問題一覧
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Clinical manifestations of bilateral vocal cord paralysis
Severe airway obstruction (Stridor, cyanosis and apnea), recalcitrant feeding problems from respiratory distress
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Laryngomalacia etiology include:
Vocal cord paralysis, laryngeal web, subglottic stenosis
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Subglottic stenosis diagnosis includes:
Lateral and anteroposterior neck and chest roentgenograms, Narrowing in the subglottic region ("steeple sign"), Direct or fiberoptic laryngoscopy (reliable way to distinguish from croup), Thickening of the subglottic tracheal wall persists even after treatment, Bronchoscopy
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For classic croup Bronchoscopy in children less than 6 months of age or in those who require intensive care for what appears to be croup.
True
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(Pathophysiology) in larngomalacia, defect involves the?
supralaryngeal cartilages and soft tissues
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Treatment for bronchomalacia
Postural Drainage, Ipratropium nebulization, Tracheostomy bypassing the malacic segment with CPAP, Surgery (aortopexy or bronchopexy) for life threatening apnea, cyanosis, and bradycardia
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For the management of vocal cord paralysis, if it is life-threatening airway obstruction, what should be done?
Endotracheal Intubation
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In classic croup, 75% of most cases is caused by
Parainfluenza virus
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Early sign of obstruction
tachypnea and nasal flaring
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Foreign body aspiration etiology
Children, younger than 3 yr of age, The most common objects that children choke on are food, coins, balloons, and toys, One-third of aspirated objects are peanuts.
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causes stridor during inspiration. The deeply negative intrathoracic pressure causes the pressure inside the trachea to fall & allows the higher atmospheric pressure (outside of the trachea) to collapse the trachea & larynx. In exhalation, the positive intra-airway pressure forces the airway open & eliminate stridor
Extrathoracic obstruction of the trachea
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intrathoracic trachea, bronchi and bronchiole
lower airway
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Diagnosis for vocal cord paralysis
Direct or fiberoptic laryngoscopoy, Cause of the paralysis is evaluated by chest and lateral neck xray and an MRI or CT scan of the chest or head
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Signs of airway obstruction/ clinical signs of impaired respiratory function
Tachypnea, Nasal flaring, Retractions, Cyanosis, Change in mental state
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FBO pathophysiology Due to underdeveloped ability to swallow food, smaller diameter airway more prone to obstruction, less force of air during coughing
True
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In laryngomalacia during inspiration: flaccid supralaryngeal tissues collapse into the lumen of the larynx.
True
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Insufficient cartilage to maintain airway patency
chrondomalacia
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Decreased diameter of the lower airway lumen leads to?
Atelectasis and increased transthoracic pressure and WOB
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Adult’s narrowest part of airway
glottis
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What causes Bilateral vocal cord paralysis
CNS disease, Arnold-Chiari malformation, myelomeningocele, and hydrocephalus (more common), surgery around the brain stem, head, or neck, difficult endotracheal intubation, birth trauma
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Decreased diameter of the upper airway lumen leads to?
Increased work of breathing and increased transthoracic pressure
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For the management of vocal cord paralysis, if it is severe obstruction, what should be done?
Tracheostomy
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over the trachea
upper airway
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Laryngomalacia can result in retractions from the increased work of breathing
True
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Management for moderate classic croup
Nebulized epinephrine , bronchodilation and reduction of airway wall edema
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over the thorax
lower airway
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Subglottic Stenosis treatment
Endotracheal intubation for severe airway obstruction , Anterior cricoid split operation (preferred), tracheostomy, or a laryngotracheoplasty., Moderate stridor and growth failure
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Etiology of subglottic stenosis do not include the following:
Vocal cords are innervated by the recurrent laryngeal branch of the Vagus nerve
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Management of FBO
Prompt endoscopic removal with rigid instruments.
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stridor is present during a forced exhalation. The positive intrathoracic pressure that occurs with exhalation causes the circumferential tracheal cartilage, thus the trachea, to collapse. During inspiration, stridor from an intrathoracic airway obstruction is minimized by the radially outward tracheal traction caused by negative intrathoracic pressures.
intrathoracic obstruction
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Management of Bacterial Tracheitis include:
IV antibiotics: Vancomycin or Clindamycin with 3rd Gen Cephalosporin , Intubation and mechanical ventilation in 50-60% cases
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If infant with laryngonalacia has a severe respiratory distress or failure to thrive, what management should be done?
Tracheostomy or laser (Supraglottoplasty, Epiglottoplasty)
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A catheter cannot be passed into the pharnyx from the nose.
Choanal Atresia
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bacterial tracheitis
Laryngotracheobronchitis,
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Typical craniofacial malformations include:
orbital hypotelorism or hypertelorism, cranial synostosis, facial clefts
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Clinical Manifestations of subglottic stenosis includes:
Severe respiratory distress immediately after birth, Most common physical finding is stridor, not positional, Less than 6 months of age who have stridor, regardless of the severity, should be thoroughly evaluated for subglottic stenosis
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Most common bacteria in bacterial tracheitis
Staphylococcus Aureus
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For Croup Obstruction is greatest beneath the cricoid cartilage
True
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Pediatric larynx sits…
higher and more anterior in the neck
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Classic croup site
Subglottic
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low pitched stridor indicates?
mild obstruction
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Tracheomalacia
Trachea
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Subglottic Stenosis prognosis
3 years old most are asymptomatic, As the child grow, lumen of the trachea increases in diameter, must anticipate the possibility of severe airway obstruction with URTI
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(pathophysiology) In laryngomalacia, aryepiglottic folds are lax and redundant while the epiglottis is
longer and more omega shaped
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Management of infants with laryngomalacia do not include:
child supine
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For unilateral vocal cord paralysis improvement of voice
Teflon
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Opening of the laryngeal airway requires activation of the abductor muscles by the recurrent laryngeal nerve.
True for the etiology of vocal cord paralysis
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Management for Choanal Atresia:
Manually displacing the mandible anteriorly, Inserting an oral airway or nasopharyngeal airway, Infant in the prone position, tracheostomy, Feeding problems treated with specially designed nipples, tracheal tube or ET tube
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musical, high pitched expiratory sounds indicating turbulent gas flow within the lower airway
Wheezing
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For respiratory problems • calming the infant, placing the infant prone, or gently hyperextending the infant's neck. this is a management for what disease?
Laryngomalacia
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Subglottic stenosis location
Cricoid cartilage region
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Laryngomalacia location
Supraglottic structure
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Etiology Bacterial infection of the larynx and trachea
Bacterial Tracheitis
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Gold standard for the diagnosis of Bronchomalacia/tracheomalacia
Flexible or rigid bronchoscopy
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Bacterial Tracheitis is confirmed by
Bronchoscopy and positive culture
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Choanal Atresia is confirmed by?
MRI or CT scan
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Secondary bronchomalacia/treacheomalacia includes:
EA, TEA, vascular rings (double aortic arch), tracheal compression from aberrant innominate artery, mediastinal masses
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Most common cause of infective upper airway obstruction in children
Classic Croup
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Classic croup age range
3mo - 5yr peaks at 2 year old
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(Pathophysiology) In laryngomalacia, this cartilage is more mobile
arytenoid cartilage
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Pharynx, larynx, and extrathoracic trachea is part of what airway?
upper airway
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Narrowest portion of the pediatric’s larynx
cricoid cartilage
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Laryngomalacia appears 1st 2 weeks of life, peaks at _ months and disappears at 1 year of age
6
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Is bronchomalacia/tracheomalacia responsive to bronchodilators?
NO
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Three stages of FBO
Initial event, Asymptomatic interval, complications
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Results from inflammatory edema within the subglottic tracheal wall
CROUP/ LARYNGOTRACHEOBRONCHIS
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a harsh, high pitched inspiratory sound caused by turbulent flow of gas in the upper airway thus a sign of upper airway obstruction
Stridor
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Diagnosis of spasmodic croup includes:
Clinically, History of a a previously healthy child suddenly awakens at night with stridor, shortness of breath, and a barky cough that lasts several hours and then abruptly ceases., Family history of spasmodic croup and allergies, Eventually have asthma or other atopic diseases, Neck and chest roentgenograms
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Vocal cords are innervated by
recurrent laryngeal branch of the vagus nerve
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Second most common cause of stridor in infancy
Subglottic stenosis
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laryngomalacia prognosis do not include:
Laryngeal tissues mature and become less floppy at 12 to 16 months of age
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vital to determine the extent of air movement & obstruction
auscultation
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Most airway foreign bodies lodge in
Right bronchus
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Severe croup management is intubation. What are the indications for it?
Paco2 > 70 mmHg, Pao2 < 70 mmHg, respiratory failure appears imminent, Use special extra-length endotracheal tubes, Heavily sedate the child
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this presents shortly after birth because infants are cyanotic while quiet or asleep and well oxygenated while they cry as they breathe through their mouth.
Choanal Atresia
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Injury to the Vagus nerve paralyze the vocal cords.
True
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the most accurate test in diagnosis of subglottic stenosis
Laryngoscopy
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Most common cause of stridor in newborns
Laryngomalacia
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Clinical manifestations of classic croup except
High grade fever
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Etiology of Unilateral Vocal cord paralysis
Compression of the vagus nerve within the mediastinum, Left vagus nerve has a longer course, The left vocal cord is paralyzed more often than the right
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Epiglottitis is mainly caused by
H. influenzae Type B
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Laryngomalacia is confirmed by
direct or fiberoptic laryngoscopy
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high pitched stridor indicates?
child is more distress, severe obstruction
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For classic croup airway management, the child who is hypoxic, cyanotic, pale, obtunded needs
URGENT airway management
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Laryngomalacia can cause or exacerbate reflux which can then make the breathing worse
True
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Pharyngeal Airway Obstruction has three episodes, namely:
vomiting, choking, cyanosis
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Clinical manifestation of bacterial tracheitis do not include the following:
Low fever
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Diagnosis of classic croup involves
Clinical diagnosis, Xray: steeple sign, Xray: subglottic narrowing, impeding airflow ("ballooning the hypopharynx, subglottic tracheal wall is edematous (blurring of tissue air interface), Endoscopic Findings: deep red mucosa and subglottic edema
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Laryngotracheitis
Classic Croup
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Expiratory wheezes over the central airways and NOT responsive to bronchodilators
Bronchomalacia/tracheomalacia
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If the bronchomalacia/tracheomalacia has a congenital absence of cartilages, this is
Primary
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Management: Severe croup settings in mech ven
End-expiratory pressure (CPAP or PEEP of 2-4 cmH2O, Supplemental oxygen (25% to 40%), Supplemental oxygen (25% to 40%)
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Most common congenital laryngeal anomaly
Laryngomalacia
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Size and the position of the tongue may be altered and it contacts the pharyngeal wall more easily
pharyngeal airway obstruction
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Infants with laryngomalacia are are able to cry loudly and clearly
True
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Most common congenital lesion producing severe respiratory distress during infancy.
Subglottic stenosis
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Beckwith-wiedemann Syndrome Or Down Syndrome
macroglossia
98
Allergic response is suspected and usually begins during infancy and recurs frequently until 4 years of age and does not recur.
Spasmodic Croup
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Mild croup is managed at home with:
Fluids, Antipyretic, Humidification (steam or cool mist), Corticosteroids- oral, Nebulized, IM, single dose dexamethasone
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laryngomalacia worsens in
feeding, crying, supine