Pediatric Respiratory Infections Flashcards
The number one cause of cardiac arrest in children is
respiratory arrest
stridor is
upper airway obstruction
wheezing is
lower airway obsturction
Upper Respiratory Infections (Colds)
- 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 *daycareappear 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.
URI cont’d: symptoms
Most common sxs:
–*Fevermay 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
–Coughoccurs in more than two-thirds of children with the common cold
Abnormal middle ear pressures
-viral nasopharyngitismay 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
Typical viral pathogens:
Rhinovirus (about 30-50%)
RSV
fever over 100.4 rectally requires
sepsis workup
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
treatment of uri
Supportice care only pushe fluids antipyretics prn nasal saline with bulb suction cool mist humidifier
do not use otc cough meds/decongestants in young children
Acute Otitis Media
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
otitis media peak incidence
3-18 months
otitis media prevention
Tympanostomytube placement for recurrent episodes
3 epsidosde in 6 onths
4 episodes in 1 year with 1 episode in the preceding 6 months
otitis media complication
Intratemporal-*Perforationof the tympanic membrane, acute coalescent *mastoiditis, *facial nerve palsy, acute *labyrinthitis, petrositis, acute necrotic otitis, or development of chronic otitis media
Sinusitis symptoms
Symptoms include: cough, nasal symptoms, fever, headache, facial painand swelling, sore throat, and halitosis
Sinusitis cont’d
•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
Did you know that kids don’t have all their sinuses developed until about
12 years old
frontal sinuses are formed around
8 years
sinusitis work up
ct
Herpangina
CoxsackievirusesA 1-10, 12, 16, and 22
papules that vesiculate and then ulceratecentrally
Herpetic gingivostomatitis
clusters of small vesicles
•Coalesce to form large, painful ulcers of the oral and perioral tissues
Acute Pharyngitis
EBV
Monospot testing is not accurate under 4-5 years of age or before 2ndweek of illness
Acute pharyngitis
Group A beta hemolytic streptococcus
15 to 30 percentof all cases of pharyngitis in children between the ages of 5 and 15 years
Strep pharyngitis
History
–Typically has an abrupt onset of symptoms
–Typically the school aged child
–Sore throat
–Fever
–Headache
–GI symptoms: abdominal pain, nausea, and vomiting
–Poor oral intake
–*NO cough or rhinorrhea!!Aka, no viral symptoms ( coryza, conjunctivitis, hoarseness, anterior stomatitis, discrete ulcerative lesions or vesicles)
Strep pharyngitis
Physical
–Exudative pharyngitis or erythema of posterior orophayngeal mucosa
–Enlarged tender anterior cervical lymph nodes
–Palatal petechiae
–Inflamed uvula
–Scarlatiniform rash
–Pastia’s lines
Strep pharyngitis
workup
Rapid strep with back up culture if negative
Strep pharyngitis cont’d
•Goals of antimicrobial therapy for eradication of group A streptococcus (GAS) from the pharynx in the setting of acute streptococcal pharyngitis include:
–Reducing duration and severity of clinical signs and symptoms, including suppurative complications
–Reducing incidence of nonsuppurative complications (eg, acute rheumatic fever)
–Reducing transmission to close contacts by reducing infectivity
•Initiation of treatment within *9 days of onset of illness will prevent complications
Treatment of strep pharyngitis
•Penicillin V
250mg PO BID or TID for 10 days for children 27 kg or adults
(liquid formulation tastes icky, by the way)
•Amoxicillin 50mg/kg/day divided BID-TID (“low dose amox”) for 10 days
(bubblegum flavor!)
•*Pen G (BenzathinePCN):
–27 kg-adult:1.2 million U/dose IM X 1
Recurrence of strep
For patients with as many as six GAS infections in a single year or three to four episodes in two consecutive years, *tonsillectomy may be an appropriate therapeutic consideration
Peritonsillar Abscess overview
*Most common deep neck infectionin children and adolescents, accounting for at least 50 percent of cases
Peritonsillar Abscess
Symptoms
–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
Retropharyngeal abscess
most commonly in children between the *ages of two and four years
little kids dont get strep throat or rheumatic fever
Retropharyngeal abscess cont’d
Symptoms:
- Difficulty swallowing (dysphagia)
- pain with swallowing (odynophagia)
- drooling with decreased oral intake
- Unwillingness to move the neck secondary to pain (torticollis), particularly unwillingness to extend the neck
- Change in vocal quality (muffled, or with a *“hot potato” quality [dysphonia])
- gurgling sound, or stertor (snoring sound)
- Respiratory distress (stridor, tachypnea, or both); stridor develops as disease progresses
- Neck swelling, mass, or lymphadenopathy
- *Trismus (in approximately 20 percent)
- Chest pain (if there is mediastinal extension
ct with contrast when looking for
abcess
Epiglottitis
4 ds
–Drooling
–Dysphagia
–Dysphonia
–Dyspnea
Epiglottitis
h flu type b
•*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)
Laryngotracheitis (croup) overview
•Most commonly occurs in children *6 to 36 months of age. It is seen in younger infants (as young as three months) and in preschool children, but it is rare beyond age six years
Laryngotracheitis (croup)
most common caused by
*parainfluenza
influence
rsv
adenovirus
Typical features of croup include
–nasal congestion
–low-grade fever
–barking-type cough (like a seal)
–inspiratory stridor that may worsen with crying.
Croupcont’d
•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). (do this if they don’t have stridor at rest)
–Inhaled racemic epinephrinehas 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. (do this if they have stridor at rest)
–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).
croup sign
steeple
Bacterial Tracheitis
Acute *bacterial laryngotracheobronchitis”
Bacterial tracheitis
Suspect in child with
•acute onset of airway obstruction in the setting of viral upper respiratory infection and in children with laryngotracheitis who arefebrile, toxic-appearing, and have a poor response to treatment with nebulized epinephrine or glucocorticoids
Bronchiolitis
Caused by RSV
Bronchiolitis is a clinical syndrome that most commonly occurs in children younger than 2 years, with a peak incidence between 2 and 6 months of age and is characterized by *upper respiratory symptoms(eg, rhinorrhea) followed by *lower respiratory(eg, small airway/bronchiole) infection with inflammation, which results in *wheezing and or crackles (rales).
Bronchiolitis
Risk factors for severe disease:
–young age –*preterm birth (specific guidelines for immunization with Synagis = palivizumab) –low birth weight –chronic pulmonary disease –cyanotic or complicated cardiac disease –neurologic disease –immunodeficiency or immunosuppression –congenital defects of the airway
Just about all kids have had RSV infection by age
3
Bronchiolitis Symptoms
one-to three-day history of upper respiratory tract symptoms, such as nasal congestion discharge and mild cough, followed by lower respiratory infection with inflammation, which results increased respiratory effort(eg, tachypnea,nasal flaring, chest retractions) and wheezing and/or crackles (rales).
Bronchilotis Pathogens
Pathogens:
–RSV, rhinovirus
–less common causes include parainfluenza virus, human metapneumovirus, influenza virus, adenovirus, coronaviruses, and human bocavirus
bronchiolitis Treatment
–Admit if hypoxic (oxygen saturations below 90% on room air) or dehydrated
–IVFs if dehydrated
–Trial of albuterol nebs no longer routinely recommended (new AAP guidelines 2015)
what do pats with bronchiolitis need?
oxygen
PneumoniaPresenting signs/sxs
Presenting signs/sxs –*Fever –*Cough –tachypnea –increased work of breathing (retractions, nasal flaring, grunting, use of accessory muscles) –*hypoxemia –*adventitious lung sounds
Pneumonia: Bacterial
cxr
may reveal a focal infiltrate (segmental or lobar consolidation).
may reveal a focal infiltrate (segmental or lobar consolidation).
are the most common complication occurring in up to 40% of bacterial pneumonias; progression to empyema occurs in more than 50% of these cases.
Pneumonia: Viral
Most likely cause of pneumonia in children
CXR with perihilar and diffuse parenchymal infiltrates (though sensitivity and specificity may be low)
Pneumonia:Atypical and Other Pathogens
•Mycoplasma pneumoniae
–Adolescents or children over 5
–Most commonly URI symptoms without pneumonia
–Gradual onset and usually is heralded by headache, malaise, and low-grade fever
–Occasionally can be more acute and mimic pneumococcal pneumonia
–Nonproductive to mildly productive cough
–Wheezing and dyspnea also may occur
–Scattered rales and wheezeson lung exam may be present
pneumonia cxr
diffuse infiltrates on CXR
Pertussis stages
–Cattarhal (usually 7-10 days, range 4-21 days)
–Paroxysmal (1-6 weeks, but up to 10 weeks)
–Convalescence (usually 7-10 days, range 4-21 days)
pertusiss infants dont
whoop
pertussis overview
check nasal wash or aspirate for pertusis (pcr)
macrolides are drug of choise
antibiotics started during the paroxysmal state will not lessen symptoms>but they are given to prevent spread of illness
after five full days of treatment the child is no longer contagious
influenza
No testing or treatment unless risk factors present:
–Age less than 2
–Immunocompromised family member in home (including pregnant women, infants)
–Asthma
–Heart disease
influenza treatment
–Clinical benefit is greatest when antiviral treatment is administered early, especially within 48 hours of influenza illness onset.
Decreased oral intake. 3 wet diapers in past 24 hours.
General: coughing intermittently, appears in mild resp distress with tachypnea and subcostal retractions, no nasal flaring, no cyanosis, alert and interactive
AFSF.
tachypneic, with mild subcostal retractions, moderate expiratory wheezing and crackles bilaterally in all lung fields
bronchiolitis
–Oxygen via nasal cannula to keep sats over 90%
–Encourage adequate hydration
–Nasal suctioning q 2 hours PRN
–Tylenol/ibuprofen PRN fever
appears NAD, alert and interactive, playful in room, one prolonged coughing spell with associated perioral cyanosis witnessed
–Nasal wash for Pertussis PCR
azithromycin (most commonly used
Moderate erythema of posterior oropharyngeal mucosa; there is trace exudate present on both tonsils; no petechiae present. MMM.
Rapid strep is positive Strep pharyngitis
•Treatment:
–Amoxicillin, push fluids, salt water gargles, throat lozenges, popsicles/milkshakes, soft diet, antipyretics PRN
Voice is hoarse and muffled.
Peritonsillar abscess
•Treatment:
–Consult ENT for needle aspiration, C&S
–Augmentin or Clindamycin
–Fluids, soft diet, antipyretics/analgesics
