pediatric pulmonology specialty review and study guide by austin roland
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pediatric pulmonology specialty review and study guide by austin rolandGroups Discussions Quotes Ask the Author This text contains multiple-choice questions with explanations that are linked to additional online references. To see what your friends thought of this book,This book is not yet featured on Listopia.There are no discussion topics on this book yet.We've got you covered with the buzziest new releases of the day. You may have to register before you can post: click the register link above to proceed. To start viewing messages, select the forum that you want to visit from the selection below. Chapters focus on the pulmonary complications associated with: the major organ systems, types of disorders, metabolic conditions, and various modalities. Although specific diseases will be discussed, the main focus will be on describing the associated organ mechanisms and how they can negatively affect the respiratory system. Each chapter will also discuss methods of prevention, the diagnostic test(s) that may be necessary to diagnose or monitor these complications, and, if applicable, the recommended therapeutic modalities. Pulmonary Complications of Non-Pulmonary Pediatric Disorders provides pulmonologists, pediatricians, and other clinicians with a detailed, reliable explanation of seemingly unrelated signs and symptoms so they can form a more thorough differential diagnosis and prescribe the appropriate diagnostic tests and treatment. By continuing to browseFind out about Lean Library here Find out about Lean Library here Sign in using your membership username and password. Download PDFThis product could help you Lean Library can solve it Content ListAcknowledgementsSimply select your manager software from the list below and click on download.Simply select your manager software from the list below and click on download.For more information view the SAGE Journals Sharing page.http://psiholab.com/royal/userfiles/cs-3000-manual.xml
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Search Google ScholarSearch Google ScholarSearch Google ScholarSearch Google ScholarSearch Google ScholarSearch Google ScholarSearch Google ScholarSearch Google ScholarSearch Google ScholarSearch Google ScholarSearch Google ScholarSearch Google ScholarSearch Google ScholarSearch Google ScholarSearch Google Scholar. See all articles by this author. Search Google ScholarTonsillectomy is one of the most common surgical procedures in the United States, with 289,000 ambulatory procedures performed annually in children Purpose The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing children under consideration for tonsillectomy and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Additional goals include the following: optimizing the perioperative management of children undergoing tonsillectomy, emphasizing the need for evaluation and intervention in special populations, improving the counseling and education of families who are considering tonsillectomy for their children, highlighting the management options for patients with modifying factors, and reducing inappropriate or unnecessary variations in care. Children aged 1 to 18 years under consideration for tonsillectomy are the target patient for the guideline. Keywords tonsillectomy, adenotonsillectomy, child, tonsillitis, sleep-disordered breathing, obstructive sleep apnea, polysomnography Tonsillectomy is one of the most common surgical procedures in the United States, with 289,000 ambulatory procedures performed annually in children 1 Indications for surgery include recurrent throat infections and obstructive sleep-disordered breathing (oSDB), 2 both of which can substantially affect child health status and quality of life (QoL).http://mestan.by/images/cs-370-chainsaw-manual.xml Although there are benefits of tonsillectomy, complications of surgery may include throat pain, postoperative nausea and vomiting, dehydration, delayed feeding, speech disorders (eg, velopharyngeal incompetence), bleeding, and rarely death. 3, 4 The frequency of tonsillectomy, the associated morbidity, and the availability of new randomized clinical trials create a need for an updated evidence-based guidance to aid clinicians. The following definitions were used during this guideline update: Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Throat infection is defined as a sore throat caused by viral or bacterial infection of the pharynx, palatine tonsils, or both, which may or may not be culture positive for group A streptococcus. This includes the term strep throat, acute tonsillitis, pharyngitis, adenotonsillitis, or tonsillopharyngitis.Daytime symptoms associated with oSDB may include inattention, poor concentration, hyperactivity, or excessive sleepiness. View larger version Guideline Scope and Purpose The purpose of this multidisciplinary updated guideline is to identify quality improvement opportunities in managing children undergoing tonsillectomy and to create clear and actionable recommendations to implement these opportunities in clinical practice. The target patient population for the guideline is any child 1 to 18 years of age who may be a candidate for tonsillectomy. The guideline does not apply to populations of children excluded from most tonsillectomy research studies, including those with neuromuscular disease, diabetes mellitus, chronic cardiopulmonary disease, congenital anomalies of the head and neck region, coagulopathies, or immunodeficiency. This guideline predominantly addresses indications for tonsillectomy based on obstructive and infectious causes.http://www.diamondsinthemaking.com/content/boss-725ca-manual The evidence that supports tonsillectomy for orthodontic concerns, dysphagia, dysphonia, secondary enuresis, tonsilliths, halitosis, and chronic tonsillitis is limited and generally of lesser quality, and a role for shared decision making is present. Equally, tonsillectomy is strongly indicated for posttransplant lymphoproliferative disorders or malignancy, but these indications are outside the scope of this document. Although the development group recognizes that partial intracapsular tonsillectomy (also known as tonsillotomy or intracapsular tonsillectomy) is frequently performed, we decided not to include it in this guideline because the evidence base is found predominantly in children undergoing complete tonsillectomy. Therefore, the group decided not to compare tonsillectomy and partial tonsillectomy outcomes; a separate commentary is being prepared to address this topic. 11 This updated guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the working group. It is not intended to be a comprehensive, general guide for managing patients undergoing tonsillectomy. In this context, the purpose is to define useful actions for clinicians, regardless of discipline, and to improve quality of care. Conversely, the statements in this guideline are not intended to limit or restrict care provided by clinicians based on the assessment of individual patients. Throat infections are a common reason to see a primary care provider and often result in antibiotic treatment. 17 The cost of outpatient visits and the medications prescribed for sore throats, including antibiotics, are substantial. Indirect costs associated with throat infections and oSDB are significant due to missed school and, for caregivers, loss of time from work. 17, 18 Treatment of oSDB is associated with an increase in health care utilization and cost.http://crieedelaboucherie.com/images/car-camcorder-gs8000l-manual.pdf Children with oSDB versus controls have a significantly higher rate of antibiotic use, 40 more hospital visits, and an overall elevation of 215 in health care usage, mostly from increased respiratory tract infections. 18 Failure to thrive is reported in 27 to 62 of pediatric OSA cases. 19 Children with tonsillar disease, including children with throat infections and oSDB, also show significantly lower scores on several QoL subscales, including general health, physical functioning, behavior, bodily pain, and caregiver impact, when compared with healthy children. 20 oSDB represents a spectrum of disorders, ranging in severity from primary snoring to hypoventilation and OSA. The prevalence of OSA in children is 1.2 to 5.7, 21 - 23 while as many as 10 of children have primary snoring. 24 Up to 40 of children with oSDB exhibit behavioral problems that include enuresis, 25 hyperactivity, aggression, anxiety, depression, and somatization. 26 OSA is also associated with poor school performance and a decrease in QoL. 27 The QoL of children with OSA is comparable to that of children with other chronic conditions, such as asthma and juvenile rheumatoid arthritis. 28 Controversy persists regarding the actual benefits of tonsillectomy as compared with observation and medical treatment of throat infections. There is also generalized satisfaction with tonsillectomy in up to 92 of patients and their caregivers. 33 - 35 Evidence supporting tonsillectomy as an effective treatment for oSDB 36 is based on tonsillar hypertrophy being the principal cause of crowding of the oropharynx. A meta-analysis of case series 37 and another study 38 showed that tonsillectomy was effective at improving or resolving oSDB in the majority of children. The Childhood Adenotonsillectomy Trial (CHAT) showed that, as compared with a strategy of watchful waiting, surgical treatment for OSA in school-aged children did not significantly improve attention or executive function as measured by neuropsychological testing. Tonsillectomy did reduce symptoms and improve secondary outcomes of behavior, QoL, and polysomnographic findings as compared with 7 months of observation. 39 The AHRQ review also demonstrated that tonsillectomy can lead to short-term improvement in sleep outcomes when compared with no surgery in children with oSDB (moderate strength of evidence). 29 There is also evidence that behavioral parameters, school performance, and QoL improve after resolution of oSDB. 27 Harms and Adverse Events of Tonsillectomy Tonsillectomy is a surgical procedure with an associated morbidity that includes possible hospitalization, risks of anesthesia, prolonged throat pain, and financial costs. A common complication of tonsillectomy is bleeding during or after the surgery. Other complications of tonsillectomy are diverse and have been well described. 4 Operative complications include trauma to the teeth, larynx, pharyngeal wall (constrictor muscle or underlying arterial structures), or soft palate, as well as difficult intubation, laryngospasm, laryngeal edema, aspiration, respiratory compromise, endotracheal tube ignition, and cardiac arrest. Injury to nearby structures have been reported, including carotid artery injury, tongue swelling, altered taste, lip burn, eye injury, and fracture of the mandibular condyle. Postoperative complications include nausea, vomiting, pain, dehydration, referred otalgia, postobstructive pulmonary edema, velopharyngeal insufficiency, and nasopharyngeal stenosis. Complications are more common in children with craniofacial disorders, Down syndrome, cerebral palsy, neuromuscular diseases, major heart disease, or bleeding diatheses and in children 40 - 44 After tonsillectomy, about 1.3 of patients experience delayed discharge of 4 to 24 hours during the initial hospital stay, and up to 3.9 have secondary complications requiring readmission. 45 The primary reasons for readmission or prolonged initial stay include pain, vomiting, fever, and tonsillar bleeding. A prospective audit reported only 1 postoperative death after 33,921 procedures in England and Northern Ireland. 45 About one-third of deaths are attributable to bleeding, while the remainder are related to aspiration, cardiopulmonary failure, electrolyte imbalance, or anesthetic complications. 3, 48 Similarly, airway compromise is the major cause of death or major injury in malpractice claims after tonsillectomy. 49 Structure and Function of the Tonsils The palatine tonsils are lymphoepithelial organs located at the junction of the oral cavity and oropharynx. They are strategically positioned to serve as secondary lymphoid organs, initiating immune responses against antigens entering the body through the mouth or nose. The greatest immunologic activity of the tonsils is found between the ages of 3 and 10 years. 50 As a result, the tonsils are most prominent during this period of childhood and subsequently demonstrate age-dependent involution. 51 The epithelium of the tonsils is cryptic and reticulated and contains a system of specialized channels lined by “M” cells. 52 These cells take up antigens into vesicles and transport them to the extrafollicular region or the lymphoid follicles. In the extrafollicular region, interdigitating dendritic cells and macrophages process the antigens and present them to helper T lymphocytes. These lymphocytes stimulate proliferation of follicular B lymphocytes and their development into either antibody-expressing B memory cells capable of migration to the nasopharynx and other sites or plasma cells that produce antibodies and release them into the lumen of the crypt. 52 While all 5 immunoglobulin (Ig) isotypes are produced in the palatine tonsils, IgA is arguably the most important product of the tonsillar immune system. In its dimeric form, IgA may attach to the transmembrane secretory component to form secretory IgA, a critical component of the mucosal immune system of the upper airway. Although the secretory component is produced only in the extratonsillar epithelium, the tonsils do produce immunocytes bearing the J (joining) chain carbohydrate. 53 This component is necessary for binding of IgA monomers to one another and to the secretory component and is an important product of B-cell activity in the follicles of the tonsil. In addition, the tonsillar lymphocytes can become so overwhelmed with persistent antigenic stimulation that they may be unable to respond to other antigens. Once this immunologic impairment occurs, the tonsil is no longer able to function adequately in local protection, nor can it appropriately reinforce the secretory immune system of the upper respiratory tract. There would therefore appear to be a therapeutic advantage to removing recurrently diseased tonsils. Several group members had significant prior experience in developing clinical practice guidelines. The reviewers concluded that the original guideline action statements remained valid but should be updated with major modifications. Suggestions were also made for new key action statements. Literature Search An information specialist conducted 2 literature searches from January 2017 through February 2017, using a validated filter strategy, to identify clinical practice guidelines, systematic reviews, and randomized controlled trials. These search terms were used to capture all evidence on the population, incorporating all relevant treatments and outcomes. The English-language searches were performed in multiple databases, including BIOSIS Previews, CAB Abstracts, AMED, EMBASE, PubMed Search, and the Cumulative Index to Nursing and Allied Health Literature. The initial English-language search identified 11 clinical practice guidelines, 71 systematic reviews, and 814 randomized controlled trials published in 2010 or later. Clinical practice guidelines were included if they met quality criteria of (1) an explicit scope and purpose, (2) multidisciplinary stakeholder involvement, (3) systematic literature review, (4) explicit system for ranking evidence, and (5) explicit system for linking evidence to recommendations. The final data set retained 4 guidelines that met inclusion criteria. Systematic reviews were emphasized and included if they met quality criteria of (1) clear objective and methodology, (2) explicit search strategy, and (3) valid data extraction methods. Randomized controlled trials were included if they met the following quality criteria: (1) trials involved study randomization; (2) trials were described as double blind; or (3) trials denoted a clear description of withdrawals and dropouts of study participants. After removal of duplicates, irrelevant references, and non-English-language articles, 4 clinical practice guidelines, 30 systematic reviews, and 101 randomized controlled trials were retained prior to the update of the guideline. Additional evidence was identified, as needed, with targeted searches to support the needs of the guideline development group in updating sections of the guideline text from April 2017 through August 2017. Therefore, in total, the evidence supporting this guideline includes 1 new clinical practice guideline, 26 new systematic reviews, and 13 new randomized controlled trials. The recommendations in this clinical practice guideline are based on systematic reviews identified by a professional information specialist using an explicit search strategy. Additional background evidence included randomized controlled trials and observational studies, as needed, to supplement the systematic reviews or to fill gaps when a review was not available. The group had several conference calls and 1 in-person meeting during which it defined the scope and objectives of updating the guideline, reviewed comments from the expert panel review for each key action statement, identified other quality improvement opportunities, reviewed the literature search results, and drafted the document. The evidence profile for each statement in the earlier guideline was then converted into an expanded action statement profile for consistency with our current development standards. 59 Information was added to the action statement profiles regarding quality improvement opportunities, level of confidence in the evidence, differences of opinion, role of patient preferences, and any exclusion to which the action statement does not apply. New key action statements were developed with an explicit and transparent a priori protocol for creating actionable statements based on supporting evidence and the associated balance of benefit and harm. Electronic decision support software (BRIDGE-Wiz; Yale Center for Medical Informatics, New Haven, Connecticut) was used to facilitate creating actionable recommendations and evidence profiles. 61 The updated guideline then underwent guideline implementability appraisal to appraise adherence to methodologic standards, to improve clarity of recommendations, and to predict potential obstacles to implementation. 62 The guideline update group received summary appraisals and modified an advanced draft of the guideline based on the appraisal. The final draft of the updated clinical practice guideline was revised on the basis of comments received during multidisciplinary peer review, open public comment, and journal editorial peer review. A scheduled review process will occur at 5 years from publication or sooner if new compelling evidence warrants earlier consideration. Classification of Evidence-Based Statements Guidelines are intended to produce optimal health outcomes for patients, to minimize harm, and to reduce inappropriate variations in clinical care. The evidence-based approach to guideline development requires that the evidence supporting a policy be identified, appraised, and summarized and that an explicit link between evidence and statements be defined. Evidence-based statements reflect both the quality of evidence and the balance of benefit and harm that is anticipated when the statement is followed. The definitions for evidence-based statements are listed in Tables 2 and 3. 63 - 65 Table 2. Aggregate Grades of Evidence by Question Type. a Table 2. Aggregate Grades of Evidence by Question Type.View larger version Guidelines are not intended to supersede professional judgment but rather may be viewed as a relative constraint on individual clinician discretion in a particular clinical circumstance. 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