Pediatric Primary Care: Practice Guidelines for Nurses, 2nd Ed.

CHAPTER 24

Respiratory Disorders

Marti Michel

I. CROUP

Airway obstruction, severe, 519.8

 

Laryngotracheobronchitis, 490

Anxiety, 300

 

Laryngotracheobronchopneumonia, 485

Change in level of consciousness, 780.09

 

Mild erythema, 695.9

Croup, 464.4

 

Mild fever, 780.6

Croup, spasmodic, 478.78

 

Progressive restlessness, 799.2

Cyanosis, 782.5

 

Respiratory distress, 786.09

Edema of larynx, 478.6

 

Restlessness, 799.2

Edema of nasal mucosa, 478.25

 

Rhinorrhea, 478.1

Fatigue, 780.79

 

Sore throat, 462

Harsh, barking cough, 786.2

 

Suprasternal, 738.3

Hoarseness, 784.49

 

Tachycardia, 785

Hypoxemia, 799

 

Tachypnea, 786.06

Increased retractions, 786

 

Upper airway obstruction, acute, 519.8

Inspiratory stridor, 786.1

 

Wheezing, 786.07

Laryngotracheitis, 464.2

   

A. Etiology.

1. Acute upper airway obstruction in children, most often caused by viral infection.

a. Most common form of viral croup is laryngotracheitis resulting from inflammation and edema of larynx, subglottic area.

• Causative agents include parainfluenza 1, 2, 3 (parainfluenza 1 and 3 most common), influenza A and B, respiratory syncytial virus (RSV), adenovirus, measles.

b. Spasmodic croup is similar to viral croup but is not associated with fever and symptoms, lasts only hours, not days.

• Onset typically occurs during night in a child who has been well.

• May represent allergic reaction to viral antigen.

c. Laryngotracheobronchitis (LTB) and laryngotracheobronchopneumonia (LTBP) involve upper airway; also affect lower airway, specifically bronchi.

• Same viral agents are common to LTB and LTBP.

• Bacterial superinfection occurs more commonly in this croup variant; includes Staphylococcus aureus, Streptococcus pyogenes, Streptococcus pneumoniae, Haemophilus influenzae, Corynebacterium diphtheria.

i.  Agents are infrequent causes but tend to cause more severe illness.

B. Occurrence.

1. Viral croup occurs at 6 months to 5 years of age, with peak in second year of life.

2. Affects boys more than girls.

3. Occurs in late fall, early winter; correlates with the activity of viral agents causing the syndrome.

4. Symptoms typically last 3-7 days.

C. Clinical manifestations.

1. Gradual onset with rhinorrhea, sore throat, mild fever.

2. Disease has wide spectrum from very mild illness to severe illness.

3. Harsh, “seal-like” barking cough.

4. Hoarseness.

5. Inspiratory stridor.

6. Increasing obstruction.

a. Tachycardia, tachypnea–usually not > 50 breaths/min.

b. Suprasternal, supraclavicular, substernal, and intercostal retractions.

c. Paradoxical abdominal and chest wall movement.

d. Progressive restlessness and anxiety correlates with hypoxemia.

D. Physical findings.

1. Normal or mildly elevated temperature.

2. Mild erythema and edema of nasal mucosa.

3. Inspiratory stridor.

4. Hoarseness.

5. Harsh, barky cough.

6. Nontoxic appearing.

7. On auscultation, normal breath sounds except transmission of stridor.

8. With increased obstruction: wheezing, prolonged expiration, decreased breath sounds.

E. Diagnostic tests.

1. Diagnosis made on basis of history and clinical presentation.

2. Imaging is not usually necessary in the ambulatory setting; posteroanterior neck X-ray.

a. Classic “steeple sign”: narrowed air column consistent with narrowing of subglottic space.

b. Lateral view is useful in ruling out epiglottitis, retropharyngeal abscess, or radiopaque foreign body.

3. If indicated, WBC normal or low with polymorphonucleotides (PMNs).

4. Clinical croup score can classify severity of illness and aid in decision making regarding hospitalization.

F. Differential diagnosis.

Diphtheria, 032.9

 

Peritonsillar abscess, 475

Epiglottitis, 464.3

 

Retropharyngeal abscess, 478.24

Foreign obstruction, 933.1

   

1. Epiglottitis: toxic appearing, drooling, high fever, acute onset, age range typically 3-7 years.

2. Laryngeal foreign body: history, age, abrupt onset, lack of preceding respiratory symptoms.

3. Diphtheria: characteristic thin, gray membrane extends from tonsil to associated soft/hard palate.

4. Retropharyngeal or peritonsillar abscess: severe throat pain, refusal to swallow or speak, fever to 105°F (40.6°C).

5. Bacterial tracheitis: affects children of any age, acute onset with respiratory stridor, high fever, and copious and purulent secretions.

G. Treatment.

1. Most children have mild airway obstruction that resolves without specific treatment.

2. Supportive care at home includes making the child comfortable, avoiding fatigue and anxiety; encourage fluids and antipyretics for fever.

3. Cool mist vaporizer may be used.

4. Nebulized epinephrine has been beneficial for children with more severe croup in the emergency department or hospital setting.

5. Corticosteroids.

a. Systemic or nebulized corticosteroids are mainstay of both outpatient and inpatient treatment.

b. Decrease edema of laryngeal mucosa.

c. Single dose 0.6 mg dexamethasone given orally or IM or 2 mg dose of nebulized budesonide.

d. Clinical improvement in 6-12 hours.

e. Efficacy did not vary according to route of administration

f. Facilitates clinical improvement, decreases hospitalizations and fewer follow-up visits.

6. Criteria for hospitalization:

a. Signs of moderate to severe airway obstruction.

b. Increased work of breathing and respiratory distress.

c. Hypoxemia.

d. Restlessness, anxiety, or fatigue.

e. Change in level of consciousness.

f. Dehydration.

H. Follow up.

1. Call healthcare provider immediately if signs of respiratory distress increase.

2. Increased respiratory rate.

3. Stridor at rest.

4. Increased retractions.

5. Change in level of consciousness, restlessness, or anxiety.

6. Cyanosis.

I. Complications.

1. Acute deterioration in respiratory status requires hospitalization/ intubation.

J. Education.

1. Croup usually lasts 3-7 days; typically worse at night.

2. Give guidelines about oral intake (fluids) and urine output.

3. Use of bathroom mist, cool night air, cool-mist vaporizer to relieve symptoms.

4. Signs of increasing respiratory distress and hypoxemia.

5. Good handwashing, containment of coughs/sneezes prevents spread of illness.

6. Maintain calm, reassuring manner. Avoid situations that provoke stress or crying, which can worsen respiratory distress.

7. Children may have repeated episodes of croup.

8. Antibiotics are not indicated for viral croup.

9. Avoid secondhand smoke exposure.

II. BRONCHIOLITIS

Apnea, 770.81

 

Poor appetite, 783

Atelectasis, 518

 

Poor feeding, 783.3

Bronchiolitis, 466.19

 

Respiratory syncytial virus, 079.6

Cough, 786.2

 

Rhinorrhea, 478.1

Dyspnea, 786.09

 

Sneezing, 784.9

Hypoxemia, 799

 

Subsegmental consolidation, 481

Irritability, 799.2

 

Tachypnea, 786.06

Lethargy, 780.79

 

Upper respiratory tract infection, 465.9

Low-grade fever, 780.6

 

Vomiting, 787.03

Nasal congestion, 478.1

 

Wheezing, 786.07

A. Etiology.

1. Bronchiolitis is common viral illness.

a. RSV, bronchiolitis is most common cause of acute lower respiratory infection (LRI) in first 2 years of life.

b. Bronchiolitis is also caused by parainfluenza 1 and 3, adenovirus, rhinoviruses, influenza, and human metapneumovirus.

2. Transmission.

a. Highly contagious.

• Virus shed 5-12 days and up to 30 days with underlying disease.

• Virus spreads by large droplet aerosols generated by coughing, sneezing.

• Transmitted by direct contact with nasopharyngeal secretions from infected person.

i.  Virus survives on skin approximately 20 minutes.

ii.  Virus survives on gowns/tissues approximately 30-60 minutes.

iii. Virus survives on hard, nonporous surfaces approximately 6 hours.

• High-risk factors for more severe disease: prematurity, chronic lung disease, congenital heart disease, immunosuppression.

b. Reinfection occurs throughout life.

B. Occurrence.

1. Seasonal prevalence.

a. Yearly epidemics in early winter/spring.

b. In temperate climates, typically start in November and persist through April.

c. Strains A and B circulated concurrently during outbreaks; strain A more dominant.

d. By age 3, most children have been infected with RSV.

e. Only 1-5% require hospitalization.

f. Adolescents, adults with RSV have symptoms of upper respiratory tract infection.

C. Clinical manifestations.

1. Initial presentation.

a. Mild upper respiratory infection (URI) with rhinorrhea and nasal congestion.

b. Low-grade fever for 2-3 days.

c. Poor appetite.

d. Hoarse cough progresses to deep, wet cough.

• Often paroxysmal.

• Often associated with post-tussive vomiting.

• Associated with wheezing.

2. Clinical progression.

a. LRT involvement evident by:

• Tachypnea: 60-80 breaths/minute.

• Dyspnea.

• Coughing, wheezing.

b. Neonatal presentation.

• Lethargy, irritability.

• Poor feeding.

• URI symptoms.

• Apnea: occurrence is inversely proportional to age.

D. Physical findings.

1. Increased work of breathing.

a. Nasal congestion with thick purulent secretions.

b. Respirations rapid, shallow with accessory muscle use, retractions.

c. Nasal flaring, grunting, head bobbing.

d. Paroxysmal cough, wheezing, crackles.

e. Prolonged expiratory phase, chest hyperexpansion and hyperresonance.

f. Liver and spleen may be palpable secondary to chest hyperexpansion.

g. Hypoxemia correlates with severity of tachypnea.

h. Paradoxical abdominal and chest wall movement.

E. Diagnostic tests.

1. Diagnosis often made on basis of clinical presentation, physical findings, epidemiology.

a. Definitive diagnosis may not be necessary in infants with mild disease.

2. Chest X-ray (CXR).

a. Hyperinflation may be only abnormality: flattened diaphragms, increased lucency.

b. Peribronchial thickening and increased interstitial markings.

c. Subsegmental consolidation in upper and middle lobes: patchy atel-ectasis or consolidation due to atelectasis.

3. Oximetry: to determine oxygenation status.

4. Laboratory tests.

a. Identification of virus or viral antigen in respiratory secretions.

• Specimen obtained by nasal swab.

• Rapid diagnostic tests detect antigen using immunofluorescence techniques or enzyme-linked immunoassays.

• Viral culture.

F. Differential diagnosis.

Aspiration, 934.8

 

Hypoxemia, 799

Asthma, 493.9

 

Immunodeficiency, 279.3

Bacterial pneumonia, 482.9

 

Mycoplasma pneumoniae, 483

Cervical lymphadenopathy, 785.6

 

Nasal congestion, 478.1

Chlamydial infection, 079.98

 

Pneumonia, 486

Congenital heart disease, 746.9

 

Poor feeding, 783.3

Congestive heart failure, 428

 

Poor growth, 764.9

Cough, 786.2

 

Respiratory distress, 786.09

Cystic fibrosis, 277.02

 

Respiratory failure, 518.81

Fever, 780.6

 

Rhinitis, 477.9

Foreign body, 934.8

 

Tachypnea, 786.06

Heart murmur, 785.2

 

Upper respiratory infection, 465.9

1. Cystic fibrosis: sweat test is gold standard for diagnosis.

2. Pneumonia: viral URI symptoms and coryza with low-grade fever; bacterial pneumonia; abrupt onset with high fever; Mycobacterium pneumoniae(insidious onset and nontoxic appearance).

3. Asthma: pattern of symptoms, absence of fever, inspiratory wheezing, prolonged expiratory phase.

4. Foreign body aspiration: typically in toddler; may be detected on X-ray or by bronchoscopy.

5. Aspiration: swallowing study to determine silent or free aspiration.

6. Chlamydial infection: manifests from 3 to 19 weeks of age, afebrile, repetitive, staccato cough with tachypnea; wheezing is rare; cervical lymphadenopathy.

7. Immunodeficiency: systemic illness following vaccination with live virus; severe, life-threatening illness with viral infection.

8. Congenital heart disease: accompanied by heart murmur, signs of CHF, poor feeding, poor growth.

9. Gastroesophageal reflux.

G. Treatment.

1. Treatment is supportive, maintaining adequate hydration, oxygenation; monitor closely for increasing respiratory distress.

a. Management of nasal congestion and rhinitis.

b. Use of antipyretics.

c. Guidelines for feeding and urine output.

d. Recognition of signs of increasing respiratory distress.

e. Patients have a worsening of clinical symptoms with peak at day 3-4 of illness.

f. Bronchodilators are not routinely recommended.

g. Consider a monitored trial of bronchodilator and continue only if a clinical response is documented.

2. Criteria for hospitalization.

a. Age (younger more likely).

b. Tachypnea/hypoxemia.

c. Hydration management.

H. Follow up.

1. Most infants improve within 4-6 days.

a. Guidelines for parents to call healthcare provider: increased respiratory distress, poor fluid intake, or low urine output.

b. Close outpatient follow-up by telephone or visit may be indicated.

I. Complications.

Lung disease, chronic, 518.89

 

Respiratory syncytial virus, 079.6

Pneumothorax, spontaneous, 512.8

 

Wheezing, 786.07

Respiratory failure, 518.81

   

1. Acute complications.

a. Respiratory failure, apnea: rarely secondary bacterial infection.

b. Spontaneous pneumothorax due to air trapping, airway narrowing.

c. Worsening of chronic lung disease.

d. Mortality 1-5% with higher rates in high-risk groups.

2. Long-term complications.

a. Recurrent episodes of wheezing.

b. Infants have airway hyperreactivity and impaired pulmonary function for up to 10 years after RSV infection.

J. Education.

1. Avoid secondhand smoke exposure.

2. Prevention.

a. For high-risk populations passive immunity (monoclonal antibody technology) through monthly administration of palivizumab (Synagis) from October/November through April. Check current guidelines for recommended number of doses.

b. Good handwashing, avoidance of ill contacts during bronchiolitis season.

3. Post-illness.

a. Reinfection common; having RSV offers no immunity to subsequent infections.

b. May have period of prolonged wheezing after infection.

c. Recurrent wheezing is common, especially with URIs.

d. Cough and other signs resolve gradually over 1-2 weeks.

III. INFLUENZA

Abdominal pain, 789

Increased retractions, 786.9

Anxiety, 300

Influenza, 487.1

Atelectasis, 518

Irritability, 799.2

Change in level of consciousness, 780.09

Myalgia, 729.1

Change in mental status, 780.99

Nausea, 787.02

Chills, 780.99

Pharyngitis, 462

Conjunctivitis, 372.3

Pneumonia, 486

Cough, 786.2

Respiratory distress, 786.09

Croup, 464.4

Respiratory rate, increased, 786.01

Cyanosis, 782.5

Restlessness, 799.2

Diffuse myalgia, 729.1

Shortness of breath, 786.05

Dyspnea, 786.09

Tachycardia, 785

Extreme fatigue, 780.79

Tachypnea, 786.06

Fever, 780.6

Upper respiratory infection, 465.9

Generalized malaise, 780.79

Vomiting, 787.03

Headache, 784

Wheezing, 786.07

A. Etiology.

1. Influenza is a highly contagious respiratory illness caused by influenza viruses.

a. Influenza viruses are orthomyxoviruses.

b. Type A and B are primary pathogens, responsible for community outbreaks.

c. Influenza A viruses are subcategorized based on surface (H) and neuraminidase (N).

• Subtypes include H1N1, H1N2, and H3N2.

2. Influenza is spread by large-particle respiratory droplet.

a. Close contact with person with influenza.

b Direct contact with articles contaminated with nasopharyngeal secretions.

c. Virus is shed 1 day prior to developing symptoms.

• Children may shed virus several days prior to developing symptoms and can remain infectious more than 10 days.

• Immunocompromised persons may shed virus for weeks to months.

d. Incubation period is 1-4 days with average of 2 days after exposure.

B. Occurrence.

1. Peak of flu season can occur from December through March.

2. About 1% of children require hospitalization annually.

3. Influenza can cause URI, croup, bronchiolitis, pneumonia.

C. Clinical manifestations.

1. Abrupt onset of fever with rigors, chills.

2. Pharyngitis.

3. Cough.

4. Diffuse myalgia.

5. Extreme fatigue, headache, and generalized malaise.

6. Gastrointestinal symptoms: abdominal pain, nausea, vomiting.

7. Conjunctivitis.

8. With severe disease: irritability, change in mental status.

9. Symptoms progressively worsen over 12-24 hours.

10. May present with nonspecific signs of febrile illness, limited respiratory symptoms.

D. Physical findings.

1. High fever.

2. Tachycardia, tachypnea.

3. Nonproductive cough.

4. If lower respiratory tract infected, physical findings consistent with pneumonia or bronchiolitis.

E. Diagnostic tests.

1. Identification of virus or viral antigen in nasopharyngeal secretions.

a. Specimens should be obtained within 72 hours of illness, due to decrease in viral shedding after that time.

b. Specimen obtained by swab, nasal aspirate, or wash.

c. Viral culture.

d. Rapid diagnostic tests via fluorescent antibody staining, enzyme-linked immunoassay, or optical immunoassay.

• Rapid tests are more sensitive on pediatric specimens than adult specimens.

• Some tests detect both influenza A and B; some detect only one strain.

e. Reverse transcriptase-polymerase chain reaction (RT-PCR).

2. Diagnosis of specific flu-related complications.

3. Chest X-ray normal or areas of atelectasis.

F. Differential diagnosis.

Bronchiolitis, 466.19

Laryngotracheobronchitis, 490

Pneumonia, 486

1. Other lower respiratory illness (e.g., bronchiolitis, laryngotracheobronchitis, pneumonia).

G. Treatment.

1. Encourage fluids.

2. Antipyretics for fever (never use salicylates in children or adolescents).

3. Monitor for complications of influenza.

4. Antiviral therapy.

a. Recommendations for selection of antiviral drugs are made annually: www.cdc.gov.

b. Must be administered within 48 hours of onset of illness.

c. Relenza (Zanamivir): administered by inhalation for treatment of influenza A and B for children > 7 years of age; side effects include dizziness, runny or stuffy nose, cough, diarrhea, or headache. Can cause bronchospasm; not recommended for use in persons with underlying lung disease such as asthma.

d. Tamiflu (Oseltamivir): administered orally (liquid for children or capsule formulation) for treatment of influenza A and B for children and adults > 1 year of age; adverse effects nausea, vomiting in first 2 days of treatment. Taking Tamiflu with food can reduce these side effects.

e. Confusion and abnormal behavior have been reported with both antiviral drugs and may be more common in children.

H. Follow up.

1. Call healthcare provider immediately if signs of respiratory distress increase.

a. Increased respiratory rate, shortness of breath.

b. Increased retractions.

c. Change in level of consciousness, restlessness, or anxiety.

d. Cyanosis.

2. Close telephone follow up for those at high risk for flu-related complications.

I. Complications.

Asthma, 493.9

 

Dehydration, 276.5

Bacterial pneumonia, 482.9

 

Diabetes, 250

Chronic heart failure, 428

 

Viral pneumonia, 480.9

1. Viral and bacterial pneumonia.

2. Severe illness requiring hospitalization.

3. Dehydration.

4. Worsening of chronic illness, including CHF, asthma, or diabetes.

5. Death.

J. Education.

1. Prevention.

a. Annual intranasal vaccine (LAIV–live attenuated intranasal vaccine) is an option for healthy children and adults 2-49 years of age.

b. Yearly influenza vaccine in fall for all children 6 months to 18 years of age with special attention to those at high risk of complications and their close contacts.

• Trivalent inactivated vaccine is administered IM and is approved for children 6 months of age or older.

• Children younger than 9 years of age require 2 doses of vaccine in the first year they received the vaccine, administered 1 month apart to produce sufficient antibody response.

c. Good handwashing, avoidance of ill contacts during influenza outbreaks.

2. Post-illness.

a. Treat with antiviral agents within 48 hours after onset of symptoms to reduce duration of illness.

b. Recognize signs of severe illness requiring medical intervention including shortness of breath, dyspnea, cyanosis, change in level of consciousness.

c. Encourage fluids to maintain adequate hydration and urine output.

d. Acetaminophen for treatment of myalgia, headache, fever.

e. Recurrent wheezing is common, especially with URIs.

f. Avoid secondhand smoke exposure.

IV. BRONCHITIS

Bacterial infection, 041.9

 

Mycoplasmal infection, 041.81

Bronchitis, 490

 

Pharyngitis, 462

Bronchitis, acute, 466

 

Pulmonary disease, chronic, 518.89

Bronchitis, chronic, 491.9

 

Respiratory syncytial virus, 079.6

Chest pain, 786.5

 

Rhinitis, 472

Cough, 786.2

 

Upper respiratory infection, 465.9

Fever, 780.6

 

Vomiting, 787.03

Fungal infection, 117.9

 

Wheezing, 786.07

A. Etiology.

1. Bronchitis is a common respiratory problem of childhood characterized by cough.

2. Most commonly occurs after viral infection.

a. Rhinovirus, RSV, influenza, parainfluenza, adenovirus, coxsackievirus, paramyxoviruses can be etiologic agent.

3. May occur with bacterial, mycoplasmal, or fungal infection.

4. May occur as result of inflammation caused by frequent viral infection, secondhand smoke exposure, and air pollution.

5. Chronic bronchitis is poorly defined in children.

B. Occurrence.

1. Peak months in young children are related to high RSV activity.

2. Peak incidence is in winter months.

3. Chronic/recurrent bronchitis: cough lasting > 1 month or 4 episodes within 1 year.

C. Clinical manifestations.

1. Mild URI symptoms including rhinitis and pharyngitis.

2. Dry hacking cough begins 3-4 days after onset of rhinitis.

3. Cough often becomes productive after a few days.

4. Older patients may complain of chest pain, worse with coughing.

5. As cough progressively worsens, the child has more signs of generalized illness.

6. Younger children may have post-tussive vomiting.

7. Normal temperature or mild elevation.

D. Physical findings.

1. Physical findings vary with phase of illness.

2. Initially clear or mucopurulent nasal secretions.

3. Auscultation initially may be normal.

4. Cough is dry, hacking in nature.

5. Normal or slightly elevated temperature.

6. Over next week, cough becomes productive as condition progresses to include lower respiratory symptoms.

a. Coarse crackles with variable wheezing may be present.

b. Moderate to severe productive cough, chest pain.

c. Post-tussive vomiting, thick yellow mucopurulent sputum.

7. Elevated temperature is likely during this time.

E. Diagnostic tests.

1. Diagnosis is often diagnosis of exclusion (see “Differential Diagnosis”).

2. Assessment of general health status including height, weight, signs of chronic pulmonary disease.

3. Elevated neutrophil count or C-reactive protein is suggestive of bacterial etiology.

4. CXR is usually normal, but may show peribronchial thickening.

5. RSV wash for rapid testing.

F. Differential diagnosis.

Anorexia, 783

 

Headache, 784

Asthma, 493.9

 

Heart murmur, 785.2

Bronchiectasis, 494

 

Immunodeficiency, 279.3

Bronchopulmonary dysplasia, 770.7

 

Irritability, 799.2

Chronic pulmonary disorders, other, 518.

 

Poor feeding, 783

Congenital heart disease, 746.9

 

Poor growth, 764.9

Congestive heart failure, 428

 

Purulent rhinitis, 472

Digital clubbing, 781.5

 

Sinusitis, 473.9

Foreign body aspiration, 934.8

 

Wheezing, 786.07

Gastroesophageal reflux, 530.81

   

1. Asthma: pattern of symptoms, absence of fever, expiratory wheezing, prolonged expiratory phase.

2. Bronchiectasis: recurrent pulmonary infections, anorexia, irritability, poor growth, digital clubbing, rule out other chronic pulmonary disorders.

3. Bronchopulmonary dysplasia: history of prematurity, treatment with oxygen therapy, and/or mechanical ventilation during neonatal period.

4. Immunodeficiency: systemic illness following vaccination with live virus; severe life-threatening illness with viral infection.

5. Gastroesophageal reflux: barium swallow demonstrates reflux of barium into esophagus; esophageal pH monitoring.

6. Congenital heart disease: accompanied by heart murmur, signs of CHF, poor feeding, poor growth.

7. Sinusitis: purulent rhinitis lasting 2 weeks, facial/dental pain, headache, pressure over affected area.

8. Foreign body aspiration: typically in toddler, unilateral physical findings, X-ray or by bronchoscopy.

G. Treatment.

1. Treatment is supportive.

2. Cough suppressants should be avoided in children with productive cough.

3. Rest as needed.

4. Avoidance of environmental irritants.

5. Empiric trial of bronchodilator therapy.

6. Acetaminophen for chest pain, fever.

7. Antibiotic therapy may be considered if bacterial infection is strongly suspected (prolonged symptoms, patient's age, high fever).

8. Humidification of air promotes comfort.

9. Chest physiotherapy may be indicated if productive cough, coarse crackles on exam.

H. Follow up.

1. If cough for 2 weeks or worsens, fever, or signs of respiratory distress: contact healthcare provider.

I. Complications.

Otitis media, chronic, 382.9

Pneumonia, 486

Sinusitis, 473.9

1. In healthy children, bronchitis is not a serious illness.

2. In chronically ill children, may develop concurrent otitis, sinusitis, pneumonia.

J. Education.

1. Avoid large daycare settings for young children to minimize frequency of viral infection.

2. Avoid secondhand smoke exposure.

3. Bronchitis is usually caused by viral infection; antibiotics are not effective.

4. Acute bronchitis is a benign, self-limited illness usually lasting 2 weeks.

5. Should consult with healthcare providers before administering cough suppressants.

6. If child has signs of respiratory distress, contact healthcare provider.

7. If cough does not resolve within 2 weeks or worsens or fever recurs, contact healthcare provider.

V. PERTUSSIS

Apnea, 770.81

 

Leukocytosis, 288.8

Atelectasis, 518

 

Pertussis, 033.9

Choking, 784.9

 

Petechiae, 782.7

Cough, 786.2

 

Pneumonia, 486

Cough, paroxysmal, 780.2

 

Rhinorrhea, 478.1

Cyanosis, 782.5

 

Sneezing, 784.9

Exhaustion, 780.79

 

Subconjunctival hemorrhages, 372.72

Fever, 780.6

 

Upper respiratory infection, 065.9

Lacrimation, 375.2

 

Vomiting, 787.03

Lymphocytosis, 288.8

 

Whooping cough, 033.9

A. Etiology.

1. Pertussis: highly contagious, vaccine-preventable bacterial infection caused by Bordetella pertussis, less commonly by B. parapertussis (Gramnegative coccobacillus).

2. Transmission: airborne, occurs by contact with respiratory droplets of infected person or by indirect contact with contaminated surfaces.

3. Disease is endemic in United States, with all 50 states reporting cases annually.

4. Most cases in United States occur between June and October.

B. Occurrence.

1. Pertussis causes disease in every age group.

a. Significantly impacts nonimmunized or partially immunized young children; can cause severe disease. Highest mortality in infants younger than 6 months of age.

2. Incubation period is 7-10 days with a range of 5-21 days.

3. Persons with pertussis are considered infectious from 7 days after exposure to 3 weeks after person enters paroxysmal stage.

a. Pertussis is most contagious from catarrhal stage until 2 weeks after onset of cough without appropriate therapy.

C. Clinical manifestations.

1. Pertussis is lengthy disease lasting 6-10 weeks, divided into 3 stages.

a. Catarrhal stage lasts 1-2 weeks, may not be recognized in infants younger than 3 months.

• Characterized by URI symptoms such as rhinorrhea, sneezing, mild cough, low-grade fever.

b. The paroxysmal stage lasts 2-4 weeks or longer.

• Characterized by paroxysmal cough/bouts of rapid cough, sudden coughing.

• Have color change, bulging eyes, tearing, tongue protrusion.

• May be triggered by feeding, crying, excitement, activity.

• May have multiple episodes each hour during peak but appear well between episodes.

• May have characteristic whoop during forceful inspiration.

• Post-tussive vomiting, exhaustion are common following episode.

• Infants younger than 3 months of age have apnea, choking, gasping.

c. Convalescent stage lasts 1-2 weeks, but cough can persist for several months. During this stage, cough and post-tussive vomiting decrease.

D. Physical findings.

1. Cough.

a. Catarrhal stage: mild.

b. Paroxysmal cough: associated with cyanosis, lacrimation, exhaustion, post-tussive vomiting.

c. Subconjunctival hemorrhages and petechiae on head and neck.

2. Breath sounds are normal, unless significant atelectasis or pneumonia.

E. Diagnostic tests.

1. Consider in cases of prolonged cough with history of post-tussive vomiting, whoop, paroxysmal cough.

2. Culture is “gold standard” for laboratory diagnosis.

a. Most likely to be positive during catarrhal stage to peak of paroxysmal stage.

b. Use calcium alginate or Dacron swab of posterior nasopharynx for 15-30 seconds or by nasal wash and plate on specialized media, incubate for 7 days.

3. Rapid testing by nasal wash for direct fluorescent antibody (DFA) or polymerase chain reaction (PCR).

a. Do not use calcium alginate swabs for PCR as it is inhibitory to PCR.

4. Serology.

a. Enzyme immunoassay detects antibody to B pertussis in acute and convalescent samples: not helpful during acute illness and difficult to interpret in immunized persons.

5. CBC: leukocytosis with lymphocytosis in catarrhal and early paroxysmal stages.

a. Present in infants and young children but not in adolescents.

F. Differential diagnosis.

Adenoviral infection, 079

Chlamydial infection, unspecified, 079.98

Bordetella parapertussis infection, 033.1

Cytomegalovirus, 078.5

1. Adenoviral infection: presence of fever distinguishes from pertussis.

2. Mycoplasma infection: causes prolonged cough but fever, systemic symptoms, crackles on auscultation help differentiate from pertussis.

3. B. parapertussis infection: less severe illness.

4. In infancy, consider chlamydia, cytomegalovirus (CMV).

G. Treatment.

1. Most children beyond infancy can be managed at home.

2. Macrolides are treatment of choice for infected persons and close contacts.

3. Azithromycin, erythromycin, or clarithromycin are first-line agents for treatment and prophylaxis.

a. Do not use in young infants because of association with infantile hypertrophic pyloric stenosis (IFPS).

4. Dosing.

a. Less than 30 days of age:

• Azithromycin 10 mg/kg/day as single daily dose for 5 days.

• All infants younger than 30 days of age who receive macrolides should be monitored for IFPH during and for 1 month following completion of course.

b. 1-5 months of age.

• Azithromycin 10 mg/kg/day as single daily dose for 5 days OR

• Erythromycin 40-50 mg/kg/day in 4 divided doses for 14 days OR

• Clarithromycin 15 mg/kg/day in 2 divided doses for 7 days.

c. Infants 6 months of age or older and children.

• Azithromycin 10 mg/kg/day as single daily dose on day 1 (maximum dose 500 mg), then 5 mg/kg/day (maximum dose 250 mg) on days 2-5 OR

• Erythromycin 40-50 mg/kg/day in 4 divided doses for 14 days OR

• Clarithromycin 15 mg/kg/day in 2 divided doses for 7 days.

d. Adults.

• Azithromycin 500 mg as single daily dose on day 1, then 250 mg on days 2-5 OR

• Erythromycin 2 g/day in 4 divided doses for 14 days OR

• Clarithromycin 1 g/day in 2 divided doses for 7 days.

5. Alternatively use trimethoprim-sulfamethoxazole (TMP-SMX), 8-12 mg/kg/day divided every 12 hours for 14 days, if unable to take macrolides or culture resistant to macrolides.

6. Those with pertussis should be considered contagious until treatment with appropriate therapy for 5 days.

7. Treat all household and close contacts including daycare and school regardless of age, immunization status, symptoms.

8. In addition to chemoprophylaxis, for children younger than 7 years of age who are not immunized or partially immunized, follow schedule for accelerated vaccination.

9. Reportable disease to local and state health departments.

H. Follow up.

1. Guidelines for parents to call healthcare provider for poor fluid intake, low urine output, change in level of consciousness, cyanosis, or respiratory distress.

2. Close outpatient follow up by telephone to monitor and reassure family.

I. Complications.

Apnea, 770.81

 

Fluid and electrolyte imbalances, 276.9

Bacterial pneumonia, 482.9

 

Otitis media, 382.9

Conjunctival hemorrhage, 372.72

 

Petechiae, 782.7

Encephalopathy, 348.3

 

Seizures, 780.39

Epistaxis, 784.7

 

Viral pneumonia, 480.9

1. Infants younger than 6 months of age have highest rate of hospitalization, secondary pneumonia, and seizures.

2. Children with history of prematurity or underlying chronic heart, pulmonary, or neurologic disease are at high risk for severe disease.

3. Apnea.

4. Secondary infection causing viral or bacterial pneumonia or otitis media. a. Secondary bacterial pneumonia causes most pertussis-related deaths.

5. Neurologic complications include encephalopathy and seizures.

6. Sequelae of violent coughing including conjunctival hemorrhage, CNS hemorrhage, pneumothorax, epistaxis, petechiae.

7. Fluid and electrolyte imbalances.

8. Death: Infants younger than 1 year of age are at highest risk.

J. Education.

1. Very contagious and spread by direct or indirect contact with respiratory droplets.

2. Good handwashing, containment of coughs/sneezes prevents spread of illness.

3. Guidelines about adequate hydration and nutrition.

4. Children may continue to have cough for several months.

5. Provide adequate rest and avoid activity that triggers cough.

6. Need for antibiotic treatment of all household and close contacts.

7. Household and close contacts are considered contagious until completed 5 days of erythromycin therapy.

8. Need for accelerated immunization for contacts younger than 7 years of age partially immunized/not immunized.

9. Avoid secondhand smoke exposure.

VI. ASTHMA

Airflow obstruction, episodic, 519.8

Family history of eczema, dermatitis, V19.4

Allergens, inhalant, 477.9

Fatigue, 780.79

Allergens, outdoor, 477.9

Itching, 698.9

Animal allergens, house-dust mites,

Mucosal swelling, 784.2

cockroach allergens, molds, 477.8

Nasal polyps, 471.9

Asthma, 493.9

Otitis, 382.9

Bronchiolitis, recurrent, 466.19

Pneumonia, 486

Bronchitis, allergic, 493.9

Rhinitis, 472

Chest pain, 786.5

Rhinorrhea, clear, 478.1

Chest tightness, 786.59

Shortness of breath, 786.05

Conjunctivitis, 372.3

Sinusitis, 473.9

Cough, 786.2

Sleep disturbances, 780.5

Eczema, 691.8

Sneezing, 784.9

Family history of allergy, V19.6

Upper respiratory infection, 465.9

Family history of asthma, V17.5

Wheezing, 786.07

A. Etiology.

1. Asthma is chronic inflammatory disorder of airways in which many cells and cellular elements play a role.

a. Mast cells, eosinophils, T-lymphocytes, neutrophils.

2. May have genetic predisposition (with critical interaction with environment).

3. The characteristics of asthma are:

a. Symptoms of episodic airflow obstruction that is reversible.

b. Airway inflammation.

c. Increased airway responsiveness to variety of stimuli.

4. Hyperresponsiveness.

a. Chronically inflamed airways are hyperresponsive.

b. When exposed to “triggers,” there is bronchoconstriction and airflow limitation.

c. Inflammation contributes to airway edema and increased mucous production.

d. Cough and wheeze are characteristic of asthma but are also common nonspecific symptoms associated with many other clinical entities.

5. Common triggers.

a. Inhalant allergens: animal allergens, house dust mites, cockroach allergens, molds, outdoor allergens.

b. Irritants: active/passive tobacco smoke exposure, indoor and outdoor air pollution, strong odors, chemical cleaning products.

c. Viral illness.

• URI, sinusitis, rhinitis, otitis, lower respiratory infection.

• Viral illness is primary trigger for asthma in young children.

d. Weather: rapid change in weather; hot, humid weather; or cold air.

e. Exercise.

f. Emotions or stress.

g. Occupational exposures: farm and barn exposures, formaldehydes, paint fumes, smoke, strong odors.

h. Aspirin sensitivity (more common in adults): includes other NSAIDs.

i. Sulfite sensitivity: in many processed foods, dried fruit, salad bars, beer, wine.

j. Risk factors.

• Atopy: family history or eczema.

• Gender: preadolescent boys are at higher risk.

• Smoking: history of mother smoking perinatally.

• Respiratory viral disease.

k. Aggravating factors: smoking, gastroesophageal reflux, sinusitis.

B. Occurrence.

1. Most common serious chronic illness among children.

2. Onset at any age from infancy to old age; 50-80% of children with asthma develop symptoms before 5 years of age.

C. Clinical manifestations.

1. Recurrent wheezing.

2. Dry, persistent cough, nocturnal cough.

3. Recurrent chest tightness or shortness of breath, chest pain.

4. Sputum production.

5. Exercise-induced cough, wheezing, shortness of breath, or chest tightness.

6. In younger children, difficulty keeping up with peers.

7. Atopic profile.

a. Eczema.

b. Seasonal or perennial allergy symptoms.

c. Rhinitis, sneezing, itching and rubbing of nose, throat clearing.

d. Conjunctivitis.

8. Fatigue secondary to sleep disturbance.

9. Poor school performance secondary to sleep disturbance.

D. Physical findings.

1. Upper respiratory tract.

a. Allergic shiners, “allergic salute” (characteristic crease at bridge of nose due to chronic rhinitis).

b. Conjunctivitis.

c. Boggy, pale nasal mucosa, mucosal swelling, clear rhinorrhea, nasal polyps, nasal flaring.

d. Grunting.

2. Chest exam.

a. Normal chest examination does not rule out asthma.

b. Bilateral wheezing, end-expiratory wheezing on forced expiration.

c. Prolonged expiratory phase; rapid, shallow respirations.

d. Hyperresonance to percussion.

e. Hyperexpansion of chest, increased anterior-posterior diameter.

f. Intercostal, suprasternal, and/or subcostal retractions.

g. In infants, paradoxical breathing.

h. In young children, pushing with abdominal musculature on expiration.

i. Dry, tight-sounding cough.

E. Diagnostic tests.

1. Detailed medical history.

a. Family history of allergy, asthma, eczema, dermatitis.

b. Identify symptoms consistent with asthma.

c. Identify pattern of symptoms that occur or worsen in presence of specific triggers.

• Consider diagnosis after 3 episodes of cough and/or wheezing, once alternative diagnoses are excluded.

2. Focused physical examination with special attention on the upper respiratory tract, chest, and skin.

3. Laboratory procedures.

a. Spirometry.

• Age limited; difficult to accurately test children younger than 5-7 years of age in most settings.

• Pre- and postbronchodilator to validate reversibility.

i.  May be normal.

ii. Essential for diagnosis.

iii. Test annually to establish baseline pulmonary function. b. Peak flow is monitoring tool, not diagnostic tool.

4. Chest X-ray: important in newly diagnosed asthmatic, rules out alternative diagnoses.

5. Special studies.

a. Sinus X-rays or CT to evaluate sinusitis.

b. pH probe or barium swallow to evaluate gastroesophageal reflux (GER).

c. Allergy testing.

• Referral to board-certified allergist to administer skin tests and interpret.

• RAST testing: not as sensitive as skin testing, results not immediate.

• Allergic bronchitis, wheezy bronchitis.

• Recurrent bronchiolitis or pneumonia.

i.  Even children with mild persistent asthma have significant airway inflammation.

ii. Without adequate anti-inflammatory therapy, there may be airway remodeling or irreversible changes in asthma airway.

6. Asthma classification.

a. Severity: intrinsic to the disease process.

• First step in initiating therapy for patient who has not been taking long-term controller medication.

b. Control: fluctuates over time.

c. Impairment: assessment component for severity and control; effect of asthma on quality of life and functional capacity.

d. Risk: assessment component for severity and control; refers to future impact on quality of life and functional capacity.

e. Four categories: intermittent, mild persistent, moderate persistent, and severe persistent.

• Symptoms > 2 times per week, nighttime symptoms > 2 times a month.

• Asymptomatic and normal peak flow between exacerbations.

• Exacerbations brief; intensity may vary.

• May have severe or lethal episodes.

f. Mild persistent asthma.

• Symptoms 2 times per week but less than daily. Nighttime symptoms 2 times a month.

• Exacerbations may affect activity.

• Nighttime symptoms 2 times per month.

g. Moderate persistent asthma.

• Daily symptoms, daily use of inhaled quick-relief bronchodilators.

• Nighttime symptoms 1 time a week.

• Exacerbations affect activity, occur 2 times per week; may last days.

h. Severe persistent.

• Continual symptoms; frequent exacerbations, nighttime symptoms.

• Limited physical activity.

F. Differential diagnosis.

Bronchiolitis, viral, 466.19

Malabsorption, 579.9

Bronchopulmonary dysplasia, 770.7

Poor growth, 764.9

Cystic fibrosis, 277

Pulmonary infection, chronic, 518.89

Foreign body aspiration, 934.8

Tracheoesophageal fistula, 530.84

Gastroesophageal reflux, 530.81

 

1. Vocal cord dysfunction: paradoxical adduction of vocal cords during inspiration (often in adolescent girls). Symptoms of distress including inspiratory wheezing and are out of proportion to clinical exam, including normal oxygen saturations. Diagnosis established by direct visualization of vocal cords using flexible rhinolaryngoscopy or flexible laryngoscopy.

2. Congenital pulmonary malformations: radiologic testing, bronchoscopy to rule out abnormality.

a. Tracheoesophageal fistula.

b. Vascular ring, sling, or extrinsic mass.

3. Foreign body aspiration: focal findings on auscultation; medical history key.

4. Bronchopulmonary dysplasia: history of prematurity, treatment with oxygen therapy, mechanical ventilation during neonatal period.

5. Viral bronchiolitis: virus may be identified by antigen testing or culture; may be trigger for asthma. Asthma differentiated by pattern of symptoms over time.

6. Gastroesophageal reflux: reflux of barium into esophagus by barium swallow or esophageal pH monitoring. Can be aggravating factor in asthma control.

7. Cystic fibrosis: genetic disease characterized by excessive production of thick, tenacious respiratory secretions, chronic pulmonary infection, malabsorption, subsequent poor growth.

G. Treatment.

1. Goals of treatment.

a. No coughing, shortness of breath/rapid breathing, wheezing, chest tightness.

b. No waking up at night because of asthma symptoms.

c. Normal activities including play, sports, exercise.

d. No absences from school or activities or work (for parent or caregiver).

e. Normal lung function.

2. Key principles.

a. Prevent airway inflammation by eliminating or avoiding triggers.

b. Asthma can be controlled, not cured.

c. Reverse and suppress inflammation.

3. Nonpharmacologic therapy.

a. Patient education.

b. Objective measures of lung function using peak flow monitoring and follow-up spirometry.

c. Control or avoid aggravating factors.

4. Pharmacologic therapy.

a. Simplify treatment plan whenever possible.

b. Classification of severity guides choice and frequency of therapy.

c. Persistent asthma is most effectively controlled with daily anti-inflammatory medications.

d. National Asthma Education and Prevention guidelines support aggressive therapy to achieve rapid control of symptoms and then step down to lowest level of therapy to maintain control.

e. Goals in treatment of acute episode are:

• Rapid reversal of acute airway obstruction.

• Identify causes of asthma episode.

• Adjust chronic maintenance to prevent recurrence of asthma flare.

• Inhaled beta2-agonist is quick-relief medication for all levels of severity and treatment of choice for prevention of exercise-induced asthma.

• Short “burst” of oral glucocorticoids is used to reduce inflammation during acute episode.

5. Build child/family and healthcare provider partnership.

a. Understand and address reasons for adherence problems in asthma.

b. Explore patient/family misconceptions about asthma.

c. Agree on goals and expectations of treatment.

d. Jointly develop treatment plan.

H. Follow up.

1. Before increasing medications, investigate reasons for poor asthma control.

a. Improper inhaler technique.

b. Adherence issues, knowledge deficit.

c. Environmental exposures.

d. Exacerbation of aggravating conditions (e.g., GER, sinusitis).

2. Many children have multiple caretakers.

a. Each caretaker must have access to medications, appropriate devices, asthma action plan.

b. Provide information to all caregivers including daycare providers, teachers, coaches, school nurses.

c. Ensure reliable, immediate access to medications in all settings including school.

3. Regular use of quick-relief medicine indicates deterioration in control of asthma and need to assess maintenance therapy.

4. Regular follow-up visits are encouraged to achieve and maintain control with appropriate intensity of therapy.

5. Monitor child for side effects of medications.

6. Refer to asthma specialist for difficult-to-control asthma in children older than 5 years of age: consider at step 3; refer at step 4. (See Figures 24-5 through 24-8).

7. For children younger than 5 years of age: consider referral at step 2; refer at steps 3 and 4. (See Figures 24-5 through 24-8).

8. Peak-flow monitoring to establish personal best: more specific than predicted value.

9. At each encounter, reassess concerns and correct misconceptions.

10. Monitor quality of life on regular basis.

11. Recognize and address barriers to asthma self-management.

12. Assess source of social support for child and family.

13. Assess child and family satisfaction with asthma care.

14. Yearly influenza vaccine for child and household contacts.

I. Complications.

Pneumonia, 486

Pneumothorax, 512.8

1. Pneumothorax, pneumonia.

2. Acute exacerbation requiring hospitalization, intubation, mechanical ventilation.

3. Death.

J. Education.

1. Asthma education should begin at diagnosis and continue at every encounter: include child as developmentally appropriate and all caregivers.

2. Key components.

a. Basic asthma facts to enable child and family to understand rationale for treatment decisions and asthma self-management.

b. Roles of medications in treating acute symptoms and achieving/maintaining asthma control.

c. Environmental avoidance and control measures.

d. Teach relevant skills: how to use devices such as spacers, other medication-delivery devices, peak-flow meter; have child demonstrate relevant skills at each encounter.

e. Provide asthma action plan: daily maintenance therapy including avoidance of triggers, plan for recognizing and treating worsening asthma, and when to seek medical attention.

3. Establish goals of therapy jointly and monitor child and family's perception of progress toward reaching goals.

VII. PNEUMONIA

Abdominal distention, 787.3

Pleural effusion, 511.9

Anorexia, 783

Pleuritic pain, 786.52

Arthritic symptoms, transient, 716.4

Pneumonia, 486

Arthropathy, 716.9

Pneumonia, bacterial, 482.9

Cervical lymphadenopathy, 785.6

Pneumonia, bronchopneumonia, 485

Conjunctivitis, unilateral, 372.3

Pneumonia, interstitial, 516.8

Coryza, 460

Pneumonia, lobar, 481

Cough, 786.2

Pneumonia, mycoplasma, 483

Dehydration, 276.5

Pneumonia, viral, 480.9

Drowsiness, 780.09

Respiratory syncytial virus, 079.6

Dyspnea, 786.09

Restlessness, 799.2

Ear pain, 388.7

Retractions, substernal, 738.3

Empyema, 510.9

Retractions, suprasternal, 738.8

Fever, 780.6

Rhinitis, 472

Headache, 784

Rigors, 780.99

Hoarseness, 784.49

Seizure, 780.39

Hypoxemia, 799

Sneezes, 7884.9

Lethargy, 780.79

Sore throat, 462

Leukocytosis, 288.8

Staphylococcus pneumoniae, 482.3

Malaise, 780.79

Tachycardia, 785

Meningismus, 781.6

Tachypnea, 786.06

Mycoplasma pneumoniae, 483

Tactile fremitus, 785.3

Nasal congestion, 478.1

Upper respiratory infection, 465.9

Nausea, 787.02

Urticaria, 708.9

Nuchal rigidity, 781.6

Vomiting, 787.03

Otitis media, 382.9

Wheezing, 786.07

Parainfluenza infection, 480.2

 

A. Etiology.

1. Pneumonia is inflammation and infection of lung parenchyma due to infectious pathogens.

2. It represents wide spectrum of signs/symptoms and disease severity.

3. Pathogens vary depending on age of patient.

4. Classification.

a. By pathogen (bacterial, including mycoplasma or viral).

b. By anatomic location: lobar, interstitial, bronchopneumonia.

5. Common viral pathogens.

a. RSV; adenovirus; parainfluenza 1, 2, 3; influenza A and B; rhinovirus.

b. Transmission: highly contagious.

• Transmitted by direct contact with nasopharyngeal secretions from infected person.

• Pneumonia results from spread of infection along airways.

i.  Causes direct injury to respiratory epithelium, resulting in airway obstruction, abnormal secretion and necrotic debris in airway lumen and lymphocytic infiltrations of interstitium and lung parenchyma.

ii. Small airways are obstructed, resulting in poor oxygenation and air trapping, which leads to ventilation and perfusion mismatch.

6. Common bacterial pathogens.

a. Streptococcus pneumoniae, Mycoplasma pneumoniae, Streptococcus(group A) pyogenes, Staphylococcus aureus.

b. Transmission: contagious.

• Bacterial pathogens may be aspirated or inhaled, rarely by hematogenous spread.

• Transmitted via person-to-person contact by large droplet aerosolization during coughing/sneezing.

• Viral infection damages host's normal airway defense mechanisms, facilitating secondary bacterial infection.

c. S. pneumoniae.

• Many have S. pneumoniae colonization in upper respiratory tract.

• Gram-positive encapsulated diplococci produce local edema.

i.  Organism is distributed into adjacent areas of lung, resulting in typical focal lobar consolidation.

ii. More than 90 serotypes exist.

d. S. aureus.

• Gram-positive organism; beta-lactamase producer.

• Produces exoproducts, enzymes, toxins, which contribute to virulence of this organism.

• Causes confluent bronchopneumonia; often unilateral with areas of hemorrhagic necrosis, cavitation of lung parenchyma, resulting in formation of pneumatocele, empyema, or bronchopulmonary fistula.

e. M. pneumoniae.

• Smallest self-replicating bacterium; lacks cell wall, dependent on host.

• Binds to ciliated respiratory epithelium and inhibits ciliary action.

• Airways and areas surrounding are filled with infiltrates.

• Causes cellular destruction and inflammatory response.

B. Occurrence.

1. Acute childhood respiratory infections result in 4.5 million deaths/year.

a. 70% are pneumonia-related deaths.

b. Bacterial pneumonia less common than viral pneumonia, but has highest mortality.

2. Viral pneumonia.

a. Peak attack rate between 2-3 years of life.

b. More common in fall and winter.

• Fall: parainfluenza infection causing croup.

• Winter: RSV and influenza.

• Viral pneumonia can be complicated by secondary bacterial infection.

3. Bacterial pneumonia.

a. More common in children older than 5 years of age.

b. Occurs in winter to early spring.

c. Organisms vary according to age of child.

• S. pneumoniae.

i.  Children younger than 4 years of age at highest risk.

ii. Risks factors: male > female, daycare attendance, frequent otitis media (3 times in 6 months), frequent URIs (3 infections in 6 months), prematurity, and previous hospitalization for respiratory disease.

iii. Incubation period varies by serotype but generally short: 1-3 days.

• M. pneumoniae.

i.  Leading cause of pneumonia in school-age children, adolescents.

ii. Occurs year round. Incubation period: 2-3 weeks (range: 1-4 weeks).

iii. Rarely severe enough to warrant hospitalization.

• S. aureus: children younger than 2 years of age at highest risk.

C. Clinical manifestations.

1. Viral pneumonia: symptoms variable depending on age.

a. Onset may be acute or gradual but typically progresses more slowly than bacterial infection.

b. Nasal congestion and coryza.

c. Lower respiratory symptoms develop insidiously.

d. Temperature variable depending on causative agent.

e. Nontoxic appearing.

f. History of URI symptoms, rhinitis, cough.

g. Hoarseness, wheezing, rapid/shallow respirations.

2. Bacterial pneumonia.

a. S. pneumoniae.

• Infants initially.

i.  Mild URI symptoms, unilateral conjunctivitis or OM.

ii. Abrupt onset of fever to 104°F. May have seizure due to abrupt spike in temperature.

iii. Mild cough; may have diarrhea, vomiting.

• Infant progress.

i.  Restlessness, apprehension.

ii. Nasal flaring; rapid, shallow respiration; grunting.

iii. Abdominal distention.

iv. Cough may be absent.

v. Circumoral cyanosis.

• Older children and adolescents.

i.  Onset abrupt with rigors followed by temperature 102-104°F.

ii. Appears ill.

iii. Headache.

iv. Anorexia, nausea, vomiting, diarrhea, abdominal pain.

v. Dyspnea, pleuritic pain, and cough; cough may be productive.

vi. Alternating restlessness and drowsiness.

3. M. pneumoniae.

a. Slow onset.

b. Malaise, transient arthritic symptoms.

c. Persistent dry, hacking cough; sore throat often followed by hoarseness.

d. Low-grade temperature and chills.

e. May have ear pain.

D. Physical findings.

1. Viral pneumonia: symptoms dependent on causative agent and age of child.

a. Nontoxic appearing.

b. Tachypnea, cough, diffuse bilateral wheezing, decreased breath sounds throughout lung fields.

c. Suprasternal, intercostal, substernal retractions.

d. Cyanosis.

2. Bacterial pneumonia.

a. S. pneumoniae.

• Infants.

i.  Tachypnea; nasal flaring, grunting, retractions; diminished breath sounds; crackles, wheezing.

ii. Fever.

iii. Tachycardia.

iv. Palpable liver or spleen secondary to abdominal distention.

v. Air hunger and cyanosis.

• Older children and adolescents.

i.  Diminished breath sounds over affected area of lung.

ii.  Dullness to percussion over area of consolidation.

iii. Increased tactile fremitus over area of consolidation.

iv. Cough productive of bloody or rust-tinged sputum.

v.  Crackles, wheezing, splinting of respirations on affected side.

vi.  Fever.

vii. Nuchal rigidity and other signs of meningeus may be present if upper lobes are involved.

viii. Drowsiness, restlessness.

ix.  Respiratory distress and hypoxemia are variable or mild without widespread disease or pleural effusion.

3. M. pneumoniae.

a. Fever.

b. Diminished breath sounds; coarse, harsh breath sounds.

c. May have macular rash, erythematous macular rash, urticaria.

d. Cervical lymphadenopathy.

e. Conjunctivitis, otitis media.

f. Arthropathy.

E. Diagnostic tests.

1. Viral pneumonia.

a. Definitive diagnosis: viral isolation/viral antigens in respiratory tract infection.

b. CXR: typically shows bilateral, diffuse infiltrates.

c. WBC: normal or leukocytosis (not usually 20,000) with lymphocytosis.

2. Bacterial pneumonia.

a. No “gold standard” definitive test.

b. Blood cultures are positive for the causative agent only about 10% of the time.

c. WBC: leukocytosis (15,000-40,000) with granulocytosis.

d. CXR.

• S. pneumoniae: lobar consolidation; typically single focus but may be multiple foci; “spherical” infiltrate or round pneumonia; right lobes are preferentially affected.

• S. aureus: bronchopneumonia (multiple, central segmental infiltrates become confluent and diffuse); these infiltrates lead to necrosis, cavitation, pneumatoceles, and abscess formation.

3. M. pneumoniae.

a. Clinical manifestation and physical exam are essential to diagnosis.

• Insidious onset, nontoxic.

• Child older than 5 years of age.

• Low-grade fever.

b. M. pneumoniae detected by polymerase chain reaction (PCR) technology.

c. Cold agglutinins (during acute phase) with titer 1:64 or greater are predictive of M. pneumoniae.

d. WBC: normal.

F. Differential diagnosis.

A spirations, 934.8

Foreign body aspiration, 934.8

Asthma, 493.9

Mycoplasma pneumoniae, 483

Bronchiolitis, 466.49

Pneumonia, viral, 480.9

Coryza, 460

Tracheoesophageal fi stula, 530.84

Cystic fibrosis, 277

Upper respiratory infection, 465.9

Fever, 780.6

 

1. Viral pneumonia: URI symptoms and coryza with low-grade fever; bacterial pneumonia: abrupt onset with high fever; M. pneumoniae: insidious onset and nontoxic appearance.

2. Foreign body aspiration: may be detected on X-ray or by bronchoscopy.

3. Cystic fibrosis: sweat test is definitive diagnostic test.

4. Asthma: pattern of symptoms, absence of fever; inspiratory wheezing; prolonged expiratory phase.

5. Aspiration: swallowing study to determine silent or free aspiration.

6. Tracheoesophageal fistula: gas-filled bowel on X-ray in an infant with respiratory problems and drooling at birth.

7. Bronchiolitis: rapid testing for viral antigen.

8. Right lower lobe pneumonia can present as GI process; X-ray can differentiate.

9. Right upper lobe pneumonia can present as meningitis, severity of illness, lumbar puncture.

G. Treatment.

1. Viral pneumonia.

a. Supportive care; typically mild illness and can be managed at home; young infant at risk for respiratory fatigue and more severe symptoms.

2. Bacterial pneumonia.

a. Dependent on bacteria; dependent on condition of child (oxygenation, hydration status, age: infants younger than 4-6 months are usually hospitalized).

b. Acetaminophen for fever and chest pain.

c. Antibiotic treatment is generally 7-10 days.

d. Amoxicillin is outpatient drug of choice; alternative choices are clarithromycin for children 6 weeks to 4 years of age; erythromycin for children older than 4 years of age.

e. With high level of penicillin-resistant pneumococci present in community, consider cefuroxime, amoxicillin-clavulanate (Augmentin), or azithromycin.

3. M. pneumoniae.

a. Usually mild disease that can be managed at home.

b. Erythromycin is drug of choice.

c. Antibiotic treatment is generally 7-10 days.

d. Acetaminophen for fever.

H. Follow up.

1. Follow-up X-ray not needed in most cases of community-acquired pneumonia.

a. Exceptions include severe illness requiring hospitalization, complications such as abscess, empyema, pleural effusion.

b. May take up to 6 weeks for significant improvement.

2. Daily contact with healthcare provider may be indicated with more serious illness, in children with underlying conditions, and in very young children.

3. Recheck child if no improvement after 48 hours of treatment or if worsening occurs.

4. Follow-up visit at 10-14 days; occasional relapse may occur.

I. Complications.

Empyema, 510.9

Pleural effusion, 511.9

Encephalopathy, 248.3

Pulmonary abscess, 513

Guillain-Barré syndrome, 357

Staphylococcus aureus, 041.11

Meningoencephalitis, 323.9

Stevens-Johnson syndrome, 695.1

Mycoplasma pneumoniae, 483

Toxic shock syndrome, 040.82

Pericarditis, 423.9

Transverse myelitis, 323.9

1. Severe disease requiring hospitalization and ventilatory support.

2. Empyema, pulmonary abscess, pleural effusion, pericarditis.

3. S. aureus: toxic shock syndrome.

4. M. pneumoniae: Stevens-Johnson syndrome, transverse myelitis, meningoencephalitis, encephalopathy, Guillain-Barré syndrome.

J. Education.

1. Immunizations are essential to decrease individual morbidity and mortality associated with pneumonia but also to reduce incidence in community.

2. Understand symptoms that warrant immediate attention (lethargy, seizure, severe respiratory distress) and symptoms that require follow up (no improvement 48 hours after starting antibiotics, worsening of respiratory symptoms, signs of dehydration).

Figure 24-1 Assessing asthma control and adjusting therapy in children 0-4 years of age.

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3. Need to give antibiotic as prescribed for full course.

4. Careful handwashing, containment of coughs/sneezes reduces spread of disease.

5. M. pneumoniae: common for close household contacts to develop illness.

Figure 24-2 Assessing asthma control and adjusting therapy in children 5-11 years of age.

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Figure 24-3 Assessing asthma control and adjusting therapy in youths ≥ 12 years of age and adults.

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Figure 24-4a Classifying asthma severity and initiating treatment in children 0–4 years of age.

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Figure 24-4b Classifying asthma severity and initiating treatment in children 5–11 years of age.

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Figure 24-5 Classifying asthma severity and initiating treatment in youths ≥ 12 years of age adults.

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Figure 24-6 Estimated comparative daily dosages for inhaled corticosteroids in children.

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Figure 24-7a Stepwise approach for managing asthma in children 0–4 years of age.

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Figure 24-7b Stepwise approach for managing asthma in children 5–11 years of age.

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Figure 24-8 Stepwise approach for managing asthma in youths ≥ 12 years of age and adults.

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BIBLIOGRAPHY

Behrman R, Kliegman R, Jenson H. Nelson textbook of pediatrics. 17th ed. Philadelphia, PA: W.B. Saunders; 2004.

CDC fact sheet: influenza technical information. Atlanta, GA: Centers for Disease Control and Prevention; 2003.

CDC fact sheet: pertussis technical information. Atlanta, GA: Centers for Disease Control and Prevention; 2003.

Klassen T, et al. Nebulized budesonide and oral dexamethasone for treatment of croup: a randomized controlled trial. J Am Med Assoc. 1998;279(20):1635.

Long S, Pickering L, Prober C. Principles and practice of pediatric infectious diseases. 2nd ed. Philadelphia, PA: Churchill Livingstone; 2003.

Michael M. Scope and impact of pediatric asthma. NursePract. 2002;27(S):7.

National Heart, Lung, and Blood Institute, Global Initiative for Asthma. Global burden of asthma (NIH Publication No 02-3659:3) Bethesda, MD: National Institutes of Health; 2003.

National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. NAEPP expert panel report guidelines for the diagnosis and management of asthma, update on selected topics 2002(NIH Publication No 02-5075). Bethesda, MD: National Institutes of Health; 2002.

National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. Practical guide for the diagnosis and management of asthma (NIH Publication No 97-4053). Bethesda, MD: National Institutes of Health; 1997.

Pickering L. Influenza diagnosis and treatment in children: a review of studies on clinically useful test and antiviral treatment for influenza. Pediatr Infect Dis J. 2003;22(2):170.

Pickering L. Red book. 26th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2003; p. 383.

Storch G. Rapid diagnostic tests for influenza. Curr Opin Pediatr. 2003;15:79.

Taussig M, Landau L. Pediatric respiratory medicine. St. Louis: Mosby; 1999; p. 565.



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