Lower Respiratory Tract Infections in Children

Question 1

LRTI is infection distal to the _______

Answer 1

larynx

Question 2

Principles of management:

• Make a diagnosis (____)
• Assess the patient (____) - Oxygenation, hydration, nutrition
• To treat or not to treat (____)

Answer 2

easy

easy

grey - Biggest dilemma is to weather to treat or not

Question 3

Putting LRTI into context - how common are they?

Answer 3

More than a third of all admissions of all hospitals, of all children to all hospitals in Scotland in 2018 were explained by upper and lower respiratory tract infection

Question 4

what is Tracheitis?

Answer 4

• Uncommon
• “croup which does not get better”
• Fever, sick child
• Staph or Strep invasive infection
• Augmentin

Question 5

what is Bronchitis and what are the symptoms?

Answer 5

• Common ++++
• Endobronchial infection
• Loose rattly cough with URTI
• Post-tussive vomit - “glut” (sputum)
• Chest free of wheeze/creps
• Haemophilus/Pneumococcus
• Mostly self-limiting
• Child VERY well, parent worried

Question 6

what is the mechanism of Bacterial bronchitis?

Answer 6

•Disturbed mucociliary clearance

• Minor airway malacia
• RSV/adenovirus
• Lack of social inhibition!
• Bacterial infection/overgrowth is secondary

Virus switches of mucociliary clearance

Question 7

Bronchitis:

So what happens in winter is……

Answer 7

Common for child to have 4 or 5 cycles of this in winter

Question 8

how long may a cough last?

Answer 8

Question 9

what is the natural history of Bacterial bronchitis?

Answer 9

• Following URTI
• Lasts 4 weeks
• 60-80% respond (antibiotics)
• First winter bad
• Second winter better
• Third winter fine
• Pneumococcus/H flu

Question 10

Persistent bacterial bronchitis: what is the management?

Answer 10

1. Make the diagnosis
2. Reassure
3. Do not treat

Question 11

Bronchiolitis – a clinical diagnosis

what is it?

(Different form bronchitis (infection of large airways). As this is infection of small airways)

Answer 11

• LRTI of infants
• Affects 30-40% of all infants
• Usually RSV, others include paraflu III, HMPV
• Nasal stuffiness, tachypnoea, poor feeding
• Crackles +/- wheeze

Question 12

Not many conditions that are as predictable as bronchiolitis - what does the progression of it look like?

Answer 12

If you see them at day 3 and they are bad then admit to hospital as you know they will get worse but if you see them at day 5 and their oxygenation and hydration are fine then you know tomorrow they wont be any worse

Question 13

what is the duration of bronchiolitis?

Answer 13

Question 14

when about does bronchitis occur?

Answer 14

Comes at Christmas

Question 15

Bronchiolitis:

• <12 months old
• One off (___ recurrent)
• Typical _______….

Answer 15

12 (Condition of infancy)

NOT

history

Question 16

what is the Management of bronchiolitis?

Answer 16

• Maximal observation
• Minimal intervention

Question 17

what investigation can be done for bronchiolitis?

Answer 17

a clinical diagnosis

• NPA (nursing in same ward) (identify what the virus is)
• Oxygen saturations (severity)
• No routine need for - CXR, Bloods, Bacterial cultures

Question 18

what Medications proven to work in bronchiolitis?

Answer 18

none

Question 19

Lower respiratory tract infection - what are the typical features?

Answer 19

• 48 hrs (history of), fever (>38.5oC), SOB, cough, grunting
• Wheeze makes bacterial cause unlikely
• Reduced or bronchial breath sounds
• “Infective agents” - Virus+commensal bacteria/bacterium

Question 20

if a patient presents, Is it pneumonia or not?

Answer 20

• Totally academic! (does the child care??)
• Word causes great anxiety
• You might call it pneumonia if:
• Signs are focal, ie in one area (LLZ – left lower zone)
• Creps
• High fever

•Otherwise call it LRTI (or chest infection)

Question 21

should you x-ray in pneumonia?

Answer 21

Regardless of these x-rays, the management is exactly the same

This is the chest X-ray of a child with a 48 hour history of fever, cough, shortness of breath, and is treated with amoxicillin

Question 22

BTS guidelines – community acquired pneumonia

what are the guidlines?

Answer 22

• Investigations - CXR and inflammatory makers (e.g. CRP, BC) NOT “routine”
• Management:
• Nothing if symptoms are mild (oxygen and hydration normal)
• (always offer to review if things get worse!)
• Oral Amoxycillin first line
• Oral Macrolide second choice (if allergic to amoxycillin)
• Only for iv if vomiting

Question 23

iv versus oral antibiotics:

When:

1. antibiotics are indicated (48 hours, etc, etc)
2. in non-severe LRTI
3. when child is not vomiting

If child fills 3 criteria, then they get away with oral antibiotics - why is oral better than IV?

Answer 23

Oral antibiotics “win” 2:1

√ Shorter hospital stay

√ Cheaper

X Fever for a few more hours

Question 24

What is the difference between LRTI and bronchiolitis?

Answer 24

Both technically the same thing

bronchiolitis has a 12 month age limit

Question 25

what is Pertussis? and what does it cause?

(whooping cough)

Answer 25

• This is common!
• Vaccination reduces risk
• Vaccination reduces severity
• “Coughing fits”
• Vomiting and colour change

Question 26

what is Empyaema?

Answer 26

• Complication of pneumonia
• Extension of infection (from lung tissue) into pleural space
• Chest pain and very unwell
• Antibiotics+/- drainage
• Good prognosis (in contrast with adults)

Question 27

To treat or not to treat?

Answer 27

First sort out oxygenation, hydration and nutrition (people die because of hypoxia, dehydration, and malnutrition so sort that first then worry about antibiotics)

Then worry about antibiotics!

*2 days fever, cough, focal signs (ie one side)

Question 28

Take home messages:

• LRTI are common in children
• Oxygenation, hydration and nutrition
• Then think about antibiotics
• Review if needed