice or clubbing CXR:
variable Transient infiltrates Similar to miliary TB
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- Dx: hemosiderin-laden macrophages (suggestive) Lung bx
definitive
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- School age children and adults May imitate viral URI Progress
to lower resp tract Persistent Cough variable, may become
productive May progress to consolidation Lower lobes Physical
findings minimal (crackles/wheezing) Mycoplasma PCR available
Primarily clinical diagnosis
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- Usually following LRTI May persist for weeks or months Loud
honking barking Disturbing to family members, classmates Always
disappears with sleep Worse with: Stress Attention to cough
Extensive evaluation may exacerbate problem
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- Most common cause of inspiratory stridor kids Acute viral
illness Parainfluenza Almost any viral resp illness Clinical
findings Coryza 1-2 days Harsh cough Hoarseness stridor
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- Mostly self limited Airway obstruction possible Treatment
Dexamethasone Racemic Epi nebs (vaponeb) Warm or cool humidified
air: no significant benefit
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- Child treated for croup returns 3 days later looking toxic,
stridor has returned Bacterial Tracheitis
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- An 12 month old has been having daily stridor and intermittent
ronchi. Mom was told that her child has laryngomalacia. What is
your diagnosis? A. Laryngomalacia B. Laryngeal web C. Hemangioma D.
Chronic aspiration E. Vascular ring
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- Congenitally floppy glottis Symptoms Stridor usually by 1 st
week of life Varies with activity May be biphasic Worse supine
Usually self limited Improvement at 6-10 months of age
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- Diagnosis Clinical Airway flouro or direct visualization if
concerned Treat for GE Reflux Refer to ENT if failure to thrive or
other complications
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- Congenital Improves with age Acquired Endotracheal intubation
Problematic May require tracheostomy
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- Laryngeal papillomatosis Rare Life threatening Presents in
first decade Vocal cords or entire tracheobronchial tree Clinical
features Hoarseness Stridor Brassy cough
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- Hemangiomas Stridor, brassy cough Cutaneous hemangiomas may
offer clues Now treated with beta-blockers
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- Laryngeal webs, cysts, laryngoceles Uncommon Clinical
manifestations Resp distress Feeding difficulties Stridor
Cyanosis
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- Clinical Findings Weak or absent cry Hoarseness Insp stridor
with/without distress Feeding difficulties Diagnosis Flexible
bronchoscopy
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- Unilateral Causes Cardiomegaly Vascular ring May be subltle
Bilateral Causes Hydrocephalus Myelomeningocele Arnold-chiari
malformation
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- A 13 year old athlete has had wheezing and shortness of breath
at multiple track meets this season. A. PFTs consistent with asthma
B. PFTs consistent with restrictive lung disease C. PFTs consistent
with vocal cord dysfunction D. Normal PFTs
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- Often mistaken for exercise-induced asthma Many have BOTH Vocal
cords adduct during inspiration Psychogenic origin Highly pressured
adolescent female athlete Competitive event Sensation of dyspnea
trouble getting air IN Localized to throat
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- Diagnosis Clinical suspicion PFTs Flexible nasolaryngoscopy
Treatment Speech therapists, breathing exercises Psychology may be
needed
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- Increased wheezing in previously well controlled asthmatic or
CF patient Insidious presentation Low-grade fevers Fatigue Weight
loss Productive cough Physical Wheeze Bibasilar crackles
clubbing
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- Imaging Consolidation or atelectasis Dilated bronchi radiating
from hila Diagnosis Skin prick to Aspergillus fumigatus antigen
Elevated total and specific IgE Isolation of A.fumigatus from
sputum Worsened PFTs (obstruction)
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- Recurrent wheezing or stridor CXR: Right sided aortic arch
Tracheal deviation to the Left Barium swallow Inexpensive screening
test MRI Delineates airway and vascular anatomy Necessary prior to
surgery
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- Dont forget about Goiter Mediastinal mass
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- CXR: Large, hyperlucent area Few bronchovascular markings
Compression atelectasis of adjacent lobes LUL most common Middle
lobe also seen Treatment Conservative if infant thriving Resection
for prolonged resp distress, recurrent infxn
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- Any resp infection may cause severe illness May develop Chronic
resp insufficiency Pulmonary HTN Cor pulmonale Most continue with
reactive airways
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- Bronchioles become inflamed/fibrosed Non-reversible obstructive
lung disease Causes Idiopathic Post adenoviral Toxic inhalation
Conjunction with other diseases (rheumatoid arthritis)
Post-transplant
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- CXR: hyperinflation decreased vascularity increased
interstitial markings areas of atelectasis and consolidation PFTs:
fixed lower airway obstruction Prognosis is poor