Pulmonology Pediatric Diagnostics PDF

CLINICAL MEDICINE I: PULMONOLOGY DIAGNOSTICS & PEDIATRIC PULMONOLOGY Ryane Lester, PA-C Clinical Assistant Professor Augsburg Physician Assistant Studies  OBJECTIVES 1. Establish a comprehensive differential diagnosis for the following presen...

CLINICAL MEDICINE I: PULMONOLOGY DIAGNOSTICS & PEDIATRIC PULMONOLOGY Ryane Lester, PA-C Clinical Assistant Professor Augsburg Physician Assistant Studies  OBJECTIVES 1. Establish a comprehensive differential diagnosis for the following presentations: cough, dyspnea, hypoxemia, sputum production, hemoptysis, and clubbing. 2. Assess the following laboratory and diagnostic studies including indications for assessment, interpretation of results, invasiveness, potential complications, and patient education: Chest x-ray Pulmonary Function Test/Peak Flow Testing CT Scan, Spiral CT V-Q Scan D-dimer Cardiopulmonary exercise stress testing Sputum Culture WBC and differential Bronchoscopy Oximetry Pulmonary angiography  OBJECTIVES 3. Analyze and interpret a chest x-ray using a systematic approach. 4. Summarize the method of obtaining Arterial Blood Gases (ABGs). 5. Define acidosis and alkalosis in relationship to the pathological changes occurring in the body. 6. Diagnose respiratory acidosis, respiratory alkalosis, metabolic acidosis and metabolic alkalosis based on arterial blood gas (ABG) findings.  OBJECTIVES 7. Summarize the essentials of diagnosis, signs and symptoms, laboratory findings, general approach to treatment, course and prognosis for the following pediatric pulmonology diagnoses: Upper respiratory tract infection Bronchiolitis/Respiratory syncytial virus Pneumonia Foreign body aspiration  PULMONARY DDX Cough Dyspnea Hypoxemia Sputum production Hemoptysis Clubbing  CXR: INDICATIONS Infection: exclude pneumonia, positive Mantoux test Major trauma: exclude widened mediastinum, pneumothorax and hemothorax Acute chest pain: exclude pneumothorax, perforated viscus, aortic dissection Asthma/bronchiolitis: when diagnosis unclear and/or not responding to usual therapy Acute dyspnea: exclude heart failure, pleural effusion Chronic dyspnea: exclude heart failure, effusion and interstitial lung disease Hemoptysis Suspected mass, metastasis or lymphadenopathy CXR INTERPRETATION: AP VS PA A P P A CXR INTERPRETATION: AP VS PA  CXR INTERPRETATION: SYSTEMATIC APPROACH A- ASSESSMENT OF QUALITY/AIRWAY B- BONES AND SOFT TISSUES C- CARDIAC D- DIAPHRAGM E- EFFUSIONS F- FIELDS, FISSURES & FOREIGN BODIES G- GREAT VESSELS & GASTRIC BUBBLE H- HILA AND MEDIASTINUM I- IMPRESSION  CXR INTERPRETATION: SYSTEMATIC APPROACH A- ASSESSMENT OF QUALITY/AIRWAY Position: AP? PA? Lateral? Inspiration: Count the posterior ribs, 10-11 = good inspiratory effort Exposure: Good lung detail & outline of spinal column Rotation: Space b/w clavicle & adjacent vertebrae should be equal bilaterally, check for indwelling lines/objects (ie ______)  B- BONES AND SOFT TISSUES Check for symmetry, fractures, lesions in bones Check soft tissue for FB, edema, subcutaneous air C- CARDIAC Evaluate heart size, nl < 50% chest diameter on PA films Check heart shape, calcifications, prosthetic valves D- DIAPHRAGM Physiologically nl for right hemidiaphragm slightly higher than left, why? _____ Check position Look below the diaphragm for free air  E- EFFUSIONS Check costophrenic angles (blunted 🡪 small pleural effusion) Check lateral film for small posterior effusions F- FIELDS, FISSURES & FOREIGN BODIES Check for infiltrates Check for masses, consolidations, pneumothoraces & vascular markings Evaluate fissures Check for FB (lines, surgical markings)  G- GREAT VESSELS & GASTRIC BUBBLE Check aortic size/shape Check outline pulmonary vessels Verify gastric bubble position H- HILA AND MEDIASTINUM Evaluate hila for lymphadenopathy, calcifications & masses Check widening of mediastinum (assoc w/ _______) Check tracheal deviation: mass effect or tension ptx I- IMPRESSION Synthesis of all these findings (ie Stable right middle lobe infiltrate, ETT remains in position, interim development of small bibasilar pleural effusions). CXR INTERPRETATION: ANATOMICAL REVIEW CXR INTERPRETATION: ANATOMICAL REVIEW CXR INTERPRETATION: ANATOMICAL REVIEW CXR INTERPRETATION: ANATOMICAL REVIEW  CXR INTERPRETATION: ANATOMICAL REVIEW A loss of heart border would correlate w/ an infiltrate < 50% = nl where? CXR INTERPRETATION: ANATOMICAL REVIEW CXR INTERPRETATION: ANATOMICAL REVIEW CXR INTERPRETATION: ANATOMICAL REVIEW  CXR: FLUID SPECIFICS Pulmonary infiltrate: Fluid or material fill the spaces within the lungs, where air should be. Etiologies: Pleural effusion: Fluid that accumulates between the two pleural layers, the fluid- filled space that surrounds the lungs. Etiologies: CXR: INFILTRATE CXR: PLEURAL EFFUSION  CXR: INVASIVENESS/POTENTIAL COMPLICATIONS Non-painful, non-invasive Can be done bedside or in XR unit Done in a gown to avoid interference Need to be still. Take a deep breath & hold. Lateral arms above head. Small level of radiation, equivalent to that which naturally occurs in the environment  PFTS: INDICATIONS Evaluation for chronic cough, dyspnea Assessment & monitoring of disease severity & progression Monitoring for drug efficacy Pre-operative assessment  PFTS: INTERPRETATION Forced vital capacity (FVC): maximum air inhaled & exhaled ↓ restrictive & obstructive lung disease Forced expiratory volume in 1 sec (FEV1): max volume of air exhaled in 1 sec ↓ ↓ obstructive lung disease Nl or small ↓ restrictive FEV1/FVC ratio: ↓ obstructive, nl restrictive  PFTS: INVASIVENESS/POTENTIAL COMPLICATIONS Non-invasive but requires capacity for deep breathing Contraindicated in any acute event (ie MI, PE) or active TB given potential spread  CT SCAN: INDICATIONS Lung Disease ie complex chest infection (abscess, empyema), complex pleural disease Vascular Occlusions (ie PE) Cancer diagnosis and staging Trauma  CT SCAN: INTERPRETATION Radiation through the body creates an “electron stream” which is converted to numbers (Hounsfield Units) 🡪 those numbers are converted into the black, white and shades of gray picture we view. = density data displayed as image CT can take “pictures” from 1mm-10mm thick slices 1mm: small structures like the inner ear 10mm: large structures in the abdomen and chest  CT SCAN: INTERPRETATION  CT SCAN: INTERPRETATION Spiral or helical CT scan is the most common CT Windows: display settings that can be manipulated to optimize the appearance of the image. ie Lung window, bone window You can utilize your mouse allows to center your window on the type of tissue you are interested in viewing and adjust your ability to distinguish objects with a lot or only a little contrast. Essentially, turning up and down the dial to get the picture/enhancement of the structure you want to view.  CT SCAN: INTERPRETATION  CT SCAN: INVASIVENESS/POTENTIAL COMPLICATIONS Non-invasive but has radiation dose Standard is w/ IV contrast Contrast = iodine that causes varying degrees of x-ray absorption, improves visualization Possible contraindications: History of reaction to contrast agents Pregnancy Renal dysfunction  VQ SCAN: INDICATIONS = Ventilation (V) & perfusion (Q) nuclear medicine scan Diagnostic for PE when CTA contraindicated but not as accurate Assess for viability of good lung prior to lobe resection  VQ SCAN: INTERPRETATION Looking for a mismatch between ventilation &  VQ SCAN: INVASIVENESS/POTENTIAL COMPLICATIONS Non-invasive w/ lower radiation levels Patient needs to inhale radioactive isotope through non-rebreather mask & also have isotope injected IV for imaging Not as accurate for PE dx as CTA  D-DIMER: INDICATIONS = fibrin degradation byproduct Exclude diagnose of PE/DVT Part of DIC diagnosis  D-DIMER: INTERPRETATION Highly sensitive but low specificity ie lots of false positives Part of Wells Criteria for VTE work-up: MD Calc PE Wells Criteria  D-DIMER: INVASIVENESS/POTENTIAL COMPLICATIONS Serum blood draw In appropriate use of this lab can cause escalated imaging, etc So, don’t order one when you know its going to be positive (ie post-op, trauma, infectious, etc)  CARDIOPULMONARY EXERCISE STRESS TESTING: INDICATIONS Evaluation of exercise tolerance in pts with cardiovascular disease or chronic pulmonary disease Unexplained dyspnea Evaluation children and adolescents with congenital heart disease Pre-operative evaluation prior to heart or lung transplantation, lung resection surgery Functional and prognostic evaluation of persons with  CARDIOPULMONARY EXERCISE STRESS TESTING: INTERPRETATION = Measures O2 uptake (VO2), carbon dioxide production (VCO2) and ventilation parameters during exercise Cardiac stress test at the same time CARDIOPULMONARY EXERCISE STRESS TESTING: INVASIVENESS/POTENTIAL COMPLICATIONS Requires capacity for cycle or treadmill Potential complications: Fatigue, SOB, bronchospasm, cardiac arrhythmia, syncope  SPUTUM CULTURE: INDICATIONS Bronchiectasis Pulmonary abscess VAP Unresolving ICU PNA Cavitary opacities PNA in immunocompromised pts  SPUTUM CULTURE: INTERPRETATION Can aid in taper of HAP abx therapy from empiric to culture directed Not ideal for all pathogens  SPUTUM CULTURE: INVASIVENESS/POTENTIAL COMPLICATIONS Deep cough to facilitate sputum sample If patient unable to voluntary give sputum, obtained via bronchoscopy or ETT  WBC & DIFFERENTIAL: Give some indications where this would be helpful from a pulmonary diagnostic standpoint….  BRONCHOSCOPY: INDICATIONS Persistent cough Unresolving infection Bronchial obstruction Potential malignancy on imaging Hemoptysis Concern for FB  BRONCHOSCOPY: INTERPRETATION Allows view of respiratory tract Take samples for culture, cytology, biopsies Ability to remove foreign bodies  BRONCHOSCOPY: INVASIVENESS/POTENTIAL COMPLICATIONS Sedated but awake Potential complications: bleeding, pneumothorax, infection  OXIMETRY: INDICATIONS Measures O2 saturation as light passes through blood in finger During/after sedation Acute pulmonary or cardiac complaint  OXIMETRY: INTERPRETATION/ INVASIVENESS/POTENTIAL COMPLICATIONS Nl 95-100% 45 mm Hg HCO3 nl (22-26 mEq/L)  RESPIRATORY ALKALOSIS pH high > 7.45 PaO2 nl (80-100 mmHg) Blowing off excess CO2 PaCO2 low < 35 mm Hg HCO3 nl (22-26 mEq/L)  Respiratory Acidosis Respiratory alkalosis ↓ pH, pCO2 high ↑ pH, pCO2 low Diseases that impair lung Hyperventilation function ↓ RR ↑ RR Sxs: HA, drowsiness Sxs: lightheadedness, confusion, tingling, syncope  METABOLIC ACIDOSIS pH low < 7.35 PaO2 nl (80-100 mmHg) Excreting PaCO2 nl (35-45 mm Hg) excess HCO3 HCO3 low < 22 mEq/L  METABOLIC ALKALOSIS pH high PaO2 nl Retaining excess HCO3 PaCO2 nl HCO3 high  ABG INTERPRETATION STEPS #1: Is pH abnl? #2: Is respiratory (PaCO2) or metabolic (HCO3-) component abnl? Does it correlate w/ pH change? #3: Is there compensation? IE does the opposite system respiratory or metabolic working to correct? #4: What does PaO2 tell you?  ABG INTERPRETATION STEPS: PRACTICE pH 7.2, PaO2 100 mm Hg, PaCO2 25 mm Hg, and HCO3 10 mmol/L #1: Is pH abnl? ______ #2: Is respiratory (PaCO2) or metabolic (HCO3-) component abnl? Does it correlate w/ pH change? ______ #3: Is there compensation? IE does the opposite system respiratory or metabolic working to correct? ______ #4: What does PaO2 tell you? ______  BOARD QUESTION A 36-year-old female is brought to the emergency department with altered mental status. Her medical record reflects that she has a history of depression and suicide attempts in the past. Physical exam is significant for tachypnea with an alcohol smell to her breath. ABG results: pH: 7.22, pCO2: 33, HCO3: 16, pO2: 93, Anion Gap: 24 Which of the following acid-base disorders is most likely? A.Metabolic acidosis B.Metabolic alkalosis C.Respiratory acidosis D.Respiratory alkalosis PRACTICE  UPPER RESPIRATORY TRACT INFECTION: ESSENTIALS = common cold = URI Children highly susceptible given lack of previous infection immunity & close contact Etiology MC rhinovirus, also RSV, coronavirus, coxsackie, adenovirus etc Peak fall to spring season 1-3 days from exposure to infection  UPPER RESPIRATORY TRACT INFECTION: DIAGNOSIS Sxs: rhinorrhea, nasal congestion +/- fever, sore throat, occasional non-productive cough PE: Swollen, erythematous nasal turbinates Clinical diagnosis, no labs or diagnostics  UPPER RESPIRATORY TRACT INFECTION: TREATMENT Resolves in 5-7 days No antibiotics 5% children will develop AOM _________ Symptomatic mgmt Antihistamines & decongestants not recommended < 6 ya  BRONCHIOLITIS: ESSENTIALS Small bronchioles w/ increased mucus & occasional bronchospasm 4-6 day incubation Etiology usually viral LRTI Respiratory syncytial virus (RSV) is MC Also parainfluenza, influenza, adeno/rhinoviruses, coronavirus MC in infants & young kids 🡪 < 2 ya, peak 2- 6 mos, why? _______  BRONCHIOLITIS: DIAGNOSIS Sxs: progressive sxs, starts w/ cold like cough/rhinorrhea 🡪 raspy breathing & wheezing, fever RSV may not have prodrome & apnea is 1st sx PE: prolonged expiratory phase, ↑ work of breathing (intercostal retractions, nasal flaring) Auscultation: diffuse wheeze & crackles  BRONCHIOLITIS: DIAGNOSIS Labs not required for dx Pulse oximetry check Nasopharyngeal swab for common pathogens (__________) done to confirm infection CXR if obtained shows hyperinflation, flattened diaphragms, why? _______  BRONCHIOLITIS: TREATMENT Admit if: Supportive therapy: High risk: premature, lung or Respiratory monitoring heart disease, Antipyretics immunodeficiency Hydration Marked respiratory distress Upper airway suctioning Hypoxemia O2 prn Apnea Inability to tolerate oral  PNEUMONIA: ESSENTIALS LRTI of airways & parenchyma w/ consolidation of alveolar spaces MC Streptococcus pneumoniae Also RSV, parainfluenza, influenza, adenovirus Mycoplasma pneumoniae > 5 ya  PNEUMONIA: DIAGNOSIS Sxs: cough, wheezing, hemoptysis, chest pain, abdominal pain, failure to thrive, F/C Though not Neonates: fever & hypoxemia diagnostic… What might Infant: Apnea may be 1 sign st help PE: Fever, tachypnea differentiate Retractions, splinting bacterial vs Auscultation: crackles, rhonchi over viral etiology? consolidation  PNEUMONIA: DIAGNOSIS CBC: ↑ WBC, utilize diff to help delineate etiology Clinical dx in outpatient children Why not Hospitalized pts: CXR on ________ CXR outpts? Bacterial ____ infiltrate & viral ______ Blood cultures  PNEUMONIA: TREATMENT Admit w/ hypoxemia, inability to maintain hydration or moderate respiratory distress Pts < 6 mos old w/ bacterial PNA or care concerns When bacterial, tx w/ abx therapy…  FOREIGN BODY ASPIRATION: ESSENTIALS Usually < 3 ya Most commonly lodge where? ______ Most often small food & toys  FOREIGN BODY ASPIRATION: DIAGNOSIS/TREATMENT Sxs: cough, stridor, hemoptysis May have history of choking, witnessed event PE: localized wheezing or unilateral absence of breath sounds Imaging: Radiopaque objects visualized, note focal air trapping Bronchoscopy for FB removal CXR PRACTICE: TWO CASES CXR PRACTICE: ONE PATIENT  DERMATOLOGY REVIEW A 25-year-old male reports he went hiking a week ago. At the end of the day, his friend noticed a tick on him and removed it. The patient now reports fever, chills and body aches and has a skin lesion where the tick bit him. The lesion has a red border with central clearing. Which of the following is the most appropriate intervention? A. Acetaminophen B. Ceftriaxone C. Doxycycline D. Erythromycin E. Rifampin  DERMATOLOGY REVIEW Angioedema Eczema Psoriasis Measles Melanoma  HEMATOLOGY REVIEW Which of the following best describes the laboratory evaluation of a patient diagnosed with acute myeloid leukemia? A. Elevated WBC > 10,000, Philadelphia chromosome B. Isolated lymphocytosis, lymphocytes appear small & immature C. Pancytopenia & hairy cells D. Pancytopenia with circulating blasts and presence of Auer rods  HEMATOLOGY REVIEW Acute blood loss anemia Iron deficiency anemia Disseminated intravascular coagulation (DIC) Venous thromboembolism  CARDIOLOGY REVIEW A 20-year-old woman complains of easy fatigability. Physical examination reveals a systolic ejection murmur best hear over the pulmonic region and a fixed split second heart sound. Which of the following is the most likely diagnosis? A. Aortic stenosis B. Ventricular septal defect C. Atrial septal defect D. Mitral regurgitation E. Tricuspid regurgitation  CARDIOLOGY REVIEW Atrial fibrillation Third degree AV block Aortic stenosis Abdominal aortic aneurysm  QUESTIONS? Radiopaedia