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.
