Bronchiolitis, RSV, Croup, Pertussis, infant IDS, Epiglottitis

SHE'S BACK ITS EPIGLOTTITIS WITH THE STEEL CHAIR

Bronchiolitis

A clinical syndrome occurring in kids < 2 y/o characterized by upper respiratory symptoms followed by lower respiratory symptoms associated with acute inflammation and damage to the small airways that leads bronchospasm and is a leading cause of hospitalization in infants under 1

RSV (M. pneumoniae is the most common bacteria)

Most common cause of bronchiolitis

October- March (peaks in january)

RSV season

4-6 days

Incubation time for RSV

Admit, maintain hydration, suction, supplemental oxygen (HFNC or CPAP), systemic steroids, SABA trial

An 18 month old patient presents to the ER for fever and rhinorrhea. Mother reports that patient has been super sleepy and has had a cough the last few days. On a physical exam you note tachypnea with increased work of breathing followed by apneic episodes. The child grunts with every breath. Wheezing and crackles are present on auscultation. Vitals are stable with the exception of 101.6 temp and 93% on RA. Patient is up to date on all vaccines and has hit all developmental makers. Nasal swab is positive for RSV. What is your treatment plan?

Patient education, nasal suction, maintain hydration, no OTC decongestants

An 18 month old patient presents to the ER for fever and rhinorrhea. Mother reports that patient has been super sleepy and has had a cough the last few days. Wheezing and crackles are present on auscultation. Vitals are stable with the exception of 101.6 temp. Patient is up to date on all vaccines and has hit all developmental makers. Nasal swab is positive for RSV. What is your treatment plan?

Apnea, cyanosis, poor feeding, new fever, tachypnea, increased work in breathing (grunts), decreased fluid intake, exhaustion

For non-severe RSV infections what are some PLEASE COME BACK red flags?

POC swab, CXR (if high risk)

How do we diagnose RSV

hyperexpansion, peri-bronchial thickening

What are some red flags in a CXR for an RSV patient?

increase respiratory effort, hypoxemia, apneic episodes, acute respiratory failure

Signs of severe bronchiolitis

less than 60 breaths a minute

Discharge guidelines for RSV for patients less than 6 months

less than 55 breaths a min

Discharge guidelines for RSV for patients 6-11 months

less than 45 breaths a minute

Discharge guidelines for RSV for patients 12+ months

Caretakers know how to bulb suction, stable on RA for 12 hours, no/minimal respiratory distress, adequate oral intake, adequate home resources, patient education complete

Discharge criteria for everybody with RSV

Croup (laryngotracheonronchitis)

A common parainfluenza infection that leads to the narrowing of the subglottic airway usually in children 6 months - 3 years and peaks in fall/winter months

supplemental oxygen, Nebulized epi, Single dose dexamethasone, admit (Wesley score is like 4)

A 2 y/o female presents to the ER with fever and hoarse voice. Mother reports that she started with nasal discharge, congestion, and a cough yesterday, but other than that is a healthy girl. On a physical exam you note a barking cough and inspiratory stridor as well as mild/moderate retractions. Air entry is slightly decreased. Patient is awake and skin is WNL. A neck x-ray shows a steeple sign. What’s your treatment plan?

Level of consciousness, cyanosis, stridor, air movement in lungs, retractions

What factors are included in the wesley’s score?

Single dose of dexamethosone, antipyretics, humidifier, oral fluids (Welseys is like 1)

A 2 y/o female presents to the ER with fever and hoarse voice. Mother reports that she started with nasal discharge, congestion, and a cough yesterday, but other than that is a healthy girl. On a physical exam you note an occasional barking cough and stridor with agitation, mild/no retractions. Patient is awake and skin is WNL. A neck x-ray shows a steeple sign. What’s your treatment plan?

repeated nebulized Epi, Single dose dexamethosone, admit (wesley’s is like 8)

A 2 y/o female presents to the ER with fever and hoarse voice. Mother reports that she started with nasal discharge, congestion, and a cough yesterday, but other than that is a healthy girl. On a physical exam you note a barking cough and inspiratory stridor as well as marked retractions. Air entry is slightly decreased. Patient is awake and skin is WNL. A neck x-ray shows a steeple sign. What’s your treatment plan?

repeated nebulized Epi, Single dose dexamethosone, admit to ICU, prepare to intubate (wesleys is like 15)

A 2 y/o female presents to the ER with fever and hoarse voice. Mother reports that she started with nasal discharge, congestion, and a cough yesterday, but other than that is a healthy girl. On a physical exam you note a barking cough and inspiratory stridor at rest as well as severe retractions. Air entry is decreased. Patient is disoriented and skin is cyanotic. A neck x-ray shows a steeple sign. What’s your treatment plan?

Pertussis (whooping cough)

An acute infection of the respiratory tract that is caused by Bordetella pertusis and is transmitted by respiratory droplets

7-10 days

Incubation period for pertussis

Report it!

If you suspect pertussis what do we need to do?

catarrhal, paroxysmal, convalescent

What are the stages of pertussis?

lacrimation, conjunctival injection, sneezing, coryza, anorexia, malaise, hacking night cough

Catarrhal stage of whooping cough is characterized by

burst of rapid, consecutive coughs followed by a deep high-pitched whoop

Paroxysmal stage of pertussis is characterized by

slow resolution of symptoms

Convalescent stage of pertussis is characterized by

paroxysm of coughing, inspiratory whoop, post-tussive vomiting, occurrence during an outbreak, prolong cough w/o explanation

Whooping cough can be diagnosed with an acute cough illness for 2 or more weeks with at least one of what?

nasopharyngeal culture, pertussis PCR, elevated WBC (lymphocytes)

How can we confirm our diagnosis of whooping cough?

Azithromycin (1st line), erythromycin, clarithromycin, Bactrim (if intolerant to macrolide)

How are we treating whooping cough?

Prophylactic antibiotics for peeps with known exposure, vaccines (booster @ 11/12)

How are we preventing the spread of whooping cough?

Infant respiratory distress syndrome (RDS)

A deficiency of pulmonary surfactant in an immature neonate lung leading to increasing hypoxia and respiratory distress within the first few hours of life.

preterm infants (born early = high risk)

Who is at risk for neonate RDS?

lamellar body count

What can we test to determine fetal lung maturity using amniotic fluid?

Preterm infants don’t have enough and/or good enough surfactant so we get increased tension, increase atelectasis, V/Q mismatch

Explain the pathophysiology of infant RDS

Nasal CPAP (1st line), intubate, surfactant therapy

You deliver a 30 week preterm infant while on the L and D unit. While conducting a physical on the baby you note nasal flaring, expiratory grunting, and chest wall retractions. The patient is slightly cyanotic. Vitals are stable with the exception of tachypnea and tachycardia. CXR shows ground glass. What is your treatment plan?

antenatal corticosteroids

What can we give moms that are high risk for preterm delivery to try to avoid infant RDS?

acute epiglottitis

A patient presents to the ER with a sore throat that they state started about an hour ago and is extremely painful. They also note odynphagia. What are we thinking team?

H. influenzae (decline due to vaccines)

In Peds what is the most common cause of acute epiglottitis?

strep

In adults what is the most common cause of acute epiglottitis?

Dysphagia, drooling, distress

What are the 3Ds of acute epiglottitis?

intubate if needed (Crike if necessary), admit, IV ceftriaxone+VANC

A 8 y/o patient presents to the ER for a sore throat. He states the pain is worse when he swallows. You note drooling and the patient refuses to lie down on the stretcher. The child has a hoarse voice and is sitting in the tripod position. On a physical exam you note that you can SEE the epiglottis. A Neck xray shows a thumb sign. What is your treatment plan?

nasopharyngeal fiberoptic scope

What can provide a definitive diagnosis of acute epiglottitis?

Mid risk (not low/high)

When do you order a neck xray for epiglottitis patients?

visualization of epiglottis → anxiety → laryngospasm → CRASH

For patients with abrupt stridor, fever, respiratory distress over 24 hours why do we need to take precautions?