Pediatric cough Flashcards
Nasal congestion with discharge, sneezing, cough and sore throat is called _________ and is commonly caused by ______ .
Nasopharyngitis (common cold)
Caused by:
- Rhinovirus
- Influenza virus
- Parainfluenza virus
- RSV
- Coronovirus
The common cold is a self-limited syndrome resolving in 1 to 1.5 weeks usually from an upper respiratory virus infection causing rhinitis, pharyngitis, nasal congestion, sore throat, cough, and malaise. It is clinically diagnosed and management involves treatment of symptoms with NSAIDs for pain, antihistamines, decongestants, and if severe Dextromethorphan.
What is the most common cause of a barking cough in children?
Croup (laryngotracheobronchitis).
Croup (laryngotracheitis) presents with ______ and is caused by _____
Croup (laryngotracheitis) is an upper respiratory tract infection that presents with hoarseness, barking cough, stridor, and possibly respiratory distress.
Most commonly caused by Parainfluenza virus.
A child who presents with “barking” or “brassy” cough, inspiratory stridor, hoarseness, and low-grade fever. What is the most common cause for this child’s condition?
This is likely croup, and the most common cause is Parainfluenza virus.
What are the characteristic symptoms of croup?
Fever, brassy or barking cough (seal bark), and stridor most likely has croup (laryngotracheitis), an infection of the larynx and trachea most commonly due to parainfluenza virus. Croup usually affects children age 6 months to 3 years, Patients typically have upper respiratory symptoms, such as congestion, rhinorrhea and fever before developing a characteristic barking cough, inspiratory stridor, and hoarseness. Stridor is worse with agitation (eg, crying), which exacerbates airway narrowing, and may be absent at rest. In mild croup, there is no stridor at rest. For moderate croup, stridor is appreciated at rest.
A 20-month-old girl is brought to the emergency department due to cough and fever. She had nasal congestion and a dry cough yesterday, but the symptoms are worse today. The patient developed fever overnight and the cough is now more forceful. Her father says, “She was coughing so hard that it sounded like she couldn’t breathe.” Her appetite is mildly decreased, but she has been drinking water and juice frequently throughout the day. The patient’s immunizations are up to date, and she takes no medications. Temperature is 38.1 C (100.6 F), pulse is 100/min, and respirations are 28/min. Physical examination demonstrates an awake, alert patient playing with a toy on her father’s lap. When the examiner approaches her, she cries and has an episode of harsh, brassy coughing followed by inspiratory stridor that resolves when she calms down. The nares are patent with clear rhinorrhea, the pharynx has no erythema or exudate, and the tympanic membranes are clear. S1 and S2 are present without murmurs. The lungs are clear to auscultation, but there are mild intercostal retractions. The abdomen is soft and nontender without organomegaly. There are no rashes or lesions. What is the most appropriate next step in management of this patient?
This patient with fever, brassy cough, and stridor most likely has croup (laryngotracheitis), an infection of the larynx and trachea most commonly due to parainfluenza virus. Croup usually affects children age 6 months to 3 years, with peak incidence in the fall and early winter. Patients typically have upper respiratory symptoms, such as, congestion, rhinorrhea and fever before developing a characteristic barking cough, inspiratory stridor, and hoarseness. Stridor is worse with agitation (eg, crying), which exacerbates airway narrowing, and may be absent at rest. Croup is usually a clinical diagnosis in patients with a classic presentation. Although subglottic narrowing (ie, steeple sign) on x-ray supports the diagnosis, radiographs are generally reserved for patients with atypical features (eg, unresponsive to treatment) or suspected foreign body (eg, choking episode, absent viral symptoms). Treatment of croup is based on severity. For mild croup (ie, no stridor at rest) is treated with a single dose of corticosteroids (eg, dexamethasone) to decrease airway edema and humidified air to help soften secretions and moisten inflamed mucosa. For moderate to severe croup (ie, stridor at rest) treatment is with nebulized racemic epinephrine in addition to corticosteroids. Nebulized epinephrine (nonspecific alpha-and beta-agonist) works primarily by its alpha-agonist activity via constriction of mucosal arterioles in the upper airway and alteration of capillary hydrostatic pressure, leading to decreased airway edema and reduced secretions.
What age group is most affected by croup?
Children aged 6 months to 3 years.
What season is Croup most commonly encountered?
The peak incidence is in the fall and early winter.
Which condition causes a steeple sign on x-ray?
Croup.
What is the characteristic x-ray finding in croup?
Steeple sign (tapering of the upper trachea due to subglottic narrowing).
Is a CXR required for diagnosis?
Croup is usually a clinical diagnosis in patients with a classic presentation. Although subglottic narrowing (ie, steeple sign) on x-ray supports the diagnosis, radiographs are generally reserved for patients with atypical features (eg, unresponsive to treatment) or suspected foreign body (eg, choking episode, absent viral symptoms).
How is mild croup managed?
Treatment of croup is based on severity:
- Mild croup (ie, no stridor at rest, as in this patient) is treated with a single dose of corticosteroids (eg, dexamethasone) to decrease airway edema; humidified air also helps soften secretions and moisten inflamed mucosa.
- Moderate/severe croup (ie, stridor at rest) is treated with nebulized racemic epinephrine in addition to corticosteroids. Nebulized epinephrine (nonspecific alpha-and beta-agonist) works primarily by its alpha-agonist activity via constriction of mucosal arterioles in the upper airway and alteration of capillary hydrostatic pressure, leading to decreased airway edema and reduced secretions.
What is the treatment for mild croup?
Humidified air and corticosteroids (dexamethasone).
What is the treatment for moderate to severe croup?
Racemic epinephrine and corticosteroids.
What is the most common cause for a child who previously experienced an upper respiratory infection, and now has respiratory distress, tachypnea, wheezing, and hypoxemia?
Bronchiolitis. This is a lower respiratory tract infection most commonly caused by respiratory syncytial virus that presents with nasal congestion, rhinorrhea, and cough followed by wheezing and often respiratory distress. The cause for the wheeze is secondary to bronchiolar obstruction from sloughed epithelial cells, leukocytes & mucus. Treatment is supportive and includes fluids, nasal suctioning, and supplemental oxygen when indicated.
An infant with and upper respiratory tract infection that is followed by wheezing, cough, and respiratory distress, with a household full of others who share symptoms but lack a fever, is likely ______ , which is caused by ________ .
This is likely bronchiolitis
commonly caused by
Respiratory syncytial virus (RSV).
Could bronchiolitis be caused by another other pathogen?
Yes, for example Influenza can cause bronchiolitis and apnea in infants. However, patients along with sick contacts with influenza would typically also have fever, body aches, and cough in addition to upper respiratory symptoms. Fever is not always present with bronchiolitis secondary to RSV.
What is the hallmark auscultatory finding in bronchiolitis?
Wheezing.
What age group is most commonly affected by bronchiolitis?
Children under 2 years old.
Clinical improvement in the context of bronchiolitis is measured by (1) retraction severity, (2) respiratory rate, (3) room air oxygen saturation, and (4) hydration status, which patient demographic tend to fare worse if they require hospitalization?
Children who worsened were more likely to be younger, premature infants presenting in more severe distress.
What is the common prophylactic treatment for high-risk infants to prevent RSV bronchiolitis?
Palivizumab.
What is the common prophylactic treatment for ALL infants (less than 8 months) to prevent RSV bronchiolitis?
Nersevimab.
A 5-week-old full-term boy is brought to the emergency department during winter due to intermittent respiratory pauses and cyanosis. He has had rhinorrhea and nasal congestion for the past 2 days. Over the past few weeks, the patient’s father and older sibling have had nasal congestion and rhinorrhea but no fever or cough. The boy has received the hepatitis B vaccination and no other immunizations due to his young age. His temperature is 37.1 C (98.8 F). Physical examination shows bilateral crackles and wheezes and intermittent apnea. Leukocyte count is 9,000 cells/mm’, with 60% lymphocytes and 30% neutrophils. What is the most likely etiology of this patient’s condition?
This patient’s clinical presentation in the setting of winter and household contacts with upper respiratory infection is concerning for respiratory syncytial virus (RSV) infection. RSV outbreaks cause uncomplicated nasal congestion and rhinorrhea in adults. Children age <2 years tend to have upper and lower respiratory tract involvement (eg, bronchiolitis). Infants age <2 months or those with a history of prematurity, congenital heart disease, and chronic lung disease are most susceptible to life-threatening apnea. The other pathogens to consider are Pertussis, Influenza, Mycoplasma, and Croup. Pertussis can be potentially lethal in infants due to relentless coughing fits, posttussive emesis, and apnea. Patients with pertussis typically have significant lymphocyte-predominant leukocytosis (>20,000/mm3 with ≥50% lymphocytes) and sick contacts with coughing paroxysms. Influenza can cause bronchiolitis and apnea in infants, but sick contacts with influenza typically have fever, body aches, and cough in addition to upper respiratory symptoms. Mycoplasma pneumoniae causes respiratory tract infection most often in school-aged children and young adults. The clinical presentation is usually gradual and is characterized by malaise, headache, fever, rhinorrhea, and sore throat with progression to an atypical pneumonia (eg, “walking pneumonia”). It does not normally cause bronchiolitis and is an uncommon pathogen in children age <5 years. Croup is an upper respiratory syndrome consisting of hoarseness, a barky cough, and inspiratory stridor due to upper airway inflammation. Parainfluenza virus is the most common causative organism.
What are the main symptoms of bronchiolitis?
Upper respiratory prodrome followed by respiratory distress, tachypnea, wheezing, and hypoxemia. Patients typically develop nasal congestion, rhinorrhea, and cough followed by the onset of lower respiratory signs, including wheezing and crackles. Symptoms usually peak between days 3 and 5 of illness and are often associated with increased work of breathing, including accessory muscle use (eg, retractions), nasal flaring, and grunting. Respiratory symptoms may interfere with feeding, increasing the risk of dehydration; low-grade fever may also be present.
What does the viral prodrome typically encompass in terms of symptoms when suspecting bronchiolitis as the underlying etiology?
Rhinorrhea and congestion. Patients tend to have an accompanying cough (as opposed with bacterial) and a low-grade fever (not always present, but common).
Is imaging required for bronchiolitis?
No. Radiographic studies and laboratory evaluation are not required for the diagnosis of bronchiolitis and do not change management in a patient with a classic presentation. However, a classic finding is bilateral hyperinflation, increased interstitial markings & peribronchial cuffing. Because chest x-ray findings in bronchiolitis are nonspecific (eg, patchy atelectasis, peribronchial thickening), imaging is not routinely recommended in a patient with a classic presentation of bronchiolitis, as seen in this patient.
What is the best treatment for bronchiolitis?
Supportive care with oxygen nasal suction and hydration. Antibiotics have no role in the treatment of bronchiolitis, which is typically viral, but they are indicated for signs and symptoms of a coexisting bacterial pneumonia (eg, persistent fever, focal crackles), not seen in this patient. Nebulized hypertonic saline is not generally recommended for routine treatment of bronchiolitis, as it has not been shown to consistently improve clinical outcomes or to reduce length of hospital stay. This intervention may be attempted for bronchiolitis requiring prolonged hospitalization.Systemic corticosteroids are not recommended for first-time bronchiolitis due to their lack of clinical effect. Corticosteroids can be considered in patients with recurrent wheezing or asthma exacerbation.
What are used as prophylaxis either in high-risk patients (children, premature infants, bronchopulmonary dysplasia, congenital heart disease or immunocompromised), or in infants less than 8 months, for the mitigation of RSV infection and sequelae?
Palivizumab for premature infants
Nersevimab for all children age <8 months
Why should more care for bronchiolitis be directed towards the younger aged children (<2 months)?
Infants age <2 months and those born prematurely or with cardiopulmonary disease are at greatest risk for apnea and/or respiratory failure during peak symptoms (~5 days). In contrast, older, full-term, healthy infants and young toddlers typically recover with no acute complications.
What bias is implicated here: After symptom resolution, bronchiolitis caused by respiratory syncytial virus (RSV) is associated with an increased risk of recurrent wheezing in early childhood, affecting up to 30% of HOSPITALIZED patients. Parents should be counseled on minimizing potential triggers of airway hyperreactivity, such as secondhand smoke exposure, to reduce the risk of recurrent wheezing.
This assessment regarding hospitalized children for bronchiectasis is true, and a worthy fact to discuss with the parents of these pediatric patients. Yet, “hospitalization” is sort of a misnomer simply for the fact that the study primarily focused on hospitalized patients and found that apnea is more common with patients at this age (<2 months). This is classic selection bias, and limits generalizability. Regardless of any bias, following the resolution of symptoms, bronchiolitis caused by respiratory syncytial virus that requires hospitalization is indeed associated with the development of recurrent wheezing in early childhood in up to 30% of patients, therefore, parents should be advised to limit avoidable triggers of airway reactivity (eg, exposure to secondhand cigarette smoke). It is important to note that children older, full-term, healthy infants and young toddlers (~3 years) typically recover with no acute complications, yet, there is a 30% chance of experiencing long effects, such as wheezing, if they were hospitalized.
Does ribavirin have any efficacy towards bronchiolitis?
Although ribavirin has in vitro activity against RSV, its efficacy has not been proven, and therefore it is usually reserved for immunocompromised patients with severe disease.
What bacteria causes pertussis?
Bordetella pertussis.
What are the three stages of pertussis?
Catarrhal (mild flu-like)
Paroxysmal (severe coughing fits with whoop and post-tussive emesis)
Convalescent (gradual resolution)
How is pertussis diagnosed?
PCR or culture (if <4 weeks of symptoms), serology (if >4 weeks of symptoms).
Pertussis can be potentially lethal in infants due to relentless coughing fits, posttussive emesis, and apnea. Patients with pertussis typically have significant lymphocyte-predominant leukocytosis (>20,000/mm^3 with ≥50% lymphocytes) and sick contacts with coughing paroxysms.
What is the treatment for pertussis?
Macrolides (azithromycin).
What is the prophylaxis for pertussis?
Macrolides for close contacts, even if asymptomatic.
What is the most common cause of epiglottitis in vaccinated children?
Group A Streptococcus. In unvaccinated children, the most common pathogen is Haemophilus influenzae.
What are the characteristic symptoms of epiglottitis?
High fever, drooling, dysphagia, respiratory distress, and tripod positioning.
What is the best way to diagnose epiglottitis?
Direct visualization of the epiglottis or x-ray showing the ‘thumbprint sign’.
What childhood respiratory infection presents with sudden high fever, drooling, and tripoding?
Epiglottitis.
Which childhood respiratory condition is worsened by lying supine and improved with sitting up?
Epiglottitis.
Which condition causes a thumbprint sign on x-ray?
Epiglottitis.
Does epiglottitis have any obvious pharyngeal signs?
Lateral neck radiography in epiglottitis reveals a classic “thumbprint sign” due to the edematous epiglottis. However, the diagnosis is usually made based on clinical presentation due to impending respiratory arrest, so intubation should be performed prior to obtaining radiographs. The clinical signs of epiglottitis are fever, dysphagia, severe sore throat, and muffled voice, pharyngeal findings are typically normal.
What is the immediate management for suspected epiglottitis?
Airway management and broad-spectrum IV antibiotics (ceftriaxone + vancomycin). Epiglottitis is a potentially life-threatening emergency in children, as epiglottis edema can rapidly obstruct the trachea, resulting in respiratory arrest. Emergency airway management is the priority; therefore, preparation for endotracheal intubation is almost always the best next step. This is ideally performed in the operating room by an experienced practitioner (eg, anesthesiologist,
otolaryngologist). Intravenous antibiotics are administered only after the airway is secure.
A child appears anxious with a constellation of noisy breathing, stridor, hoarseness, high fever, and drooling, while sitting upright with the jaw thrusted forward, what is the most important consideration in management of this patient?
Secure the airway!
This condition is likely a result of infections, and epiglottitis, should first come to mind. Once common in children, epiglottitis is now rare because of the widespread utilization of vaccination against Haemophilus influenzae. Even though this condition is still rare, epiglottitis can be caused by other pathogens, such as other strains of H influenzae, Streptococcus species (S pneumoniae, S pyogenes), and Staphylococcus aureus. Most commonly glottitis is caused by group a strep.
Epiglottitis is cellulitis of the epiglottis, aryepiglottic folds, and other adjacent tissue. Swelling of these structures often leads to rapid airway deterioration. Epiglottic or supraglottic edema prevents swallowing. Early recognition of the constellation of noisy breathing, hoarseness, high fever, drooling, and the characteristic posture—sitting upright with the jaw thrust forward—may be lifesaving. Relaxation and an upright position keep the airway open. These patients must not be examined until after the airway is secured, therefore, airway management is the main priority. In patients unable to maintain adequate oxygen saturations, bag-valve-mask ventilation (BVM) with 100% oxygen (to keep oxygen saturation ≥88%) should be initiated. If BVM does not result in adequate oxygenation (ie, oxygen saturation remains low), endotracheal intubation using a video laryngoscope (to facilitate direct visualization of the epiglottis) should be attempted. Given the risk of rapid respiratory deterioration, failure of a single attempt at endotracheal intubation with a video laryngoscope should immediately prompt the establishment of a surgical cricothyrotomy by the most experienced provider available (preferably an otolaryngologist or general surgeon). Cricothyrotomy establishes an airway below the epiglottal swelling and potential obstruction.
What is given as post-exposure prophylaxis for epiglottitis?
Rifampin to close contacts.
Why is it rifampin given as post exposure prophylaxis when Haemophilus influenzae is a less common cause for epiglottitis than other causes?
Due to contagion.
What is the typical age group for foreign body aspiration?
1-3 years old.
What are the risk factors for foreign body aspiration in children?
Playing with small objects, eating while running, lack of molars.
What are the symptoms of foreign body aspiration?
Sudden onset of coughing, wheezing, stridor, and unilateral decreased breath sounds.
How is foreign body aspiration diagnosed?
Chest x-ray with inspiratory/expiratory views or CT scan if equivocal.
hyperinflation of the obstructed lobe or segment following an aspiration is due to to a … ?
ball-valve obstruction
If a ball-valve obstruction results, hyperinflation of the obstructed lobe or segment can occur and this is easier to visualize on __________ .
inspiration-expiration films
What is the management for partial obstruction?
Flexible bronchoscopy.
What is the management for complete obstruction?
Back blows (infants), Heimlich maneuver (older children), emergent rigid bronchoscopy.
Foreign bodies in the pharynx or laryngeal inlet can often be extracted by … ?
Magill forceps
These are used after laryngeal exposure with a standard laryngoscope. The patient will usually vomit, so suction is mandatory.
Bronchial foreign bodies will require ______ for removal.
Operative bronchoscopy
Occasionally, a tracheotomy will be required, such as for a patient who has aspirated a partial denture with imbedded hooks.
These patients can present as airway emergencies, although they more typically present with unexplained cough or pneumonia.
What is the most common cause of pneumonia in neonates (<1 month)?
Group B Streptococcus and E. coli.
What is the most common bacterial cause of pneumonia in children aged 1-5 years?
Streptococcus pneumoniae.
What is the most common cause of atypical pneumonia in school-aged children?
Mycoplasma pneumoniae.
Mycoplasma pneumoniae causes respiratory tract infection most often in school-aged children and young adults. The clinical presentation is usually gradual and is characterized by malaise, headache, fever, rhinorrhea, and sore throat with progression to an atypical pneumonia (eg, “walking pneumonia”). It does not normally cause bronchiolitis and is an uncommon pathogen in children age <5 years.
What is the outpatient treatment for typical bacterial pneumonia in children?
Amoxicillin.
What is the outpatient treatment for atypical pneumonia in children?
Macrolides (e.g., azithromycin).
What is the inpatient treatment for pneumonia in children?
Ceftriaxone or cefotaxime, plus a macrolide if atypical is suspected.
For chronic coughs, what is the initial step, given no real clear cut signs of underlying etiologies for the persistent cough?
Pediatric patients that have a chronic cough, which is defined as daily cough lasting >4 weeks in children (>8 weeks in adults), the initial evaluation includes a thorough history and physical examination to look for a specific underlying cause and guide management. For example, a history of choking preceding symptom onset may suggest an aspirated foreign body, and poor growth may suggest a chronic illness (eg, cystic fibrosis [CF]). In the absence of specific findings, the first step in evaluation is spirometry. This simple pulmonary function test can assess for asthma, a common cause of chronic cough in children. Although asthma may be associated with other findings (eg, wheezing, dyspnea, history of atopy), it can present with cough alone and a normal examination. Spirometry can be performed in a cooperative child (generally age >6) and, in asthma, it shows an obstructive pattern (due to bronchial inflammation and smooth muscle contraction) that is reversible with a bronchodilator (eg, albuterol). Symptom improvement following a 2-week trial of a short-acting beta agonist and inhaled corticosteroid is confirmatory. This trial can be conducted empirically (ie, without spirometry) in children unable to perform spirometry.
Children who have a cough along with progressive hoarseness with recurrence of respiratory symptoms, such as cough or dyspnea, should be evaluated using a …
Laryngoscope. The most severe condition being laryngeal papillomas. Additional symptoms include cough, dysphonia or aphonia, stridor, and dysphagia. The differential diagnosis for pediatric hoarseness can be broad. Diagnoses to consider include vocal cord pathology (e.g., vocal cord paralysis), vocal cord lesions (e.g., nodules, cysts, polyps), benign tumors (e.g., laryngeal papillomatosis), congenital lesions (e.g., laryngeal webs), laryngopharyngeal reflux, and functional (nonanatomic) disorders. Most cases of pediatric hoarseness are related to benign lesions or functional disorders. A thorough history that elicits chronicity, impact, and any associated airway symptoms, dysphagia, or reflux symptoms is critical for narrowing the diagnosis and assessing the timing of laryngoscopy. Laryngoscopy enables visualization of the larynx and is imperative to rule out more sinister
What is the first-line imaging test for foreign body aspiration?
Chest x-ray with inspiratory and expiratory views.
What would prompt evaluation for CF (sweat chloride) in a child who has been coughing for weeks?
- Failure to thrive
- Recurring pneumonia
- Evidence of pancreatic insufficiency
- Gi disturbances like constipation
What clinical sign would prompt evaluation of a chronic cough in a child using a sputum sample?
Sputum culture can be obtained for chronic cough due to suspected chronic pulmonary infection (eg, mycobacterial, fungal). However, fungi and nontuberculous mycobacteria typically affect immunocompromised patients. This might be evidenced with other symptoms like fever or weight loss, which are clear signs of tuberculosis.
