Flashcards in Respiratory Disease Deck (96):
what is croup and what is it caused by
-is an inflammation of the vocal cords and trachea caused:
- 75% of the time by parainfluenzae virus, but also
-influenza A and B, and
-respiratory synctial virus (RSV).
who does croup mostly affect
children 3 months-5 years in the fall and winter
sx of croup
1. runny nose
2. low grade fever in the initial 1-3 days followed by
5. barking cough and
6. varying degrees of stridor and respiratory distress.
7. In mild cases, the stridor is only with agitation.
8. When the child’s symptoms move to the moderate level, the stridor occurs at rest
9. in severe croup, the child develops retractions and possibly cyanosis.
xray finding of Croup
-classic “steeple” sign of a narrowed upper airway
*The clinical presentation is enough to make a diagnosis and x-rays are usually not indicated.
what is spasmodic croup?
-similar presentation but seen in children 3-6 y/o
- there is no preceding illness and it may not be the typical croup “season”.
-pathophysiology seems to be more allergic
*their symptoms usually do not advance beyond mild, and the children outgrow their propensity to “have croup” every time they get a viral respiratory illness.
how do you manage mild and moderate/severe cases of croup
Mild case- oral steroids x 3-5d
Moderate/severe case: treated in ED or facility w/ appropriate monitoring
-nebulized racemic epinephrine
-Oxygen as needed
what is the dosing of oral steroids for croup compared to asthma
*typically work best if even in the AM but have the caregivers start as soon as they can get the prescription filled
what is a complications of racemic epinephrine in a child w/ mod/severe croup?
-these children can have rebound respiratory distress after treatment so they require observation for 3h after.
-If they do not have stridor at rest after observation, they can go home on oral steroids. The first steroid dose should be given in the ED/alternative facility and can be IM, oral or inhaled as all 3 have shown similar efficacy.
for mild cases of croup, what are RTC precautions
1. fever over 102
2. stridor or respiratory distress
Indications for hospitalizition:
1. worsening stridor
2. severe stridor at rest
3. poor feeding
5. unreliable home care
risk factors of TB
1. Contact with known/suspected person with active TB
2. Children immigrating from endemic countries- Asia, Africa, Middle East, Latin America
3. Children with travel histories and substantial contact in endemic countries
4. Children exposed to homeless, incarcerated or HIV + adults
*these pts need PPD screening
*start asking at age 1
when do we screen TB w/ PPD in Colorado?
We don’t routinely screen with PPD in Colorado, but any patient with a “yes” response to one of these questions, should receive a screening PPD.
-If +, they require a chest x-ray to look for active TB. If their CXR is negative, they are considered to have latent tuberculosis AKA “PPD converter” and require prophylaxis to prevent them from developing active TB.
what is the management for a child w/ active TB
-refer to infectious disease or Red Book
-take a 1-2 drug regimen for 9 months
*will likely have +PPD for lifes
how do you screen a child who has a hx of TB vaccine (BCG) in a TB endemic country
special serum testing- QuantiFERON to look for latent TB as their PPD skin tests may be + from their prior vx.
when should active TB be on your ddx
1. children w/ recurrent wheezing which does not respond to bronchodilator or oral steroid tx
2. recurrent hospitalization for respiratory distress--even if thought to be "asthma" exacerbation
3. hilar lymphadenopathy on CXR
what organisms cause epiglottitis
1. H. influenza (now rare after Hib vx)
sx of epiglottitis
1. acute onset of fever
2. difficulty speaking/swallowing
3. respiratory distress
4. sever sore throat causing drooling and lack of cough**
5. toxic appearing
6. can obstruct their airway
7. usually sitting forward in a "sniffing dog" position
*key features which separate this disease from croup
A patient with an obstructed airway at any time, an ill-appearing, drooling, respiratory distress patient (usually sitting forward in a “sniffing dog” position) should has a limited exam, specifically excluding any manipulation of their oral cavity. What should you're next step be?
emergency transportation to an ED and/or anesthesiologist present for immediate intubation.
"tumb sign" - inflammed epiglottis
Epiglottitis is contagious, so household contacts of patients with Hib epiglottitis should receive rifampin prophylaxis if:
-less than 48m/o with incomplete Hib (less than 4 administrations)
- less than 12m/o with incomplete primary Hib series (less than 3 administrations)
*There is not currently a prophylaxis recommendation for exposures to staph/strep epiglottitis
ddx for croup
2. bacterial tracheitis
sx of bacterial tracheitis
1. HIGH fever (croup has low grade fever)
2. toxic appearing
3. age 5-7y/o
4. acute onset of high fever and toxic appearance is PRECEDED by viral croup illness
what organism causes bacterial tracheitis
management of bacterial tracheitis
1. airway management
2. IV antibiotics
4. tx w/ racemic epinephrine is not helpful
The children most at risk for foreign body aspiration are ____ as they explore their world with their mouths.
clinical presentation of foreign body aspiration can vary depending on
what item they aspirated and how far down into the lungs the item is
Most FB that are aspirated are in the ___, and so represent a ____. Larger objects lodge in the ____ and may present as ____
larynx or trachea
complete airway obstruction
The most common FB that are aspirated are
NUTS, popcorn and small toys.
presentation of FB aspiration
1. Almost all children with f.b. aspiration will have a history of sudden onset of severe coughing.
2. In partial obstruction, this will be followed by drooling, stridor, decreased breath sounds, cough, and continuous or recurrent episodes of wheezing and respiratory distress.
3. Some small objects can get very far down into the lungs, so consider f.b. in a child with chronic cough and persistent wheezing (especially those unresponsive or minimally responsive to oral steroids) and recurrent pneumonia
- hyperinflated lung with a flat diaphragm on inspiration and on expiration the remains hyperinflated to the extent that it pushes the mediastinum over toward the unaffected side, which has deflated during expiration
tx for known or suspected FB aspiration
rigid bronchoscopy to locate and remove the object
what is bronchiolitis
an acute inflammatory disease of the small airways in children less than 2 y/o
-Peaks 2-6 months
*When children over 2y develop a similar clinical presentation, the involved airways are larger and the disease is referred to as bronchitis
what organisms causes bronchioloitis and when is the peak time to get it
-By far, the most common pathogen in young children is respiratory synctial virus (RSV) which occurs Nov-April, with a peak Dec-Feb.
-Other viruses include parainfluenzae, influenza, adenovirus and human metapneumo virus.
describe the progression of bronchiolitis
-Children with bronchiolitis develop URI symptoms initially, but as the virus infects their lungs, they develop LRI symptoms as their airways become plugged by mucus and sloughing of the respiratory tract lining.
___ infection is the most serious in children less than 12m, especially those less than 6m
what is the most sensitive indicator of lower respiratory tract compromise
During peak RSV season, it is ____ to prove that a child has RSV bronchiolitis if they have a clinical picture consistent with bronchiolitis.
In late fall/early winter, it is common for ED’s to:
-perform nasal washes in infants with bronchiolitis symptoms to perform a rapid RSV antigen test.
*When an increased number of patients test positive, this helps to alert community providers that RSV season is underway.
what season is RSV bronchiolitis most common in
sx of bronchiolotiis
1. Runny nose, fever, slight cough x 1-2days
2. Progressing to wheezing/rales, tachypnea Day 3-10
3. Respiratory distress, work of breathing- nasal flaring, retractions
4. +/- apnea
5. Poor feeding
management of infants w/ bronchiolitis
need careful monitoring as they are most likely to deteriorate 48-72h after the onset of cough, usually around day 3 or 4, and will begin to improve in their symptoms around day 7-10.
tx of bronchiolitis
-There is no definitive treatment other than time and maintaining hydration.
-Because these infants are tachypneic and often febrile initially, they are losing water during this illness. RSV causes extensive mucus production in both the UR and LR tract, so nasal suctioning does help these children breathe.
-Teach parents to do effective suctioning via bulb syringe and normal saline by demonstrating in the office.
-There is no role for antibiotics or steroids in these patients.
-Bronchodilators may be effective, but only in those patients who have or may have a component of atopic disease. Therefore, it is reasonable to attempt bronchodilator therapy to assess response, but continue only if a response (decreased tachypnea, wheezing) can be demonstrated.
what are the key points to effectie suctioning
1. deflation of the bulb prior to nares insertion
2. placement of the bulb tip far enough into the nose to get a complete seal of the nares prior to releasing the bulb to reinflate.
* Parents are uncomfortable with placing a bulb syringe tip so far into their infant’s nose.
discuss the use of supplemental oxygen for bronchiolitis
-In high altitudes, we routinely use home supplemental oxygen for bronchiolitic infants if their pulse ox on room air is in the high 80’s and oxygen improves their pulse ox to 95%.
-These infants are seen every 1-2 days and around day 7 we attempt to wean/discontinue the oxygen by doing room air challenges.
-To pass, the infant must be able to be on room air during feeding and sleeping without desaturations below 95% on pulse ox.
-Often this is successful during feeding first, leaving the infants with a few days of needing supplemental oxygen during naps and bedtime.
who should you admit for RSV bronchiolitis
1. hypoxic on room air (less than 95% at low altitude)
2. history of apnea
3. tachypnea with feeding problems
4. marked respiratory distress with retractions--attempt nasal suctioning to see if the retractions significantly improve/resolve
5. less than 3m with LRT symptoms as they are more likely to become apneic at home
6. infants w/ bronchopulmonary dyplasia,
7. congenital heart defects,
8. cystic fibrosis,
9. anatomical airway defects
10. immunodeficiency as the course of their illness may be quite severe.
what is the best prevention for RSV
1. good handwashing/hygiene***
2. During peak RSV season, I often tell the parents of infants less than 3m to keep older, URI-symptomatic siblings away from the baby until their rhinorrhea/cough has resolved.
3. Synagis- given monthly to children who are premature, have bronchopulmonary dysplasia or hemodynamically cardiac defect
Older kids do not develop the ____, but are a vector for RSV disease.
1. give monthly Nov-April in children who are premature, have bronchopulmonary dyplasia or hemodynamically significant cardiac defects
2. provides passive immunity to RSV, but is very expensive so not used in otherwise healthy infants.
3. It is administered by home health nurses to reduce these infants’ exposures to sick children in the clinic setting.
4. There is a form for medical providers to complete which indicates their dose and documents the medical necessity. This form provides the guidelines for weeks of prematurity and clarifies the cardiorespiratory diseases which provide medical indication for immunization.
describe the difference in the presentation of pneumonia in infants and older infants
. Infants usually don’t have a cough, and older infants often don’t have abnormal breath sounds. Fever can be reliably present, depending on the organism, and tachypnea is the most sensitive indicator of LRT involvement although it is not specific as tachypnea has more causes than just LRT issues
what organisms cause pneumonia
1. S.Pneumo is the #1 organism in pneumonia in children 3w-4y,
2. chlamydia should be considered in 2-12w who are usually afebrile,
3. viruses cause a significant amount of pneumonia in children less than 5y--although up to 30% of these kids will have a secondary bacterial infection too.
4. Mycoplasma is usually not a problem until over 5y.
how do you diagnose pneumonia
-you can diagnose pneumonia on clinical signs and symptoms only-cough, fever, tachypnea, abnormal breath sounds, and no labs or x-rays are needed.
-Young or very sick children need a CBC, blood C/S (to rule out bacteremia), CXR, often electrolytes and blood gases (if very ill).
small infiltrates, and lobar consolidations are unusual, peribronchial cuffing or interstitial infiltrates are indicative of viral pathology.
what are the signs and symptoms of pneumonia in neonates
what are the signs and symptoms of pneumonia in 3-36 months
usually a cough
coarse breath sounds or rales, crackles
sometimes vomiting, respiratory distress
what are the signs and symptoms of pneumonia in 3 y/o
abnormal breath sounds
We don’t use supplemental home oxygen on pediatric patients with pneumonia until___, as pneumonia can compromise oxygenation fairly rapidly in kids, so hypoxia remains an indication for admission
they have significantly improved in the hospital
why do pts w/ underlying cardiopulmonary disease, sickle cell, asplenia with pneumonia need to be treated inpatient?
risk of overwhelming sepsis from streptococcal bacterial
what is the outpatient management of pneumonia
-amoxicillin (preferably high dose-same as AOM) is 1st line,
-but 3rd generation cephalosporins and Augmentin are also used.
-If school age (mycoplasma) or infants (chlamydia) or suspected pertussis- use azithromycin.
-Plan f/u in 1-2d and give good return precautions around increasing fever, tachypnea, poor feeding, irritability.
what are RTC precautions for pneumonia
increasing fever, tachypnea, poor feeding, irritability.
signs and sx of hypoxia
children who are hypoxic get fussy as their oxygen levels drop and do develop agitation, so irritability is something we look for as clinical evidence of hypoxia.
who should you hospitalize for pneumonia tx
1. infants less than 6m/o due to risk of sepsis
2. respiratory distress, toxic appearance
3. poor blood gases/ pulse oximetry
4. pleural effusion, multiple lobes
5. poor feeding, vomiting
6. questionable/poor home environment
7. patients w/ underlying cardiopulmonary disease, sickle cell, asplenia
what is laryngomalacia, laryngotracheomalacia caused by
Caused by poorly-supported epiglottis or opening of supraglottic structures
who suffers from laryngomalacia, laryngotracheomalacia
Infants who were intubated, premature, NICU graduates often have more problems with this
signs and sx of laryngomalacia, laryngotracheomalacia
1. inspiratory stridor
2. worse with URI, after feedings/exercise, if lying down
3. usually starts in 1st 2 mos of life
4. Most kids worsen up to age 6m and then improve with no intervention to complete resolution by age 2y.
5. These patients do not cough, so that helps separate their stridor and “funny” breathing sounds from lower respiratory tract or from croup
The caregivers will complain of loud breathing after feeding or may think their child sounds “croupy
management of laryngomalacia, laryngotracheomalacia
-We refer kids with this to ENT or pulmonology if they have feeding difficulties, severe dyspnea, or signs of OSA.
-It can be treated with laser therapy which stiffens the cartilaginous support.
-They will have a rigid bronchoscopy first, and possibly other tests, to look for f.b. or congenital anomalies.
describe the difference btwn congenital anomalies of the airway and obstructive stridor
-congenital anomalies of the airway- will increase obstructive stridor with exercise and while awake
-obstructive stridor- occurring while sleeping which may be due to tonsillar/adenoidal hypertrophy and more of an OSA picture.
The congenital abnormalities which cause stridor, recurrent respiratory distress, etc. are
-hemangiomas in the subglottic space
Hemangiomas are common in infants in __ area and may be in the ___
the facial area, and may be lurking unseen in their airway.
*50% of kids with airway hemangiomas will have facial hemangiomas.
hemangiomas grow in the first year of life, and then begin to recede in size until resolution around age ___
sx of hemangiomas in the airway
progressive stridor, respiratory distress.
what are vascular rings
a malformation of the aorta that wraps around the esophagus and trachea, causing constriction,
management of laryngeal web, subglottic hemangioma, and vascular ring
if you suspect these congenital anomalies in a young child, refer them to pulmonology where they will have a bronchoscopy, and, for those suspected of a vascular ring, a barium esophagram
*refer to bronchoscopy
sx of laryngeal web, subglottic hemangioma, and vascular ring
Persistent/recurrent hoarseness, stridor, evidence of upper airway obstruction
what is cystic fibrosis
-an autosomal-recessive disease of the apocrine glands, so the affected organs are lungs, sweat glands, pancreas and intestines
CF is currently tested for in the newborn screen but __% of affected patients will be missed on newborn screen, so CF needs to be part of your differential in kids with ___, __, or __
recurrent wheezing, respiratory distress and pneumonia.
Pts with CF may have a history of __, __, __. __, but the symptoms vary with some patients having significant apocrine gland involvement and others having more of the GI or more of the respiratory symptoms.
meconium ileus, bulky, greasy stools, poor weight gain
Children who respond poorly to bronchodilator therapy (irreversible bronchospasm) or full-dose oral steroids should alert you to consider what differentials
Foreign Body Aspiration
Congestive Heart Failure
how do you diagnose CF
-a sweat chloride test as their abnormal apocrine glands will produce a high chloride level.
-Abnormal sweat chloride level is over 60, but borderline is 40-59, and these children should be repeated in 1-2 mos.
*Children with cystic fibrosis should be cared for by a pulmonologist.
sx of CF
1. recurrent pulmonary infection
2. abnormal sweat
3. cor pulmonale
4. chronic pancreatitis
5. meconium ileus (newborn)
morning vs nighttime vs paroxysmal cough could suggest
Morning cough – accumulation of excessive secretions during night = sinusitis, allergic rhinitis, bronchial infection
Nighttime cough = signature for asthma or also GERD
Paroxysmal cough = pertussis or foreign body aspiration
Bacterial infection which should be considered in child with croup
Leading cause of hospitalizations in infants
what organism causes pertussis
B. pertussis (gram -) bacillus
who is most at risk for pertussis
Less than 4 months of age most common and most dangerous but seen between 1-10y
describe the time course of pertussis
Incubates for 7-10 days and most contagious during 1st 2 weeks of cough
describe the stages of pertussis
1. Catarrhal: nonspecific signs like nasal congestion and low grade fever (1-2 weeks)
2. Paroxysmal: coughing during expiration and losing breath “whoop” +/- post emesis(2-4 weeks)
3. Convalescent stage: resolution of symptoms, less severe coughing, woops disappear (1-2 weeks)
*Residual cough may last for months
describe the non-classic presentation of pertussis
in infants they may present firstly with apnea. Infants and adolescents typically don’t have the whoop cough
labs/imaging for pertussis
1. Culture: in early phases specimens can be swabbed but difficult
2. PCR: okay choice
3. Serologic tests: not for acute infection but confirmatory in convalescent
3. Lymphocytosis in 75-85% of children and elevated WBC
4. CXR: may show segmental atelectasis and peripheral infiltrates are common
tx of pertussis
1. Azithromycin, clarithromycin, or erythromycin recommended for those under 1 month
2. Catarrhal phase- eradicate nasopharyngeal carriage
3. Paroxysmal – does not alter course of treatment but decreases spread
4. Trimethoprim-sulffmethoxazole is alternative for older than 2 months
common complications of pertussis
Most common complication is pneumonia, if forceful could cause PE, pneumomediatsitun, epistaxis, hernias
what is tracheomalacia
Floppy trachea due to lack of structural integrity of the tracheal wall. Most pronounced during expiration. May be congenital or acquired (long term ventilation)
clinical manifestations of tracheomalacia
1. Tracheal collapse occurs with forced exhalation or with cough and commonly aggravated by respiratory infections
2. May cause recurrent wheezing with prolonged expiratory phase
3. Predisposed to infections
4. Severe – during agitation may become cyanotic and resemble breath holding spells
5. Voice and inspiratory efforts are normal
6. Older children classic hallmark sign – brassy, barky cough due to the vibration
tx of tracheomalacia
1. Infant with mild-moderate = no intervention. Will improve with airway growth
2. Older symptomatic kids = treating precipitating cause for cough and supportive care- abx for current infecitons
3. Severe infants = may need tracheostomy tubes to administer CPAP
Indications for hospitalization of croup
1. worsening stridor
2. severe stridor at rest
3. poor feeding
5. unreliable home care