Respiratory Flashcards
Recurrent Respiratory Infections Warrant:
- Investigations:
- Immunodeficiency: SCID, IgG or IgA deficiencies (look at immunoglobulins)
- Ciliary dyskinesia: familial disorder
- Cystic fibrosis
- Alpha-1 Antitrypsin deficiency: lung (kids) & liver (adults)
Keys to look at immunodeficiency
- 8+ new severe ear infections
- 2+ serious sinus infections
- Persistent oral candidiasis
- 2+ months on ABX without improvement and/or need for IV ABX to clear infection
- Recurrent PNA
- Failure to thrive
- Family Hx of immunodeficiency
- 2+ deep skin infections
Respiratory: Physical Exam
- Rate, Rhythm, Effort
- Grunting: NEVER normal
- Accessory muscles
- Level of anxiety (is child speaking)
- Nasal flaring
- Nose: rhinorrhea, color, mucoid, etc.
- Sinuses
- Throat: (If epiglottitis is suspected do NOT elicit gag reflex)
- Chest: If decreased sounds on one side, think PNA)
Respiratory: Dx
- SpO2, Imaging; soft tissue of neck (croup, epiglottitis); CXR; CBC-diff; sweat chloride; bronchoscopy, lavage, biopsy, genetic testing
Respiratory: Meds (general)
- Decongestants: generally avoid, not under 4yr; caution under 6yr
- Expectorants: not under 4yr
- Suppressants: use rarely
Common Cold: Basics
- ~10-12/yr
- Most common viral etiology: parainfluenza; RSV; coronavirus; adenovirus; influenza; enterovirus
- An increase in polymorphonuclear leukocytes causes changes in color of nasal mucous to yellow
Common Cold: S/S
- Rhinorrhea
- Sore throat
- Mild cough
- Low grade fever
- After variable period, nasal secretions get thicker, more purulent
Common Cold: PE
- Mild injected conjunctiva
- Red nasal mucosa with secretions of varying colors; Anterior cervical adenopathy with freely moveable nodes <2cm
- CTAB
Common Cold: Dx
- Throat culture
- Nasal culture
Common Cold: Mgmt.
- No ABX
- Saline/suction
- Cool mist/hydration
- Educate parents on potential for secondary infections such as ear and sinuses
Pharyngitis/Tonsillitis: Basics
- Pharyngitis: inflammation of the mucosa lining of the structures of the throat including tonsils, pharynx, uvula, soft palate, and nasopharynx
- Nasopharyngitis: nasal symptoms present
- Pharyngitis/Tonsillitis: without nasal symptoms
Pharyngitis/Tonsillitis: Etiology
- Usually viral: same as cold + EBV, coxsackie, HSV
- Bacterial: Strep group A, C, or G; mycoplasma PNA
Pharyngitis/Tonsillitis: Hx
- Sore throat
- dysphagia
- fever
- myalgia
- arthralgia
Pharyngitis/Tonsillitis: Viral PE
- reactive lymphadenopathy common
- EBV: Exudate on tonsils; soft palate petechiae; diffuse adenopathy (***posterior)
- Adenovirus: cobblestoning of pharynx
- Enterovirus: vesicles or ulcers onn tonsillar pillars assoc. w/coryza, vomit, diarrhea
- Herpesvirus: ulcers, adenopathy
- Parainfluenza and RSV: Croup (stridor), rales (PNA), Bronchiolitis (wheezing)
- Influenza: more systemic symptoms
Pharyngitis/Tonsillitis: Viral PE & Mgmt.
- Throat culture
- CBC-diff
- Monospot
- EBV panel
- Supportive
- NO Abx
Pharyngitis/Tonsillitis: Bacterial (Facts)
- Most common: GABHS
- IF throat culture is positive for other bacteria (staph, strep PNA, or GBHS or GGBHS, treatment not neccessary)
- Sexually active: consider gonorrhea
- Chlamydia: possible in newborns (cough, conjunctivitis)
Pharyngitis/Tonsillitis:Bacterial Hx
- Rare <2yr
- Abrupt onset without nasal Sx or coughing
- Constitutional: arthralgia, myalgia, HA
- Mod-to-high fever
- malaise
- prominent sore throat
- dysphagia
- ABD pain, N/V (esp. children)
- HA
- tonsillar exudate
- Rash (**Scarlet Fever)
Pharyngitis/Tonsillitis: Bacterial PE
- Soft palate/pharynx petechiae
- Swollen beefy red tonsils or uvula
- Exudate, maybe yellow/blood-tinged
- Tender lymphadenopathy
- bad breath
- Scarlatinoform rash (can be confused with Kawasaki Dz)
- peeling hands and feet: delay in Dx
- Strawberry Tongue: (can be confused with Kawasaki Dz)
- May have mild Sx without exudate
Pharyngitis/Tonsillitis: Bacterial Dx
- Throat culture
- Antistreptolysin titers (ASLO): antibody titer; peaks 3-6wk after infection
- Anti-deoxyribose B tests (anti-Dnase B): peaks 8wk after infection
Pharyngitis/Tonsillitis: Bacterial ABX
- PCN: any kind; Amoxicillin; IM LA Bicillin; Augmentin
- Cephalosporins (any gen.): Keflex, omnicef, ceftin, cedax
- Azithromycin
- Clarithromycin
- Clindamycin (SAVE for resistant cases)
- Sulfa: NOT effective
Pharyngitis/Tonsillitis: Bacterial Mgmt.
- May return to school after 24hr fever free and on ABX >24hr
Pharyngitis/Tonsillitis: Complications
- Rheumatic fever
- Post-streptococcal reactive arthritis and acute glomerulnephritis
- Secondary PNA, mastoiditis, otitis media
Rhinosinusitis: Basics
- Inflammation and secondary infection of the paranasal sinuses
- 3 Sx required for Dx:
1) purulent nasal discharge
2) nasal obstruction
3) facial pain, pressure, fullness lasting b/n 10d and 4wk
Rhinosinusitis: 3 Clinical Presentations
1) Persistence of URI for >10d and <30d without improvement
2) Severe sx with high fever and purulent rhinitis at the onset and lasting at least 3-4d
3) Biphasic illness with worsening on day 6/7 of a common cold, wen patient develops an increase in respiratory Sx, nasal congestion, or new onset of fever
