13 Flashcards
Pathophys
Acute vs chronic cough
A cough is a protective action, and can be initiated both voluntarily and via stimulation of cough receptors located throughout the respiratory tract (ear, upper and lower airways, pleura, pericardium, and diaphragm).
The receptors send out signals that travel to the cough center in the medulla.
From the cough center, signals travel outward through the vagus, phrenic and spinal motor nerves to produce the cough.
Coughing can also be initiated or suppressed in the higher centers of the brain.
Acute Chronic
Duration < 4 weeks > 4 weeks
Etiologies
Generally infectious: Including viral upper respiratory infections (URI) and pneumonia (viral or bacterial). - acute
Prolonged or chronic cough accounts for approximately 7% of pediatric visits.
The etiology is usually benign, resulting from a viral upper respiratory infection.
A viral upper respiratory infection can induce airway reactivity in a healthy host for weeks and the cough may persist long after other symptoms have subsided. - chronic
Differentiating descriptors of cough - 8
Descriptor Possible Etiology Dry environmental irritant asthma fungal infection
Wet/productive
lower-respiratory infection
Barking
croup
subglottic disease
foreign body
Brassy or honking
habitual cough
tracheitis
Paroxysmal - short and frequently pertussis chlamydia mycoplasma foreign body
Worse at night
asthma
sinusitis
Disappears at night
habitual cough
Associated with gagging or choking
Gastroesophageal reflux
ROS for school aged child with cough - 6
In a focused review of systems in a school-aged child with cough, look for:
Finding Possible Indication
Change in voice
Dysphonia or hoarseness may suggest laryngeal irritation due to chronic rhinitis or gastroesophageal reflux.
Chest pain
Probe for evidence of gastrointestinal causes of her cough, not cardiac conditions; t rue cardiac chest pain is rare in children.
Alternatively, you could also ask the patient if she “ever gets a bad taste in her mouth” or “if food ever comes back up.”
While rare, congestive heart failure, most commonly due to infectious myocarditis, can present in school-aged children with cough and wheezing and can easily be mistaken for a more common pulmonary condition, such as asthma or bronchitis.
Choking event
Although a foreign body aspiration is more likely in a toddler, otherwise healthy school-aged children and adults are still at a small risk for aspiration pneumonia secondary to inadvertently choking on food.
Children with neurological impairment are at a significantly higher risk for aspiration, either from secretions (“above”) or from refluxed gastric contents (“below”).
Fever
Suggests an infectious etiology for cough, primarily pneumonia and sinusitis.
Lobar pneumonia, particularly in the lower quadrants, may also present with abdominal pain mimicking appendicitis.
In this case, however, the symptoms are too subacute to be very consistent with bacterial pneumonia.
Headaches
Frontal or orbital headaches may suggest a sinusitis, a common cause of persistent cough in children due to the associated post-nasal drip, which is often worse at night when the child is supine.
Sore throat
May suggest evidence of post-nasal drip and pharyngeal irritation due to allergies or sinusitis. (May be present in conjunction with nasal congestion, and/or a history of itchy, watery eyes.)
Heritable conditions causing cough 3
Asthma
Asthma is the most significant condition to inquire about:
A genetic predisposition, combined with environmental factors, may explain most cases of childhood asthma.
A child with an affected parent has about a 25% risk of developing asthma; the risk increases to about 50% if both parents are asthmatic.
Inheritance of asthma is most compatible with a multifactorial pattern.
Immunodeficiency
Although rare and unlikely, a family history of chronic sinopulmonary or skin infections in siblings or first-degree relatives may indicate an immunodeficiency such as chronic granulomatous disease - deficient superoxide production by pmns and macrophages and increase susceptibility to catalase positive org ( E. coli, staph aureus, pseudo, candida) or IgG deficiency.
A history of sterility, particularly in males, may also suggest primary ciliary dyskinesia (or immotile cilia syndrome), which is more common in Caucasian children.
In addition to chronic otitis, sinusitis and pneumonia, children with these conditions usually develop serious bacterial skin or systemic infections as well.
Cystic Fibrosis
Given Sunita’s normal growth curve, and the very low incidence of cystic fibrosis in the Pakistani population, this question is not relevant to her cough.
In a Caucasian child, even with good growth, cystic fibrosis would be a more relevant question–although most cases are new mutations and the majority of first-born children diagnosed with cystic fibrosis have no family history of the disease.
Pulm TB in children Transmission Symptoms Lung findings Dx
Transmission - spread through droplets
In the U.S., most children are infected by Mycobacterium tuberculosis in the home by someone close to them, but outbreaks in daycare centers and schools do occur.
The case rates for all ages are highest in urban, low-income areas and in foreign-born children, among whom more than two-thirds of reported cases in the U.S. now occur.
A diagnosis of tuberculosis in a young child is a public health sentinel event usually representing recent transmission.
Signs and Symptoms
The signs and symptoms of primary pulmonary tuberculosis (due to M. tuberculosis) in most children are few to none, often in sharp contrast to their degree of radiographic changes.
More than 50% of infants and children with radiographically evident disease have no physical findings and are discovered only by contact tracing.
Infants and toddlers are more likely to experience symptoms such as nonproductive cough, mild dyspnea or wheezing due to bronchial compression by enlarged regional lymph nodes.
Infants may present with failure to thrive.
Severe cough and sputum production, together with systemic complaints (such as fever, night sweats and anorexia) usually signify intrapulmonary dissemination.
Night sweats and weight loss are uncommon in children
Lung Findings
All lobar segments of the lung are at equal risk of initial infection.
Two or more primary foci are present in 25% of cases.
The hallmark of tuberculosis in the lung is a primary complex (relatively large size of the hilar lymphadenopathy compared with the relatively small size of the initial lung focus).
The common sequence is hilar adenopathy, focal hyperinflation and then atelectasis, with minimal evidence of the primary lung focus itself.
Small local pleural effusions are common.
The chest x-ray findings may be confused with foreign body obstruction.
Small local pleural effusions are common; large effusions are rarely seen in children under 6 years.
Diagnosis
The Mantoux skin test (formerly called a “PPD” but now more correctly referred to as a “TST,” which stands for “tuberculin skin test”) is the only practical tool for diagnosing TB infections in asymptomatic children.
A test is considered positive if it is: > 5 mm in high-risk children, > 10 mm in moderate-risk children and > 15 mm in low-risk children.
In symptomatic children, a culture of the M. tuberculosis organism should be obtained from a sputum sample, or from a first morning gastric aspirate in young children.
Diff dx for cough 6
Condition
Asthma
Asthma is a very common diagnosis in pediatrics, and is often triggered by an upper respiratory infection.
Coughing—worse at night and exacerbated by exercise and cold air—are common presenting features.
Allergies
Allergies are also commonly diagnosed in pediatrics.
Nasal congestion is a prominent feature, resulting in nocturnal cough due to post-nasal drip.
A personal and family history of atopic diathesis may be found.
Sinusitis
Sinusitis is often preceded by an upper respiratory infection.
Nasal congestion is a prominent feature, leading to complaint of nocturnal cough due to post-nasal drip.
You might also expect findings such as headache or frequent nasal drainage.
Bronchitis
Acute bronchitis in children is a clinical diagnosis characterized by complaint of a prolonged congested cough associated with upper respiratory symptoms.
Bronchitis in children is thought to be due to extension of viral inflammation into the lower respiratory tree and does not require antibiotic therapy.
Cough is equal during the day and night, with no change in symptoms due to exercise or change in air temperature.
Additional findings may include fever and significant sputum production.
GERD
Clinically significant GERD in children is more commonly seen in infants and in older children with neurologic impairments.
Cough from GERD is classically worse at night.
Nasal reflux may result in congestion.
GERD may present with cough.
Atypical pneumonia
An atypical or viral pneumonia may present with symptoms consistent with an upper respiratory infection.
The cough is the same during the day and night but may be exacerbated by exercise or cold air.
Cough may persist for 8-12 weeks.
The most common causative organisms for a previously healthy 6-year-old child include influenza, adenovirus, and mycoplasma; other organisms to consider include pertussis, HIV, and fungal.
Children receive vaccination against pertussis starting at 2 months of age, but immunity wanes during the teenage years if a booster is not given.
Signs and symptoms of bacterial sinusitis 3
There is much similarity in the presenting symptoms of viral upper respiratory infection (URI) and acute bacterial sinusitis, and specific criteria are used to help distinguish between the two.
One of the most important distinguishing characteristics of sinusitis is persistence of symptoms without improvement, as viral URI symptoms tend to improve gradually over the course of a week or so.
In younger children, a diagnosis of sinusitis should be made based on:
Persistence of bilateral nasal discharge of any quality or daytime cough, or both, lasting for more than 10 days without significant improvement (unilateral symptoms suggest a nasal foreign body), OR
Worsening after initial improvement (“double-sickening”) OR
High fever and purulent nasal discharge for more than 3 days.
Bacterial sinusitis Anatomy Pathophy Common org Dx Tx Complications
Anatomy
The sinuses develop as outpouchings of the nasal chamber:
The ethmoid and maxillary sinuses are clinically significant at birth and reach adult size by 12 and 18 years, respectively.
The frontal sinuses become clinically significant at 6-8 years of life and reach adult size by 18 years.
Pathophysiology
Factors that cause obstruction of the sinuses include:
Allergies
Viral upper respiratory infections (URIs)
Trauma
Nasal polyps
Thickened secretions from cystic fibrosis
Common Organisms
The classic bacteria found in acute sinusitis include S. pneumoniae, H. influenzae, and M. catarrhalis (the same organisms that cause acute otitis media). Staph aureus is a rare cause of sinusitis (although it is often found in the complications of acute sinusitis listed below).
Diagnosis
The diagnosis of sinusitis in children is a combination of clinical signs and symptoms. According to the AAP’s 2013 Clinical Practice Guideline, the diagnosis of bacterial sinusitis is made “when a child with a URI presents with:
Persistent illness (nasal discharge [of any quality] or daytime cough or both lasting more than 10 days without improvement) or
A worsening course (worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement), or
Severe onset (concurrent fever [temperature ≥ 39° C / 102.2° F] and purulent nasal discharge for at least 3 consecutive days).”
Plain sinus films are notoriously non-specific and inaccurate for diagnosing sinusitis in the pediatric population and should not be obtained.
Antibiotic Treatment
Antibiotic therapy should be initiated in children with severe onset or a worsening course. Additional observation (for 3 days) may be recommended for those with a persistent but not worsening course.
The recommended first-line antibiotic treatment for sinusitis is amoxicillin (with or without clavulanate).
Results of cultures taken from the nose, nasopharynx, and throat do not accurately predict the bacteria in infected sinus secretions and are not recommended as a guide for therapy.
Complications
Complications of acute sinusitis are infrequent but may be severe, including:
Orbital sinusitis Cavernous sinus thrombosis Meningitis Epidural abscess CT imaging may be helpful in the evaluation of these potential complications.
PE in asthma and allergies
Rhonchi vs wheezes
Asthma
An end-expiratory wheeze is a classic finding in asthma.
Allergies
Allergic shiners- dark circles/bruises under the eye due to venous stasis from congestion of the nose or sinuses, clear nasal secretions, and cobblestoning of the posterior pharynx due to post-nasal drip are all frequentlly seen in individuals with allergies.
Edematous (“boggy”) turbinates are consistent with this diagnosis.
Low pitched wheezes (rhonchi) are continuous, both inspiratory and expiratory, low pitched adventitious lung sounds that are similar to wheezes. They often have a snoring, gurgling or rattle-like quality. Rhonchi occur in the bronchi.
Aeroallergens and asthma- indoor and outdoor allergens
Atopic diathesis - Atopic diathesis is a predisposition to develop one or more of hay fever, allergic rhinitis, bronchial asthma, or atopic dermatitis.
Aeroallergens and Asthma
Most patients with asthma have inhalational allergies as a common trigger for their asthma.
The most common indoor aeroallergens that are responsible for sensitizing susceptible people include:
House dust mites
Animal dander
Cockroaches
Other common outdoor aeroallergens include fungi and some grass and ragweed pollens.
Atopic Diathesis
Allergies suggest an atopic diathesis, which can be associated with asthma—one of the most common causes of cough in school-aged children.
Atopy is defined as the genetic predisposition for the development of an IgE-mediated response to common aeroallergens, leading to the development of allergic rhinitis, asthma, and atopic dermatitis (eczema).
Both genetic and environmental factors contribute to the development of the atopy:
Children of an atopic parent have a 30% risk for development of an atopic disorder and are more likely to become sensitized when exposed to allergens.
Management of allergies
2
The approach to evaluation and treatment of allergies in children varies somewhat among doctors and from one area of the country to the other.
Exposure Avoidance
Most doctors agree that reducing exposure to known outdoor and indoor allergens—such as cigarette smoke or wood smoke from a stove—is a good choice. In an individual who already demonstrates sensitivity to some environmental allergens, the risk of becoming sensitized to other environmental allergens is greater. However, some doctors would not recommend any changes in the indoor environment because the expense and effort involved in implementing indoor environmental allergen controls may be greater than any potential benefit.
Medication
Most doctors also would use some sort of oral medication to treat a 6-year-old child who has clinical evidence of seasonal allergies, with or without allergy skin tests that suggest seasonal allergies.
Some would start with an oral antihistamine, others with a leukotriene receptor antagonist, and some might use both, particularly in a patient with both allergies and asthma.
Antihistamines (H1 antagonists) are safe and effective for controlling the symptoms of sneezing, nasal pruritus and rhinorrhea, particularly associated with intermittent or short-term seasonal allergies. Newer antihistamines are available that are significantly less sedating than the earliest ones available.
Leukotriene receptor antagonists may be useful in the treatment of both asthma and allergic rhinitis.
Topical and systemic decongestants are effective treatments for nasal congestion but should be used judiciously in small children.
Topical nasal steroids are the most effective pharmacologic agents for the treatment of allergic rhinitis, but may not be indicated for short-term symptoms of seasonal allergies.
Leukotrienes can cause bronchoconstriction and nasal congestion
Dx asthma
Tx
An accurate history remains the key to a diagnosis of asthma, focusing primarily on the following:
The episodic nature of the symptoms
Precipitating factors
Family history
However, spirometry (pulmonary function testing)—before and after bronchodilator therapy—is the most specific means of determining whether or not a child has reversible obstructive airway disease, the most common of which is asthma.
Together with a history and physical examination suggestive of asthma, spirometry remains the most sensitive diagnostic test in children old enough to perform the test (around 5-6 years).
Note: Bronchoprovocation with methacholine, histamine or exercise challenge is reserved for cases in which asthma is suspected and spirometry is normal or near normal, and should be performed by trained individuals.
Do a cxr and pulmonary function test just to be sure of no other cause
Treatment
Although there is no cure for asthma, there are good ways to control it. Medications (to treat both allergies and asthma) and avoidance of triggers are the primary treatments.
Albuterol is an inhaled medication that will relax the muscle constriction in the air passages.
Anti-inflammatories may also be beneficial.
Long term management of asthma in children 5
- Classify severity: Assign patient to most severe step in which any feature occurs (PEF is % of personal best; FEV1 is % predicted).
- Gain control as quickly as possible, then step down to the least medication necessary to maintain control.
- Minimize use of short-acting inhaled beta2-agonists.
Over-reliance on short-acting inhaled beta2-agonists (e.g., use of approximately one canister a month even if not using it every day) indicates inadequate control of asthma and the need to initiate or intensify long-term-control therapy. - Asthma management is a multifaceted approach, including patient education on self-management and controlling environmental factors that make asthma worse (e.g., allergens and irritants).
- Refer to an asthma specialist if there are difficulties controlling asthma or if step 4 care is required. Referral may be considered if Step 3 or greater care is required.
Anti inflammatory therapy for persistent asthma 3 meds
Mechanism of Inhaled Corticosteroids in Therapy of Asthma
All patients with persistent asthma should receive daily prophylaxis with anti-inflammatory therapy, not only those with severe asthma.
Steroid Medications
Inhaled corticosteroids are intended to diminish the need for systemic steroids. Inhalation of the medication allows for more rapid onset of action, lowers dosage requirements, and eliminates many systemic side effects.
The steroid medications most commonly prescribed include:
Beclomethasone
Fluticasone
Budesonide
Dose and Frequency
The micrograms of steroid medication per puff vary with each type of steroid inhaler and must be considered when prescribing.
Inhaled steroids require several weeks of daily use before the beneficial effects are realized.
Children with only seasonal symptomatology may require daily use of anti-inflammatory medications, starting several weeks before the expected antigen exposure.
Side Effects
Children with asthma are often undertreated, based on the misperception by parents and physicians that long-term treatment with inhaled corticosteroids is deleterious.
Side effects are rare, but can occur, especially when high doses are used.
Children receiving long-term therapy should be routinely monitored for elevation in blood pressure, serum blood sugar, growth delay, and cataract development.
Mechanism of Inhaled Corticosteroids in Therapy of Asthma
Inhaled corticosteroids provide a direct anti-inflammatory effect as well as upregulating the number of beta-adrenergic receptors on bronchial smooth muscle, thereby improving the efficacy of beta-agonists as well.
The anti-inflammatory effects are likely to be via directly inhibiting the binding of certain transcription factors to cellular DNA that are activated by signals from inflammatory cells.
Within the respiratory epithelium, corticosteroids decrease the numbers of inflammatory cells such as eosinophils, basophils and polymorphonuclear cells.
It may take as long as 6 months to reverse the histologic changes present in asthma-affected airways.
Types of asthma therapy
Rescue vs maintenance
“Rescue” Medication
Short-acting beta-agonists (SABA) such as albuterol are used in addition on an as-needed (PRN) basis, often referred to as a “rescue” medication.
In well controlled asthma, SABA should not be required more than 2 times per week.
Bronchodilator monotherapy (e.g., short-acting beta-agonist such as albuterol) is used for children with intermittent and exercise-induced asthma as needed for wheezing, respiratory distress or tachypnea ("Step 1 therapy").
Maintenance Therapy
Daily long-acting beta-agonist bronchodilators (LABA, such as salmeterol) are used in children with moderate persistent and severe asthma in addition to medium-dose inhaled corticosteroids and short-acting beta-agonist rescue medications.
Children with severe, uncontrollable asthma (less than 10% of cases) may require the use of 2 or 3 types of bronchodilators.
For children with frequent flares of intermittent asthma, a trial of a low-dose inhaled corticosteroids or an inhaled form of a nonsteroidal anti-inflammatory drug (such as cromolyn sodium) may be warranted, given the extremely low level of adverse reaction and lack of systemic uptake of the drug.
For patients with more severe forms of exercise-induced asthma, a long-acting beta-agonist (LABA) may be added to inhaled steroid therapy but must not be used as monotherapy.
Leukotriene receptor antagonists and leukotriene-synthesis inhibitors (LTI, such as monoleukast) block the inflammatory airway response to the inhaled aeroallergen challenge. In chronic asthma, this may reduce symptoms and can frequently allow for reduced doses of inhaled corticosteroids. Several studies have shown that LTIs are less effective than steroids, and are therefore not recommended as a first-line medication or for monotherapy.
