Cough Paeds Flashcards
A 5 month old baby has a one week Hx of rhinorrhoea but has now developed a cough that is worse at night and a distinct sound when they breath in. They are up to date with their vaccinations and their FBC shows a marked Lymphocytosis. What is the most likely Dx and what is your management?
- Croup
- Bronchiolitis
- Pneumonia
- Pertussis
- Pertussis
This is whooping cough caused by Bordetella Pertussis. - The patient had a catarrhal phase with common cold symptoms lasting about a week and has now developed a paroxysmal cough associated with an inspiratory whoop that is characteristic of Pertussis. The cough can cause vomiting, Epistaxis and Subconjunctival haemorrhage.
- Despite a Hx of vaccination, the IPV vaccination does not guarantee protection.
- Risk factors include: <6 months, not vaccinated, close contact with infected individuals and maternal infection at 34 weeks gestation or after
Management
- Isolate and notify PHE
- FBC and Nasal aspirate for PCR/Culture
- 1st line = Clarithromycin or Azithromycin (Erythromycin for pregnant mothers)
- 2nd line = Trimethoprim or Sulfamethoxazole
- Vaccination of children and prophylaxis (macrolide) for relatives
PACES
- Explain condition and course (Catarrhal, Paroxysmal and Convalescent)
- Explain vaccination and elicit ICE if not vaccinated
- Explain you cannot get 2nd infection
- Explain antibiotics do not prevent cough if given outside Catarrhal phase
- Avoid school for 48hrs after antibiotics or for 21 days after onset of cough if untreated
A 10 month old baby, born prematurely, presents with a Fever, dry cough, wheeze and diffuse crepitations This is the first time this has happened. O/E you notice tachypnoea, subcostal recession and nasal flaring. You perform a Nasal Aspirate with PCR revealing RSV. What is the most likely Dx and what is your management?
- Croup
- Bronchiolitis
- Pertussis
- Pneumonia
- Asthma
Bronchiolitis
- Bronchiolitis is the most common cause of hospital admission in those <1yr
- It is most commonly caused by RSV but can also be caused by Paninfluenza types 1-3, Influenza A/B, Human Metapneumovirus, Adenovirus and rarely Rhinovirus.
- Children present with Cough, Fever, Wheeze and crepitations +/- signs of respiratory distress (tachypnoea, recession, cyanosis and reduced air entry)
- This child has 2 risk factors: prematurity/small airways and <3yrs. Others include passive smoking, Congenital Heart Disease and Immunodeficiency
Management
- Isolation and infection control
- Oxygen via nasal cannula as they are showing signs of distress (if desaturation on oxygen and/or reduce respiratory effort = consider ventilatory support)
- Paracetamol for Fever
- Admit if for more extensive supportive measures/monitoring if respiratory compromise or feeding difficulty (Fluid, ventilation or NG tube if feeding difficulty)
PACES
- Explain condition and course (acute for 10-14 days and cough may persist)
- Explain patients often worse on day 5 and so they may get worse before they get better
- Explain Red Flags (Tachypnoea/apnoea, nasal flaring, cyanosis or child becomes acutely unwell) and to call 999
- Educate about symptomatic relief and good hydration
What are the most common causative organisms in a child with Pneumonia?
Younger children = Viral>Bacteria
- Typical = RSV, Influenza, Paninfluenza, Adeno and Rhino
- Atypical = CMV and VZV
Older Children = Bacteria>Viral
- Neonates = Group B strep
- Infants = Strep Pneumoniae and HiB/Bordetella Pertussis in unvaccinated children
- Older Children = Strep Pneumoniae
Atypicals
- Mycoplasma pneumoniae and Chlamydia Trachomatis in younger children
- Mycoplasma/Chlamydia Pneumoniae in older children
- Legionella
HAPs
- Gram -ve (Klebsiella, E.Coli and Pseudomonas) + MRSA and Anaerobes (aspirational)
Immunocompromised = Fungal
- Aspergillus
- Pneumocystis pneumoniae
Describe the Pathophysiology of Pneumonia and its patterns of infection?
- Acute phase -> hyperaemia and oedema -> airway congestion
- Inflammatory cells arrive and fibrotic exudate deposition
- Infection cleared with resolution of injury in the majority of cases
- In some individuals, infection and/or fibrosis persists
What are the risk factors for pneumonia?
- <16 or >65
- Co-morbidities (CF, recent viral infection, malabsorption)
- Immunosuppression
- Poor living conditions/hygiene
Describe the generic presentation of a child with Pneumonia?
- Tachypnoea is the most sensitive sign
- Others complaints include fever, cough, malaise and anorexia
- CHILDREN DO NOT ALWAYS HAVE A COUGH
O/E
- Increased respiratory effort and tachynoea
- End-inspiratory crackles
- Classical triad may or may not be present (Dull to percussion, reduced breath sounds and increased vocal fremitus)
What are the Pathogen specific signs of pneumonia?
Strep
- Often preceded by Influenza
- Acute onset
- Rusty sputum
- Chest pain = Pleurisy
- High fevers
Mycoplasma
- Mild with normal WBC
- Extrapulmonary symptoms (Myalgia and Headache)
Legionella
- Hx of inhaled/shared water mist or stagnent water
- Neurological and GI symptoms
- Lymphopenia
HiB/Bordetella
- Missed vaccinations
- Epiglottitis if HiB (Difficulty breathing with dysphagia/drooling)
- Whooping cough
S.Aureus
- Severe presentation with preceding influenza
Chlamydia
- Psittaci = Bird contact
- Pneumonia = mild disease wtih prolonged prodrome
APBA
- Difficult controlling asthma with recurrent infections
Management of Pneumonia?
Ix
- Asses using CRB-65/CURB-65 or NICE Traffic light system
- Admit anyone who is 2 or more on CURB-65 or orange/red on NICE traffic light
- Hx, Examination and basic Obs
- Bloods = FBC, CRP, U&E, LFT + Culture and ABG if infection/sepsis indicated
- Sputum culture
- Urinalysis for legionella/Strep
- CXR
Tx
Low severity CAP
- 1st line = Amoxicillin oral for 5 days
(Clari/Azithro or Doxycycline if allergic to penicillin)
- Consider prolonging if no improvement after day 3
Moderate severity CAP
= 1st line = Amox + Clari/Azithro
Severe CAP
- 1st line = Beta-lactamase stable beta-lactam (Ceftriaxone/Co-Amox/Cefotaxime or Pip-Taz) + Clari/Azithro
HAP
- Consult local guidelines and give 5-10 day Tx course
When is it safe to discharge?
If they have 2 or ore of the following within 24hrs, they are not fit for discharge:
- Temp >37.5
- RR >24
- HR >100
- SBP 90 or below
- Sats <90% on room air
- Difficulty eating and drinking
- Abnormal mental status
A 3y/o presents with a barking cough and an abnormal inspiratory sound that is worrying the mother. The cough is worse at night and present at rest. O/E you see signs of increased respiratory effort and the child is a little confused and drowsy. What is your most likely Dx and what is your management?
- Bronchiolitis
- Pneumonia
- Epiglottitis
- Pharnygitis
- Croup
- Croup
This child has the characteristic seal-like cough and harsh stridor of croup. The symptoms are worse at night.
As this child has the stridor at rest and is showing signs of reduced consciousness, this is a severe case and senior help should be sort.
- Mild = no stridor
- Moderate = stridor upon exertion
Management
- Basic obs
- Calculate Westley score
Stridor (0 = absent, 1 = agitation, 2 = at rest)
Recessions (0 = absent, 1 = minor, 2 = moderate and 3 = severe)
Air entry (0 = normal, 1 = mild impairment and 2 = severe impairment)
Consciousness (0 = normal, 5 = reduced)
Cyanosis (0 = none, 4 = agitation and 5 = rest)
- Admit and seek senior help as severe
Mild (1-3) = 0.15-0.5mg/kg dexamethasone + Supportive
Reassess after 30 mins
• Improve and able to eat/drink = discharge with education
• No improvement = 2nd dose of 0.6mg/kg dexamethasone
Moderate (4-6) = 0.3mg/kg of dexamethasone + supportive
Reassess after 30 mins
• Improve and able to eat/drink = discharge with education
• No improvement = second dose at 0.6mg/kg dexamethasone
o Improve = monitor for 1-2 hours then discharge
o Same or worsen -> Tx as severe
Severe (7+) = ADMIT
Senior help including anaesthetics/ENT for possible airway intervention
Oxygen
Nebulised adrenaline
Nebulised budesonide if oral dexamethasone is not tolerable/possible
PACES Counselling
o Explain diagnosis (common infection of the airways)
o Explain that it gets better over 48 hours and steroids have been given to help that
o If it gets worse, come back
o If the child becomes blue or very pale for more than a few seconds, unusually sleepy or unresponsive or serious breathing difficulties call an ambulance
o Paracetamol or ibuprofen if distressed
o Advise good fluid intake
o Advise regularly checking on the child at night (cough is worse)
