bronchiolitis, croup, RDS, epiglottitis, etc

what is a clinical syndrome that happens in kids under 2, characterized by upper respiratory symptoms and then followed by lower respiratory symptoms

bronchiolitis

what is the leading cause of hospitalization in infants under 1yo

bronchiolitis

what is the most common bronchiolitis cause

respiratory syncytial virus (RSV) (mostly viruses in general)

how many kids have been infected by RSV by 2yo

majority of kids, and reinfection is common

who is affected by RSV

kids under 5, but also elderly and immunocomp

what can RSV cause

bronchial epithelium proliferation and necrosis. can also get airway obstruction as sloughed epithelium and mucus from inc inflammation blocks the airway. can also cause pneumonia

symptoms of RSV

fever, fatigued w inc sleeping, rhinorrhea, sore throat, tachypnea w increased work of breathing, cough, wheezing and crackles, possible apneic episodes

how do we diagnose RSV

nasopharynx swab for PCR, chest xray (to check for possible pneumonia, or if theyre immunocomp/have genetic issues/disability/underlying pulm issues)

how do we define severe bronchiolitis

if we have ANY of the following: tachypnea/nasal flaring/retractions/accessory muscle use/grunting during repeated exams seperated by 15+min, hypoxemia less than 95%, apneic episodes, acute respiratory failure

how do we treat non severe RSV infections

pt education (lower resp symptoms peak on day 3-5 then resolve over 2-4wks), nasal suction, maintain oral hydration, avoid OTC decongestants/cough meds cause they dont help, lemon w honey water

how do we treat severe RSV infections for general pts

admit, maintain oral or IV hydration, nasal suction, supplemental O2 to maintain O2 over 90%, heated humidified high flow nasal cannula and CPAP, TRIAL of SABA’s

what additional treatment for severe RSV do we add if the pt is immunocomp

ribavirin (antiviral) (reduced mortality)

what are the discharge criteria for a kid under 6mo old w RSV

less than 60 breaths per min and caretaker knows how to clear the infants airway using bulb suctioning

what are the discharge criteria for a kid 6-11 months old w RSV

less than 55 breaths per min and caretaker knows how to clear the infants airway using bulb suctioning

what are the discharge criteria for a kid 12 months old or older w RSV

less than 45 breaths per min and caretaker knows how to clear the infants airway using bulb suctioning

what are the general discharge criteria for an RSV pt regardless of age

can remain stable for over 12 hours on room air, no/minimal respiratory distress, adequate oral intake, adequate PO hydration, resources at home are adequate, caretakers are confident they can provide care at home, family education is complete

croup aka

laryngotracheobronchitis

what causes croup

parainfluenza virus

what age group gets croup

6mo-3yrs

what happens in croup

viral infection leads to narrowing of the subglottic airway (right below the vocal folds)

croup symptoms

starts as upper respiratory infection (nasal discharge, congestion, cough), after 12-48hrs pt gets fever, hoarse voice, barking seal like cough and inspiratory stridor

what do we see on an xray for croup

steeple sign

what is used to determine the severity of croup

the westley croup score which factors in stuff like: level of consciousness, cyanosis, stridor, air movement in lungs, retractions (high score=bad)

scoring related to level of consciousness in the Westley croup score

normal, including sleep = 0

disoriented = 5

scoring related to cyanosis in the Westley croup score

none = 0

with agitation = 4

at rest = 5

scoring related to stridor in the Westley croup score

none = 0

with agitation = 1

at rest = 2

scoring related to air entry in the Westley croup score

normal = 0

decreased = 1

markedly decreased = 2

scoring related to retractions in the Westley croup score

none = 0

mild = 1

moderate = 2

severe = 3

what treatment would we give to a pt w croup that presents w occasional barky cough, no stridor at rest, and mild/no retractions (score 0-2)

outpatient single dose of PO dexamethasone, antipyretics, humidifier, oral fluids

what treatment would we give to a pt w croup that presents w a frequent barky cough, stridor at rest, and mild to moderate retractions but little to no distress or agitation (score 3-7)

single dose of PO dexamethasone and nebulized EPI. ADMIT PT hospitalize for persistent or worsening symptoms after tx

what treatment would we give to a pt w croup that presents w frequent barky cough, stridor at rest, marked retractions, and significant distress/agitation (score 8-11)

single dose of PO/IM/IV dexamethasone and repeated nebulized epi. ADMIT PT.

what treatment would we give to a pt w croup that presents w a depressed level of conciousness, stridor at rest, severe retractions, poor air entry, cyanosis or pallor (score 12-17)

single dose IM/IV dexamethasone and repeated nebulized epi. ICU admission. probable intubation

what is an acute infection of the respiratory tract caused by bordetella pertussis

pertussis (whooping cough)

how many kids under 1yo who get pertussis end up in the hospital

1/3

pertussis symptoms

any cough over 2wks accompanied by vomitting, post-tussive apnea, or post tussive “whoop”

who do we have to call if our pt has whooping cough

ghost busters! (actually the state and local health dept cause this is reportable)

what are the symptoms of the first stage (catarrhal stage) of pertussis (1-2wks)

lacrimation, conjunctival injection, sneezing, and coryza, anorexia, malaise, hacking night cough that becomes constant

what are the symptoms of the second stage (paroxysmal stage) of pertussis (1-2wks)

bursts of rapid, consecutive coughs followed by a deep, high pitched inspiration (whoop)

what are the symptoms of the third stage (convalescent stage) of pertussis (1-2 wks)

slow resolution of symptoms (recovery stage)

how do we diagnose whooping cough

acute cough lasting 2wks or more with AT LEAST one of the following: paroxysms of coughing, inspiratory whoop, post tussive vomiting, occurrence during a known or suspected outbreak, prolonged cough w/o explanation

concurrent nasopharyngeal culture and pertussis PCR, elevated WBC count w inc in lymphocytes

how do we treat pertussis

AZITHROMYCIN, erythromycin, clarithromycin OR trimethoprim-sulfamethoxazole DS (bactrum) if over 2mo and intolerant to macrolide

how do we prevent pertussis

prophylactic antibiotic tx for known contacts of confirmed diagnosis (same as tx abx), primary vaccine series for all infants and kids, booster at 11-12yo

other names for infant respiratory distress syndrome (RSD)

neonatal respiratory distress syndrome, hyaline membrane disease, surfactant deficiency disorder

what causes infant RSD

deficiency of pulmonary surfactant in premature babies lungs → high surface tension in alveoli → alveoli stick together in large portions → increasing hypoxia and respiratory distress within the first few hrs of life

what is surfactant

a substance that reduces the tension of a liquid

what increases the risk of a neonate developing infant RSD

infant risk increases the more preterm they are

when is surfactant expressed in the lung during gestation and why does that matter for preterm babies

surfactant is made around the 20th week of gestation, preterm infants are lacking in both the necessary quantity and quality of surfactant.

what cells make surfactant in the lungs

alveolar type 2 cells

surfactant in lungs =

alveoli stay open

what does a less than 15K lamellar body count indicate

indicates immature lungs and a higher chance for RSV once the baby is born

what does a over 50k lamellar body count indicate

mature lungs and a lower chance for RSV after birth

when would we do a lamellar body count test

if the mom is high risk but not in labor yet, otherwise if you cant do anything about it then dont bother

infant RDS symptoms

tachycardia, tachypnea, nasal flaring, expiratory grunting, chest wall retractions, cyanosis, apneic episodes leading to respiratory failure

what would you see on a chest xray of RDS

ground glass appearance, if severe then total white out of the lungs

what treatment can we give to high RSV risk moms 1-7days before birth (give to all preg women at 23-24wks at high risk)

antenatal corticosteroids

what treatments can we give to babies w RSV

nasal CPAP (first line), intubate, surfactant therapy via endotracheal tube

a medical emergency that can proceed to life threatening airway obstruction. caused by cellulitis and inflammation of the epiglottis, aryepiglottic folds and surrounding tissues

acute epiglottitis

when should you suspect acute epiglottitis

rapidly developing sore throat or when odynophagia (pain w swallowing) is out of proportion to exam (can occur in adults but more in kids)

what is the microbial cause of epiglottitis in kids

H influenzae

what is the microbial cause of epiglottitis in adults

strep pneumonia

epiglottitis symptoms

rapid onset of dysphagia (hard to swallow), drooling, distress, sniffing or tripod position, wont lie down, muffled or hoarse voice

what should you not do w a pt who has acute epiglottitis

upset them or force them to lie down

what confirms an epiglottitis dx

visualization of the epiglottis (w nasopharyngeal fiberoptic scope) (xray often not needed)

what would you see on an xray for acute epiglottitis

thumb sign

epiglottitis treatment

intubate if needed, if you cant intubate do a cricothyroidotomy, IV ceftriaxone + vancomycin