19. +++ Acute respiratory infections and their complications. Flashcards
what are the acute infections of the upper respiratory tract ?
nasopharyngitis acute epiglottitis bacterial pharyngitis croup rhinosinusitis
what are the symptoms in nasopharyngitis of viral
nose -
rhinorrhea - most characteristic of viral
goes from clear to opaque white to green to yellow within 2-3 days (THERFORE COLOR AND OPACITY DOES NOT RELIABILY DISTINGUISH VIRAL FROM BACTERIA)
obstruction of nasal breathing -DUE TO SINUSES being infected
grunting , tachypnea
sneezing
pharynx sore throat odynophagia dysphagia feeding compromised cough
systemic headache Usually no fever (but infleunza as high as 40 ) fatigue malaise vomitting , diarrhea
on examination of acute infection of the upper respiratory tract what do we have to check ?
nasal mucosa erythema
pharyngeal erythema and edema
tonsillar hypertrophy an edema
anterior cervical lymphadenopathy - (EBV mononucleosis)
Conjunctivitis: in adenoviral pharyngoconjunctival
what are the symptom of bacterial pharyngitis ?
Sudden onset of symptoms
Fever:
Pharyngeal symptoms:
Sore or scratchy throat -Group A streptococcal infections often produce a sudden sore throat.
odynophagia, or dysphagia
Pain or feeling of a lump when swallowing.
Erythema and Edema of pharynx - especially prominent in persons with group A streptococcal pyogenes .
Palatal petechiae may be seen.
Pharangeal and tonsilar exudates
Scarlintiform rash - fine maculopapular rash that first appears on the torso and spreads to the extremities. Characteristically spares the palms, soles, and perioral area
No cough
Cervical lymphadenitis
Diagnosis of nasopharyngitis
Suspected acute bacterial tonsillopharyngitis: Evaluate for acute GAS
Initial test: rapid GAS antigen detection test (RADT)
Through tonsil and throat swab
Children ≥ 3 years: Obtain a throat culture - confirmatory test
———
Cbc
Consider CT of head and neck if there is clinical suspicion of suppurative complications
.
Etiology of nasopharyngitis
Acute tonsillopharyngitis
Viral (50–80% of cases): adenovirus, EBV, CMV, HSV, rhinovirus, coronavirus, influenza and parainfluenza viruses,
Bacterial (15–30% of cases)
Most common: Streptococcus pyogenes (also known as group A streptococcus or GAS)
Rare: Neisseria gonorrhoeae, Corynebacterium diphtheriae, Mycoplasma pneumoniae
Recurrent tonsillopharyngitis and chronic tonsillitis: polymicrobial infections with aerobic bacteria (typically streptococci, staphylococci, Haemophilus influenzae) and anaerobic bacteria
treatment for nasopharyngitis viral cause
antipyretics
antitussives
antihistamines and nasal decongestants in older children
supportive therapy
—> Most URIs are self-limited viral infections that resolve without prescription
drugs
—> antiviral drugs have no proven effect
treatment for bacterial nasopharyngitis
GAS pharyngitis and/or tonsillitis: self-limited; antibiotic therapy for acute GAS pharyngitis recommended to prevent rheumatic fever
Ensure adequate hydration.
Consider household remedies such as salt-water gargles.
Analgesics and antipyretics
Acetaminophen
NSAIDs: e.g., ibuprofen
Antibiotics for children more that two years old
First line- Penicillin v 250mg PO every 8-12 hrs for ten days
Amoxicillin po 50mg /kg /day for ten days
Or penicillin g single dose
Tonsillectomy in severe cases - such as extreme hypertrophy - kissing tonsils
Which can be total or subtotal
Etiology of acute epiglottis
bacterial - haemophilus influenza type b
Strep pyo
Strep pneumo
Staph aureu
what are the clinical features of acute epiglottis?
m SUDDEN ONSET -12-24HRS
high fever
DROOLING
sore throat
Dysphagia and odenophsgia
progressing resp obstruction
hyperextended neck
tripod position
Respiratory distress - inspiratory retractions, cyanosis
DYSPHONIA
Muffled vioice
Inspiratory stridor late finding
diagnosis of epiglottis ?
TOUNGUE DEPRESSOR
cherry red epiglottis on INDIRECT laryngoscopy = however this is not suggested due to FEAR of complete obstruction
Pharyngoscopy - not used aswell
Direct laryngoscopy during or after intubation (not used)
thumb sing on lateral neck x ray
CT and MRI
Blood culture
Epiglottis swab
what is the treatment for acute epiglottis ?
it is an emergency and LIFE THREATENING
needs endotracheal intubation or tracheostomy
blood culture
IV ampicillin sublactum or ceftriaxone (effective against h influenza)
Emperic steroids can be considered dexamethasone or methylprednisone
humidification and oxygen
IV fluid
infectious croup (syndrome) also called laryngeotracheobronchitis is caused by ?
Parainfluenza virus (types 1, 2, and 3),
RSV,
influenza or adenovirus
croup the incidence is highest in?
2nd year of life
what are the clinical features of croup syndrome ?
Barklike cough • Hoarseness • Inspiratory stridor and prolonged inspiration • Respiratory distress of varying severity
symptoms worsens at night and lying down
how do we diagnose croup ?
exclude other obstructive conditions of the upper airway, especially
epiglottitis, an airway foreign body, subglottic stenosis, angioedema,
X-ray- subglottic narrowing
Nasopharyngeal washing and PCR test
what is the severity of croup defined by ?
WESTLEY score
chest wall retraction 0 = none 1 = mild 2 = moderate 3 = severe
stridor
0= none
1 = mild
2= at rest
cyanosis
0=none
4 = with agitation
5 = at rest
level of consciousness
0 = normal
5= disorientated
air entry
0= normal
1- decreased
2- markedlydecreased
≤ 2 indicates mild croup
no stridor at rest.
3–5 is classified as
moderate
croup. It presents with
easily heard stridor
6–11 is severe
croup. presents with obvious
stridor, marked chest wall indrawing
≥ 12 indicates impending respiratory failure.
what is the treatment for croup ?
Mild:
—> Home therapy:
Cool mist air
Decrease infant anxiety
Make them go to sleep in upright position
Dexamethasone oral syrup IV or IM
———-
Moderate-Severe
Always hospitilised
Inhale nebuliser epinephrine
dexamethasone
Nebulized: budesonide
Humidified Air or oxygen
—> IV fluid
—> Endotracheal intubation, needed if:
Increased stridor or respiratory rate, onset of cyanosis,
exhaustion, confusion or failure to respond to nebulized
epinephrine
how can we differentiate between croup and acute epiglottitis ?
course
croup: days
epi : hours
cough
croup - barking
epi : slight if any
feeding
croup - can drink
epi - no
mouth
croup - closed
epi = DROOLING SALIVA
fever
<38.5
>38.5
etiology of rhino sinusitis ?
often follows a common cold, which is of viral etiology Rhinovirus Coronavirus Adenovirus Influenza
predisposing factors: Obstruction of the sinus ostia due to deviation
of the nasal septum, presence of foreign bodies, polyps or tumors
Dental extractions or an extension of infection from the roots of the
upper teeth
Hypertrophy of nasal turbinates, nasal polyps, deviation of nasal septum
Impairments of ciliary function such as cystic fibrosis, primary ciliary dyskinesia,
what are the bacterial etiology of rhino sinusitis ?
Streptococcus pneumoniae, Haemophilus
influenzae,
Moraxella catarrhalis
signs and symptoms rhinosinusitis?
Mucopurulent nasal secretions are seen with both viral and bacteria
Frontal, facial, or retroorbital pain or pressure is common
—> Maxillary sinus inflammation may manifest as pain in the upper teeth on the affected side
—> Pain radiating to the ear may represent otitis media or a peritonsillar abscess
—> Sore throat may result from irritation from nasal secretions dripping on the posterior pharynx
—> Mouth breathing may especially noted in children
Cough:
—> The cough may also be most prominent on awakening, occurring in
response to the presence of secretions that have gathered in the posterior pharynx overnight
—>
Daytime cough that lasts more than 10-14 days suggests sinus
disease, asthma
Fever:
—> More likely to occur in children than adults with rhinosinusitis
periorbital swelling: may be present in ethmoid sinusiti
diagnosis of rhino sinusitis ?
Sinus CT
MRI
Nasal endoscopy
bacterial culture of the nasal discharge is not helpful.
An antral puncture to obtain sinusal specimens for bacterial culture is
needed to establish a specific microbiologic diagnosis
what is the treatment for rhinosinusitus ?
analgesics
—> decongestants
—> antibiotics: amoxicillin + clavulanic acid and/or cephalosporin
—> For chronic sinusitis, when conservative treatment does not lead to a cure, surgical irrigation
complication of acute infections in the upper respiratory tract ?
acute otitis media
adenoid vegetation
acute sinusitis
what is acute otitis media ?
commonly follows an upper respiratory infection extending from the nasopharynx via
the eustachian tube to the middle ear
etiology of acute otitis media ?
Etiology:
Streptococcus pneumoniae, Hemophilus influenzae
beta-lactamase producing Moraxella catarrhalis
risk factors :
Vigorous nose blowing during a common cold,
sudden changes of air pressure,
perforation of the tympanic membrane
complication of otitis media ?
presence of purulent exudate in the middle ear may lead to a spread of infection to the
inner ear and mastoids or even meninges
what is the clinical manifestation of otitis media ?
Otologic examination reveals a bulging, erythematous tympanic membrane with loss of
light reflex and landmarks
-
If perforation of the tympanic membrane occurs, serosanguinous or purulent discharge
may be present
-
In the event of an obstruction of the eustachian tube, accumulation of a usually sterile
effusion in the middle ear results in serous otitis media
what is the treatment of otitis media ?
Amoxicillin is an effective and preferred antibiotic for treatment of acute otitis media
-
Since beta-lactamase producing H influenzae and M catarrhalis can be a problem in
some communities, amoxicillin-clavulanate is used by many physicians
-
second and third generation cephalosporins, tetracyclines and macrolides can also be
used
-
When there is a large effusion, tympanocentesis may hasten the resolution process by
decreasing the sterile effusion
-
In those patients with persistent effusion of the middle ear, surgical interventions with
myringotomy, adenoidectomy and the placement of tympanostomy tubes has been
helpful
what is adenoid vegetation ?
hyperplasia of the pharyngeal tonsils
occur after an acute UTR
has familial predisposition
what is the clinical picture of adenoidal vegetation ?
Bacterial nasopharyngitis symptoms
nasal speech , snorting ,breathing through the mouth since through the nose is impaired
nasal discharge
obstructive sleep apnea- tired during the day
facies adenoid - typical picture in children
permanent open mouth
visible tip of the tongue
teeth disarrangement
what is the diagnosis of adenoidal vegetation ?
Direct visualisation of throat
Rapid gas antigen test - through nasal or pharyngeal swab
Children over three years throat culture
rhinos copy
otoscope
audiometry
transnasal endoscopy to differentiate between rhino sinusitis and adenoidiitis
what is the treatment of adenoidal vegetation ?
GAS treatment for strep pyo
If viral self limited or
nasal corticosteroids
Analgesics
Antipyuretics
adequate hydration
surgical - tonsilectomy
what re the reflex response to URT and LRT in irritation ?
URT - sneezing
LRT - coughing
what are the common acute diseases in the lower respiratory tract ?
acute tracheitis
tracheobrochitis
acute bronchitis
what is bacterial tracheaitis ?
occurs commonly in 3-5 years old
dangerous condition is similar to severe epiglottitis- EMERGENCY
what causes bacterial tracheaitis / PSEUDOMEMBRANOUS CROUP
Usually preceding viral croup
Getting infected with organism
organism most often isolated is:
Staphylococcus aureus
but organisms such as H. influenzae, group A Streptococcus pyogenes, Neisseria species, Moraxella catarrhalis
what are the clinical manifestations of bacterial tracheitis ?
early clinical picture is similar to that of viral croup
but instead of gradual improvement, patients develop higher fever!!!
bark cough
dyspnea
patient will look like croup - but TOXIC appearing
inspiratory and expiratory stridor
copious purulent secretions
what is the diagnosis of bacterial tracheitis ?
tracheal secretion culture - positive
blood culture - almost always negative
cdc - leukocytosis
X ray - lateral neck - normal epiglottis , but severe subglottic and tracheal narrowing
direct laryngoscopy confrims - normal epiglottis and copious purulent tracheal secretion and PSEUDOMEMBRANE
what is the management of bacterial tracheitis ?
emergency airway treatmnet
IV antibiotics - Initial antibiotics should cover S. aureus, including methicillin-resistant S. aureus (MRSA), and streptococcal species; IV vancomycin and ceftriaxone may be appropriate empirically.
ceftriaxone plus nafcillin or vancomycin, or clindamycin plus a third-generation cephalosporin, or ampicillin-sulbactam.
IV fluids
what is cause of acute tracheobronchitis ?
Influenza (the “flu” virus) and the viruses that cause the common cold
Occasionally, caused by a bacterial infection, particularly Chlamydia pneumoniae( azithromycin) and Mycoplasma pneumoniae.(erythromycin and azithromycin)
what are the clinical manifestations of tracheobronchitis ?
dry irritating cough • fever and night sweats • headache and malaise • shortness of breath, noisy breath, purulent sputum
what is the etiology of acute bronchiolitis and demographic?
usually viral - MOST commonly RSV, parainfluenza , adenovirus , influenza
= highly contagious
spread from direct contact with nasal secretions and airborne droplets
INFANTS breastfed with colostrum rich in immunoglobulin A relatively protected from bronchiolitis
occurs at any age , but severe symptoms only evident in young infants less than 2 years old with peak at 3-6 months
MOST COMMON CAUSE OF LOWER RESPIRATORY TRACT INFECTION IN THE FIRST YEAR OF LIFE
what is the clinical manifestations of acute bronchiolitis ?
Following viral cold symptoms
infants becomes fussy , difficulty feeding during the first 2-5 day incubation period
LOW GRADE FEVER - general cold symptoms and congestion
progresses from UTI to LTI !!
and these leads to sharp dry cough ,
dyspnea ,
wheezing
in severe forms : respiratory distress - subcostal and intercostal retraction
tachypnea ,
nasal flaring
possibly cyanosis
otitis media and pharyngitis are sometimes present
what is the diagnosis of acute bronchiolitis ?
diagnosis is based on the age and seasonal occruance
occurs in children under 2 years of age and most commonly in the first year of life, peaking between 3 and 6 months.
When diagnosing bronchiolitis, take into account that symptoms usually peak between 3 and 5 days, and that cough resolves in 90% of infants within 3 weeks.
Diagnose bronchiolitis if the child has a coryzal prodrome lasting 1 to 3 days, followed by:
• persistent cough and
• either tachypnoea or chest recession (or both) and
• either wheeze or crackles on chest auscultation (or both).
Consider a diagnosis of pneumonia if the child has:
• high fever (over 39°C) and/or
• persistently focal crackles.
Think about a diagnosis of viral-induced wheeze or early-onset asthma rather
than bronchiolitis in older infants and young children if they have:
• persistent wheeze without crackles or
• recurrent episodic wheeze or
• a personal or family history of atopy.
auscultation fine end inspiratory crackles
fine end inspiratory crackles
prolonged expiration
ABG - hypoxia - determines the severity of the disease
Chest x-rays may be done on severely ill children to rule out other conditions.
what is the treatmnet of bronchiolitis ?
symptomatic and anticipation
oxygen therapy - contiious positive airway pressure
warm humidified air high flow nasal canula
endotracheal intubation
children with compromised immune systems transplant patients and Children with congenital heart and lung disorders are also at higher risk, as are infants under six weeks old. treated with ribvarin (Virazole), a drug that keeps the virus from reproducing. This drug is reserved for the most critical cases.
Do not use any of the following to treat bronchiolitis in children: • antibiotics • hypertonic saline • adrenaline (nebulised) • salbutamol or corticosteroid!!!!
Nasal Saline drops Keep upright position Antipyurtiics Frequent nasal suction Adequate hydration
complication of acute bronchitis ?
there is apnea in those age younger than 6 months
respiratory failure
dehydration
