Pediatric Respiratory System Disorders in Primary Care Flashcards
The Common Cold (URI)
Young children average 6-10 colds per year
Initial low-grade fever with sore throat followed by rhinorrhea, cough, and congestion
Other s/s: sneezing, hoarseness, pharyngitis, and sometimes poor sleep
PE: mild conjunctival injection, Red nasal mucosa with secretions of varying colors; mild erythema of pharynx; anterior cervical lymphadenopathy; chest clear to auscultation
Lasts 7-9 days
Usually viral (50% rhinovirus) - other causes include parainfluenza, RSV, adenovirus, coronavirus, human bocavirus, and human metapneumovirus
Dx: if presenting symptom is sore throat - rapid strep test
Tx: symptomatic (antipyretics, NS drops, cool mist humidifier, bulb sx, fluids)
Acute VIRAL Pharyngitis, Tonsillitis, or Tonsillopharyngitis
Adenoviruses cause pharyngitis as prominent symptom (enterovirus, herpes virus, and EBV are also common causes of pharyngitis)
Hoarseness, cough, coryza, conjunctivitis, and diarrhea are classic features of a viral infection
- Viral: rhinitis, cough, hoarseness, stomatitis, stridor and conjunctivitis, nonspecific rash, or diarrhea
PE:
- Erythema of the tonsils and the pharynx
- Reactive tender cervical lymphadenopathy
- Other virus-specific physical findings (Page 673)
Tx: Supportive care only (dietary modifications, acetaminophen or ibuprofen, adequate fluid intake)
Acute BACTERIAL Pharyngitis, Tonsillitis, or Tonsillopharyngitis
Most commonly GABHS (strep)
M. pneumonia and C. pneumonia = cough with pharyngitis
M. Pneumonia = Severe sore throat with the lower tract symptoms
S/Sx with GABHS
- Most common in 5 to 13-year-old
- Abrupt and acute onset without nasal symptoms
- Tender lymph nodes (not necessarily enlarged)
- Constitutional symptoms (Arthralgia, myalgia, headache)
- Moderate to high fever, malaise, prominent sore throat, dysphasia
- Nausea, abdominal discomfort, vomiting, headache
- Usually in the late winter or early spring
PE:
- Petechiae on soft palate and pharynx, swollen beefy red uvula, red enlarged tonsillopharyngeal tissue
- Exudate is yellow, blood-tinged
- Tender and enlarged anterior cervical lymph nodes; bad breath
- Stigmata of scarlet fever – scarlatiniform rash, Strawberry tongue, and circumoral pallor
- Lack of a cough or nasal symptoms, along with exudative, erythematous pharyngitis with a follicular pattern and typical historical findings = GABHS
Dx: RADT or rapid strep on child >3 years
Tx: Antibiotics should be started within 9 days to prevent rheumatic fever
- Penicillin is the drug of choice (Usually Amoxicillin 50 mg per kilogram once daily for 10 days)
- If allergic to penicillin: cephalexin, cefadroxil, clindamycin, clarithromycin
- Supportive care with antipyretics, fluids, and rest
- Fomites should be discarded or clean
- Children can return to school when afebrile and taking antibiotics for at least 12 to 24 hours
- Recommended IM benzathine penicillin (Bicillin) with treatment failure due to noncompliance
Nonsupportive complications: rheumatic fever, post-streptococcal reactive arthritis, Sydenham chorea, and acute glomerulonephritis
- Retropharyngeal abscess is more common in children younger than 6 years, whereas peritonsillar abscess peaks in adolescence
- Post streptococcal arthritis and pediatric autoimmune neuropsychiatric disorder syndrome (PANDAS)
Rhinosinusitis vs Common Cold
Rhinosinusitis: high fever and purulent nasal drainage
Common Cold: low-grade fever and nasal congestion
Rhinosinusitis
Inflammation of mucous membranes in sinuses (bacterial invasion)
Acute (<4 weeks) v chronic (>12 weeks)
Usually in kids older than 5 years old when sinuses fully developed
Clinical findings:
- Acute: High fever, purulent nasal discharge, or “double sickening” with worsening URI symptoms
- Headache, bad breath, fatigue
- Facial pain, congestion/fullness, nasal discharge, purulence or discolored postnatal drip, hyposmia or anosmia, fever
Management:
- Refer chronic/recurrent to ENT
- Treat with antibiotics (Zithromax or amoxicillin)
- Analgesics
- Can try Afrin or Flonase
- OTC meds not drug of choice < 6 years
- Antihistamines not helpful
Croup
Acute, inflammatory disease of larynx, trachea, and bronchi
Viral croup is most common
Clinical findings:
- URI with acute hoarseness; brassy, barking cough
- Mild to severe laryngeal obstruction (Stridor)
- Symptoms worse at night
- Slight dyspnea, tachypnea, retractions
- Low grade to high fever
- Retractions, Prolonged inspiration
- Wheezing/rales if lower airway involvement
- NO swollen tonsils
Dx: Clinical diagnosis or subglottic narrowing on radiograph (Steeple sign)
Management:
- Humidified air (cold air helps)
- Nebulized epinephrine
- Corticosteroids
- Cough/cold medication not recommended
- Bronchodilators if bronchospasm occurs
- Oxygen if saturation under 92%
- Heliox for severe croup
Indications for admission to hospital:
- RR of 70 to 90 per minute; in distress
- Temperature greater than 102.2°F
- Racemic epi in conjunction with corticosteroids
- Hydration/IV fluids
Epiglottitis
Inflammation of epiglottitis by Hib (usually 1-5 years)
S/S:
- Abnormal onset of fever; severe sore throat; dyspnea; inspiratory distress without stridor; drooling
- Aphonia; high fever; rapidly progressive respiratory obstruction; severe retractions; hyperextension of the neck
Dx: blood cx
Management: emergency; established airway; start antimicrobial IV; administer oxygen/respiratory support
Prevention: Immunization against Hib
Bronchitis vs. Bronchiolitis
Infant to 4 years = bronchiolitis
Older child/School-age = bronchitis
Bronchiolitis
Inflammation, necrosis, and edema of respiratory epithelial cells in small airways
Viral illness, primarily RSV
Starts as common cold
Clinical Findings: URI symptoms; gradual development of respiratory distress; Low-grade to moderate fever; decreased appetite; otitis media; Tachypnea; Retractions; expiratory wheezing; fine/coarse crackles
Dx: History and PE
Management:
- Nebulized hypertonic saline for hospitalized infants
- Supportive care with hydration and antipyretics
- Supplemental oxygen if low saturations
- Fluid intake monitoring
- Nasal suctioning (Avoid deep airway suctioning)
- Sometimes treat with albuterol (no EBP)
- No antibiotics
Prevention: Palivizumab for high-risk infants
Bronchitis
Nonspecific inflammation of bronchioles (caused by influenza, RSV, adenovirus, parainfluenza)
Clinical findings:
- Dry, hacking cough
- Low substernal discomfort, burning chest pain
- Family history of asthma, CF, atopy, infections, irritants
- History of prematurity or GERD
- Variable rhinitis
- Low grade or no fever
- Coarse breath sounds, rhonchi, rales (Usually clears with cough)
Dx: Chest x-ray not routinely done
Management:
- Supportive care for acute bronchitis
- Analgesia, hydration, Bromphed may help
- Antivirals if influenza
- Cough suppressants not recommended
- Bronchodilators not recommended
- Chronic bronchitis may require bronchodilators or steroids
Foreign Body Aspiration
Laryngeal FB: Rapid onset of hoarseness/chronic croupy cough; Unilateral wheezing, recurrent pneumonia
Tracheal FB: Brassy cough/hoarseness, dyspnea, cyanosis; homophonic wheeze
Bronchial FB: Most in right lung; Initial episode of coughing, gagging, choking; blood-streaked sputum; Limited chest expansion, decreased vocal fremitus, atelectasis; Crackles, rhonchi, wheezes
Management: Referral to pulmonary specialist for bronchoscopy and treatment of secondary lung infections or bronchospasm
- Always get XR and refer to ER
Pneumonia
Lower respiratory tract infection
- Lobar = Typical pneumonia (Usually bacterial)
- Atypical pneumonia = Patterns of consolidation not localized (Mycoplasma)
Viral pneumonia sets the stage for bacterial pneumonia (Most common)
Etiology:
- Neonate = GBS
- Toddlers = RSV, parainfluenza, adenovirus
- Adolescent = Mycoplasma
Hospitalization if: 02 required
- Neonate - fever, poor oral intake, pulmonary complications (abscess)
- Infants and children - Hypoxemia (<90%), tachypnea (>60%), grunting, poor feedings with signs of dehydration, toxic appearance
Clinical findings:
- Infant = Slower onset of respiratory symptoms
- Child/adolescent = Abrupt high fever; history of mild URI; restlessness, shaking chills, apprehension, SOB, pleuritic chest pain
PE:
- Respiratory distress (Nasal flaring, grunting, retractions), apnea, tachycardia
- Tachypnea, air hunger, cyanosis
- Fine crackles, dullness, diminished breath sounds
Bacterial = Fever, hypoxia, lethargy; splinting affected side, tachypnea, retractions; plural effusion
Viral = wheezing; repetitive, staccato cough (C. trachomatis)
Dx: Chest x-ray, blood cultures if fails to improve; Rapid tests for viruses
Management: (Usually outpatient)
- Supportive care with antipyretics, hydration, rest
- Antibiotics only if bacterial suspected (High dose amoxicillin or Augmentin is the go-to drug)
Cystic Fibrosis
Multisystem genetic disorder (COPD, GI disturbances, exocrine dysfunction)
Autosomal recessive - Mutation of CFTR causing defective ion transport, airway surface liquid depletion, defective mucociliary clearance
Clinical findings:
- Chronic lung disease, inflammation, viscous mucus, dysfunctional mucociliary transport, obstruction, chronic infections; Chronic cough, sputum production, respiratory failure
- Meconium ileus, pancreatic insufficiency, rectal prolapse; thick fatty stools, Failure to thrive; Volvulus, duodenal inflammation, Gerd, & A, K, E, D deficiencies; distal intestinal obstructive syndrome
- Biliary cirrhosis, jaundice, ascites, hematemesis
- Recurrent pancreatitis, DM
- Vitamin D deficiency = Osteoporosis
- Delayed sexual development and male sterility
Dx: Newborn screening; sweat test; genetic analysis for CFTR mutation
Management: Complicated treatment regimens managed at a CF accredited center with multidisciplinary team (pancreatic enzymes with every meal and snack; water soluble vitamins; MiraLAX; chest PT therapy)
Asthma Characteristics
Asthma Triad
Triggers
- Chronic respiratory disease characterized by periods of: coughing, wheezing, respiratory distress, and bronchospasm
- Asthma TRIAD: Mucus, Inflammation, Bronchoconstriction
- Triggers: Exercise-induced bronchospasm Allergic component Chemical exposure Pollution / Smog Stress
Asthma Clinical Findings
Well-controlled child: symptoms <2 days/week & use SABA <2 times/week
Poorly controlled: symptoms >2 days/week & need step up in medication
Family history of asthma/atopy
Conditions associated with asthma = GERD, sinusitis, chronic OM
PE:
- Wheeze, cough
- Prolonged expiratory phase
- Diminished breath sounds
- Increased work of breathing/ signs of distress
- Cyanosis
