問題一覧
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Narrowest portion of the pediatric’s larynx
cricoid cartilage
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Adult’s narrowest part of airway
glottis
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Pediatric larynx sits…
higher and more anterior in the neck
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Pharynx, larynx, and extrathoracic trachea is part of what airway?
upper airway
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intrathoracic trachea, bronchi and bronchiole
lower airway
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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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Decreased diameter of the lower airway lumen leads to?
Atelectasis and increased transthoracic pressure and WOB
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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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musical, high pitched expiratory sounds indicating turbulent gas flow within the lower airway
Wheezing
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Early sign of obstruction
tachypnea and nasal flaring
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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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vital to determine the extent of air movement & obstruction
auscultation
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over the trachea
upper airway
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over the thorax
lower airway
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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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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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low pitched stridor indicates?
mild obstruction
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high pitched stridor indicates?
child is more distress, severe obstruction
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Beckwith-wiedemann Syndrome Or Down Syndrome
macroglossia
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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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Pharyngeal Airway Obstruction has three episodes, namely:
vomiting, choking, cyanosis
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Typical craniofacial malformations include:
orbital hypotelorism or hypertelorism, cranial synostosis, facial clefts
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A catheter cannot be passed into the pharnyx from the nose.
Choanal Atresia
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Choanal Atresia is confirmed by?
MRI or CT scan
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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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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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Most common congenital laryngeal anomaly
Laryngomalacia
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Laryngomalacia etiology include:
Vocal cord paralysis, laryngeal web, subglottic stenosis
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(Pathophysiology) in larngomalacia, defect involves the?
supralaryngeal cartilages and soft tissues
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(Pathophysiology) In laryngomalacia, this cartilage is more mobile
arytenoid cartilage
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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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Most common cause of stridor in newborns
Laryngomalacia
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laryngomalacia worsens in
feeding, crying, supine
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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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Infants with laryngomalacia are are able to cry loudly and clearly
True
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Laryngomalacia is confirmed by
direct or fiberoptic laryngoscopy
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In laryngomalacia during inspiration: flaccid supralaryngeal tissues collapse into the lumen of the larynx.
True
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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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Management of infants with laryngomalacia do not include:
child supine
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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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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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Laryngomalacia can cause or exacerbate reflux which can then make the breathing worse
True
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Laryngomalacia can result in retractions from the increased work of breathing
True
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Insufficient cartilage to maintain airway patency
chrondomalacia
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If the bronchomalacia/tracheomalacia has a congenital absence of cartilages, this is
Primary
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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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Is bronchomalacia/tracheomalacia responsive to bronchodilators?
NO
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Expiratory wheezes over the central airways and NOT responsive to bronchodilators
Bronchomalacia/tracheomalacia
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Gold standard for the diagnosis of Bronchomalacia/tracheomalacia
Flexible or rigid bronchoscopy
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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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Vocal cords are innervated by
recurrent laryngeal branch of the vagus nerve
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Injury to the Vagus nerve paralyze the vocal cords.
True
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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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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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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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Clinical manifestations of bilateral vocal cord paralysis
Severe airway obstruction (Stridor, cyanosis and apnea), recalcitrant feeding problems from respiratory distress
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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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For the management of vocal cord paralysis, if it is life-threatening airway obstruction, what should be done?
Endotracheal Intubation
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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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For unilateral vocal cord paralysis improvement of voice
Teflon
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Most common congenital lesion producing severe respiratory distress during infancy.
Subglottic stenosis
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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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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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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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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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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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Laryngomalacia location
Supraglottic structure
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Subglottic stenosis location
Cricoid cartilage region
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Tracheomalacia
Trachea
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Second most common cause of stridor in infancy
Subglottic stenosis
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the most accurate test in diagnosis of subglottic stenosis
Laryngoscopy
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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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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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Three stages of FBO
Initial event, Asymptomatic interval, complications
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Most airway foreign bodies lodge in
Right bronchus
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Management of FBO
Prompt endoscopic removal with rigid instruments.
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Results from inflammatory edema within the subglottic tracheal wall
CROUP/ LARYNGOTRACHEOBRONCHIS
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For Croup Obstruction is greatest beneath the cricoid cartilage
True
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Laryngotracheitis
Classic Croup
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bacterial tracheitis
Laryngotracheobronchitis,
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Most common cause of infective upper airway obstruction in children
Classic Croup
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In classic croup, 75% of most cases is caused by
Parainfluenza virus
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Classic croup site
Subglottic
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Classic croup age range
3mo - 5yr peaks at 2 year old
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Clinical manifestations of classic croup except
High grade 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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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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For classic croup airway management, the child who is hypoxic, cyanotic, pale, obtunded needs
URGENT airway management
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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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Management for moderate classic croup
Nebulized epinephrine , bronchodilation and reduction of airway wall edema
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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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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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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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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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Etiology Bacterial infection of the larynx and trachea
Bacterial Tracheitis
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Most common bacteria in bacterial tracheitis
Staphylococcus Aureus
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Clinical manifestation of bacterial tracheitis do not include the following:
Low fever
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Bacterial Tracheitis is confirmed by
Bronchoscopy and positive culture
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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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Epiglottitis is mainly caused by
H. influenzae Type B