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0

The most common pathogens associated with the common cold

Rhinoviruses - most common
Coronaviruses

2

The most common complication of a cold is

otitis media

- Sinusitis is another complication of the common cold
- diagnosis of bacterial sinusitis should be considered if rhinorrhea or daytime cough persists without improvement for at least 10-14 days or if signs of more-severe sinus involvement such as fever, facial pain, or facial swelling develop

3

Clinical control of asthma is defined as

No (twice or less/week) daytime symptoms
No limitations of daily activities, including exercise
No nocturnal symptoms or awakening because of asthma
No (twice or less/week) need for reliever treatment
Normal or near-normal lung function
No exacerbations

4

When are the best times to monitor PEF (peak expiratory flow)?

PEF is measured first thing in the morning before treatment is taken, when values are often close to their lowest, and last thing at night when values are usually higher

5

How is the diagnosis of asthma confirmed through PEF?

60 L/min (or 20% or more of pre-bronchodilator PEF) improvement after inhalation of a bronchodilator,
OR
diurnal variation in PEF of more than 20% (with twice daily readings, more than 10%) suggests a diagnosis of asthma

6

What are the parameters that describe partly controlled asthma?

Any measure present would be sufficient to categorize px as having partly controlled asthma:

LANDR (Lung fcn, limitation of Activities, Nocturnal, Daytime Sxs, need for Reliever tx)
L- 2x/wk
R - > 2x/wk


7

What are the parameters that describe uncontrolled asthma?

Three or more features of partly controlled asthma

LANDR (Lung fcn, Activity limitation, Night sxs, Daytime Sxs, Reliever tx)

8

What is the single best measure of assessing severity of airflow obstruction?

FEV1 (forced expiratory volume in one second)

9

The primary therapies for asthma exacerbations are

Reference: GINA
- repetitive administration of rapid-acting inhaled bronchodilators
- early introduction of systemic glucocorticosteroids
- oxygen supplementation

10

Normal rates of breathing in awake children

< 2 mos
2-12 mos
1-5 yrs
6-8 yrs

< 2 mos < 60
2-12 mos < 50
1-5 yrs. < 40
6-8 yrs < 30 breaths/min

11

In the management of acute asthma exacerbation, what is the best and most cost-effective method of achieving rapid reversal of airflow limitation?


repeated administration of rapid-acting inhaled β-agonists
(2 to 4 puffs every 20 minutes for the first hour)

12

In a patient with acute exacerbation of asthma, what is the O2 sat value indicative of the need for hospitalization?


< 92%
- Oxygen saturation in children should normally be greater than 95%, and oxygen saturation less than 92% is a good predictor of the need for hospitalization

13

In managing a patient in acute asthma exacerbation, it was noted that the patient progressed further from moderate to severe exacerbation. What would be the difference in treatment between moderate and severe exacerbation?

Primary difference: from oral glucocorticosteroids, patient will be given systemic glucocorticosteroids and magnesium

Treament of moderate exacerbation:
Oxygen • Inhaled B2-agonist and inhaled anticholinergic every 60 min • Oral glucocorticosteroids • Continue treatment for 1-3 hours, provided there is improvement

Tx of severe exacerbation:
Oxygen • Inhaled B2-agonist and inhaled anticholinergic • Systemic glucocorticosteroids • Intravenous magnesium

14

What is the PEF in a patient in moderate exacerbation vs severe exacerbation?

Moderate: 60-80 % of personal best / predicted
Severe: <60% of personal best/predicted

15

What procedure should be done to ascertain the diagnosis of asthma?

Spirometry
- Increase in FEV1 of ≥ 12% and ≥ 200 ml after administration of a bronchodilator indicates reversible airflow limitation consistent with asthma
- An improvement of 60 L/min (or≥ 20% of the pre-bronchodilator PEF) after inhalation of a bronchodilator
- Diurnal variation in PEF of more than 20% (with twice-daily readings, more than 10%), suggests a diagnosis of asthma.

16

What is the predicted normal PEFR for Filipino children between 6-17 yo with a height of at least 100 cm?

male: (Ht in cm - 100)5 + 175
female: (Ht in cm - 100)5 + 170

17

What is the only accurate method of diagnosis of bacterial sinusitis but is not practical for routine use for immunocompetent patients?

Sinus aspirate culture

- clinical diagnosis of acute bacterial sinusitis is based on history
- persistent URTI, nasal discharge, and cough for 10-14 days without improvement
- purulent nasal discharge for 3-4 consecutive days

18

What is the treatment for acute uncomplicated bacterial sinusitis?

amoxicillin (45 mkD)
alternatives: co-tri, cefu, clarithro, azithro

if not responsive in 72h, shift to high dose co-amoxiclav (80-90 mkD)

18

What is the treatment for acute uncomplicated bacterial sinusitis?

amoxicillin (45 mkD)
alternatives: co-tri, cefu, clarithro, azithro

if not responsive in 72h, shift to high dose co-amoxiclav (80-90 mkD)

19

Complications of acute bacterial sinusitis
1. characterized by edema and swelling of the forehead
2. chronic inflammatory lesions commonly located in the frontal sinuses that can expand, causing displacement of the eye with resultant diplopia

1. osteomyelitis of the frontal bone (Pott puffy tumor)
2. mucoceles

periorbital and orbital cellulitis are also common complications
- meds usually started if with intracranial complications: broad spectrum IV antibiotics (ceftri + vanco)

20

What are the most important agents causing pharyngitis in children?

1. viruses (adenoviruses, coronaviruses, enteroviruses, rhinoviruses, respiratory syncytial virus [RSV], Epstein-Barr virus [EBV], herpes simplex virus [HSV], metapneumovirus)
2. group A β-hemolytic streptococcus (GABHS)

21

What are the symptoms suggestive of allergic rhinitis?

2 or more of the following symptoms for > 1 hr on most days:
– watery anterior rhinorrhea
– sneezing, especially paroxysmal
– nasal obstruction
– nasal pruritis ± conjunctivitis

** Purulent discharge, postnasal drip, facial pain, and loss of smell are common symptoms of sinusitis

22

What is the probable etiology of pharyngitis characterized as rapid in onset, not associated with cough, with the following symptoms: fever, red pharynx, enlarged tonsils covered with yellow blood-tinged exudate, doughnut lesions on soft palate and red stippled uvula?

a. Streptococcal pharyngitis
b. Viral pharyngitis

A. Streptococcal pharyngitis (GABHS)

Viral pharyngitis is more gradual in onset, associated with cough, coryza and conjunctivitis, with hoarseness and sometimes with accompanying diarrhea

23

What is the probable viral etiology of the ff case descriptions

A. pharyngitis + concurrent conjunctivitis and fever
B. pharyngitis + small grayish vesicles and punched out ulcers in posterior pharynx
C. pharyngitis + small yellowish-white nodules in posterior pharynx
D. pharyngitis + prominent tonsillar enlargement with exudate, cervical lymphadenitis, hepatosplenomegaly, rash and generalized fatigue

A. pharyngoconjunctival fever caused by adenovirus
B. Herpangina caused by coxsackievirus
C. acute lymphonodular pharyngitis caused by coxsackievirus
D. infectious mononucleosis caused by EBV

24

What is the primary benefit of treatment of acute streptococcal pharyngitis even if spontaneous resolution of symptoms is expected ina few days?

What is the drug of choice?

1. prevention of acute rheumatic fever
2. Penicillin

- prevention is almost completely successful if antibiotic treatment is instituted within 9 days of illness
- Antibiotic therapy should be started immediately without culture for children with symptomatic pharyngitis and a positive rapid streptococcal antigen test, a clinical diagnosis of scarlet fever, a household contact with documented streptococcal pharyngitis, a past history of acute rheumatic fever, or a recent history of acute rheumatic fever in a family member.
- oral amoxicillin is preferred in children, 50 mkD x 10 days

25

What is treatment regimen most effective for eradicating streptococcal carriage?

clindamycin

20 mkD TID for 10 days

26

When is tonsillectomy considered in a patient with recurrent strep pharyngitis?

If pharyngitis occurs >7 episodes in the previous year, or >5 in each of the preceding 2 yr

- Tonsillectomy lowers the incidence of pharyngitis for 1-2 yr among children with recurrent, culture-positive GABHS pharyngitis that has been severe and frequent

27

Encircles the airway just below the vocal cords and defines the narrowest portion of the upper airway in children <10 yr of age.

the cricoid cartilage

- 4 major cartilages that constitute the larynx, in descending order: epiglottis, arytenoid, trachea, cricoid cartilage (EAT-C)

28

Refers to a heterogeneous group of mainly acute and infectious processes that are characterized by a bark-like or brassy cough and may be associated with hoarseness, inspiratory stridor, and respiratory distress

croup

29

Harsh, high-pitched respiratory sound, which is usually inspiratory but can be biphasic and is produced by turbulent airflow; it is not a diagnosis but a sign of upper airway obstruction

stridor