Cough (Quiz 2) Flashcards Preview

SPRING16 N833 Adv Pedi > Cough (Quiz 2) > Flashcards

Flashcards in Cough (Quiz 2) Deck (132):
1

Important Cough HPI Qs

  • Onset
    • •Duration
    • •Began suddenly while eating/playing?
  • Characteristics
    • •Wet
    • •Dry
    • •Productive
  • Associated signs and symptoms
    • •Upper respiratory symptoms
    • •Wheezing, shortness of breath, or chest pain
    • •Post-tussive emesis
    • •Time of day-- nighttime awakenings?
  • Aggravating/Relieving Factors:
    • •Exacerbated by feeds, exercise?
    • •Worsens with sleep/recumbent position?
    • •Triggered by cold weather, allergen, or pollution?

2

Cough PE

•Vitals

•Cough quality

•Wet

•Dry

•High pitched

•Whooping

•Barking

•Cough frequency

•Respiratory effort

•Lung sounds auscultation:

•Wheezing

•Rhonchi

•Rales/Crackles

•Diminished

•Uneven

•Bronchophony/egophony

•Percussion:

•Fremitus

3

Red flags on cough PE

•Abnormal RR

•Low O2

•Breathlessness

•Hemoptysis

•A chronic cough with no identifiable cause

•Retractions

•Supraclavicular

•Suprasternal

•Intercostal

•Subcostal

4

Who is at risk for chlamydial pneumonia?

Neonatal / early infancy

•Mothers: untreated C. trachomatis or no prenatal care (50-70% transmission rate)

5

Onset, S/S of chlamydial pneumonia

  • •5-14 days after delivery => conjunctivitis => lacrimal ducts => nasopharynx => lungs => pneumonia in 50%
  • •(-) conjunctivitis => pneumonia in 11-20%
  • •Pneumonia Sx’s at 4-12 weeks
  • S/S
    • unique cough: staccato
    • •Intermittent low-pitched "wet" inspiratory stridor
    • •Loudest when feeding or sleeping
    • •Unremarkable birth hx
    • •Otherwise healthy

6

Dx and Tx chlamydial pneumonia

  • •Culture – gold standard (can take time)
  • •Start empiric therapy
    • –Oral erythromycin (50 mg/kg per day in four divided doses) x 14 days
  • •Mother & sexual partners (treat and/or refer)

7

What is laryngomalacia, + age group?

  • •Collapse of supraglottic structures during inspiration
    • –Vs. tracheomalacia collapse of the trachea
  • •Frequency is unknown
  • neonatal / early infancy

8

S/S of laryngomalacia

  • •symptoms (similar to tracheomalacia)
    • –Intermittent low-pitched "wet" inspiratory stridor
      • •Mild-Mod – loudest when feeding or sleeping; may disappear completely when crying
      • •Severe – loudest when crying (red flag)

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Dx and PCP mgmt of laryngomalacia

  • •Diagnosis -- Suspected by history and physical
  • •PCP Management
    • –Noisy but not dangerous; often resolves spontaneously
    • –Monitor for wt. gain, adjust feeding position, may need high calorie formula, manage GER
    • –Severe/progressive stridor, apnea, cyanotic episodes, poor feeding failure to thrive: red flags, refer

10

When/where to refer for laryngomalacia, what will they do?

  • –If severe – otolaryngologist
  • –Flexible fiberoptic laryngoscopy
    • •And/or bronchoscopy for tracheomalacia
  • –May benefit from surgery

11

Etiology, temporal pattern of bronchiolitis

  • •Acute inflammation, edema, necrosis of epithelial cells lining small airways, and increased mucous production
  • •Most commonly caused by viral lower respiratory tract infection with RSV
    • Increased RSV December-March

12

Population characteristics of bronchiolitis

  • •Occurs in children <2 years of age
  • •Most common cause of hospitalization in infants during the first 12 months of life
  • •Associated with increased risk of later development of asthma and recurrent wheezing
  • •Increased risk among infants  < 12 weeks of age, premature infants, or those with other underlying conditions

13

S/S of bronchiolitis

  • Viral upper respiratory tract prodrome followed by increased respiratory effort and wheezing
    • Prodrome: 1-3 days of nasal congestion, rhinorrhea, mild cough, fever, decreased appetite
    • Progresses to the lower airways: Rhinorrhea, wet cough, tachypnea, wheezing, crackles, and increased respiratory effort

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Assessment of bronchiolitis

  • •Vitals
  • •Upper respiratory involvement
  • •Lung sounds
    • Wheezing, may have crackles
  • •Signs of increased respiratory effort:
    • Nasal flaring, retractions, grunting, apnea, tiring, cyanosis
  • •Risk factors (prematurity, smoke exposure, sick contacts)

15

Differentials for bronchiolitis

•Asthma/Reactive airway disease (asthma typically not diagnosed < 2): how many episodes have they had?

Asthma: big differential. Ask about previous episodes. If repeated – may be RAD dx and NOT bronchiolitis, may be txed with albuterol and steroids

16

Diagnosis and Disease Severity: Bronchiolitis

  • •Based on history and physical exam
  • •Radiographic or laboratory studies not routinely obtained (no evidence CXR correlates w/severity)

17

Management of bronchiolitis

  • •Non-severe:
    • Supportive care
      • •Adequate hydration, relief of nasal congestion 
  • •Severe:
    • Nebulized hypertonic saline
      • •Recommended for use for infants and children hospitalized with bronchiolitis
    • Oxygen
      • •Based on provider discretion if O2 saturation > 90%
    • Continuous pulse oximetry
      • •Based on provider discretion
    • Nutrition and hydration
      • •Nasogastric or IV fluids recommended for infants who cannot maintain hydration orally

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What is RSV prophylaxis, who is it for?

•RSV prophylaxis with palivizumab (Synagis) for high risk children infected with RSV

19

What is influenza?

•Acute respiratory virus caused by Influenza A or Influenza B virus

20

Population characteristics of influenza

  • •Distinct outbreaks each year, concentrated during winter months
  • •20,000 children < 5 hospitalized each year from the flu. Last year, > 140 flu-related pediatric deaths reported.
  • •In children, greatest incidence of influenza-related hospitalization is among those < 6 months of age
  • •Children with asthma, diabetes, or nervous system disorders at increased risk for complications

21

S/S of influenza

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Important components of assessment of flu

  • •Respiratory effort
  • •Vaccine status, sick contacts
  • •Clinical suspicion with fever and acute onset of respiratory illness

23

Complications of flu

  • •Otitis Media
  • •Asthma exacerbation
  • •Pneumonia
  • •Neurologic complications
  • •Secondary bacterial infections

24

Differentials of flu

  • •RSV or other viral illnesses (often difficult to distinguish from influenza in infants)
  • •Bacterial infection
  • Hard to distinguish flu from other URIs – could be a good idea to test for

25

Diagnosis of flu

  • Specimen collection methods:
    • Nasopharyngeal swab (optimal method overall) cannot be collected in infants
    • Nasopharyngeal aspirate/wash may not be possible in infants
    • Combined nasal/throat swab: can be done for infants
  • Tests:
    • Rapid Antigen Detection
    • Viral tissue cell culture
    • Direct and indirect fluorescent antibody assays
    • RT-PCR: most sensitive and specific

26

MGMT of flu

  • Laboratory confirmation should not delay antiviral therapy initiation
  • Antiviral therapies:
    • Oseltamivir (Tamiflu)
      • FDA approved in ages ≥ 2 weeks of age who have been symptomatic for ≤ 2 days
      • Approved for prophylaxis of influenza in those ≥ 1 year of age
    • Peramivir (Rapivab): very limited data on use in neonates
    • Zanamivir (Relenza): Only approved for those ≥ 7
    • Rimantadine and amantadine previously used but now most flu viruses are resistant to them
  • Supportive care:
    • Hydration, relief of nasal congestion

27

Forms of flu vaccine + candidates

  • •Trivalent shot (6 months and older)
  • •Quadrivalent shot (6 months to < 36 months)
  • •Quadrivalent shot (> 36 months)
  • •Flumist (2- 49 years old)

28

Flu vaccine considerations for Children ages 6 months to 8 years old

  • Should receive 2 doses of the vaccine if they have never received ≥ 2 total flu vaccines prior to July 1st of that year.
  • Doses should be administered 4 weeks apart.

29

Considerations when adminstering flu mist

  • •Flu mist is a live attenuated vaccine:
  • §Other live vaccines that are not administered on the same day should be administered at least 4 weeks apart.

30

Etiology of croup

  • •Croup (laryngotracheobrochitis): generic term for a spectrum of common viral respiratory tract illness
  • •Edema of the subglottic structures (larynx, trachea, and sometimes bronchi), leading to the brassy/barky cough
  • •Most often caused by parainfluenza virus and sometimes adenovirus or RSV

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Population characteristics of croup

  • •Affects children 6 months- 6 years of age
  • •Leading cause of hospitalizations in children under 4
  • •Tends to occur in the fall and early winter

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S/S of croup

  • •Usually begins with nasal congestion, rhinorrhea
  • •Within 12-24 hours: followed by relatively acute onset of fever, hoarseness, barky, seal-like cough, stridor (Johnson, 2009)
  • •Symptoms  worse at night
  • •Usually lasts less than one week

33

How to assess severity of croup

  • •Severity scoring:
    • •Cough frequency
    • •Degree of stridor
    • •Degree of respiratory distress

34

Differentials of croup

  • Epiglottitis: drooling, trouble swallowing, vaccination status?
  • Peritonsillar abscess: displaced uvula, visible abscess?
  • Allergic reactions: known allergen and exposure, hives, rash?
  • Foreign body aspiration: cyanosis, wheeze, diminished breath sounds in focal area?

35

Diagnosis of croup

  • •Physical Exam
  • •Steeple Sign

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MGMT of croup

  • •Fever treated with antipyretics
  • •Oral or IM/IV dexamethasone
  • •Nebulized epinephrine
  • •Increase fluids
  • •Avoid smoke exposure
  • •Keep head of bed elevated
  • •Cough medicines and decongestants not routinely recommended and can mask symptoms
  • •Humidifier mist for comfort
  • •Moderate to severe croup should be evaluated in the emergency department or clinic capable of handling urgent respiratory illness

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algorithm for clinical assessment of croup severity

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38

Etiology of pertussis

  • •Pertussis (whooping cough) caused by bacteria, Bordetella pertussis
  • •Bacteria attach to the lung cilia and release toxins, causing the airway to swell

39

Population characteristics: pertussis

  • •Most common in < 1 year olds
  • •About half of those < 1 year old are hospitalized
  • •Often transmitted to babies by caregivers who do not yet know they have the disease
  • •Infants and pregnant women are high risk

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Pertussis: S/S

stages

  • Catarrhal Stage (last 1-2 weeks) (highly contagious):
    • Rhinorrhea, low-grade fever, mild, occasional cough
  • Paroxysmal Stage (lasts up to 10 weeks):
    • Numerous coughing fits, with rapid cough followed by “whoop” sound
    • Posttussive emesis and exhaustion from coughing
  • Convalescence stage (lasts 2-3 weeks):
    • Coughing lessens, but fits may return

Whoop not always present in infants

41

assessment / diagnosis of pertussis

  • Clinical diagnosis
  • Can confirm via:
    • PCR testing
    • If available: nasopharyngeal specimen
    • Serology testing: not standardized. Gold standard: in the presence of pre-existing immunity, rise in titers using paired specimens 2 to 3 weeks after onset of clinical illness.

42

DDx of pertussis

Pneumonia, TB, RSV, flu, or other viral illness

43

MGMT of pertussis

  • Humidifier mist
  • Increase fluids
  • Avoid irritants that can trigger cough
  • Treat with antibiotics:
    • First line: Azithromycin, erythromycin or clarithromycin
    • For infants < 1 month: azithromycin is preferred and clarithromycin is not recommended
    • Second line: Trimethoprim-sulfamethoxazole (TMP-SMX) for children > 2 months who have a contraindication to first line therapy

44

Vaccination for pertussis: what and when

  • •DTap series: 2 months, 4 months, 6 months, 15-18 months, 4-6 years
  • •TDap: 11-12 years
  • •Waning protection seen among adolescents

45

Infant GER/GERD:

GER vs GERD vs regurgitate vs vomit

  • GER: passage of gastric contents into the esophagus (nl physiologic process, very common in infants)
  • GERD: when reflux is associated with complications (i.e. esophagitis, poor weight gain)
  • Regurgitate: reflux into oropharynx
  • Vomit: expulsion of reflux contents

46

Population characteristics: infant GER/GERD

  • Regurgitation in healthy infants is extremely common
    • 50% of 0-3 month olds
    • 75% of 4 months olds
    • 5-10% of 1 year olds
  • Increased risk with prematurity, cystic fibrosis

47

S/S of infant GERD

  • •Regurgitation
  • •Choking
  • •Gagging
  • •Irritability
  • •Opisthotonic posturing
  • •Excessive hiccups
  • •Refusing feeds
  • •Respiratory involvement (less common): cough, wheeze, stridor
  • Back arching characteristic

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Assessment of infant GERD

  • •Weight gain
  • •Irritability directly following feeds?
  • •Amount infant is feeding (make sure not overfed)
  • •Breastfeeding or formula
    • If breastfeeding, assess mom’s diet

49

Differentials for infant GERD

  • •Colic: crying ≥ 3 hours, ≥ 3 days/week, ≤ 3 months of age?
  • •Milk protein allergy: atopic dermatitis, diarrhea?
  • •Eosinophillic esophagitis: unresponsive to GERD meds, dysphagia, vomiting, weight loss?
  • •Pyloric stenosis: projectile vomiting in a 3-6 week old, “hungry vomiter”?

50

Diagnosis of infant GERD

  • •Clinical diagnosis: based on history and PE in the absence of warning signs
  • Diagnostic Studies
    • •Endoscopy and Esophageal Biopsy
      • •Can pursue if infant has significant symptoms and trial pharmacotherapy and lifestyle/feeding modifications not responsive
    • •Upper GI series
      • Not routinely recommended for evaluation of GERD. Would be done to rule out anatomic abnormalities.

51

MGMT of infant GERD: lifestyle / feeding

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MGMT of infant GERD: pharm tx

not indicated for infants with uncomplicated reflux, because of lack of efficacy and modest safety concerns, and because the symptoms resolve without treatment in many infants (Winter et al., 2016)

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quick summary chart of bronhiolitis, flu, croup, pertussis, infant GERD

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What is vocal cord dysfunction?

Also called: Paradoxical Vocal Fold Motion

•Adduction of vocal cords during inspiration instead of abduction.

–Can more rarely occur during exhalation

55

Image of vocal cord dysfunction in action

Vocal cord movement during inspiration

A: Normal vocal cord movement

B: Adduction

C: Adduction with “chinking”

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Prevalence of VCD

*Prevalence increased in females and early adolescence: controversial

57

Assessment of VCD?

  • •HPI:
    • –Triggered by emotional stress
    • –Reflux, exercise, chemical irritant exposure in last 24H (chlorine, perfume, smoke)
    • –Throat tightness, difficulty swallowing
    • –Anxiety, panic
  • •PMH: Asthma, GERD
  • •Social:
    • –Elite athletes
    • –Recent traumatic event involving breathing
    • –Playing wind instrument
    • –Voice demands (singing, drama)
  • •Meds: Asthma treatments may have been ineffective

58

An important differential for VCD

ASTHMA

  • Comorbid with asthma in as many as 40% of pediatric patients
  • Average time of asthma treatment: 4.8 years
  • Asthma co morbid and misdx
  • Elite athletes: prone to VCD, asthma
  • Traumatic event: near-drowning, suffocation, witnessing severe asthma attack

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Assessment: HPI and exam for VCD

  • •HPI and Exam – signs are often intermittent and may not be present in office:
  • –Dizzy, heavy extremities, paresthesias
  • –Aphonia /dysphonia / hoarseness
  • –Throat clearing, sensation of choking
  • –Dry cough
  • –Stridor: loudest over neck,
  •   quieter in chest,
  •   often inspiratory
  • –Dyspnea
  • –Tachypnea
  • –Throat /  upper chest tightness
  • –Harder to get air “in” than “out”

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VCD: diagnosis

  • 1.History and physical
  • 2.Spirometry with inspiratory loops
  • 3.Document normal O2 sat during episodes
  • 4.Gold standard: Laryngoscopy, if needed can do after exercise or irritant challenge

Attenuation is extrathoracic, asthma causes intrathoracic

Spirometry shows attenuation/flattening

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Tx of VCD

  • •Manage underlying conditions (GERD, asthma)
  • •Speech and language pathologist
    • –Breathing exercises and relaxation techniques: Focusing attention away from larynx, abdominal breathing, neck relaxation, pursed lip breathing
  • •Possible: Psychologist, otolaryngologist (lesions, paralysis)
  • •Providing information to school, coaches, work

18-53% of patients with VCD have underlying GERD. VCD may resolve once GERD is managed.

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Definition of pneumonia

  • •Inflammation of pulmonary parenchyma
    • –Aspiration: food, saliva, gastric contents enters airways
    • –Bacterial:
      • Streptococcus pneumoniae (gram+): 3w to 4yo
      • mycoplasma pneum and  chlmydophilia pneum (gram negs): >5yo
    • –Viral: most common cause of LRTI, 2 - 3 yo, decreases aftr
    • –Incidence 3-5%, most often in children <5yo

63

Risk factors for pneumonia

  • •Younger age, previous URI, asthma history, more that three children at home, smoking
  • •Fall and winter

64

Etiologic agents for pneumonia by age

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Pneumonia: HPI

  • •Several days of URI symptoms
  • •Fever
  • •Abrupt onset of chills, cough
  • •Change in activity, feeding
  • •Abdominal, neck or chest pain

66

Pneumonia: S/S

  • •General: ill appearing, “something is wrong”, splinting of affected side, knees drawn up to chest
  • •VS: Fever, decreased O2 sat
  • •Wet cough
    • –Pneumonia cough
  • •Respiratory:
    • –Tachypnea (most specific)
    • –Increased WOB (retractions, nasal flaring)
    • –Wheezing
    • –Early: Crackles, rhonchi, diminished breath sounds
    • –Late: Dullness to percussion, diminished breath sounds
  • •Variable rash from viral etiology
  • •Nausea/vomiting

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WHO guidelines for tachypnea by age

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How is pneumonia diagnosed?

  • •Clinical >> enough if stable
  • •CXR >> confirmation, severe or failed treatment
  • –Infiltrate
  • •Consider: PPD, Influenza test for viral cause, CBC w/diff
  • •Bacterial vs. viral vs. aspiration
  • Labs:
    • -CBC with diff
    • -VIRAL: 20,000 WBC with lymphocytes
    • -BACT: 15,000-40,000 WBC with granulocytes
  • -Sputum cultures difficult to obtain and do not accurately reflect the cause of the LRTI
  • -Aspiration:
    • -History of level of consciousness change, predisposing condition
    • -Unwitnessed choking event à foreign body à weeks later, pneumonia develops. Often treated as pneumonia and aspiration not identified. Abx will help symptoms but infiltrates will remain and pneumonia will recur.

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CXR normal vs infiltrate

pneumonia

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Viral vs bacterial pneumonia

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Characteristics of aspiration pneumonia

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Treatment of pneumonia

  • •Viral: self limited within one month
    • –Most pre-school cases are viral
    • –Antivirals (even after 48h if sever)
  • •Bacterial
    • –Amoxicillin 90 mg/kg/day divided in 2 or 3 divided doses with max of 4g/day for 10-14 days
    • –If atypical: Azithromycin 10 mg/kg day 1, 5 mg/kg days 2-5 once daily with max of 500mg day 1, 250mg days 2-5
  • •Aspiration
    • –Amoxicillin-clavulanate 40-50mg/kg/day in 2 or 3 divided doses (max 1750 Amoxicillin component)
  • •Follow up 12 hrs – 5 days*
  • •Supportive care: antipyretics, nasal suctioning, fluids

73

Prognosis for pneumonia

  • •*48-96 hr improvement with abx
  • •Cough may last 1 month after resolution
  • •No repeat CXR needed

74

When to hospitalize for pneumonia

  • –Any child <3-6 mo unless mostly asymptomatic
  • –Sustained O2 sat <90%
  • –Dehydration (older) /inability to feed (infants)
  • –Toxic
  • –Immunocompromised
  • –Cap refill >/= 2 seconds
  • –Severe respiratory distress
  • •RR > 70 in infants <12 mo
  • •RR  >50 in older children
  • •Moderate to severe retrations in infants <12 mo
  • •Severe difficulty breathing in older children
  • •Grunting, nasal flaring, apnea, Significant SOB
  • –Temp >101.3
  • –Outpatient failure / complications

75

Complications of pneumonia

•Pleural effusion, empyema, necrotizing pneumonia, pneumatocele, lung abscess

76

What is recurrent pneumonia?

  • •2 or more episodes in one year OR 3 or more lifetime episodes
  • •Must be radiographically clear between

77

What to do if nonresponsive or recurrent pneumonia

  • •Return to list of differentials
  • •Complications
  • •CXR
  • •Consider adding antibiotic coverage

78

What is an asthma cough?

  • •Most common cause of cough in children >3 yo
  • •Cough - often sole presenting complaint
    • –Nocturnal (unlike vcd)
    • –Seasonal
    • –Exposure history (cold air, laughing, crying)
    • –>3 weeks
    • –Usually associated wheezing, atopy, exceptional dyspnea
    • –Dry and hacking
      • •Can be productive with clear/white sputum but consider bronchitis

79

Diagnosis of asthma cough

  • •Spirometry (>5yo)
  • •Asthma medication trial for 2-4 weeks – ICS and SABA
  • •3-5 days oral prednisolone
  • •Bronchoprovocation test

80

Definition and prevalence of foreign body aspiration

  • Foreign body in larynx, trachea, right lung, left lung or bilaterally
  • •80% of cases in 1-3 yo

81

Assessment for foreign body aspiration

  • •HPI:
    • –Choking event (witness or apparent)
    • –When (if days or weeks before may present with complications)
    • –Activity while eating, older siblings, access to small objects/improper foods
  • •PMH: asthma nonresponsive to therapy
  • •Exam:
    • –Cough – sudden onset (most common), wheeze
    • –Tachypnea (2nd most common)
    • –Stridor, wheeze (2nd most common)
    • –Decreased, regional difference in breath sounds
    • –Dullness/crackles if pneumonia develops
    • –Location specific findings:
      • •Laryngotracheal: wheeze, dyspnea, stridor, hoarseness
      • •Large bronchi: cough and wheeze
      • •Lower airways: little acute distress
  • -Triad (cough, wheeze, decreased breath sounds): specific (96-98%) but not sensitive (27-43%)

82

MGMT of foreign body aspiration

  • •Chest or neck X-ray
  • •Possible CT
  • •Rigid bronchoscopy for diagnosis and removal
  • •Follow up 2-3 days if no findings and low clinical suspicion

83

Complications of foreign body aspiration

•Hemoptysis, recurrent or acute pneumonia, lung abscess, bronchiectasis, atelectasis

84

Chest radiograph when aspirating a peanut

A, Normal inspiratory chest radiograph in a toddler with a peanut fragment in the left main bronchus.

B, Expiratory radiograph of the same child showing the classic obstructive emphysema (air trapping) on the involved (left) side. Air leaves the normal right side allowing the lung to deflate. The medium shifts toward the unobstructed side.

Peanuts don’t show up on x ray – very commonly aspirated

85

Algorithm for suspected foreign body aspiration in children

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What is primary ciliary diskinesia

  • Definition
    • •Congenital defect
    • •Malfunctioning cilia à impaired mucociliary clearance
    • •Component of cilia is missing
  • Background
    • •Autosomal recessive
    • •Situs inversus

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assessment of primary ciliary dyskinesia

  • •HPI
    • –Recurrent URI and LRI infections
      • •Chronic, productive cough
      • •Worsens through day
    • –Recurrent AOM
    • –Rhinosinusitis (cardinal sign)
      • •Headache, fatigue
    • –Supplemental O2 at birth
    • –Associated with: pyloric stenosis, epispadias, cardiac abnormalities, transposition of great arteries
  • •Exam
    • –Voice nasal
    • –Crackles, wheezes
    • –Nasal polyps

88

Diagnostics for primary ciliary dyskinesia

  • •No gold standard
  • •Nasal nitrous oxide, nasal brushing and videomicroscopy…
  • •CXR/CT
  • •Genetic testing

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Treatment for primary ciliary dyskinesia

  • •Refer to pulmonology
  • •Clear secretions and selective antibiotics
  • •Chest physiotherapy
  • •Monitoring
  • •Manage OME, nasal polyps, chronic rhinosinusitis

90

Prognosis for primary ciliary dyskinesia

  • •Men infertile, women decreased fertility
  • •Chornic rhinosinusitis can influence work

91

Summary table for VCD, asthma, foreign body aspiration, PCD, pneumonia

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Prevalence of allergic rhinitis

  • •Affects 10% to 30% of children and adults in the U.S.
  • •Accounts for at least 2.5% of all clinician visits and 2 million lost school days per year

93

Symptoms of allergic rhinitis

  • •Paroxysms of sneezing
  • •Rhinorrhea
  • •Nasal obstruction
  • Other common symptoms
    • •Itching of the eyes, nose
    • •Palateostnasal drip
    • •Cough
    • •Irritability
    • •Fatigue
  • **Young children typically do not blow their noses, and instead, may repeatedly snort, sniff,
  • cough, and clear their throats. Some scratch their itchy palates with their tongues, producing a
  • clicking sound (palatal click).

94

Risk factors for allergic rhinitis

  • •Family history of atopy (ie, the genetic predisposition to develop allergic diseases)
  • •Male sex
  • •Birth during the pollen season
  • •Firstborn status
  • •Early use of antibiotics
  • •Maternal smoking exposure in the first year of life
  • •Exposure to indoor allergens, such as dust mite allergen
  • •Serum IgE >100 int. units/mL before age six
  • •Presence of allergen-specific immunoglobulin E (IgE)

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Diagnosis of allergic rhinitis

  • •Symptoms
  • •Physical exam
    • –Enlarged nasal turbinate
    • –Clear rhinorrhea
    • –Cobblestoning of oropharynx
  • •Allergy skin testing confirms sensitivity to aeroallergens (not necessary for the initial diagnosis)

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Classification of allergic rhinitis

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Treatment of allergic rhinitis: Mild or episodic

 

  • •A second-generation oral antihistamine, administered regularly or as needed (ideally 2-5 hours before an exposure)
  • •An antihistamine nasal spray
  • •A glucocorticoid nasal spray (more effective than antihistamines), administered regularly or as needed
  • •Montelukast or Cromolyn, administered regularly or as needed (ideally 30 minutes before an exposure)

99

Treatment of allergic rhinitis: 

Persistent or moderate-to-severe symptoms:

•Glucocorticoid nasal
•If  fail to respond, add a second agent - antihistamine nasal spray, oral antihistamines, montelukast, cromolyn, antihistamine/decongestant combination products

100

Definition and prevalence of bacterial sinusitis

  • Definition
    • •Inflammation of the lining of the nose and sinuses
  • Prevalence
    • •6%-8%

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Anatomy of the sinuses

  • •Ethmoid sinus. Located inside the face, around the area of the bridge of the nose. This sinus is present at birth, and continues to grow.
  • •Maxillary sinus. Located inside the face, around the area of the cheeks. This sinus is also present at birth, and continues to grow.
  • •Frontal sinus. Located inside the face, in the area of the forehead. This sinus does not develop until around 7 years of age.
  • •Sphenoid sinus. Located deep in the face, behind the nose. This sinus does not develop until adolescence.

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How can I tell if my child has bacterial sinusitis or simply a common cold?

Most colds have a runny nose with mucus that typically starts out clear, becomes cloudy or colored, and improves by about 10 d. Some colds will also include fever (temperature >38°C [100.4°F]) for 1 to 2 days. In contrast, acute bacterial sinusitis is likely when the pattern of illness is persistent, severe, or worsening.

Uncommon in newborns 2/2 sinuses not fully developed

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Symptoms of bacterial sinusitis

  • •A cold lasting more than 10 to 14 days, sometimes with a low-grade fever
  • •Thick yellow-green nasal drainage
  • •Post-nasal drip, sometimes leading to or exhibited as sore throat, cough, bad breath, nausea and/or vomiting
  • •Headache, usually in children age six or older
  • •Irritability or fatigue
  • •Swelling around the eyes

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Diagnosis of bacterial sinusitis

  • •Acute bacterial sinusitis when acute URI with the following:
  •   Persistent illness, ie, nasal discharge (of any quality) or daytime cough or both lasting more than 10 days without improvement;

  OR

  • •Worsening course, ie, worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement;

  OR

  • •Severe onset, ie, concurrent fever (temperature =39°C/102.2°F) and purulent nasal discharge for at least 3 consecutive days”

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Treatment of acute bacterial sinusitis

  • •Antibiotic therapy:
    • –Amoxicillin 90 mg/kg/day PO divided q8-12h x 10 days
    • –Unresponsive/allergic: Cefpodoxime 10mg/kg/day PO divided q12 x 10-14 d
    • – Nasal decongestant/saline nasal sprays: short-term relief of stuffiness
  • •Nasal saline: thins secretions and improves mucous membrane function
  • •OTC decongestants and antihistamines generally not effective
  • •Important to complete therapy even if symptoms improve

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Treatment of chronic sinusitis

  • •One or more symptoms of sinusitis for at least 12 weeks
  • •Chronic sinusitis or recurrent episodes of acute sinusitis (> 4-6/yr) à refer to ENT
  • •Surgery: for severe or persistent sinusitis symptoms despite medical therapy

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Definition of upper-airway cough syndrome (post nasal drip)

  • •When mucus drips down the throat, it tickles the nerves of the nasopharynx, triggering a cough
  • •Generally a symptom secondary to rhinitis and sinusitis
  • •If it lingers after the primary condition, it is considered Upper Airway Cough Syndrome

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Symptoms of post-nasal drip

  • •Cough more at night
  • •Tickling feeling at the back of throat

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Diagnosis and Tx of PND

  • Diagnosis
    • •History and physical exam
    • •Diagnosis generally based on response to treatment
  • Treatment
    • •Decongestant or antihistamine or combination
    • •Home remedies such as inhaling steam or nasal irrigation

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Prevalence and etiology of a tic cough

  • Prevalence
    • •Up to 10% of children and adolescents
  • Etiology
    • •No pathologic cause of the cough (chronic cough of unknown origin that does not respond to observation and primary care interventions )
    • •No response to commonly used antitussive medications

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Symptoms of tic cough

  • •Tickling in the throat
  • •Cough usually prominent during visits to the clinic, absent at night and rarely interrupts play, speech, or eating
  • •Distinctive in nature: short, single dry coughs (tics) or may be similar to laryngotracheobronchitis (a barking or honking sound after a short inhalation)
  • •Loud and disruptive in a classroom (leads to excessive absences from school

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PE of tic cough

  • •Abnormal gag reflex
  • •Abnormal corneal reflex
  • •Loud paroxysmal barking or honking sound (usually not heard when provider not in room)

Cough: Often loud cough in exam room but if you stand outside room and patient does not know you are there, there is  no coughing.

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Diagnosis and tx of tic cough

  • Diagnosis
    • • Diagnosis of exclusion
  • Treatment
    • •Suggestion therapy
    • •Bedsheet wrap: Tightly wrap a sheet around the child's chest which provides the support to stop the cough (suggestion technique that convinces patient that chest muscles have become too weak to contain the cough)

Ace wrap may be more practical than bedsheet

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Who gets legionella pneumophilia?

  • •23,076 cases last 15yrs, 1.7% were pediatric
  • –15-19 years old (44.3%)
  • •2-9% of pediatric pneumonia
  • •“Legionnaires' disease”
  • –1976 American Legion Convention, Philadelphia
  • •221 cases, 34 deaths

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Sx of legionella pneumophilia

  • •Wheezing

    •No hx of asthma

    •Wet cough – gradually getting worse x 3 days

    •No crackles/rhonchi

    •No dyspnea or pleuritic chest pain

    •Temp 100.8

  • •Neurologic findings (especially confusion), fever >39ºC, hyponatremia, hepatic dysfunction, hematuria
  • •Failure to respond to beta-lactams and/or aminoglycosides

-Beta-lactam inhibitors – Penicillins, Cephalosporins, Cephamycins, Carbapenems, Monobactams, Beta-lactamase inhibitors

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Transmission / incubation period for legionnaire's 

  • •No person-person transmission
    • –Inhalation of aerosols (showers, grocery store mist, cooling stations, decorative fountains, whirlpool spas)
  • Incubation period 2-10 days

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MGMT of legionnaire's

  • •Nationally notifiable disease
  • •Levofloxacin
    • –500 mg PO once daily x 10-14 days
  • •Azithromycin
    • –10 mg/kg (maximum dose: 500 mg) as a single dose on the first day, followed by 5 mg/kg/day (maximum dose: 250 mg) on days 2 through 5.

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CXR findings for legionnaire's

CXR: Diffuse bilateral interstitial infiltrates

 

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What is Mycoplasma pneumoniae?

“atypical pneumonia”

•20% of pediatric pneumonia

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Clinical presentation of Mycoplasma pneumoniae?

  • •Wheezing (no hx asthma)
  • •Gradual onset of sx’s, minimal respiratory distress
  • •Chest auscultation (-) early stages, but CXR (+)
  • •Extrapulmonary sx’s
    • – Rash, joint involvement, GI
      • •Dutifully investigate differential dx’s
      • Common infectious cause of SJS

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Diagnostic testing for mycoplasma pneumoniae?

•not feasible/useful in outpatient settings

•CXR: no distinguishing features

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Treatment for mycoplasma pneumonia

•Azithromycin

–10 mg/kg in one dose (maximum dose 500 mg) on the first day and 5 mg/kg in one dose (maximum dose 250 mg) for four days

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Prevalence of hodgkin's lymphoma

•6% of childhood cancers -- highest incidence 15-19 y.o.

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Clinical symptoms of hodgkin's lymphoma

  • •75% will have a mediastinal mass
    • –Of these, 30% with a mass > 1/3 diameter of intrathoracic cavity
    • •At risk for acute respiratory compromise
      • •Dysphagia, dyspnea, stridor
      • •Cough is prolonged (> 2 weeks) and has no identifiable cause
  • •80% painless adenopathy
    • – supraclavicular or cervical area
  • •25% non-specific constitutional symptoms
    • –Cough, fatigue, anorexia, weight loss, pruritus, night sweats, low grade fever
  • •EBV => HL ??
    • –25-50% cases classical HL are EBV+

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MGMT / prognosis for hodgkin's lymphoma

  • •Treatment/Prognosis
    • –Stage, B symptoms, bulky disease (size)
      • •Fever, night sweats, >10% wt.
  • •Multidisciplinary team
    • –Primary care practitioners
    • –Pediatric surgeons
    • –Pediatric medical oncologists and hematologists
    • –Rehabilitation specialists
    • –Social workers
    • –Child life professionals
    • –Psychologists
  • •5-year survival 95%
  • •Ongoing surveillance for years - 90-95% cure rate

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OTC cough tx 12yo

  • •123 deaths of children
  • •750,000 poison control center calls 2000-2011
  • •Recommendations:
    • –Do not use in children
    • –Recommended against in children 6-12 (UpToDate)
    • –Single use symptomatic relief if needed in children >12 yo
  • •Why?
    • –Not proven more efficacious
    • –Untested dosing guidelines for children
    • –Potential for enhanced toxicity
    • –Associated with fatal overdose
    • –Other ingredients: dye and alcohols

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Anti-tussives in kids

  • Antitussives
    • •No studies showing efficacy and safety
    • •Act on cough center of medulla to elevate coughing threshold
  • Antitussives – Dextromethorphan
    • •Well tolerated
    • •No evidence of cough improvement (placebo and DM treated groups both improved in 3d)
    • •Deaths from DM ingestion in children
    • •Abuse potential
    • •Recommendations:
      • –WHO: DM may be okay if interfering with sleep/feeding but should consider different diagnosis (pertussis, asthma, pneumonia)
      • –AAP: No antitussives

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Sx of DM abuse

  • -Symptoms can occur at 1.5 mg/kg (first plateau, mild stimulation) to 7.5-15mg/kg (third plateau, out of body state)
  • -   Hallucinations, euphoria
  • -School age, adolescents
  • -“dex, DXM, robo, skittles, triple-C, vitamin D, tussin, red devils, poor man’s PCP”
  • -Consume large amounts, as much as 20oz/day
  • -Coricidin HBP, RobitussinDM and Delsym have high concentrations of DM

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Recommendations for antitussives w/codeine

  • •What’s the problem?
    • –No more effective than placebo
    • –No proven efficacy in children
    • –Significant safety concerns (respiratory depression).
    • –Variations in metabolism
    • –Will never achieve full cough suppression even at highest dose
  • •Recommendations: removed or cautioned against by: AAP, WHO, American College of Chest Physicians, FDA
    • –Canadian Ministry of Health, European Medicines Agency: possibly ok > 12yo
  • •National variance in prescribing practices
  • for cough suppression

  • Variations in metabolism: 30% of population are slow metabolizers, 8% are ultra rapid metabolizers converting 5-30 times more than typical into the active form (higher percentage in Middle Eastern and North African)

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Cough Tx: Supportive care

  • •Hydration: Thins secretions, relieves cough-inducing irritation
  • •Warm liquids: loosens secretions, relieves cough-inducing irritation, increases flow of secretions
  • •Saline solution: : removes secretions, improves mucous clearance, vasoconstriction
  • –½ teaspoon salt + 1 C sterile warm water/boiled water
  • –Gargle or instillation/drops into nose
  • •Cool mist humidifiers: clean weekly!
  • •Lozenges/hard candy: > 6yo – coats thr throat
  • •Vapor rub:  reduces frequency and severity of cough, No effect on rhinitis, Irritant effect possible

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Honey for supportive care

  • •½ to 1 teaspoon straight or diluted
  • •Buckwheat, dark or any; corn syrup
  • •Eases night-time coughing
  • •Decreases severity and frequency
  • •Improves sleep quality
  • •Better than placebo, nothing and diphenhydramine, equal to DM in 2014 study of children 1-5 yo (N=300)
  • •No significant adverse effects
  • •Endorsed by WHO and AAP for children > 1yo

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Key points for exam

 

  • Important History and Physical components ( age related)
  • Definitions: 
    • wet, dry, productive
    • rales, rhonchi, wheeze, stridor,crackles, staccato, whoop
  • Conditions common to specific ages
    • Unique presentation
    • Associated symptoms
    • Methods of objective eval ( if recommended)
    • Guidelines to diagnosis, if applicable
    • Management (  not specific dosings)
    • OTC products
    • Alternative management
  • Keep study focused on primary care – not hospital or not specialist