INFECTIONS OF THE RESPIRATORY SYSTEM Flashcards by Alex Kinsky

What factors make children more susceptible to the effects of respiratory tract infection than adults?

More compliant chest wall

Fatiguability of respiratory muscles

Increased mucous gland concentration

Poor collateral ventilation

Low chest wall elastic recoil

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What is the medical name for the common cold?

Acute nasopharyngitis

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What is the main virus to cause acute nasopharyngitis in children?

Rhinovirus

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In a child with pharyngitis or tonsillitis, what signs might point to the infective organisms being bacterial rather than viral?

Purulent exudate
Lymphadenopathy
Severe pain

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What are the complications of pharyngitis and tonsillitis?

Retropharyngeal abscess
Peritonsillar abscess (quinsy)
Poststreptococcal glomerulonephritis
Rheumatic fever

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What are the indications for tonsillectomy?

The indications for tonsillectomy are controversial. NICE recommend that surgery should be considered only if the person meets all of the following criteria:

Sore throats are due to tonsillitis (i.e. not recurrent upper respiratory tract infections)
The person has five or more episodes of sore throat per year
Symptoms have been occurring for at least a year
The episodes of sore throat are disabling and prevent normal functioning

Other established indications for a tonsillectomy include:

Recurrent febrile convulsions secondary to episodes of tonsillitis
Obstructive sleep apnoea, stridor or dysphagia secondary to enlarged tonsils
Peritonsillar abscess (quinsy) if unresponsive to standard treatment

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What are the organisms responsible for acute otitis media?

Viral:

RSV
Influenza

Bacteria:

Pneumococcus
H. influenzae
group B streptococci
Moraxella catarrhalis

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What are the clinical features of otitis media?

Sore ear
Fever
Vomiting
Distress

Remember that only older toddlers will localize pain to their ear. Therefore ear drums should be checked in all febrile children.
Hearing loss is only really associated with otitis media with effusion

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What will examination of the ear reveal in someone with acute otitis media?

Red eardrum
Loss of light reflex
Bulging eardrum
Perforation might have occurred
Purulent discharge

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Why might someone have hearing loss as a result of otitis media?

In those prone to URTIs, it is common for middle ear fluid to persist (effusion), causing a conductive hearing loss and an increased susceptibility to re-infection.

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Why might an effusion of the middle ear occur without otitis media?

Poor eustachian tube ventilation due to enlarged adenoids or allergy.

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How do you treat middle ear effusions?

Normally it will clear by itself.

If it is persistent it can be surgically drained through grommet insertion.

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What is the medical name for croup?

Acute laryngotracheobronchitis

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What is the organism that most commonly causes croup?

Parainfluenza virus

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What is the peak age of incidence for croup?

Second year of life

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What are the clinical features of croup?

Coryza
Fever
Barking cough
Stridor
Typically worse at night

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What is the important differential to think about when a child presents with features of croup?

Acute epiglottitis

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How do we treat croup?

CKS recommend giving a single dose of oral dexamethasone 0.15mg/kg to all children regardless of severity. Otherwise management is usually supportive and most children will improve within 24 hours.

A child will need hospitalisation if:

Under 12 months old
Severe systemic illness (however, must consider acute epiglottitis)
Signs of fatigue or respiratory failure

In these cases dexamethasone 0.15mg/kg or nebulised budenoside 2mg has been shown to have benefits.

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What is the scoring system that separates the severity of croup into mild, moderate and severe?

Westley scoring system

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What are the clinical features of diphtheria infection?

Sore throat
Fever
Lymphadenopathy
Respiratory distress (stridor)
Thick, grey material covering back of throat

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How common is diphtheria infection?

The vaccination programme has made it very rare for children born and raised in the UK to become infected, however, it is still endemic in some countries and imported cases do occur.

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What is the organism responsible for acute epiglottitis?

Haemophilus influenzae type B

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What is the peak age group for developing acute epiglottitis?

1-6 years old

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What are the clinical features of acute epiglottitis?

Rapid onset
Intensely painful throat
Fever
Unable to speak or swallow
Muffled voice
Soft inspiratory stridor

Child is normally sat up with an open mouth to maximise airway. This may cause drooling.

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How do you manage a child with acute epiglottitis?

This child is severely unwell and their airway may close at any point. In light of this, they should not be examined and blood should not be taken as any distress can precipitate the closing of the airway. The child needs to be managed in the resuscitation room. A senior ENT paediatrician and an anaesthetist should be present for examination and intubation under general anaesthetic. Once the airway is secured, bloods should be taken for culture and IV cefuroxime (3rd generation) should be started. Intubation is not usually required for longer than 48 hours.

How common is acute epiglottitis?

Vaccination against H. influenzae type B has meant that it is very rare.

What are the organisms that cause bacterial tracheitis?

S. aureus H. influenzae Streptococci Neisseria

What are the clinical features of bacterial tracheitis?

``` Systemically unwell Fever Respiratory distress Stridor Hoarse voice No drooling (in contrast to acute epiglottitis) ```

How do you manage a child with bacterial tracheitis?

As with acute epiglottitis, you need to secure the airway and any add stress to the child may lead to the airway completely closing, therefore you should not examine the throat or take blood. The airway should be secured by an anaesthetist and paediatric ENT consultant.

What pathogens are most likely to cause a pneumonia in a neonate?

Most likely - Group B streptococci Less likely: - E. coli - Chlamydia trachomatis - Listeria monocytogenes

What pathogens are most likely to cause a pneumonia in an infant?

Most likely - Viruses - RSV, adenovirus Less likely: - S. pneumoniae - H. influenzae - Bordetella pertussis

What pathogens are most likely to cause a pneumonia in a child?

Most likely: - S. pneumoniae - H. influenzae - Group A strep Less likely: - Mycoplasma pneumoniae (over 5 years of age)

What are the clinical features of pneumonia in children or infants?

Fever Breathlessness Cough (may not appear productive but will be wet) Pain coughing Decreased breath sound (less clear in infants) Dullness to percussion (less clear in infants) Bronchial breathing (less clear in infants) Crackles Effusion

What investigations would you do in a child who presents with signs and symptoms consistent with pneumonia?

Blood cultures FBC CRP Nasopharyngeal aspirate X-ray should only be done in children if there is a failure to respond to treatment or if complications such as effusion are suspected.

What would suggest a bacterial pneumonia rather than a viral one?

Polymorphonuclear leucocytosis Lobar consolidation Pleural effusion

What are the first line antibiotics for a child with a mild - moderate pneumonia?

Penicillin

What are the antibiotics used for a child with a severe pneumonia?

Cefuroxime and flucloxacillin

What antibiotics are indicated for a child with pneumonia caused by mycoplasma?

Clarithromycin

What are the complications of pneumonia in children?

Pleural effusion | Empyema

If a child has recurrent or persistent pneumonia, what underlying causes might you suspect?

Inhaled foreign object Congenital abnormality of the lungs Cystic fibrosis Tuberculosis

What is the pathogen most commonly associated with bronchiolitis?

RSV (respiratory syncytial virus)

What is the peak incidence age for bronchiolitis?

3-6 months

Why do babies tend not to get bronchiolitis before 3 months of age?

Maternal IgG provides protection to newborns

What are the less common causes of bronchiolitis?

Mycoplasma | Adenoviruses

What are the risk factors that make bronchiolitis a more serious problem?

Bronchopulmonary dysplasia - prematurity Congenital heart disease Cystic fibrosis Down syndrome

What are the clinical features of bronchiolitis?

``` Coryzal symptoms Fever Dry cough Respiratory distress Wheezing Chest hyperinflation Bilateral fine inspiratory crackles Feeding difficulties due to dyspnoea ```

What investigations might be done in a baby with signs consistent with bronchiolitis to confirm the diagnosis?

Immunofluorescence of nasopharyngeal secretions may show RSV

What signs would make you think that a baby was suffering only a mild case of bronchiolitis and how would they be managed in this case?

Continuing to feed well Resp rate of less than 40 Minimal intercostal recession SpO2 of more than 92% Managed at home - regular review

What signs would make you think that a baby was suffering a moderate case of bronchiolitis and how would they be managed in this case?

Difficulty feeding Moderate tachypnoea (more than 40 but less than 60) Marked intercostal recession SpO2 of 92% or less Admit to hospital Nasopharyngeal aspirate to confirm RSV and hence place in side room O2 via nasal cannulae or head box Fluids IV or nasogastrically

What signs would make you think that a baby was suffering a severe case of bronchiolitis and how would they be managed in this case?

Resp rate >70 Recurrent episodes of apnoea Severe recession Hypoxia in air Admit to ICU or HDU High concentration inspired O2 Intubation and assistive ventilation for respiratory failure or recurrent severe apnoea IV fluids

What are the complications of bronchiolitis?

A subset are more likely to develop asthma

What is the medical name for whooping cough?

Pertussis

What is the organism responsible for whooping cough?

Bordetella pertussis

How is whooping cough spread and what is the incubation period?

7-10 days

Over what period is a child suffering from whooping cough infectious?

7 days after exposure to 3 weeks after onset of paroxysmal cough

What is the whooping aspect of whooping cough?

The whoop is the inspiratory phase where the child suddenly gasps for air as they cannot control the cough.

What are the clinical features of whooping cough?

Paroxysmal cough with an inspiratory 'whoop' which is worse at night Child may go blue and vomit due to intensity of cough Nosebleeds and subconjunctival haemorrhage may occur after vigorous coughing.

How do you diagnose whooping cough?

A marked lymphocytosis (over 15.0 x 10^9/L) is characteristic Pernasal swab - Organism can be cultured

How do you treat whooping cough?

Erythromycin given early in disease eradicates the organism and reduces infectivity but does not shorten duration of disease.

What are the complications of whooping cough?

Pneumonia Convulsions Apnoea and death Bronchiectasis