Pediatric Respiratory Infections Flashcards
Differences between pediatric patients and adults presenting with possible respiratory illness
Basics:
•Basics:
–Anatomically smaller airways
–Proportionately more soft tissue in nose and mouth
–“Obligate nose breathers” in early infancy (relatively large tongue and epiglottis): significant proportion are not able to breathe orally
–Breathe with diaphragms and can’t use intercostals and other accessory muscles very well
–Less reserve than adults: can deteriorate quickly
–The number one cause of cardiac arrest in children is respiratory arrest
Differences between pediatric patients and adults presenting with possible respiratory illness
Historical features
•Historical features
–A toddler may present with “decreased appetite” per mother’s report instead of c/o sore throat
–A neonate may present with apnea instead of respiratory distress
–Parents often describe their child as “lethargic”
Pediatric patients with possible respiratory illness
PE
• PE
–Physical exam
- Often examined in parent’s lap
- Must keep in mind vital sign normal values
- Tonsils and adenoids generally diminish in size after age 5 years
–Signs of respiratory distress
- Nasal flaring
- Grunting
- Head bobbing
- Retractions
- retractions, tachypnea, some stridor, head bobbing
Stridor vs Wheezing
Upper Respiratory Infections (Colds)
- Acute, self-limiting viral syndrome of the upper respiratory tract
- Children younger than six years have an average of six to eight colds per year (up to one per month, September through April), with a typical symptom duration of 14 days
- Young children in daycare appear to have more colds than children cared for at home. However, when they enter primary school, children who attended daycare are less vulnerable to colds than those who did not.
- Older children and adults have an average of two to four colds per year, with a typical symptom duration of five to seven days
URI cont’d: symptoms
Most Common Sxs
•Most common sxs:
–Fever may be the predominant manifestation of the common cold during the early phase of infection in young children. It is uncommon in older children and adults.
–Nasal congestion, nasal discharge, and sneezing are common in children
–Erythema and swelling of the nasal mucosa and nasal discharge. Nasal discharge may be clear initially, but often becomes colored (yellow or green) within a few days
–Cough occurs in more than two-thirds of children with the common cold
URI cont’d: symptoms
Other Sxs
•Other sxs:
Sore throat (typically an early manifestation), hoarseness, headache, irritability, difficulty sleeping, decreased appetite, cervical adenopathy, and conjunctival injection
URI cont’d
-Other URI findings
- Other URI findings
- You wouldn’t really order imaging, but if you did: self-limited radiographic abnormalities of the paranasal sinuses
- Abnormal middle ear pressures
- viral nasopharyngitis may result in Eustachian tube dysfunction and abnormal middle ear pressure, or
- abnormal middle ear pressure may result from the viral infection of the mucosa of the middle ear Eustachian tube
→ predisposes to otitis media
URI cont’d
Typical viral pathogens:
- Typical viral pathogens:
- Rhinovirus (about 30-50%)
- RSV
- Influenza
- Parainfluenza
- Nonpolio enteroviruses
- Echoviruses
- Coxsackieviruses
- Coronaviruses
- Human metapneumovirus (hMTP)
URI cont’d: transmission
- Hand contact: Self-inoculation of one’s own conjunctivae or nasal mucosa after touching a person or object contaminated with cold virus
- Inhalation of small particle droplets that become airborne from coughing (droplet transmission)
- Deposition of large particle droplets that are expelled during sneezing and land on nasal or conjunctival mucosa (typically requires close contact with an infected person)
Differential Diagnosis of URI
- Allergic, seasonal, or vasomotor rhinitis; rhinitis medicamentosa
- Acute bacterial sinusitis
- Nasal foreign body
- Inhaled foreign body
- Pertussis - classically begins with mild cough and coryza (catarrhal phase)
- Structural abnormalities of the nose or sinuses
- Influenza
- Although influenza virus may cause the common cold, it usually causes more severe illness; abrupt onset of fever (often >39°C [102.2°F]), headache, myalgia, and malaise in addition to cough, sore throat, and rhinitis
- Bacterial pharyngitis or tonsillitis
Complications of URI
- AOM
- Sinusitis
- Asthma exacerbation
- Pneumonia
- Epistaxis
- Conjunctivitis
- Pharyngitis
Epidemiologic and Clinical Features of Viruses that Cause the Common Cold in Children
Acute Otitis Media
RIsk Factors
Most common affliction necessitating medical therapy for children younger than 5 years
Risk factors
- Prematurity and low birth weight
- Young age - anatomical differences of ear canal
- Early onset
- Family history
- Race - Native American, Inuit, Australian aborigine
- Altered immunity
- Craniofacial abnormalities
- Neuromuscular disease
- Allergy
- Day care
- Crowded living conditions
- Low socioeconomic status
- Tobacco and pollutant exposure
- Use of pacifier
- Prone sleeping position
- Fall or winter season
- Absence of breastfeeding, prolonged bottle use
Otitis Media cont’d
•Most common bacterial pathogens: S pneumoniae, H influenzae, Moraxella catarrhalis
- Peak incidence 3-18 months
- Presentation
- Neonates: fussiness, poor feeding
- Older child: fever, otalgia, ear tugging
Otitis media cont’d
Treatment:
amoxicillin
80-90 mg/kg/day
Prevention:
- Avoid cigarette smoke exposure
- Avoid bottle propping (and no bottle after age 1 year)
- Tympanostomy tube placement for recurrent episodes
Otitis media cont’d
Complications:
- Intratemporal - Perforation of the tympanic membrane, acute coalescent mastoiditis, facial nerve palsy, acute labyrinthitis, petrositis, acute necrotic otitis, or development of chronic otitis media
- Intracranial - Meningitis, encephalitis, brain abscess, otitis hydrocephalus, subarachnoid abscess, subdural abscess, or sigmoid sinus thrombosis
- Systemic - Bacteremia, septic arthritis, or bacterial endocarditis
Mastoiditis
Sinusitis
- Inflammation of the mucosal lining of one or more of the paranasal sinuses.
- Acute bacterial rhinosinusitis = secondary bacterial infection of the sinuses.
Sinusitis
Predisposing factors
Predisposing factors
- URI
- Allergic rhinitis
- Anatomic obstruction
- Mucosal irritants
- Sudden changes in atmospheric pressure.
Sinusitis
Symptoms include:
Symptoms include: cough, nasal symptoms, fever, headache, facial pain and swelling, sore throat, and halitosis
Sinusitis cont’d
•Diagnosis is based on:
•Diagnosis is based on:
- Persistence of nasal discharge: if the child has a very congested and/or runny nose for 10 days without improvement, especially when it is associated with a daytime cough (may also have a nighttime cough)
- Severe symptoms: if the child has a high fever (over 39 C, which is 102.2 F) for 72 hours or has a high fever and is not eating or drinking and is difficult to calm
- Worsening symptoms: A child’s cold got better and then in a day or two the child is suddenly much more ill with a fever and/or pus-filled nasal discharge
Characteristic Features of Viral vs Bacterial Rhinosinusitis in Children
Differential Diagnosis
- uncomplicated viral URI
- allergic or non-allergic rhinitis
- nasal foreign body
- enlarged or infected adenoids
- mucosal cyst of the maxillary antrum
- pertussis
- Did you know that kids don’t have all their sinuses developed until about 12 years old?
- Frontal sinuses are formed by around 8 years old.
- Maxillary, ethmoid are present at birth but develop to full size by adolescence.
Work up?
- Diagnosed clinically for routine cases
- No routine imaging needed for routine cases, but…
- Plain radiographic or computed tomography (CT) findings that are compatible with sinus inflammation include
- Complete opacification
- Mucosal thickening of at least 4 mm
- Air-fluid level
- However, abnormal imaging studies cannot distinguish between bacterial, viral, or other causes of sinus inflammation
- Plain radiographic or computed tomography (CT) findings that are compatible with sinus inflammation include
- Sinus aspiration for culture and sensitivity in complicated cases
Complications of Sinusitis
- By direct extension or by retrograde thrombophlebitis
- Preseptal (periorbital) and orbital cellulitis
- Septic cavernous sinus thrombosis
- Meningitis
- Osteomyelitis of the frontal bone
- Pott’s Puffy tumor: subperiosteal abscess associated with osteomyelitis. It is usually seen as a complication of frontal sinusitis or trauma predominantly in the adolescent age group
- Epidural, subdural, or brain abscess
Herpangina
- Coxsackieviruses A 1-10, 12, 16, and 22
- Discrete erythematous-based macules à evolve into papules that vesiculate and then ulcerate centrally, creating an erythematous halo.
- Lesions are typically smaller than 5 mm in diameter. Most cases of herpangina involve 2-12 lesions
- Hand foot mouth is also coxsackievirus (usually A16 or enterovirus 71)
- Not to be confused with Herpetic gingivostomatitis (herpangina: posterior, HSV is anterior)
Herpetic gingivostomatitis
- Prodrome that lasts about four days and may include fever (>38ºC (100.4ºF)), anorexia, irritability, malaise, sleeplessness, and headache
- Enanthem begins with red, edematous marginal gingivae that bleed easily and clusters of small vesicles
- Coalesce to form large, painful ulcers of the oral and perioral tissues
- Cervical adenopathy often present
Strep pharyngitis
Work Up
Work Up:
Rapid strep with back up culture if negative
- How can you possibly get a sample??
- Use two swabs at once; double tongue depressor for stronger kids, have smaller child pant like a puppy dog
- Wear a mask because you’ll probably get coughed on
- Some facilities do a RNA probe for back up instead of culture.
Can you tell by looking? → Nope!!
Strep pharyngitis PE Findings
Peritonsillar Abscess
- Most common deep neck infection in children and adolescents, accounting for at least 50 percent of cases
- A collection of pus located between the capsule of the palatine tonsil and the pharyngeal muscles.
- Symptoms include:
- severe sore throat (usually unilateral)
- Fever
- “hot potato” or muffled voice
- Pooling of saliva or drooling may be present
- Trismus
- neck swelling and pain
- ipsilateral ear pain
- Fatigue
- Irritability
- decreased oral intake
Peritonsillar abscess
Treatment:
- Treatment:
- gold standard for diagnosis of peritonsillar abscess remains the collection of pus from the abscess through needle aspiration
- antimicrobial therapy
- amoxicillin/clavulanic, cephalosporins, and clindamycin
- supportive care (hydration, analgesia)
Retropharyngeal abscess cont’d
Dx & Tx
- Diagnosis
- Imaging: lateral neck film
- CT with contrast
- Generally, the anteroposterior diameter of the prevertebral soft tissue space in children should not exceed that of the contiguous vertebral bodies.
- retropharyngeal soft tissue swelling as more than 7 mm at C2 and more than 22 mm at C6
- Treatment:
- empiric antibiotics (ampicillin-sulbactam, clindamycin, vancomycin)
- Surgical drainage criteria
Epiglottitis
- 4 D’s:
- Drooling
- Dysphagia
- Dysphonia
- Dyspnea
- Toxic appearing
- “Tripod” position, “sniffing” position
- Management if suspected:
_*Direct examination of the airway under anesthesia (with the availability of personnel who can perform a tracheostomy if needed_
Croup cont’d
Tx
- Treatment:
- Warm mist in closed bathroom with hot water running or cool night air
- Corticosteroids, usually administered orally or parenterally, have been shown to improve symptom severity and reduce hospital length of stay (dexamethasone = Decadron).
- Inhaled racemic epinephrine has been shown to reduce stridor within 30 minutes; therefore, it will provide the most immediate benefit and should be offered to the girl described in the vignette. ED observation period of at least 3 hours to see if symptoms return after nebulized epi treatment.
- Children who have significant respiratory distress, hypoxemia, or inability to tolerate oral intake should be hospitalized for close observation.
- Mildly affected children may do well with steam (sit in bathroom with hot water running until room is steamy) or cool air (step outside into cool night).
Bacterial tracheitis cont’d
Suspect in child with:
- acute onset of airway obstruction in the setting of viral upper respiratory infection and in children with laryngotracheitis who are febrile, toxic-appearing, and have a poor response to treatment with nebulized epinephrine or glucocorticoids
- Definitive diagnosis of bacterial tracheitis requires direct visualization of an inflamed, exudate-covered trachea
Pneumonia: Bacterial
- Strep pneumoniae, Strep pyogenes, Haemophilus influenzae, Staph arueus, Klebsiella, anaerobes
- Most pediatric patients who have pneumonia will recover uneventfully
- 10% of pediatric patients with bacterial pneumonia may require hospital admission.
- Children with pneumonia who do not respond to initial therapy after 48-72 hours should have a clinical, laboratory, and radiographic reassessment.
- CXR may reveal a focal infiltrate (segmental or lobar consolidation).
Differential Diagnosis of Pneumonia
Pneumonia: Viral
- Most likely cause of pneumonia in children
- RSV, parainfluenza, adenoviruses, rhinoviruses, influenza viruses, varicella virus, rubeola virus
- URI sxs followed by onset of tachypnea, cough, fever
- PE dull or decreased breath sounds, wheezing or crackles, or normal
- CXR with perihilar and diffuse parenchymal infiltrates (though sensitivity and specificity may be low)
Case 1
Ima Wheezer
6 month old Caucasion female infant presents to your clinic with trouble breathing.
It is January in Parker, CO, and this is the 4th child you’ve seen today with this CC
HPI:
MOC reports that Ima has had cold symptoms for 4 days including clear rhinorrhea, cough, and congestion. Ima has been coughing more today, and MOC notes that she has been breathing fast. Cough is most concerning – she coughs until she gags herself. Doesn’t turn blue. Not sleeping well.
MOC has heard wheezing and states infant has had a fever to 102 this afternoon. Siblings have had colds recently.
Decreased oral intake. 3 wet diapers in past 24 hours.
PMH:
FT, VD, no complications; IUTD. No hosp/operations.
Developmentally doing well. Sitting, reaching for toys, putting things in mouth.
SH: Attends daycare, no smokers in the home. Two older sibs, ages 3 and 6
FH: asthma in older sibling that resolved when he was 4, but Baby A has never wheezed. There is no h/o atopic dermatitis or other family members with asthma.
ROS negative
VS: T 101, P 134, R 60, BP 88/50, sats 88% RA
General: coughing intermittently, appears in mild resp distress with tachypnea and subcostal retractions, no nasal flaring, no cyanosis, alert and interactive
HEENT: NCAT, AFSF. TM’s clear bilaterally, with good LM and LR, mobile upon insufflation. Oropharynx with mild post erythema, no exudate. MM moist.
Neck: supple, full active ROM, no adenopathy
Lungs: tachypneic, with mild subcostal retractions, moderate expiratory wheezing and crackles bilaterally in all lung fields
CV: S1 S2 with no M/R/G, pulses 2+/4.
Abdomen: soft, NT/ND, NABS, no HSM or mass
Ext: no c/c/e
Neuro: good strength and tone, moves all extremities. Grossly nonfocal
Skin: no rash, good turgor
•DDx and work up?
–recurrent viral-triggered wheezing or asthma
–pneumonia
–foreign body aspiration (especially if she were older: at 9 months they have a pincer grasp to pick up tiny things; older siblings fed her something?)
–chronic pulmonary disease
–aspiration pneumonia
–congenital heart disease
–heart failure
–vascular ring
–
•Viral panel (PCR) or antigen detection, or culture
Case 1 Diagnosis
- Bronchiolitis
- Treatment
–Oxygen via nasal cannula to keep sats over 90%
–Encourage adequate hydration
–Nasal suctioning q 2 hours PRN
–Tylenol/ibuprofen PRN fever
