INTERN SCHOOLPEDIATRIC RESPIRATORY

ILLNESS

Case Presentation

20 month old male who presents to the emergency department with a chief complaint of cough.

Two days ago he developed rhinorrhea, fever, a hoarse cry and a progressively worsening, harsh, "barky," cough.

Today he developed a "whistling" sound when he breathes, so his parents brought him to the emergency department.

His past medical history is unremarkable. His 6 year old brother also has cold symptoms.

Case PresentationPhysical Exam

Exam: VS T 37.5, P 140, R 36, BP 90/64, oxygen saturation 96% in room air.

GEN: alert, with good eye contact, in mild respiratory distress. He has a dry barking cough and a hoarse cry.

HEENT: some clear mucus rhinorrhea but no nasal flaring. His pharynx is slightly injected, but there is no enlargement or asymmetry.

CVS: Heart is regular without murmurs. LUNG: good aeration and slight inspiratory stridor at

rest. He has very slight subcostal retractions. No wheeze or rhonchi are noted.

Abdomen: flat, soft, and non-tender. Extremities: warm and pink with good perfusion.

Case PresentationProgression

He is treated with nebulized racemic epinephrine and his coughing subsides and his stridor resolves. He is also given oral dexamethasone

Case PresentationRadiographic imaging

A lateral neck X-ray reveals no prevertebral soft tissue widening or evidence of epiglottitis. The subglottic region is mildly narrowed.

Case PresentationDisposition

He is discharged home after one hour of monitoring and his parents were instructed to treat him with humidified mist therapy.

Bronchiolitis

< 2yo URI (rhinorrhea, congestion) LRT

inflammation (crackles/wheezes) Viral etiology 80%, Mycoplasma

Pneumonia May overlap with Asthma

Bronchiolitis

Assessing severity: Persistent increase in respiratory effort (>70

RR), nasal flaring, intercostal retractions, cyanosis, grunting

Hypoxemia (SaPO2 <95%) Apnea

Bronchiolitis

Indication for Hospitalization: Toxic appearing, decreased feeding, lethary,

dehydration SaPO2 <95% Parents/caregivers cannot manage at home

Outpatient Management

*caretakers are comfortable* Supportive Care

Hydration Nasal passage clearance Monitoring progression

Pharmacologic tx NOT recommended b/c lack of proven benefits, increased cost

Bronchiolitis

EDUCATION** Course of disease – URI symptomsLRT

symptoms 2-3 days peak 4-7 days resolution 2-3 weeks

Suctioning I/O’s – min 1 wet diaper/12 hours

Feedings/ cyanosis/ increased resp effort/lethargy

F/u 1-2 days for improvement of symptoms (phone call)

Severe Bronchiolitis

ED respiratory support (O2) Fluids Monitoring

Bronchodilators/nebulized hypertonic saline/glucocorticoids NOT routinely recommended

Contact Precautions CPAP/HFNC 1 to 23 months of age, emphasizes that testing

for specific viruses is unnecessary because bronchiolitis may be caused by multiple viruses.

Bronchiolitis

Repeated clinical assessment of the respiratory system (eg, respiratory rate; nasal flaring; retractions; grunting)

In children who do not improve at the expected rate, chest radiographs may be helpful in excluding other conditions in the differential diagnosis (eg, foreign body aspiration, heart failure, vascular ring, tuberculosis, cystic fibrosis

older than six months and require hospitalization for management of bronchiolitis, the average length of stay is three to four days

wheezing persists in some infants for a week or longer Risk factors for worsening after initial clinical improvement

included age <2 months, <37 weeks gestational age, and severe retractions, apnea, or dehydration at presentation

D/C criteria  Minimal clinical criteria for discharge from the hospital or

emergency department include ●Respiratory rate <60 breaths per minute for age <6 months, <55

breaths per minute for age 6 to 11 months, and <45 breaths per minute for age ≥12 months

●Caretaker knows how to clear the infant's airway using bulb suctioning

●Patient is stable while breathing ambient air and has maintained oxygen saturation >94 percent; discharge from the hospital requires that the patient remain stable for at least 12 hours prior to discharge

●Patient has adequate oral intake to prevent dehydration ●Resources at home are adequate to support the use of any

necessary home therapies (eg, bronchodilator therapy if the trial was successful and this therapy is to be continued)

●Caretakers are confident they can provide care at home ●Education of the family is complete

Prognosis

overall mortality rate in children hospitalized with respiratory syncytial virus (RSV) bronchiolitis in developed countries is less than 0.1 percent

Mortality is increased in young infants (6 to 12 weeks), those with low birth weight, and those with underlying medical conditions

Immunoprophylaxis with palivizumab, a humanized monoclonal antibody against the respiratory syncytial virus (RSV) F glycoprotein, decreases the risk of hospitalization due to severe RSV illness among preterm infants and those with chronic lung disease and hemodynamically significant congenital heart disease.

AAP guidance for palivizumab immunoprophylaxis has become increasingly restricted, driven in part by the high cost associated with monthly administration.

What if it isn’t a virus?

Same kiddo, but now you see this:

Or this

Last one, I promise…

Peds Bacterial pneumonia

DX: Fever Tachypnea – important

2 – 12 months (>50), 1-5 years (>40) Auscultation!! CXR – useful but not the end all be all

positive findings have not been shown to improve clinical outcomes or significantly change treatment

Lobar infiltrates more suggestive of bacterial, as are pleural effusions

Procalcitonin, CRP, WBC (>15k)

Most common etiology

2 to 24 months - Streptococcus pneumoniae Chlamydia trachomatis

2 to 5 YO - Strep pneumoniae Mycoplasma pneumoniae H. influenzae (B and nontypable) C. pneumoniae

5 years and up - Mycoplasma pneumoniae C. pneumoniae Strep pneumoniae

S. aureus accounts for 3 to 5 percent of CAP infections – MRSA is out there, more severe infections.

Outpatient Treatment

60 days to 5 years – Amoxicillin 80 mg/kg/day divided BID for 7-10 days

5 to 16 years – Azithromycin Day 1 = 10 mg/kg Day 2-5 = 5 mg/kg

Inpatient Treatment

60 days to 5 years – Cefuroxime 150 mg/kg/day IV, divided Q8 H for 10 to 14 days

If critically ill or OLDER than 5 years, add Erythromycin 40 mg/kg/day IV or orally, divided Q6 H for 10 to 14 days

Now, my caveat to this is in Waterloo we realistically just do Rocephin 50-100 mg/kg/day along with Azithromycin 10 mg/kg then 5 mg/kg.

Tips Trend procalcitonin and CRP Pay big attention to temps and respiratory

rate The absence of tachypnea is the most useful

clinical finding for ruling out CAP in children. Empiric antibiotic choices in children with

CAP should be based on the patient’s age and severity of illness, and local resistance patterns of pathogens.

Chest radiography has not been shown to improve clinical outcomes or change treatment of CAP in children.