Duke PA Pediatrics Respiratory
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| What is asthma | Airway inflammation, airway hyperreactivity, reversible airway obstruction
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| What are the symptoms of asthma | Wheezing, coughing, chest tightness or pain, shortness of breath
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| What parts of the physical exam do you include for a child with asthma | Pulmonary, HEENT, skin, extremities
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| What should be in your differential for chronic asthma | Anatomic abnormality, infection, foreign body, cystic fibrosis, gastroesophageal reflux, bronchopulmonary dysplasia, pulmonary edema, laryngeal dysfunction
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| What are the indications to get a chest x-ray when evaluating for asthma | Atypical presentation, asymmetric breath sounds, suspicion of foreign body, lack of clinical improvement, worsening of clinical course, persistent oxygen requirement
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| What is the ideal asthma management | Daily anti-inflammatory agent plus PRN bronchodilator agent
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| What are the types of bronchodilators | Methylxanthine derivatives, beta-2 agonists, anti-cholinergics
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| What are the types of anti-inflammatories used for asthma | Mast cell stabilizers, steroids, leukotriene inhibitors, anti-IgE antibodies
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| What are the beta-2 agonists | Albuterol, levalbuterol (Xopenex), salmeterol (Serevent)
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| What are the anti-cholinergics | Atropine, ipratropium (Atrovent)
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| What are the mast cell stabilizers | Cromolyn (Intal), nedocromil (tilade)
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| What are the inhaled steroids | Beclomethasone (Qvar), triamcinolone (Azmacort), flunisolide (Aerobid), fluticasone (Flovent), budesonide (Pulmicort)
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| Name two combo therapies for asthma | Advair (fluticasone and salmeterol), Symbicort (budesonide and formoterol)
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| What are systemic steroids useful for when treating asthma | Acute attacks
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| How long should a patient be on systemic steroids for a mild to moderate flare | 3-5 days with no taper
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| How long should a patient be on systemic steroids for a moderate to sever flare | 5 days with taper as per clinical course
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| What are the short term side effects of systemic steroids | Increased appetite, wt gain, fluid retention, irritability
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| What are the long term side effects of systemic steroids | Growth suppression, adrenal suppression, immunosuppression, decreased bone density, hypertension, diabetes, glaucoma, cataracts
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| What is the best way to asses inhaler canister fullness | Count the number of uses
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| What are inaccurate methods for determining canister fullness | Weight, sound, bone dry
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| Peak flow meters are very useful for __ | Following lung function at home
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| Peak flow reading of __ is in the green zone | >80%
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| Peak flow reading of __ is in the yellow zone | 50-80%
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| Peak flow reading of __ is in the red zone | <50%
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| What may be the possible reason for a patient on what appears to be a good asthma treatment plan that is still doing poorly | Not enough medication, confounding feature (allergies, GERD, CF), wrong diagnosis, suboptimal medication delivery (poor technique, poor adherence)
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| When should you refer your allergy patient | Acute life threatening attack, moderate to severe asthma, steroid dependent, atypical/complicated asthma, poor response to optimal therapy, confounding variables, more complicated diagnostic studies required
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| __% of the pediatric population experiences sleep apnea | 7-10
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| What is the male female ration for sleep apnea in children before the onset of puberty | Male=female
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| What is the treatment plan for primary snoring | No intervention
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| Partial to complete upper airway obstruction during sleep, associated with O2 desaturations and or CO2 elevations | Obstructive sleep apnea syndrome
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| __% of the pediatric population experiences obstructive sleep apnea syndrome | 1-3
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| Pediatric obstructive sleep apnea syndrome peaks at ages __ | 2-7 years
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| What are the possible etiologies of pediatric obstructive sleep apnea | Enlarged tonsils and or adenoids, obesity, craniofacial abnormalities, nasal polyps, chronic allergic rhinitis, pharyngeal infections
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| What are some complications of pediatric obstructive sleep apnea | Pulmonary hypertension, developmental delay, growth retardation, death, cor pulmonale, behavioral problems, failure to thrive
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| Symptoms of obstructive sleep apnea while asleep | Snoring, observed apnea, resuscitative gasps, disturbed or restless sleep, paradoxical chest wall movements, observed difficulty breathing, enuresis
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| Symptoms of obstructive sleep apnea while asleep | Mouth breathing, nasal obstruction, excessive daytime tiredness, behavioral problems, hyperactivity trouble concentrating
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| What are the respiratory parameters for obstructive apnea in children | Obstructive apnea for 2 or more breaths
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| What are the respiratory parameters for obstructive apnea in adults | Obstructive apnea for >10 seconds
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| What is the respiratory parameter for central apnea | Central apnea for > or = 20 seconds, any central apnea associated with an O2 desat >4% and or bradycardia
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| What is the parameter for hypopnea | Decreased in measured airflow of > or = 50%
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| The apnea index for children is >__ apneas/hour | 1
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| The apnea index for adults is > __ apneas/hour | 5-10
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| Treatment options for pediatric obstructive sleep apnea | Observation, surgery, wt loss, CPAP, dental appliance, medication
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| What are indications for surgery for obstructive sleep apnea | Failed CPAP therapy, patient not a candidate for CPAP therapy, surgically amenable problem
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| What is the key to successful surgery with obstructive sleep apnea | Correctly identifying the area of obstruction
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| What are the causes of obstruction in the nasopharynx | Turbinate enlargement, deviated septum, nasal polyps
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| What are the causes of obstruction in the oropharynx | Tonsillar hypertrophy, adenohypertrophy, macroglossia, adipose tissue
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| What are the causes of obstruction in the hypopharynx | Adipose tissue, macroglossia, mandibular size or structure abnormalities (micro/retrognathia)
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| What is the most common obstructive sleep apnea surgery in children | Adenotonsillectomy
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| What are the advantages of adenotonsillectomy | High safety record, very common, outpatient procedure, curative in many cases
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| What are the disadvantages of adenotonsillectomy | Pain, dehydration, bleeding, post-op swelling can transiently worsen obstructive sleep apnea, adenoids can grow back
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| Number of apneas decreases by up to __% for each 10% decrease in wt | 50
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| CPAP complications | Nasal/oral dryness, epistaxis, nasal congestion, sneezing, rhinorrhea, sinusitis, claustrophobia, mask irritation, nasal abrasions, aerophagy, facial deformities, decreased cardiac output
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| Medications used for treatment of obstructive sleep apnea | Oxygen, thyroxine, theophylline, acetazolamide, medroxyprogesterone, antidepressants (SSRI, tricyclic)
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| What is the main difference between the treatment of adult vs pediatric obstructive sleep apnea | Surgery is comes before CPAP, and wt loss in for children
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| What is the difference in causes of pediatric vs adult obstructive sleep apnea | Children usually have enlarged tonsils and adenoids whereas adults are usually obese
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| What are the criteria for not sending a snoring child to get a polysomnogram for evaluation of obstructive sleep apnea | Patient > 2 yo, “classic” history, excellent underlying health, normal physical exam, no underlying risk factors, low risk for post-operative complications
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| What are the indications for sending a child for polysomnography | Snoring, witnessed apneas, restless sleep, excessive daytime tiredness, sleep disturbances, neuromuscular dz with FEV1 <40-50%, poorly controlled SS dz, unexplained pulm hypertension/cor pulmonale/polycythemia
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