URTI & Stridor Flashcards
Frequency of URTI at each age according to WHO
up to 14 in the first yr of life
4 -10 yr. - 2–5 times per year
10 – 14 - 2.5–5 times per year
Adults – 1.7 times per year
How does the paediatric immune system differ to adults
Physiological hypogammaglobulimaenia during 4 –11 mo.
IgG is equal to adults - 7 – 8 yr IgM takes -1 yr. IgA - 6 – 7 yr. IgE - 6 – 7 yr NK - same as adults
Predominant lymphocytosis - 4 day – 4 yr
Relative neutropenia - 4 day – 4 yr
Complement maturity takes- 1 yr.
thymus largest at 2 yrs/ - shrinks by puberty
tonssillar enlarged for 2 – 4 yr.
How does the viral infection rate of children change according to age
Infants younger than 3 months have lower infectious rate – as they’re protected by maternal IgG antibodies
The infection rate increases from 3 to 6 months of age since their own IgG is low until 7/8
The viral infection rate increase during toddler, and preschool years d/2 increased social life of children and increased contact with immature igG
Hoe does the paediateic anatomy increase the likelihood of URTI
Smaller diameter of paediatric airways facilites rapid movement of pathogens
Which 7 factors contribute the the paediateic resistance from infections
⚫ Deficient immune system ⚫ Malnutrition ⚫ Anemia ⚫ Fatigue ⚫ Allergies ⚫ Asthma ⚫ Cardiac anomalies
How is the respiratory tract divided
Upper resp tract
1) nasal cavity
2) pharynx
3) larynx
Lowr resp tract
1) trachea
2) pulmonary bronchi
3) lungs
Types OF URTI
– Rhinitis
– Otitis media – Sinusitis
– Epiglottitis – Pharyngitis – Laryngitis
– Croup
– Tonsillitis
– Retropharengeal abscess Peritonsillar abscess
Non specific URTI
Common cold
Influenza
Adenoviruses
Gingivostomatitis
Enteroviruses
Herpangina
Hand, foot, and mouth disease
Pleurodynia
What is the common cold and how is it dg
• Etiology: more than 200 viruses – rhinoviruses 30-50% – coronaviruses 10-15% – influenza 5-15% – parainfluenza 5% – adenoviruses <5% – Enteroviruses <5% – unknown 20-30%
• Diagnosis: based on Classical Clinical features 1)clear or mucopurulent nasal discharge w/blockage 2)+/- fever
Management of the common cold
• educate parents that colds are self-limiting and have no specific cure
• Symptomatic rx regime:
Nasal blockage: Plenty of fluid intake, rest, humidified air, nasal aspiration
Pain: over-the-counter analgesics and antipyretics.
(paracetamol or ibuprofen)
- Antibiotics are of no benefit as the common cold has viral etio and super bacterial infection is very uncommon.
- assure parents Cough may persist for up to 4 weeks after a common cold.
Summarise influenza in 5 points
- Etiology: Influenza A & B
- Symptoms: Fever, myalgias, headache, rhinitis, malaise, nonproductive cough, sore throat
- Diagnosis: Influenza A &B antigen testing
- Treatment: Supportive care, tamiflue, amantidine
- Anti – influenza vaccines indication:
- children w/ chronic lung and heart diseases at school age
- children from 6 mo in USA, in EU from 2yrs
Summarise Adenoviral infection in 4 points
• Symptoms: Low grade fever,
Lymphadenomegaly , pharyngitis and NON PURULENT CONJUNCTIVITIS
• Diagnosis: based on clinical sx
• Treatment:
Adequate fluid intake, rest, humidified air, nasal aspiration and over-the-counter analgesics and antipyretics, no aspirin till 14 yr d/2 reyes syndrome
• Possible complication – pneumonia which requires Aggressive treatment
Summarise gongivostomatitis
HSV infection from 10mo - 3 years
• charac sx :
1) vesicular lesions on: lips, gums, anterior tongue and hard palate,which often progress to extensive, painful ulceration with/without bleeding
2) high fever and the child is very miserable. The illness may persist for up to 2 weeks.
3) painful eating and drinking (dysphagia), can cause dehydration.
• Management is symptomatic unless severe:
Diet – no salty and spicy food with normal ph
severe disease: intravenous fluids and aciclovir.
Summarise heorangina
mouth infection d/2 cocksackie virus
Sx:
General: Fever, ± loose stools
Specific: Vesicular and ulcerated lesions on the soft palate and uvula causing anorexia d/2 pain on swallowing
Rx:
• Severe cases need intravenous fluids, diet is the same as in gingivostomatitis
• No antibiotics, no acyclovir as its caused by cocksackie not HSV
Summary of enteroviruses
Enteroviruses are Common in Paeds
coxsackie viruses, echoviruses, and polioviruses
common cause of childhood infection.
• Transmission:
faecal–oral and respiratory droplet routes.
replication in the pharynx and gut, nthe virus spreads to infect other organs.
• Infections occur most commonly in the summer and autumn.
Sx:
• febrile illness, sometimes with a rash usually over the trunk
that is blanching or consists of fine petechiae.
• Some children have a history of loose stools or vomiting
What is pleurodynia
Aka bornholm diease
Acute illness charac by
pleuritic chest pain, fever and muscle tenderness.
• Possible pleural rub,m w/ no other signs on examination
• Recovery occurs within a few days.
• Treatment - ibuprofen
Summarise rhinitis posterior
Etio, age, sx, rx,
Pathogens: Staph aureus • Age up to 6 mo. • Signs: – Noisy inspiration —Difficult feeding – Cough when laying – can provoke Vomiting!! • No complications • No therapy
Summarise pharyngitis/ tonsilitis
Pathogenstic types
Age(all)
Sx
Time of resolution w/0 rx
Complications (2)
Acute infalmm of naso/ oropharynx
All ages susceptible
– High risk: 5-15 & Adults in freq contact w/ kids (teachers, parents)
• Signs and symptoms
– Sudden onset of sore throat, fever, dysphagia!!
– Headache, abdominal pain (children)
– Tender, enlarged lymph nodes
– Inflamm and erythema of uvula, pharynx and tonsils, with exudates!!
– Rash, petechiae due to unproductive cough
• Resolution without treatment
– 3-7 days; Few weeks for lymph nodes and tonsils
Complications:
– Acute rheumatic fever or reactive arthritis
– Acute glumerulonephritis
Rx of pharyngitis/ tonsillitis
1st line
2nd line
Rx of reccurence
Drug yherwoy for 10 days
Penicillin/ amoxicilline first line
2nd/3rd gen ceph if 1st line fails
-cefuroxime
Amoxiclav or clindamycin in case of reccurence
What is infectious mononucleosis and what are it’s cardinal signs and 3 dg criteria
Caused by EBV infection !!
Sx
• General: fever, fatigue in teens
•SEVERE tonsillitis/pharyngitis!!!
• severe petechiae on the soft palate!! limiting fluid and food intake and causing dehydration
• lymphadenopathy – of cervical LN! & diffuse lymphadenopathy elsewhere.
• splenomegaly (50%), hepatomegaly with hepatitis (10%)
• maculopapular rash (5%)
• jaundice - rare.
Dg
1) atypical lymohocytes on blood film
2) Elavated AST/ALT
3) 3 antibodies on seroconversion: IgG and IgM, and EB nuclear antigen (EBNA) antibodies.
Rx of infectious mononucleosis
Treatment is symptomatic.
corticosteroids to maintain when airway in sever cases
Ampicillin or amoxicillin can cause a maculopapular rash in children infected with EBV and should be avoided.
Dx for inextious mononucleosis
Mononucleosis like syndrome
Causes by CMV
• Pharyngitis and lymphadenopathy are not as prominent as in EBV infections.
• Patients may have atypical lymphocytes on the blood film but are antibody negative.
What is ottitis media
Why is it more freq in children
Rf
viral/bac infection of the middle ear! MC-Streptococcus pneumoniae
Other:H. Influenza
common infection in children under five usually follows an upper respiratory tract (URT) infection
D/2 short, horizontal, and poor functioning eustachian tube
MC in infants and children 6mo-3y
RF Bottle feeding/inadequate breastfeeding -increased negative P for bottle -Reduced passive immunity Passive cigarette smoke -decreased mucocilliary clearance Children who attend day care centers -increased pathogenic exposure
Parhophys of otitis media
The eustachian tube (ET) connects the middle ear with the nasopharynx and is lined with cilia, which drain the middle ear secretions into the nasopharynx.
Obstruction/blockage of the ET → lack of ventilation and drainage of the middle ear →
Resorption of the air in the middle ear
→increaes negative middle ear pressure → retraction of the tympanic membrane → otalgia and conductive hearing loss
Accumulation of middle ear secretions → bacterial superinfection → pus in the middle ear → bulging tympanic membrane → severe otalgia, fever
Main sx of otitis media and compilations
Sx 1)infants Irritability,Incessant crying, Refusal to feed (anorexia) Repeatedly touching the affected ear Fever and febrile seizures Tender mastoid in late stages 2)older children Otalgia/earache, commonly with throbbing Hearing loss in the affected ear Tender mastoid in late stages d/2 spread
Complications:
mastoiditis and meningitis, but these are now uncommon.
Dg of otitis media
Early and late findings on otoscopy
Lab
Otoscopy of tympanic membrane
Early: retracted and reduced mobility
Late: Red bulging & w/o landmarks, discharge if ruptures
Tuning fork test: conductive hearing loss( stronger on mastoid)
Lab: gram stain and culture of aspiration
Rx of otitis media
- lSymptomatic pain management (paracetamol, ibuprofen)
-Antibiotics: not always indicated Indications 1)Bilateral otitis media 2)Symptoms do not improve after 48 hours 3)Severe illness in children (very high fever, vomiting, malaise, and immunosuppression)
First line: oral amoxicillin
Add clavulanic acid if no improvement after 48 hours
Indications for tonsillectomy & adenectomy
Tonsilectomy
- Recurrent severe tonsillitis( decreases recurrence by a 1/3)
- peritonsilar abscess
- obstructive sleep apnea
Adenectomy
- recurrent otitis media w/ effusion or hearing loss
- recurrent sleep apnea adenectomy is mandatory!
What is sinusitis?
Causative agents
Types & prevalence according to age
Def: inflammation of paranasal sinuses mucous membrane usually occurs with inflammation of the nasal mucosa (rhinitis) and is therefore commonly referred to as rhinosinusitis.
More common in childhood
Acute
-usually viral
-possible Bac superinfection w/ S.pneum// Influenza
Chronic -anerobe: Prevotella, fusobac -aerobe: P. Aeriginosa, haemophillus RF’s (obstruc, shit cillia, increased mucus, stasis and pathogenic proliferation)
Cold and dry air Recurrent virus infections Allergic rhinitis Swimming GERD Immune deficiency Cillia diskynesia Pollyps Tonssillar Hypertrophy Cystic fibrosis
Signs and sx of acute vs chronic sinusitis
Acute: sinus inflamm under 4 wks – Teens • Mucopurulent nasal discharge • Maxillary tooth, sinus, or facial pain (unilateral) • swelling, and tenderness on cheek d/2 maxillary sinus infection • Morning preorbital swelling • Halitosis – Children • Cough, nasal discharge (> 10-14 days) • Fever (> 39C), facial swelling
Chronic: sinus inflamm over 3 months
- same as acute except
- history of long lasting sx
- anosmia
Rx & dg of sinusitis
Usually clinical dg
Lab for underlying etio
CT of sinuses (imaging modality of choice)
Soft tissue swelling, mucoperiosteal thickening, and air-fluid levels
Rx
Viral: Rest, adequate fluids, and antipyretics
Oral analgesics
Bac
Acute: amoxicillin, with or without clavulanate for 5–10 days or macrolides (clarithromycin or azithromycin) if allergic to penicillin
Chronic: Surgical debridement of necrotic tissue and removal of anatomical obstructions
What is Croup
Cause
Typical sx and rx
Aka spasmodic laryngotracheitisis (inflammation of larynx & trachea )
3 etio
Viral, bac (S.auraus/ group b strep), spasmodic
charac features Barking cough from tracheal collapse hoarseness from vocal cord inflamm Worse at night Fever & dyspnea
Dg:
clinical sx
laryngoscopy
neck xray shows subglottic narrowing= steeple sign
Rx: 1st line Corticosteroids Oral dexamethasone oral prednisolone, nebulized steroids budesonide
severe upper airways obstruction:
nebulized epinephrine + with oxygen by face mask —rapid but transient improvement.
Close observation for 2–3 hours after administration as the effects wear off.
Difference betw retro and peritonsillar abscess
Retropharyngeal
Affects kids under 6
Caused by S. aureus, anaerobes
•Insidious to sudden onset
• located Posterior to the pharynx
• No stridor but with disphagia and retractions
Rx: Antibiotics; surgical drainage of abscess
Peritonsillar abscess >10 yrs and above Cause by Group A streptococci, anaerobes • Biphasic with sudden worsening • Drooling, trismus Rx: Antibiotics; and aspiration of abscess
What is stridor
Obs at SGST
abnormal, high-pitched sound produced by turbulent airflow through a partially obstructed airway at the level of the supraglottis, glottis, subglottis, trachea.
It is an indication of respiratory distress
Indications of respiratory distress
Moderate (HI TURN for the worst) • Tachycardia • Use of accessory muscles • Respiratory rate over 50 bpm • Nasal flaring • Intercostal and subcostal recession • Head retraction • Cant feed to feed
Severe: low O2 high CO2
• Cyanosis
• Fatigue
• Reduced consciousness
• Saturation below 92% despite oxygen therapy
• Rising partial pressure of carbon dioxide
Management of acute upper airway obstruction
reduce anxiety by being calm
Look for signs of respiratory failure
oxygen if required and tolerated
do not examine the throat with a spatula! It may precipitate upper airway obstruction
oral, nebulized or intravenous steroids are beneficial in case of croup and have similar speed of onset (90–120 min)
if respiratory failure develops from increasing airways obstruction
urgent tracheal intubation is required
If obstruction is from severe croup An Anesthesiologist is required d/2 sublottal narrowing
