Module 2- Respiratory Flashcards
Cough
most common symptom for which patients seek attention, adversely affects person and work interaction, sleep and causes discomfort
Cough Symptoms
Acute-less than 3 weeks,
persistent- 3-8 weeks
Chronic- >8 weeks
Post-infection cough lasting 3-8 weeks also called a subacute cough
Acute Cough
due to VRI- fever, nasal congestion and sore throat help dx
Dyspnea- more serious disease,
Prominent natural cough= Asthma
persistent with phlegm= CPOD
posttussive emesis/inspiratory whoop= pertussis
Persistent and chronic Cough
Pertussis should be considered in adults/teens with severe cough more than 3 weeks
ACE inhibitors
Asthma, GERD, postnasal drip,
dyspnea not likely
Excessive mucous with chronic cough = COPD
Dry eyes with chronic cough= Sjogren Syndrome
Chronic dry may be idiopathic pulmonary fibrosis
Physical Exam for Cough
Vital sign abn? (fever, tachy, tachypnea- PNA)
airspace consolidation? (crackles, decreased, - CPNA)
Purulent Sputum- Bacterial infections in structural lung disease
Wheezing/Rhonchi- bronchitis
Chronic cough- COPD vs HF vs sinusitis
Treatment for acute cough
Target underlying issue
Flu- oseltamivir/sanamivir
Mycoplasma/Chlamydophlia-erythomycin/zithromax
bronchitis w/ wheezing- inhaled agonist therapy
Persistent and Chronic Cough tx
evaluation and management require multiple visits and trials
Pertusis- Macrolide abx early, tx does not help the cough if tx pass 7-10 of onset
Empiric therapy for nasal drip, asthma, GERD
When empiric fails- consider other causes
When to refer with cough
Failure to control cough following empiric tx trials
recurrent symptoms
When to admit with cough
High risk TB with noncompliance with precautions
Urgent bronch due to foreign body
smoke/toxic inhalational injury
gas exchange impaired by cough
high risk for barotrauma- pneumothorax
Community-acquired pneumonia- CAP Risk Factors
advanced age, alcoholism, tobacco, comorbid medical conditions (asthma/COPD), immunosuppression
CAP definition
Occurs when a defect in pulmonary defense system- cough reflex, mycocilary clearance system, immune response- or when a large infectious incoculum or a virulent pathogen overwhelms immune response
INFECTED Parenchyma
CAP Pathogenesis
30-60% of cases fail to identify cause
Bacterial: S. Pneumoniae, H. Flu, M Pneumoniae, C, pneumoniae, S aureus, Klebsiella, Legionella
Viruses- Corona, Flu, adenovirus, parainfluenza, respiratory syncytial
Signs and Symptoms of CAP
Acute/subacute fever, cough w or w/out sputum, dyspnea, Chest pain, Headache, fatigue,
Common physical findings: hypothermia, tachypnea, tachy, desaturation, crackles, bronchial breath sounds, dullness to percussion, AMS- esp with elderly
Diagnostic testing- CAP
Typically not required for ambulatory patients, empirical treatment almost always works
Xray is Gold standard
Lab work- WBC
leukocytosis
COVID/FLU
Sputum gram stain
Urinary antigen test s. pneumonia and legionella species
Treatment of Viral CAP
start within 48 hours of illness
*oesltamtivir 75mg x5 days
*Baloxavir 40-79 kg 40 mg x1 and >80kg 80mg x1
*IV Peramivir 600mg x1
*Zanamivir 10mg 2 inh BID x5 days- (don’t use with asthma=bronchospasm)
Outpatient management of Bacterial CAP
Healthy with no risk factors for MRSA/pseudomonas
*amoxicillin- 1g TID
*doxy 100mg BID x 5 days
*Macrolidies- Zithromax- 500mg x1 day then 250mg/x4 days
Clarthromycin 500mg BID x 5 days
Cormorbid medical conditions
*Macrolide or doxy plus oral beta-lactam
*mono-therapy with fluoroquinolone
*Moxifloxacin 400mg/d, Gemifloxacin 320mg/day, levofaxacin 750mg/d
Indications of Hospitalization for CAP
Severe illness- Resp compromised
inability to take oral fluids
poor compliance with medications
Substance abuse
cognitive impairment- Always
poor living situation or social support
inadequate finical resources
Prevention of CAP
Vaccine- Pneumovax 23 & Prevanr-13
Flu vaccine
Covid Vaccine
Anaerobic Pneumonia
history of aspiration, poor dentition, foul smelling purulent sputum, infiltrate in dependent lung zone- body position at time of aspiration determine zones of lungs,
Anaerobic PNA Path
Prevotella melanginigenica, peptostreptococcus, fusobacterium, neucleatum, and Bacteroids
Clinical signs of Anaerobic PNA
Constitutional symptoms and cough with expectoration of foul smelling sputum.
Dentition is poor
Imaging- lung abscess & necrotizing pneumonia & empyema
Anaerobic PNA- Treatment
Betalactam/lactamase inhibitor combined with carbapenem or clindamycin. Second line is penicillin and metronidazole and typically for 3 weeks
Thoracic surgery referral for large/non-resolving abscesses
Pulmonary Venous Thromboembolism
VTE- referred to as PE
can be caused by air, amniotic fluid, fat, foreign bodies, parasite eggs, septic emboli, tumor cells,
most common from venous system in the deep veins of lower extremities
Sign & Symptoms of VTE
depend on size and preexisting cardiopulmonary status,
dyspnea and pain (pleuritic chest pain), hemoptysis, syncope, tachy, tachypnea, hypoxia
Lab findings VTE
ECG
ABG
D-dimer
Imaging and special exam for VTE
Chest radiography
Pulmonary CT-angio- GOLD STANDARD
Ventilation-perfusion
Venous thrombosis studies- US
Pulmonary angio
WELL score/ PERC
Treatment for VTE- Anticoagulation
Mainstay for VTE- considered even before a confirmed diagnosis with low risk of bleeding. unfractionated heparin, Direct acting oral anticoagulants- First line
Measure d-dimer a month after stopping treatment, duration of anticoagulation depends on risk factors for recurrence
Pleuritis
pleuritic pain due to inflammation of the parietal pleura pain is localized, sharp and fleeting, made worst by cough, sneezing, deep breathing, and movement,
Causes- VRI, PE, inflammatory disorders, malignancy,
Tx- underlying condition and NSAIDs
Pleural Effusion
abnormal accumulation of fluid in the pleural space: Transudates, exudates, empyema, hemothorax
Transudates
Increased production of fluid in the setting of normal capillaries due to increased hydrostatic or decreased oncotic pressure- HF, Cirrhosis, Nephrotic syndrome, peritoneal dialysis, myxedema, atelectasis, constrictive pericarditis, superior vena cava obstruction, PE
Exudates
increased production of fluid due to abnormal capillary permeability; decreased lymphatic clearance of fluid from the pleural space- PNA, CA, PE, bacterial infection, TB, Infections, asbestos, and more…
Empyema
infection in the pleural space
hemothorax
bleeding in the pleural space
Diagnostic Thoracentesis- Pleural effusion
done when there is a new pleural effusion without cause
S&S of pleural effusion
dyspnea, cough, respirophasic chest pain, physical signs may not be present in small effusion, larger effusion will have dullness, diminished or absent breath sounds, massive effusions will cause trachea shift and bulging in intercostal space
Treatment of pleural effusion
Transudative- Underlying disease
Malignant pleural effusion- no tx or therapeutic tx
Parapneumonic- Uncomplicated- no tx just treat PNA, Complicated- to drain or not drain, Empyema- should be drained
Hemothorax- observation or tube
Pneumothorax
Accumulation of air in pleural space- Spontaneous (primary/secondary), traumatic, iatrogenic, tension
Primary Spontaneous Pneumothorax
occurs in absence of underlying lung disease- tall, thin, men, young age, occur from rupture of sub-pleural apical blebs in response to high negative intrapleural pressure, cigarettes correlated so are connective tissue disease
Secondary Spontaneous Pneumothorax
complication of preexisting pulmonary disease, COPD, interstitial lung disease, asthma, Cystic fibrosis, TB, pneumocystis PNA, and more
Traumatic Pneumothorax
penetrating or blunt trauma and includes iatrogenic caused by a procedure
Tension Pneumothrax
pressure of air in the pleural space exceeds alveolar and venous pressure throughout the respiratory cycle, resulting in compression of lung and reduction of venous return to hemithorax
Clinical S&S Pneuomthorax
Acute unilateral chest pain and dyspnea, cough, if large- diminished brother sounds, decreased tactile fremitus, decreased movement of chest, hyper-resonant percussion note,
Treatment of Pneumothrax
depends on severity, observation vs aspiration of air vs small bore chest tube
Hyperventilation syndrome
increased alveolar minute ventilation leads to hypocapnia can be caused by pregnancy, hypoxemia obstructive and infiltrative lung disease, sepsis, lever dysfunction, fever and pain, can be acute or chronic
Acute hyperventilation
Hyperpnea, anxiety, parenthesis, carpopedal spasm and tetany
Chronic Hyperventilation
nonspecific symptoms- fatigue, dyspnea, anxiety, palpitations and dizziness, dx established only if symptoms are reproduced during voluntary hyperventilation, tx- pursed lips breathing, rebreathing expired gas, anxiolytic drugs can help
Obesity- Hypoventilation Syndrome
Pickwickian Syndrome
result from combination of blunted ventilatory drive and increased mechanical load opposed upon chest due to obesity
tx: weight loss and avoid sedative hypnotic, opioids, alcohol and NIPPV
Obstructive Sleep Apnea in adults
upper airway obstruction during sleep when loss of normal pharyngeal muscles tone allows pharynx to collapse passively during inspiration, Risk factors: anatomically small airways (obesity, tonsillar hypertrophy), alcohol, sedatives, nasal obstruction of any type, hypothyroidism and smoking,
Sleep Apnea S&S
Middle age men, excessive daytime fatigue, cognitive impairment and recent weight gain and impotence, loud cyclical snoring, breathing cessation, restlessness, thrashing movements,
Studies for dx of Sleep Apnea
polysomnography
otorhinolaryngologic exam
RSV- Respiratory syncytial virus
paramyxovirus that has annual outbreaks in the winer
Major cause of morbidity and mortality at extreme ages and no vaccination is available
Bronchiolitis, proliferation and necrosis of bronchiolar epithelium causing obstruction from sloughed epithelium and increased mucus secretion
RSV Risk factors
Prematurity & bronchopulmonary dysplasia
comorbid conditions
immunocompromised
S&S of RSV
signs of infection- low grade fever, tachypnea, wheezes
Apnea
hyper-inflated lungs, decreased gas exchange, and increased work of breathing
Pulmonary hemorrhage is reported
Lab Findings for RSV
Rapid dx is done by viral antigen identification of nasal washing using ELISA or immunofluorescent assays; PCR rapid test
Treatment of RSV
supportive care; hydration, humidification, abx if PNA is present,
HIGH RISK- treatments are available in hospital
Human Metapneumovirus
Paramyxoviruses
Late winter- early spring
presents as mild upper to severe lower respiratory tract infection
Lower respiratory tract infection seen among immunocompromised and elderly- nursing homes
PCR dx this
Human Parainfluenza viruses- HPIVS
Paramyxovirus, commonly seen in children and cause of croup (HPIV-1 and 2). HPIV-3 bronchiolitis and PNA, type 4 is rare.
Can cause serve disease in elderly, immunocompromised and chronic illness
PCR, ELISA and immunofluorescence are used for detection
Nipah Virus
Paramyxoviruses
Mostly in south Asia- fruit bats are host
causes acute encephalitis with high fatality rate
respiratory symptoms are present but more neuro
Dx with ELISA and PCR
Seasonal Influenza
highly contagious disease transmitted by droplet
three types A-C
S&S of Flu
Incubation is 1-4 days
fever, chills, headache, malaise, myalgia, rhinorrhea, congestion, pharyngitis, hoarseness, nonproductive cough, substernal soreness
Fever can last 1-7 days
Elderly can present with confusion, without fever or respiratory symptoms
Lab findings of FLU
rapid influenza from nose or throat swabs
empirically treatment is recommended even without testing
Complications of influenza
Hospitalization due to viral pneumonitis and severe hypoxemia- high risk for 65 and older, obese and chronic conditions
Pregnant people at high risk
necrosis of respiratory epithelium and can cause bacterial PNA
MI, CVA, sudden death,
Reye Syndrom
Treatment of Influenza
Supportive
Antiviral- recommenced to start at 48 hours of illness
*oseltamivir- 75mg BID x 5 days
*Inhaled Zanamivir
*Baloxavir
Prognosis of Influenza
duration is 1-7 days of uncomplicated illness
Fatalities are related to bacterial PNA
Prevention of Influenza
Annual administration of influenza vaccine
Avian influenza
Birds are natural host
indistinguishable from seasonal influenza
Risk factors for Avian Flu
direct or indirect exposure to infected live or dead poultry or contaminated environments
Clinical Signs and Symptoms of Avian FLU
Similar to influenza
fever with lower respiratory symptoms, gastrointestinal symptoms with H5N1
conjunctivitis with H7
Lab findings for Avian Flu
commercial rapid antigen test are not sensitive to detect and should not be used ti be definitive test, RT-PCR assays are available through hospitals and state health department,
Positive test must be forwarded to state health departments
Treatment of Avian Flu
Treatment as soon as possible
Antivirals
*oseltamivir
Prevention of Avian Flu
avoidance of exposure
Adenovirus Infections
60 serotypes
self-limited and clinically inapparent
morbidity and mortality in immunocompromised
S&S of adenovirus
incubation 4-9 days
rhinitis, pharyngitis, mild malaise without fever, conjunctivitis, non streptococcal exudative pharyngitis with fever for 2-12 days, and lower respiratory infection may occur
specific adenoviruses have specific symptoms
Lab Findings of adenovirus
antigen detection with direct fluorescence assay or enzyme immunoassay are rapid
PCR is required for negative assay
CT/xray- multifocal consolidation or ground glassy opacity without airway inflammatory findings
Treatment for adenovirus
symptomatic
Ribavirin or cidofovir in immunocompromised with some success
no vaccine for general use just military personal
Pneumonococcal PNA
Pneumococcus is the most common cause of CAP
Risk factors of Pneumococcal PNA
Alcoholism, asthma, HIV, SS, splenectomy, hematologic disorders
Mortality rates are high with advanced age, multi lobar disease, hypoxemia, extra pulmonary complications and bacteremia
S&S of Pneumococcal PNA
high fever, productive cough, occasional hemoptysis, pleuritic chest pain, rigors at the start but uncommon later on, bronchial breath sounds are early sign
Lab findings for Pneumococcal PNA
Leukocytosis or leukopenia
dx requires culture- sputum or blood
rapid urinary antigen test for streptococcus
Imaging for Pneumococcal PNA
Lobar PNA with consolidation and occasionally effusion
Treatment for Pneumococcal PNA
Empiric treatment until identification
Uncomplicated: amoxicillin, cephalosporin, Zithromax, or clarithroymcin, doxy, levoquin, moxifloxacin
complicated: augmentin or cephalosporin PLUS doxy or macrolide or mono-therapy with fluoroquinolone
Prevention of Pneumococal PNA
Vaccine and smoking cessation
When to Refer/admit for pneumoncall PNA
suspected endocarditis/meningitis
seriously ill
failure to improve on abx
mulit-lobar
inability to take in fluids
high risk scores- PSI, CURB-65
Bordetella Pertussis Infection
Whooping cough- gram negative
predominantly infants under 2, adolescents and adults are reservoirs for infection
transmitted by droplets, incubation 7-17 days
Bordetella Pertussis symptoms
pertussis last 6 weeks and is divided into 3 stages,
Catarrhal stage: insidious onset, lacrimation, sneezing, coryza, anorexia, malaise and hacking nigh cough and becomes diurnal
paroxysmal stage: burst of rapid consecutive coughs followed by deep, high pitched inspiration,
convalsecent stage: 4 weeks after onset with a decrease in coughing
Lab findings for boretella pertussis
WBC elevated
dx is make from nasopharyngeal culture on special median
polymerase chain reaction assay for B pertussis available at some health departments
Prevention of Bordetella Pertussis
Acellular pertussis vaccine for all infants- combined with diphtheria and tetanus
High risk receive prophylaxis with oral macrolide
pregnant woman must receive Tdap
Treatment of Bordetella Pertussis
start on all suspected cases
erythromycin, azithromycin, clarithromycin, Trimethoprim sulfamthazazole,
Treatment shortens duration of carriage and diminish the severity of coughing
Meningococcal Meningitis
Caused by Neisseria Meningitidis groups A,B,C,Y and W-125
Group C most common in US
Transmitted by droplet
S&S of Meningococcal meningitis
High fever, Chills, Nausea, vomiting, headache with back, abd and extremity pains
rapidly developing confusion, delirium, seizures, and coma
examination- nuchal and back rigidity, + kernig and brudzinski signs, petechial rash appearing all over the body and may become gangrene and may slough off later
Lab finding for Meningococcal meningitis
LP- reveals cloudy or purulent CSF with elevated pressure and increased protein and decreased glucose content
Gram-negative intracellular diplococci in a smear or cx of CSF
Prevention of Meningococcal Meningitis
Vaccines
eliminating nasopharyngeal carriage
Treatment of Meningococcal Meningitis
ER needed
LP and IV abx
Haemophilus Species infections
H.Flu and other Haemophilus species cause sinusitis, otitis, bronchitis, epiglottitis, pneumonia, cellulitis, arthritis, meningitis, and endocarditis,
colonizes in COPD and causes purulent bronchitis
Legionnaires Disease
often immunocompromised, smoke
cigarettes or have chronic lung disease
3-4 most common CAP causes
associated with contaminated water sources and air conditioning cooling towers
S&S of Legionnaires disease
atypical PNA but looks like a normal PNA
High fevers, toxic appearance, pleurisy, grossly purulent sputum, n/v/d and relative bradycardia
Lab finding of Legionnaires disease
hyponatremia, hypophosphatemia, elevated liver enzymes, elevated creatine kinase
CX of legionella
Urine antigen less sensitive
Treatment for Legionnaires Disease
Macrolides or fluoroquinolone
NOT erythromycin
duration 10-14 days unless immunocompromised then 21 days
What represent hypoxemia in infants
Tachypnea, decreased sensorium, inconsolability, increased respiratory effort, retraction, poor color, reduced movement
What environmental hazards to avoid for children?
Outdoor air pollution, indoor pollution, diesel exhaust, household fungi (mold)
first, second and third hand smoke
ozone exposure
pet, cockroaches and mice infestation
Extrathoracic/Upper airway obstruction
disrupts inspiratory phase of respiration and manifest by stridor or noisy breathing
different dx for extrathoracic obstruction
congenital abn, viral infections including croup, and foreign-body aspiration
Intrathoracic obstruction or small airways
disrupts the expiratory phase of respiration and is often manifest by wheezing and prolongation of expiratory phase
different dx for intrathoracic obstruction
infection, acquired extrinsic compression, chronic lung diseases causing inflammation such as disorders of mucociliary clearance, dysphagia with aspiration, asthma
Fixed obstructions
disrupt every breath, and abn breath sounds are consistent, can in intrinsic or extrinsic and are often associated with anatomic abn that are fix with surgery
Variable obstruction
abn sounds with breathing that are softer/absent with normal quiet breathing and sound different with every breath, often due to dynamic changes in the airway caliber and happen in laryngomalacia, tracheomalacia, or bronchomalacia
Laryngomalacia
congenital disorder where the cartilaginous support for the supraglottic structures is underdeveloped, most common cause of variable extra-thoracic airway obstruction
Laryngomalacia Manifestions
Intermittent stridor infants, within the 1st 6 weeks, worse in supine position, increased activity, crying, infections or during feedings
Benign and resolves by age 2, severe symptoms may need larynscopy and a supraglottoplasty
Croup
infectious upper airway obstruction
affects 6m-5ys fall and early winter and caused by parainfluenza virus serotypes and M pneumoniae
S&S of Croup
barking cough, stridor and laryngitis,
no fever, mild disease only stridor when agitated, severe disease- retraction, air hunger, cyanosis and hypoxemia
Imaging of Croup
Neck radiographs- even though not routinely needed
shows subglottic narrowing w/out irregularities seen in tracheitis and normal epiglottis
Treatment of Croup
Based on symptoms
Mild- supportive therapy & oral fluids
While stridor at rest requires active intervention- O2, nebulized raemic epinephrine, dexamethasone, Refer
Epiglottitis
HiB vaccine has decreased this
Pathogenesis HFLu and streptococcus
High fever, dysphagia, drooling, muffled voice, retractions, cyanosis and soft stridor
“dog sniffing position”
REFERAL TO ER needs intubation
Bacterial Tracheitis
Pseudomembranous croup
Severe and life threatening
Pathogenesis- Staph Aureus most common
presents like normal viral croup but no improvement and develops high fever and severe upper airway obstruction
Left shift will be present
REFERAL
Foreign Body Aspiration
significant cause of death each year,
signs- coughing, wheezing, choking
6m-3yrs highest risk
inappropriate foods are mostly the cause
Dx of complete obstruction- choking
inability to vocalize or cough and cyanosis with marked distress
Dx of partial obstruction- choking
drooling stridor and ability to vocalize
Treatment of foreign body aspiration
prevention
blind finger swipe NO
jaw thrust and foreign body removed carefully, persistent apnea and inability to achieve proper ventilation- ER
Lower airway- bronch followed by b-adrenergic neb to treat bronchospasm/clear mucous
Viral PNA/Bronchiolitis
most common cause of CAP
RSV, human rhinovirus, adenovirus, parainfluenza, influenza, coronavirus, human metapneumovirous
S&S of viral PNA/bronchiolitis
upper resp infection proceeds lower
wheezing and stridor
similar to bacterial PNA
prolong expiratory phase and wheezing with bronchiolitis
lab findings for viral PNA
rapid viral diagnostics- fluorescent antibody, enzyme linked immunosorbent assay, PCR
WBC not helpful
Imaging for viral PNA
not indicated for children with b/l symmetrical findings,
nonspecific and typically included hyperinflation, peribronchial cuffing, increases interstitial markings, atelectasis
complications of viral PNA
predispose for bacterial tracheitis, development os asthma, chronic hypersensitivity PNA
Treatment for viral PNA
treated outpt but may need hospitalization of hypoxemia or resp distress
supportive treatment
mycoplasma PNA
M. Pneumoniae cause of symptomatic PNA, incubation period is slow- 2-3 weeks and onset of symptoms are slow
extra-pulmonary symptoms may be present and suggest this
S&S of Mycoplasma PNA
Fever, cough, headache, malaise,
cough is dry at first put sputum sets in as disease progresses, sore throat, otitis media/externa and bullous myringitis
Rales and chest pain with decreased breath sounds or dullness to percussion
Lab findings for Mycoplasma PNA
PCR is gold standard
EIA
IgG
Chest imaging- interstitial or bronchopneumonic infiltrates frequently in middle or lower lobes
Complications of Mycoplasma PNA
Extra-pulmonary involves the blood, CNS, skin, heart, and joints
Direct Coombs autoimmune hemolytic anemia
Treatment for mycoplasma PNA
Macrolide for 5-10 days or Ciprofloxacin
supportive measures
CAP PNA in childern
Most common is streptococcus pneumoniae
usually follows viral lower respiratory tract infections
S&S of CAP in Childeren
Severity, age and pathogen dependent
Fever, tachypnea, cough, resp distress and hypoxemia are signs of more severe
Crackles, and decreased breath sounds
May have extrapulmonary symptoms- abd pain. otitis media, sinusitis or meningitis
LAB and Film Studies for CAP in Children
xray helpful but not specific to bacterial PNA
PCR not indicated unless it changes the management of the disease
Treatment of CAP in Childeren
Empiric abx
amoxicillin 50-90mg/kg/day /by 3 doses a day
cephalosporin alternative
duration 7 days,
supportive treatment
Sleep disordered breathing- SDB
abn resp pattern which includes noisy breathing, mouth breathing, and/or pauses that have obstructive, central or mixed etiology
This is a presumptive dx where a PSG is needed to characterized the specific disease
Why evaluate SDB?
decreased concentration, impairs growth, causes cardiovascular complications, and systemic inflammation
Obstructive Sleep apnea
incidence of this in children increase with medical conditions such as obesity, cranifacial abn, neuromuscular disease, genetic syndrome (ss, trisomy 21) or use of medications (hypnotics, sedatives, anticonvulsants)
S&S of OSA in children
Night- habitual snoring along with gasping, pauses or labored breathing, night terrors, sleep walking, secondary enuresis, morning headaches
Morning- unrefreshed sleep, ADHD, emotional lability, temperamental behavior, poor weight gain, poor school performance, recurrent falling asleep in school and day time fatigue, mouth breathing or dysphagia
OSA dx studies in children
Screen all children for snoring and referral for PSG- gold standard
Treatment OSA in children
Mild- nasal steroids and leukotriene inhibitors
Adenotonsillectomy even without PSG
Severe- Cannot do AT- then Cpap or Bipap
Brief Resolved unexplained events- BRUE
replaced ALTE which replaced near-miss SIDS, infants younger than one year who are observed to have apnea or irregular breathing, cyanosis, or pallor or decease responsiveness that last less than 1 minute and returns to baseline with subsequent reassuring history and physical examination
BRUE lab findings and imaging
low risk- no inpatient observation needs or further testing- may consider infections, ECG, Pulse ox,
High risk- undergo thorough evaluation- hospitalized, blood work, ABG, cont pulse ox, infection testing, cxr, FEES, Upper GI, PSG
Treatment of BRUE
Directed at underlying cause,
educate caregivers and teach CPR,
SIDS
sudden unexpected death of infant or child that remains unexplained after a thorough case inestigation
SUID
sudden unexpected infant death whether explained or unexplained, like accidental suffocation or strangulation, infection, ingestion, metabolic disease, cardiac arrhythmias, and trauma
SIDS/SUIDS epidemiology and Pathogenesis
Peak btw 2-4 months
recent immunization is not a risk factor
delayed maturation of brainstem may be cause
Risk factors- prone positioning, bed sharing, preterm birth, low birth weight, recent infection, young maternal age, high maternal parity, maternal smoking/drug use, crowed living conditions
Prevention of SIDS/SUIDS
Back to sleep, sleep in parents room but not bed-sharing for first 6 months, no soft objects/loose bedding, zip up blankets, no covering face, breast feeding, pacifier at bedtime and naps, no cigarette smoke, no car seats/swings/slings for sleep,
Adenoviruses
50 types,
usually pharyngitis or tracheitis
droplets
winter and spring
Adenoviral Pharyngitis
Most common, fever and adenopathy are common, tonsillitis may be exudative, rhinitis and flu like systemic illness may be present, often laryngotracheitis/bronchitis accompany
Pharyngoconjunctival Fever- Adenoviruses
Conjunctivitis may occur alone and be prolonged but mostly occur with preauricular adenopathy, fever, pharyngitis, and cervical adenopathy.
Feeling of something in eye and other symptoms last less than a week
PNA- adenovirus
severe PNA can happen at any age, CXR- b/l per bronchial and patchy ground-glass interstitial infiltrates in lower lobs,
symptoms last for 2-4 weeks
can be necrotizing and cause permeant damage
pertussis like syndrome with cough, lymphocytosis
GI disease- adenoviruses
Enteric adenoviruses- 40/41- short lived diarrhea in afebrile child, Mesenteric lymphadentitis and abdominal pain mimic appendicits and pharyngitis is often associated
Adenoviruses other syndromes in children
AOM
morbilliform
encephalitis
hepatitis
myocarditis
Lab and Dx testing in adenoviruses in children
PCR- Resp/conjunctival/stool
Treatment adenovirus in children
immunocompromised with cidofovir- watch kidney function
IVIG for immunocompromised
Influenza in children
higher outbreaks in children due to lack of immune system
Seasonal- late fall through spring
Airborne
S&S of Flu in children
older kids similar to adults
Fever, diarrhea, vomiting , and abd pain common in young childern
infants- sepsis like illness and apnea
acute illness last 2-5 days
Lab findings flu in children
leukocyte normal to low with variable shift
PCR
Complications of Flu in children
hospitalization high in <2 where flu can cause croup
secondary bacterial infections are common
viral/postviral encephalitis
sever rhabdolmyolysis and kidney failure reported
Prevention of Flu in children
Flu vaccine
prophylaxis tamiflu in select children
Treatment for Flu in children
supportive measures and management of pulmonary complications
antivirals if started within the first 48 hours
Parainfluenza in children
most important cause of croup
4 types are known
1-2 cause croup
outbreaks in fall and winter
Parainfluenza in children S&S
febrile URI, laryngitis, tracheobronchitis, croup, and bronchiolotis,
Croup- Barking cough, inspiratory stridor and hoarseness
Lab for parainfluenza in children
dx is based on clinical findings and testing is not recommend but can be identified by PCR, rapid culture, direct immunofluorescence in resp secretions
Treatment for Parainfluenza in children
croup management, no vaccine, no therapy,
RSV in children
most important cause of lower respiratory tract illness, late fall to early spring,
No vaccine avaible
S&S of RSV in children
initially starts like upper resp infection, low grade fever, bronchiolitis- wheezing, variable fever, cough, tachypnea, difficulty feeding, and in sever cases cyanosis.
Hyperinflation, crackles, prolong expiration, wheezing, hypoxia, and retractions may be present.
Labs and Imaging of RSV in children
diagnostic testing is not necessary during RSV season, PCR, ELISA, rapid tissue culture
cxr- hyperinflation and peribronchiolar thickening
Complications of RSV in children
infects middle ear
resp failure is uncommon and cardiac failure may occur as a complication of pulmonary disease or myocarditis
Prevention and treatment of RSV in children
If hypoxic or cannot feed because of resp distress then- ER
Support management
No albuterol or epinephrine or steroids
Ribavirin only antiviral for RSV- rarely used
Human Metapneumonovirus (HMPV) in children
Similar to RSV
common symptoms- fever, cough, rhinorhea and sore throat, wheezing
PCR can recognize
no antiviral treatment
supportive only
Human Coronaviruses in children
common cold limited to upper respiratory signs and symptoms
lower resp tract disease and severe acute resp syndromes
PNA in immunocompromised children
dx by PCR
tx- remdesivir
Prevention- Vaccine
Enteroviruses in children
Major cause of acute febrile illness
from the family of picornaviruses
PCR for dx or culture
responsible for severe infections- sepsis and meningitis
Transmission oral-fecal or resp secretions
Acute febrile illness
nonspecific upper respiratory or enteric symptoms with sudden onset of fever and irritability
usually enteroviral infections
petechial rash
rapid recovery
duration 4-5 days
Acute Febrile Pharyngitis
sore throat, HA, myalgia, abd discomfort lasting 3-4 days
vesicles may be seen on pharynx
Cause enteroviruses
Herpangina
acute onset fever and posterior pharyngeal grayish white vesicles that form ulcer
dysphagia, drooling, vomiting, abd pain and anorexia symptoms disappear 4-5 days
Pleurodynia
Caused by coxsackie virus or non polio enteroviruses
abrupt onset of unilateral or b/l spasmodic pain over the lower ribs or upper abd
HA, fever, vomiting, myalgia and abd and neck pain
last less than a week
is a disease of the muscles
Pneumococcal Bacteremia
High fever and Leukocytosis >150000
Manage with oral abx or if severly ill then admit to hospital
Pneumococcal Pneumonia in children
fever, tachypnea, without auscultatory signs are usual presenting signs, resp distress and abd pain are common
older children the adult form is present
Chest pain, localized or diffuse rales
cxr- lobar infiltrate with effusion
dx blood cx or urine
Treatment: Mild PNA- amoxicillin or cephalosporin or fluroquinolones
Pneumococcal Meningitis in children
Fever, irritability or severe lethargy, convulsion and neck stiffness
Admit in hospital
LP necessary
H. Flu infections in children
can cause meningitis, bacteremia, epiglottis, septic arthritis and facial cellulitis
Vaccine available
All patient need to be hospitalization
Acute epiglottis- dysphagia, fever, drooling, poor feeding, Stridor is late
Bordetella Pertussis- Whooping Cough
highly communicable infection
characterized by severe bronchitis
S&S of Pertussis in children
3 stages
Catarrhal- rhinitis, sneezing, irritating cough 2 weeks
Paroxysmal- forceful cough ending with loud inspiration- coughing have cyanosis, sweating, prostration and exhaustion 2-3 weeks
Convalescent- paroxysm gradually lessens to a gradual recovery
Lab findings of Pertussis in children
PCR and culture- 1st 3 weeks
WBC elevated
Treatment of Pertussis in children
Abx early- dont wait on culture in highly likely cases
zithromax 10mg/kg/dose x1 day and the 5mg/kg/day x4 days
erythromycin can be given for 14 days- has been reported to give pyloric stenosis in <1m old use zithromax instead- less likely to happen
Chlamydia Trachomatis
Neonatal conjunctivitis and PNA
