Clinical Medecine 1( PEDIATRIC PULMONARY INFECTIOUS DISEASES)

normal vitals sign

Infant : ( 0-12 months)

- Heart rate 100-160 pbm

-Respiration rate :

0-6 months: 30-60bpm

6-12 months : 24-30

Child : (1-11 years)

-Heart rate : 70-120

-Respiration rate: 1-5 years : 20-30bpm

6-11 years: 12-20 bpm

Pre teen /teen ( 12 and up ) :

Heart rate 60-100 bpm

Respiration rate : 12-18 bpm

What is the difference between epiglotiis of adult and child ?

Adult epliglotiis is shorter

for child U shape floppier

how is older children and adult cricoid cartillage ?

glottis is narrowest point in airway

< 3 y/o cricoid ring narrowest point in airway

Stridor

•upper airway sound

•Partial obstruction larger airways

•Often during Inspiration

•Localized over neck

Wheezing

•lower airway sounds

•Partial obstruction smaller airways

•Often during Expiration

•Localized to chest

Rhonchi, crackles, rales

•lower airway sounds

•Increased secretions intrathoracic airways

•Decreased, absent, or asymmetric breath sounds is marked of?

•Atelectasis

•Lobar consolidation

•Mass

•Pleural effusion

Neonatal Respiratory Distress

•Tachypnea with rate > 60 (normal = 40-60/min)

•Grunting

•Subcostal retractions

•Nasal flaring

•Cyanosis

•Lethargy

•Poor feeding

•Hypothermia

•Hypoglycemia

•Grunting

•Subcostal retractions

•Nasal flaring

•Cyanosis

Respiratory Distress and often pending respiratory failure if not promptly managed

Respiratory distress syndrome (RDS)(Hyaline Membrane Disease)

•Premature Infants, < 34 weeks

•Surfactant deficiency & lung immaturity

•More common in moms with DM

•Symptoms of RD- immediately after birth

•Tachypnea, grunting, retractions, and cyanosis

RDS

•Symptoms normally worsen in first 12-24 hours

CXR

•Ground glass appearance

•Air bronchograms

•Hypoexpansion

ABG

•Hypoxia and acidosis

RDS Treatemnt and prevention

Treatment

•Give Surfactant (endotracheal tube)

•CPAP

Prevention

•Prevent Pre-term births

•Corticosteroids given 24 and 34 weeks (help mature lungs)

Croup (Laryngotracheobronchitis)

•Inflammation of Upper Airways

•Usually 2nd to URI

•VIRAL (80%) -

•MC Parainfluenza virus (75%) followed by

•Adenovirus, rhinovirus, RSV, influenza A & B

•MC from ~6 months- 3 years

Croup (Laryngotracheobronchitis) clinical aspect

•Abrupt onset of hard/barking cough * seal-like*

•Inspiratory and expiratory stridor

•Hoarseness

•Dyspnea (worse at night)

•Fall/early winter

•Low-grade Fever

Croup (Laryngotracheobronchitis) CXR and treament

•Steeple sign (subglottic narrowing of trachea)

•Seen on AP neck x-ray

•Treatment

•Dexamethasone (steroids)

•Supplemental O2

•Racemic epinephrine nebulizer

**Humidified air (NOT effective)

Supplemental O2 DeliveryBlow-By O2 for Croup

•In addition to the traditional nasal cannula and masks, use of a cup is much less intimidating and the children are less likely to fight and resist a "foreign device" on their face.

•To use this method

•Cut a hole in the bottom of the cup and pass the oxygen tubing through it.

croup Treatment based on severity by the WESTLEY CROUP SCORE

1-Level of consciounsousnes

2-Cyanosis

3-Stridor

3-Air entry

4-Retractions

5- Total score :

-=< 2 = mild

- 3 to 7= moderate

>= 12 impending respiratory failure

Recurrent Croup

•Risk factors for recurrent Croup:

•Prior intubation

•Prematurity

•Age < 3 y/o

•GERD

•Asthma

•Prior intubation

•Prematurity

•Age < 3 y/o

Result in clinically significant bronchoscopy findings

•GERD

•Asthma

High prevalence in patients with recurring Croup

Differentials diag of croup :

bacterial tracheitis

epiglottitis

foreign body

Hemangioma

large airway

neoplasm

peritonsillar abcess

Retropharyngeal absess

thermal injury/smoke inhalation

EpiglotTitis etiology

•MCC= haemophilus influenza type B

•Rare - due to HiB vaccine

•Kids ~ 3 months- 6 y/o

•Males>>females

What position observe on patient with epiglottitis ?

Classic Tripod Position

Epiglottitis clinical signs

•Abrupt onset high fever

•Toxic appearance (distress)

•Stridor

•Dyspnea & drooling

•Tripod appearance

•Pharyngitis & odynophagia

**Thumb print sign on lateral neck

Epiglottitis :•Direct visualization (laryngoscopy) is diagnostic**

•Do NOT attempt outside of OR

•Tx: supportive (maintain airway)

•Steroids- reduce edema

•Intubation prn

Antibiotics (2/3 gen cephalosporins

Bronchiolitis

•Inflammation of the bronchioles - narrowing

•2 months- 2y/o

•MCC in infants = RSV (Respiratory Syncytial Virus)

•Fever, rhinorrhea, pharyngitis, cough, wheezing, rhonchi, rales

•Dx - antigen detection assays

•Tx - supportive - oxygen, acetaminophen, IVF

Bronchiolitis-Prevention

•Prevention of RSV

•Highly contagious, respiratory droplets

•COVID type precautions

•At risk infants - should receive immune-prophylaxis with palivizumab (Synagis) - monoclonal antibodies

•5 doses provide 6 months of protection (duration of RSV season)

bronchiolitis predictors of severity

1-Increase severity "

-Age (Younger age predicts increased risk)

-Dehydration

-Increase work of breathing (retractions)

-Tachycardia

2- Mild disease:

Adequate oral intake

age >= two months history of eczema

Initial oxygen saturation of at least 94%

Lower respiratory rate

No history of intubation

No or Mild retractions

Treatment for acute respiratory syncytial bronchiolitis

1-Recommended therapies :

Maintain nutrition and hydration status

Maintain oxygen saturation >= 90%

2- Therapies not routinely recommended

- Antibiotic

-Bronchodilators

-Chest physiotherapy

-Epinephrine

-Excessive nasal suction of secretions

-Nebulized hypertonic saline

-Systemic or inhaled corticosteroid

Pediatric Pneumonia

Viral= MCC

•RSV, Parainfluenza types 1,2,3,

Influenza A

Bacterial= less common

•Pre-school - S. pneumoniae and HiB (vaccination reduced incidence of both)

•School age kids (5-18 y/o) - Atypical bacteria - M. pneumoniae and Chlamydia pneumoniae

Pediatric Pneumoniasymptoms

•Tachypnea & Fever

•Cough +/- sputum production

•Chest retractions

•Grunting

•Nasal flaring

•Crepitations

•Chest retractions

•Grunting

•Nasal flaring

•Crepitations

Increases the likelihood of pneumonia dx in a febrile child with tachypnea

Diagnostic testing for CAP in kids CXR

•Not required to confirm CAP in kids who are well enough to be treated as outpatients

•Recommended-- any child with suspected CAP with respiratory distress or hypoxemia

•Recommended if no clinical improvement

R/O complications of CAP: Pneumothorax, parapneumonic effusions, and necrotizing pneumonia

Diagnostic Testing for CAP in Kids :

Blood cultures

CBC w diff

Pulse OX

Blood cultures:

•Usually NOT needed in non-toxic, fully immunized kids with CAP (Clinical judgment)

CBC w. diff

•May be useful in more serious illness - clinical context

Pulse Ox

•All kids with suspected CAP and hypoxemia

•Hypoxemia will drive decisions on site of care/other testing

True or false ? For Pneumonia Once treated, should we get a follow-up x-ray to show resolution?

True

Pneumonia Follow up CXR

•Children who recover from CAP clinically without complications do NOT need f/u CXR

•Consider - kids w/ no clinical improvement, symptoms progress, or show clinical deterioration within 48-72 hours of initial antibiotic therapy

•Complicated pneumonia & worsening respiratory distress, clinically unstable, or persistent fever that does not respond to therapy within 48-72 hours

•Recurrent pneumonia same lobe or lobar atelectasis should have f/u CXR four to six weeks after diagnosis

When CAP requires admission?

•Moderate to severe CAP - respiratory distress and hypoxemia

•Altered MS

•Apnea

•Dyspnea

•Grunting

•Nasal flaring

•Pulse oximetry < 90% on room air

•Retractions

When CAP requires admission?

•Tachypnea (WHO criteria)

•0-2 months: > 60/min

•2-12 months: > 50

•1-5 years: > 40

•> 5 years: > 20

When CAP requires admission? Notes

•: infants 3-6 months old with suspected CAP - admit

•Suspect MRSA = admit

•Social concerns = admit

•? Follow up = admit

Pediatric CAP

Viral= MCC - antibiotics not routinely required in preschool-aged kids with CAP

Strep pneumoniae - amoxicillin 1st line

•Alternative

•Second or third gen cephalosporin (cefpodoxime (Vantin), cefuroxime (Ceftin), cefprozil (Cefzil))

•Levofloxacin

•Linezolid

For pediatric cap Consider atypical bacteria in school aged children and adolescents.True or false ?

True

TX dor Mycoplasma pneumoniae

Macrolides

•Azithromycin is preferred

•Alternatives - clarithromycin, doxycycline, levofloxacin and moxifloxacin

Pediatric CAP Prevention

•Immunizations against S. pneumoniae, H. influenza type b, pertussis

•Annual influenza vaccination ages > 6 months

•Parents/caretakers - DTaP (Pertussis) and annual influenza

•High risk infants should receive monoclonal antibody prophylaxis for RSV

Viral URI

OTC cough and cold medications NOT Recommended, especially in children < 4 y/o

Treatment:

•Pelargonium sidoides (geranium) extract (Umcka Coldcare)

•Nasal saline irrigation (can you hit a moving target!)

•Vapor rub if over age 2

•Zinc sulfate

Don't use antibiotics

Fever In Kids

•Abnormal pathophysiologic condition

•Rise in temp

•Tachycardia

•Disturbance of various body functions

•Fever = > 100.4 F or 38 C - rectal most accurate

•Usually does not indicate serious illness

•Discomfort & seizures

•Does not cause brain damage

•Does help fight infection

Fever in First 21 days of Life

Admit for temp > 100.4 F

All infants:

•CBC with diff

•UA and culture

•LP for CSF studies and culture

CXR if respiratory symptoms

Stool studies/fecal WBC if diarrhea present

Fever in First 21 days Etiology

•GBS (Group B strep ® S. agalalactiae (Gram + cocci with a tendency to form chains)

•E. coli

•Listeria

Fever in First 21 days •IV antibiotics

•Ampicillin + gentamicin OR

•Ampicillin + cefotaxime (Claforan)

•+/- acyclovir

•NO ceftriaxone (Rocephin) in infants < 1 month due to kernicterus risk

•Type of brain damage that can result from high levels of bilirubin in a baby's blood

A Word or Two about GBS

Clinical Features

•In neonates two syndromes exist for group B strep (GBS) disease:

•Early-onset (<7 days old)

•Late-onset (7-90 days old)

Both can manifest as bacteremia, sepsis, pneumonia, and meningitis.

Pregnancy-related infections include:

•Bloodstream infections (including sepsis)

•Amnionitis

•Urinary tract infection

•Stillbirth

A word or two about GBS •Transmission

•Asymptomatic carriage in gastrointestinal and genital tracts is common. Intrapartum transmission via ascending spread from the vagina occurs

•Maternal colonization with GBS is the primary risk for early onset disease in neonates

Risk factors for neonatal infection with group B streptococcus

Gestational age less than 37 Weeks

Group B streptococcus isolated from mother's vagina, rectum or urine

Inadequate intrapartum chemoprophylaxis (if indicated for the mother)

Longer duration of ruptured membranes (More than 18 hours)

Maternal chorioamnionitis

Preventing Neonatal GBS Infection

•Screen all pregnant women who have not already had + GBS vaginal or urine

•Rectal and vaginal swab

•Treat all GBS + pregnant women intrapartum with PCN if not allergic

COVID-19 in Pediatric PatientsSARS-CoV-2

•When children contract COVID-19, they tend to have milder symptoms than adults

•Symptoms can range from asymptomatic→ to mild URI→ to ARDS requiring assisted ventilation

•Symptoms specific to COVID-19 include:

•Loss of smell or taste, early on and prior to coryza

•May also have GI symptoms

•Nausea, vomiting, & diarrhea

Tests

•Molecular and antigen tests both have high specificity = high specific test with + result rules IN for the disease

•Antigen tests and some molecular tests have lower sensitivity → potential for false negative results

•False negative results have implications for disease spread

•Consider recommending isolation precautions despite negative test result when pretest probability is high

•Symptoms based approach preferred to test based for ending isolation

Does Test Timing Matter?

•Viral load decreases after symptom onset

•False negative results are more likely with antigen tests that are performed more than five days after symptom onset.

The FILMARRAY Respiratory Panel 2

1 test 21 pathogens in 45 min

Cystic Fibrosis

Genetic-- Autosomal recessive

CF gene encodes for cystic fibrosis transmembrane conductance regulator (CFTR), a chloride channels of epithelial cells

Leads to abnormal movement of salt and water across cell membranes

=Thick secretions impacting multiple organ systems - leading to obstruction

Cystic Fibrosis : Clinical manifestations:

•FTT, poor growth and weight gain (ADR)

•Chronic cough, recurring pulmonary infections - bronchiectasis

(Common cause of death in CF patients)

•Recurrent sinusitis, Nasal polyposis

Cystic Fibrosis: Common secondary infections

•S. aureus and P. aeruginosa - common cause of death

Diagnosis Cystic Fibrosis

•Sweat Chloride test > 60 mEq/L

•Normal test does not r/o diagnosis

•DNA testing for definitive/confirmatory diagnosis

Diagnosis Cystic Fibrosis CXR

may reveal hyperinflation, mucus plugging, focal atelectasis

management of cystic fibrosis

•Mean survival now ~ 30-40 years

•Management

•Enhancing airway clearance - chest physiotherapy

•Treating airway infections

•Reversing bronchoconstriction with bronchodilators

•Improving nutritional status

•Pancreatic enzyme replacement & fat-soluble vitamin A, D, E, K

•High fat diet

•Newer therapies are genotype specific and improve CFTR protein for some

What do you monitor for the 1st few month in management of cystic fibrosis?

•monitor and treat respiratory infections from S. aureus and HiB

•Then Pseudomonas aeruginosa is the major player for infections