Upper and Lower Respiratory Tract Infections in Children

Question 1

What are some important examples of upper respiratory tract infections?

Answer 1

Rhinitis 
Tonsilitis 
Otitis media 
Pharyngitis 
Laryngitis 
Epiglottitis

Question 2

If you see a child with an upper respiratory tract infection how would you try determine if they need treated?

Answer 2

Try determine where in it’s natural history the disease is

If you suspect the infection is self limiting and will improve you give the parents a list of symptoms to look for and a time period to observe over, if the child gets worse tell them to come back

Question 3

How common is rhinitis? How should it be treated?

Answer 3

Very common, get 5-10 per year

Usually a self limiting condition but may be a prodrome to more serious illness. Would only really be worried if symptoms get significantly worse or they last for more than 2.5 weeks ish

Question 4

What is otitis media? How does it appear on otoscopy?

Answer 4

Infection of the middle ear that causes inflammation and a buildup of fluid behind the eardrum

The TM will appear red instead of translucent and the TM will be bulging

Wouldn’t last longer than 1.5 weeks

Question 5

How should you treat otitis media infection?

Answer 5

Analgesia** (main treatment as main symptom is pain)

• Antibiotics may help a bit but don’t seem to help significantly so wouldn’t recommend
• Antibiotics only work after 24 hours which is usually the main window of pain

Question 6

What is the main dilemma regarding treatment for tosilitis and pharyngitis?

Answer 6

Determining if the infection is viral or bacterial

Viral you don’t treat, bacterial (strep throat) you give 10 days penicillin (not amoxycillin)

Duration is usually around 2-3 days

Question 7

What are some hints as to whether the cause of tonsilitis / pharyngitis is viral or bacterial?

Answer 7

Bacterial (strep throat) tends to present with:

• Scarlet fever (faint pink rash)
• Pallor around the mouth

Question 8

What is croup? How does it present? How is it treated?

Answer 8

Laryngotracheobronchitis

Presents with runny nose followed by stridor, barking cough and hoarse voice (usually lasts 1/2 days)

Treated with dexamethasone

Question 9

What causes epiglottitis? How serious is it?

Answer 9

Haemophilus infleunza (vaccine history important)

Very serious condition - swelling of the epiglottis obstructs breathing

Question 10

How does epiglottitis present? How is it treated?

Answer 10

Presents with difficulty swallowing (patient often drooling), stridor and trouble breathing

Treated with intubation and antibiotics

Question 11

What are some examples of lower respiratory tract infections?

Answer 11

Tracheitis 
Pneumonia 
Bronchitis 
Empyaema 
Bronchiolitis

Question 12

What are some bacteria that are not seen in health but may cause pathological infection?

Answer 12

Pertussis (whooping cough)

Bacteria causing TB

Question 13

How does tracheitis tend to present?

Answer 13

“Croup that doesn’t get better”

• Barking cough
• Stridor
• Fever
• Child will be unwell

Question 14

Which organisms tend to cause tracheitis? What is the treatment for the condition?

Answer 14

Staph or strep invasive infection

Augmentin (always give antibiotic)

Question 15

How does bronchitis tend to present? What organisms cause it?

Answer 15

Loose, rattly cough with URTI
Post tussive vomit (post coughing - sputum evac)
Chest free of wheeze / crepitations

Caused by viral infection followed by secondary bacterial invasion due to reduced mucociliary clearance

Question 16

What is the natural history of bronchitis like? What accounts for this?

Answer 16

Cough that resolves or nearly resolves, then recurrs

For the first 2 winters or so the child might get it very often, but after around their 3rd winter they develop some immunity

Accounted for by the fact that the viral infection inhibits the mucociliary escalator, allows for bacterial infection, finally gets cleared, and then the child gets another virus

Question 17

How should bronchitis be treated?

Answer 17

Reassure the parents and don’t treat, the child is well enough they are just taking long to clear their mucus

Question 18

What is bronchiolitis?

Answer 18

Infection of the small airways

Question 19

Who tends to get bronchiolitis? What organism causes it?

Answer 19

Infants (affects 30-40% of infants) - so less than 1 year olds, peaks at around 3 months

Usually caused by RSV (can be paraflu III / HMPV)

Question 20

How does bronchiolitis present?

Answer 20

Nasal stuffiness

Tachypnoea

Poor feeding

Crackles +/- wheeze

Question 21

What is the natural history of bronchiolitis like? When should you admit to hospital?

Answer 21

Condition gets worse progressively for about 5 days, then stabilizes for a couple days and then resolves over about a week

If you see a child early on (day 2/3) and their oxygenation and nutrition isn’t great then admit to hospital, if they’re doing alright at around day 5 they shouldn’t get much worse

Question 22

Investigations for bronchiolitis? Treatment?

Answer 22

NPA - nasophrayngeal aspirate (identify the virus)
Oxygen saturations (determine severity)

Can treat with antibiotics or bronchodilators, but want to try keep treatment to a minimum

Question 23

What is the general presentation of LRTI like?

Answer 23

48 hours in

Fever (>38.5 degrees)

SOB, coughing, grunting

Reduced bronchial breath sounds

Question 24

If wheeze is seen in a LRTI what does this indicate?

Answer 24

That bacterial cause for infection is unlikely

Question 25

What are the characteristics of pneumonia?

Answer 25

Signs are focal (eg. in left lower zone)

Crepitations present

High fever

Question 26

What investigations may be done for pneumonia?

Answer 26

CXR and inflammatory markers

Not usually done because don’t impact the treatment course

Question 27

Management of pneumonia?

Answer 27

(No treatment with mild symptoms)

Oral amoxycillin is first line **

Oral macrolide 2nd line

• IV only done if the child is vomiting

Question 28

When is it better to use oral antibiotics rather than IV?

Answer 28

If the LRTI is not severe

If the child is not vomiting

Question 29

What are some characteristics that differentiate LRTI and bronchiolitis?

Answer 29

Bronchiolitis occurs in infants (<12 months)

3 days until symptom peak for bronchiolitis, more rapid in other LRTI

Bronchiolitis rarely presents with fever

Question 30

How does vaccination against pertussis affect the chance of getting whooping cough?

Answer 30

Reduces the chance of getting it, but it is still common even in vaccinated children

Vaccination also tends to reduce severity

Question 31

How does whooping cough present?

Answer 31

Child coughs continuously (fit) until they can’t cough anymore (out of breath)

They then may vomit or wretch

The loud inhale after the coughing fit is the “whoop”

Question 32

What is empyaema? How does it present?

Answer 32

Complication of pneumonia where the infection spreads into the pleural space

Presents with chest pain and the child being very unwell in general

Question 33

How is empyaema managed? What is the prognosis like?

Answer 33

IV Antibiotics +/- drainage for treatment

Prognosis is good in children, unlike in adults

Question 34

Which antibiotic is used for tracheititis?

For LRTI / pneumonia?

Answer 34

Tracheitis - augmentin

LRTI / pneumonia - oral amoxycillin