Acute respiratory conditions in children.pptx

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1. ACUTE RESPIRATORY TRACT CONDITIONS IN CHILDREN Shakilu J. M.D Pediatrician-UDOM

2. WHY WE CARE?

3. Upper Airways Lower Airways

4. ACUTE RESPIRATORY TRACT INFECTIONS Upper RTIs Rhinitis Sinusitis Otitis media Pharyngitis Epiglotits Diptheria Lower RTIs Croup Bronchiolitis Pertusis Pneumonia

5. Rhinitis (Common Cold) Most common Pediatric infectious disease Incidence higher in early childhood Up to 6-12 episodes per year in under fives Culprit 30 to 40% rhinovirus Others- Adenovirus,Corona virus, Enterovirus Influenza and Parainfluenza viruses

6. Rhinitis cont.. CLINICAL FEATURES Clear or mucoid nasal discharge, nasal congestion, sneezing, and sore throat. Cough and fever mostly in under fives as high as 40°C without super-infection. The nose, throat, and tympanic membranes may appear red and inflamed. Usually lasts 1 week if longer 10-14 days bacterial super-infection should be considered

7. Rhinitis cont..Treatment R eassurance & Education Saline nasal drops Nasal suctioning Warm nebulized saline for severe nasal congestion Antipyretics for fever Antihistamine-no proven benefits for viral rhinitis in young kids-potential side effects Narcotic antitussives-depress respiration

8. Sinusitis Sinuses are hollow air filled sacs lined by mucous membranes S inuses have communication with the nose and nasal passages Infections, allergic reactions to the nose and upper respiratory tract may extend to the sinuses Inflammation and obstruction of the sinus may cause severe pain

9. Sinusitis ..cont..

10. Sinusitis ..cont.. An acute inflammatory process involving one of the paranasal sinuses Complicates 10% of the pediatric upper respiratory tract infections Persistence of symptoms by day 10 of an upper RTI Maxillary and ethmoid sinuses frequently involved

11. Sinusitis ..cont.. Usually follows rhinitis-viral or allergic May also result from abrupt pressure changes e.g. air travel and diving mostly in adults Inflammation-Edema-Obstruction and B acterial overgrowth Nasal anomalies such as polyps may predispose

12. Sinusitis ..cont.. Etiologies - Strep Pneum -H. influenza -M. catarrhails Others - S. aureus -S. pyogenes -Gram neg. bacilli -Respiratory viruses

13. Sinusitis ..cont.. Clinical features Excessive crying and fever in infants Mucopurulent nasal discharge Nasal mucosa swelling Facial pain in older kids Periorbital swelling

14. Sinusitis ..cont.. Diagnosis Mostly clinical High index of suspicion Imaging Plain radiograph-poor sensitivity but may show air fluid levels Rhinoscopy CT-scan MRI

15. Sinusitis ..Treatment Goals Shorten the duration of illness Prevent Chronic sinusitis Prevent secondary diseases

16. Sinusitis ..Treatment Antihistamine for allergic sinusitis Nasal decogenstants -oral or topical Antibiotics for bacterial sinusitis Hydration and humidifier to relieve dry membranes from mouth breathing Fever and pain control

17. Sinusitis ..Treatment Recommended antibiotics -Non severe cases Oral amoxycillin Amoxy clavulanic acid for beta lactamase -Severe cases IV antibiotics - Cefotaxime , Ceftriaxone

18. Sinusitis ..Treatment Complications Chronic sinusitis Meningitis/brain abscess Otitis media Pneumonia

19. Pharyngitis Inflammation of the pharynx due to acute infection Group A beta hemolytic strept is the main focus due to its potential to cause acute rheumatic fever and RHD Global estimates of 30 million cases annually in school age children

20. Pharyngitis ..cont.. Peak age 5 to 15 yrs Equal sex distribution

21. Pharyngitis-Signs and Symptoms Symptoms Sore throat Painful swallowing Fever Signs Enlarged tonsils Pharyngeal erytherma Tonsillar exudates Cervical adenopathy Pseudomembrane Pus pockets and enlarged adenoids Beefy-red uvula

22. Pharyngitis -Causes Bacterial Group A strep Hemophillus influenza Diptheria Moraxella catrrhalis N. Gonorrhea Group C&G strep Viral Rhinovirus Adeno virus Parainfluenza Coxsackie virus Corona virus Echo virus Herpes simplex virus

23. Pharyngitis -Diagnosis Clinical just by clinical assessment Supportive laboratory work -CBC -Leukocytosis and neutrophilia & C-reactive protein Throat swab culture Rapid streptococcal antigen test Serum ASOT

24. Pharyngitis treatment General principles Salt solution gargles for older kids with oral hygiene Dyclonine lozenges for older kids Analgesics and antipyretics

25. Pharyngitis treatment Antibiotic therapy For Streptococcal pharyngitis- Penicciliin is the drug of choice- full course is 10 days Procaine peniccillin 25-50mg/kg/day Allergy to penicillin erythromycin 12.5mg PO TID Amoxycillin 50mg/kg/day devided into 3 doses Cephalexin 30mg/kg/day

26. Pharyngitis -Complications Rheumatic fever Post strept glomerulonephritis Peritonsillar abscess(Quinsy) Systemic infection Mastoiditis Otitis media Sinusitis Pneumonia Meningitis

27. Otitis media Ear infection associated with middle ear effusion Classified according to its associated symptoms, otoscopic findings, duration of illeness and complications: -Acute otitis media with no effusion -Otitis media with effusion -Chronic suppurative otitis media

28. Acute otitis media Middle ear inflammation resulting in an effusion Associated with rapid onset of symptoms such as otalgia , fever, irritability, anorexia, or vomiting.

29. Acute otitis media Diagnosis Prerequisites History of acute onset of signs and symptoms Presence of MEE, and Signs and symptoms of middle-ear inflammation.

30. Acute otitis media SYMPTOMS Fever Irritability Pain referable to the ear Ear discharge in severe case SIGNS Ear discharge Bulging whitish/yellow TM Loss of visibility of the ossicular land marks Middle ear effusion Air fluid levels behind the TM

31. Acute otitis media Predisposing Factors Viral upper respiratory tract infection Bacterial colonization of the nasal pharynx Eustachian tube dysfunction( Cranial facial anomalies) Impaired host immune defenses Smoke exposure (Passive smoking) Bottle feeding (↓ IgA and aspiration) Genetic susceptibility for those with recurrent AOM e.g. DS, CF

32. Acute otitis media-Microbiology Viral Precipitating 40% of cases Cause Eustachian tube dysfunction RSV Influenza Bacterial Super infection after viral Strept pneum H. influenza -non typable M.catarrhalis Strep. Pyogenes Staph. aureus

33. Acute otitis media Precedures on exam Otoscopy -Pneumatic preferable Cerumen removal- Not by parents Tympanometry -ENT! Supportive CBC Swab culture CRP

34. Acute otitis media Treatment Supportive Dry ear wicking if otorrhea is present Antipyretic and analgesics - acetaminophen -Ibuprofen Antiseptic -Boric acid for OME/COM Tympanocentensis for severe ME Antibiotics for 10days 1 st line Amoxycillin 50mg/kg/day devided dose 2 nd line Amox-clav and Cefuruxime Ceftriaxone for severe cases Cloxacillin / Vancomycin Chloramphenicol

35. Acute otitis media-complications TM-Perforation Cholesteatoma Conductive hearing loss Facial nerve paralysis Chronic suppurative otitis media Mastoiditis Meningitis/brain abscess Pneumonia and septicemia

36. A irway obstruction

37. Children are not small adults

38. Ranges from nasal obstruction to larynx and upper trachea. Obstruction of the portion of the airways located above the thoracic inlet.

39. Causes of Acute air way obstruction Infectious Croup Epiglotitis Peritonsillar abscess Retropharyngeal absecess Bacterial tracheitis Non-Infectious Foreign body inhalation Spasmodic croup

40. Croup Also referred to as Laryngotracheobronchitis An acute respiratory condition characterized by a brassy/barking cough, inspiratory stridor hoarseness and in severe cases distress Usually preceded by mild upper respiratory tract infection symptoms 48-72hrs (Viral) And another family member with an URTI

41. Croup Mostly seen in children 3m-3yrs More in males than females

42. Croup…cont.. Etiologies Infectious…… commonest Non infectious (allergic)

43. Croup…cont.. etiologies Infectious-Mostly Viral Parainfluenza 1,2 & 3 Influenza A & B Adeno virus RSV Rarely Mycoplasma Non infectious Spasmodic croup usually recurrent No prior history of respiratory tract infection Allergic in origin

44. Croup-Pathogenesis Subglottic narrowing due to inflammation. Upper air way obstruction

45. Croup-Clinical History Parents report viral URTI symptoms 24-72hrs prior to cough(rhinorrhea, pharyngitis, mild cough, and low-grade fever ). Fever, “Barking cough ,” hoarseness , Stridor Typical course not more than 7 days Symptoms worsen at night aggravated by crying

46. Diagnosis On physical exam A hall mark of hoarse voice coryza normal to moderately inflamed pharynx slightly increased respiratory rate Rarely, the clinical picture of upper airway obstruction may ensue

47. Diagnosis-Croup cont … No specific investigations are necessary for a diagnosis of viral croup PA radiographs of the neck may show subglotic narrowing steeple sign/pencil tip sign CBC – characterized by lymphocyotosis

48. Steeples sign/Pencil sign

49. Croup Treatment Nurse in position of comfort with a parent Give oxygen Cool mist Racemic epinephrine Steroids in severe cases-dexamethasone 0.6mg/kg/day devided doses Hydration and colorie requirement

50. EPIGLOTITIS

51. Epiglottis Infection and inflammatory cellulitis of the epiglottic epithelium and neighboring structures The commonest bacterial cause of acute upper airway obstruction prior to Hib vaccine

52. Epiglotitis cont.. Peak age btn 1-7yrs of age Rapid fulminating course marked by high fever, sore throat, dyspnea and rapid progression to respiratory obstruction 4-12hours Potentially lethal condition

53. Epiglotitis cont.. Mainly bacterial etiology Strep pneumoniae Strep. Pyogenese Staph aureus H. influenza unvaccinated pt

54. Epiglotitis cont..Diagnosis Upright sitting with neck hyperextension ‘tripod position’ with ‘4Ds’ Drooling Dysphagia Dysphonia Distress Toxic appearance

55. Tripod position- epiglotitis

56. Epiglotitis cont..Diagnosis “Cherry-red" swollen epiglottis by laryngoscopy Avoid anxiety provoking interventions : phlebotomy intravenous line supine position direct inspection of the oral cavity until you have secured airways Lateral neck X-ray will show an inflamed epiglottis with thumb sign….not a pre requisite for diagnosis

57. Thumb sign on lateral neck X-ray

58. Minutes count in acute epiglottitis

59. Epiglotitis Management Epiglotitis is a medical emergency! Requires secure airways by intubation, cricothyroidotomy or tracheostomy Visualization of the pharynx should be done in ICU setting/OT Secure airways is the priority with 0 2 therapy

60. Epiglotitis Management Intubation is an option to majority of patients until edema of the epiglottis resolves-usually in 48 to 72 hrs ( 6% pts die with out intubation) IV antibiotics- Ceftriaxone,cefetaxime or a combination of ampicillin and chloramphenicol for 7 to 10 days Fever and pain control Feeding and adequate hydration

61. Foreign body inhalation

62. Foreign body inhalation Accounts for 75% of cases of acute airway obstruction in children 1 to 4 years Slightly common in males than females 3 rd most common cause of unintentional injuries in children in the US

63. FB in the airway Aspirated objects vary with age and locations Nuts, dried beans and popcorns are common Peak age btn 1yr to 3yrs due to growing curiosity and mobility Common in unsupervised children Abrupt onset of symptoms

64. Foreign body inhalation Clinical Manifestations Three stages of symptoms : Initial Event : Violent paroxysms of coughing, choking & gagging Asymptomatic Interval : The foreign body becomes lodged, reflexes fatigue, and the immediate irritating symptoms subside

65. Foreign body inhalation Clinical Manifestations 3. Complications : obstruction, erosion, or infection, fever, cough, hemoptysis , pneumonia, and atelectasis The most serious complication of foreign body aspiration is complete obstruction of the airway

66. Foreign body aspiration

67. Foreign body aspiration Diagnosis Positive history (Not always clear in unattended children) Choking or coughing episodes accompanied by wheezing Chest X-ray in expiration phase- Right side common Bronchoscopy CT-scan

68. Foreign body aspiration-Treatment Initial steps… For partial airway obstruction cough reflex through coughing may work -Attempts to remove the objects -Depending on the age of the child Back blows Heimlich maneuver/abdominal thrust

69. Foreign body aspiration removal

70. Severe air way obstruction No air entry and no cough reflex No respiratory movements Pt in fatigue Cyanosis and systemic hypoxemia Urgent bronchoscopy to remove the foreign body