Upper Respiratory Problems
Cold or upper respiratory illness prior to onset of stridor, acute or chronic noisy breathing, presence of fever, associated symptoms, exposure to illness, previous respiratory problems, maternal history of HPV.
PE: Afebrile, low grade or high fever, mild moderate or severe upper respiratory distress with stridor, retractions, wheezing, hypoxia possible.
Dx: Radiologic, direct visualization.
- X-ray: AP and lateral
- Steeple sign is classic with croup
- Thumb sign is classic with tracheitis
DDx:
- Acute: Croup, tracheomalacia, epiglotitis, tracheitis, peritonsillar or retropharyngeal abscess, airway foreign body.
- Chronic: Congenital HPV, HSV, lymphadenopathy, EBV, CMV, TB, other congenital abnormalities.
Stridor
Primary airway noise in upper airway disease.
- Airflow is forced through a narrowed airway segment.
- Local area of low pressure creates a vacuum effect distal to the narrowing.
- Airway walls collapse and vibrate.
- Generates a high pitched sound.
- Most prominent symptom of airway obstruction in infants.
Croup
Parainfluenza, adenovirus, RSV
S/S: Barky or brassy cough, inspiratory stridor, retractions, persistent low grade fever, worsens at night and on day 2-3.
Dx: x-ray shows “Steeple” sign
Tx: Dexamethasone (0.6mg/kg) as a single dose outpatient, maybe 24 hour dose inpatient, racemic epinephrine (but controversial due to ineffectiveness over time).
Tracheitis
Haemophilus influenzae (H-Flu), Strep pneumoniae
S/S: Stridor, tripod position, dysphagia, drooling, high fever > 103
Dx: x-ray shows “Thumb” sign
Tx: Broad spectrum antibiotics, such as ceftriaxone or clindamycin, symptom management, steroids as dexamethasone.
Foreign Body
Toddler age or infant with older sibling
S/S: Acute cough, onset of choking, difficulty breathing, cyanosis, severe wheezing and/or stridor.
Dx: Inspiratory films, fluoroscopic evaluation
Tx: Caution with transport, as object could progress and obstruct airway.
- Surgical emergency for bronchoscopy in the OR.
Laryngotracheomalacia
Infant age, previous injury or intubation, presence of lesion.
- Differentiate from vascular ring.
S/S: Chronic stridor, mild respiratory distress with exertion or illness.
Dx: Direct visualization with bronchoscopy
Tx: If lesion, surgical removal or repair.
Retropharyngeal Abscess
Most commonly affects children less than 3-4 years of age.
- Group A Strep, oropharyngeal anaerobic bacteria, Staph aureus common.
S/S: Fever, malaise, decreased oral intake, neck stiffness, torticollis, sore throat and neck pain, stridor, respiratory distress possible.
Dx: Soft tissue neck x-ray, CT
Tx: Incision and drainage by ENT, culture for ID
Peritonsillar Abscess
Adolescent age most common with history of acute pharyngitis.
- Group A Strep and mixed oropharyngeal anaerobes.
S/S: Recent history of pharyngitis, nonspecific symptoms including fever, lethargy, sore throat, dysphagia, trismus.
Dx: CT
Tx: Incision and drainage for ID
Lower Airway Problems
Acute or chronic wheezing, fever or not, associated symptoms, exposure to illness, previous respiratory problems, URI for prolonged period, family history of asthma, documented diagnosis of asthma.
Dx: Imaging, pulmonary function testing
- CXR
- If infectious, CBC-D, cold agglutins, CRP
- If significant distress, blood gas evaluation
DDx: Reactive airway disease, status asthmaticus, bronchiolitis, pneumonia, aspiration, aspiration pneumonia.
Wheezing
Occurs when air enters narrowed or constricted areas of the lungs.
Intermittent Asthma
Symptoms (difficulty breathing, wheezing, chest tightness, and coughing)
- Occur fewer than 2 days/week
- Do not interfere with normal activities
Nighttime symptoms occur on fewer than 2 days/month
Mild Persistent Asthma
- Symptoms occur on more than 2 days/week, but do not occur every day.
- Attacks interfere with daily activities.
- Nighttime symptoms occur 3-4 times/month.
- Lung function tests are normal when the person is not having an asthma attack.
Moderate Persistent Asthma
- Symptoms occur daily. Inhaled short-acting asthma medication is used daily.
- Symptoms interfere with daily activities.
- Nighttime symptoms occur more than 1 time/week, but do not happen every day.
- Lung function tests are abnormal.
Severe Persistent Asthma
- Symptoms occur throughout each day.
- Symptoms severely limit daily physical activities.
- Nighttime symptoms occur often, sometimes every night.
- Lung function tests are abnormal.
Acute Asthma Mild Symptoms
- Increased respiratory rate
- Accessory muscles of respiration are not used
- The heart rate is less than 100 bpm
- Pulsus paradoxus is not present
- Auscultation of chest reveals moderate wheezing, which is often respiratory
- Oxygen saturation in room air is > 95%
Acute Asthma Moderate Symptoms
- Increased respiratory rate
- Accessory muscles of respiration are used
- Suprasternal retractions are present
- Loud expiratory wheezing can be heard
- Pulsus paradoxus may be present (10-20mmHg)
- Oxygen saturation in room air is 91-95%
Acute Asthma Severe Symptoms
- The respiratory rate is of greater than 30 bpm, based on age and activity
- Accessory muscles of respiration are usually used
- Suprasternal retractions are commonly present
- The heart rate is greater than 120 bpm
- Loud biphasic (expiratory and inspiratory) wheezing can be heard
- Pulsus paradoxus is often present (20-40mmHg)
- Oxygen saturation in room air is < 91%
Asthma Action Plan
- Environmental Controls
- Algorithm for use of long-term and rescue meds
- Medication regimens and rescue meds
- Steps to take when treatment is not effective/emergent care
Treating Status Asthmaticus
- Supplemental oxygen
- Stacked inhaled bronchodilators
- Continuous inhaled bronchodilators
- Prednisone or methylprednisolone
- Magnesium sulfate as bolus
- Terbutaline (controversial)
- Heliox (controversial)
- Noninvasive ventilation (CPAP, BiPAP) for hypoxia
- Intubation and ventilation as a last resort
Pneumonia
Infection and inflammation of the lower respiratory tract in association with detectable radiographic changes of the lung parenchyma.
- Interstitial disease
- Bacterial or viral
S/S: Prolonged URI, cough, lethargy, decreased appetite, fever (could be low grade or high) depending on organism.
Dx: Presence and longevity of symptoms, chest exam, CXR, CBC, CRP, cold agglutins.
- Bacterial: x-ray findings are patchy infiltrates, pleural effusion, atelectasis.
- Viral: x-ray findings are perihilar streaking, increased interstitial markings, peribronchial cuffing or patches.
Tx: Oxygen, antibiotics, fluids, pulmonary toilet, bronchodilators on occasion.
- Indications for hospitalization: hypoxemia (oxygen saturation < 90% in room air), dehydration or inability to maintain hydration orally, inability to feed an infant, moderate to severe respiratory distress, toxic appearance, underlying conditions that predispose to a more serious course of pneumonia, complications (effusion/empyema), suspicion or confirmation that CAP is due to a pathogen with increased virulence.
Parapneumonic Effusion
Fluid leak into pleural space. Can be a complication of pneumonia.
- Exudative: pleural fluid is free-flowing.
- Fibrinopurulent: bacterial invasion, white cells and fibrin results in loculation.
S/S: Persistent cough, hypoxia, lethargy, wheezing, persistent fever.
Dx: Lateral x-ray or ultrasound. CT may be obtained.
Tx: Video-assisted Thoroscopic Surgery (VATS) should be performed when there is persistence of moderate-large effusions and ongoing respiratory compromise despite 2-3 days of management with a chest tube and completion of fibrinolytic therapy.
- Open chest debridement with decortication represents another option for management of these children, but is associated with a higher morbidity rate.
Bronchiolitis
Inflammation, edema, and necrosis of epithelial cells in lower airways with increased mucous production and bronchospasm.
- Virus induces airway obstruction (increased airway secretions and mucosal edema and/or bronchospasm).
- Can cause increased work of breathing, resulting in tachypnea and subcostal retractions, gas trapping as manifested by hyperinflation, and noisy breathing.
S/S: Most common 1st year of life. Occurs late fall to early spring. Highest risk: premature infants, age < 12 weeks of life, immunodeficiency, underlying cardiac disease.
- Polyphonic wheezing, congestion, cough, lethargy, poor feeding.
Dx: CXR - hyperinflation, streaky infiltrates, RSV antigen, Rapid Viral Panel.
- Typical organisms: RSV, adenovirus, metapneumovirus.
Tx: Supportive. Hospitalize if oxygen or IV fluids needed.
- RSV prophylaxis, if indicated.
Pertussis
Acute infectious disease caused by bacterium Bordetella pertussis (gram - organism).
S/S: Staccato, paroxysmal cough associated with apnea, hypoxia, fever.
Dx: Lymphocytosis - fluorescent stain and culture (gold standard), PCR or Serologic assay.
Tx: Azithromycin, Clarithromycin, or Erythromycin.
- Treatment of choice for infants < 1month old is Azithromycin.
Tuberculosis
Bacterial illness of lungs with other system involvement.
- Risk factors: foreign born or travel, living in urban areas, exposed to close family member who is incarcerated.
- Most common in children between 1-4 years of age.
S/S: Chronic cough, fever, anorexia, weight loss.
Dx: Nodular changes on CXR, + TB skin test.
Tx: WHO or CDC guidelines
