Respiratory Infections in Children Dr Basil Elnazir PhD, FRCPI, FRCPCH, DCH

1. Respiratory Infections in ChildrenDr Basil ElnazirPhD, FRCPI, FRCPCH, DCH

2. Upper Pharyngitis Tonsillitis Otitis media Croup Lower Croup Bronchitis Bronchiolitis Pneumonia Respiratory Tract infections

3. Respiratory Viruses • Influenza A virus 1933 • Adenovirus 1953 • Parainfluenza virus 1955 • Rhinovirus 1956 • RSV 1956 • Enterovirus 1958 • Coronavirus 1965 • Human Herpes 6 1986 • Human Metapneumovirus 2001 • SARS coronavirus 2003 • Bocca Virus 2008

4. Common Cold • Infectious viral URTI • Symptoms • Nasal discharge/stuffiness • Throat irritation > cough • Pyrexia (38o C) • Feeding & sleeping difficulties • Myalgia, lethargy & anorexia (older children) • Usually last up to 7 days

5. Common Cold • Investigations • None • Management • Antibiotics (not useful) • General measures • Fever relief • Frequent fluid intake • Nasal obstruction/stuffiness relief • Avoidance of Environmental Tobacco smoke

6. Sore Throat • Pharyngitis,Tonsillitis, Acute exudative Tons. & Pharyngotonsillitis. • Uncommon under 1 yr (peak 4-7 yrs) • Viruses • GABHS • Fever • Diffuse redness of the tonsils & Pharyngeal exudates • Tender/enlarged anterior cervical Lymph nodes

7. Tonsillitis • Investigations • Throat swab • Rapid antigen testing • Mangement • Supportive/ Symptomatic • Antibiotics (not routine) • Severe clinical condition • GABHS is suspected (10 day Penicillin course) • Infectious mononucleosis !!

8. Otitis Media • Most common reason for GP/ER visits in children. • Causative organisms • Strept. Pneumonia (40-50%) • H. Influenza (20-30%) • Morexalla Catarrhalis (10-15%) • Amoxicillin ( macrolides if Penicillin allergy)

12. CROUPAcute Laryngotracheobronchitis

16. Croup • Acute Respiratory disease of children • 6 months –5 years (peak 2 years) • Viral prodrome • Runny nose, cough & congestion then • Barking or seal- like cough, hoarseness, sore throat, stridor & respiratory distress of varying degree

18. Pathology

19. Diagnosis • History • Examine Oropharynx ( DON’T) • Xray (lateral neck) • Laboratory work (generally unnecessary) • D/D

20. Croup: Assessment of Severity • Mild • Stridor with excitement or at rest; no RD • Moderate • Stridor at rest with I/C & S/C or Sternal recession • Severe • Stridor at rest with marked recession, decreased air entry and altered level of consciousness

21. Management • Supportive care in calm environment • Humidified O2 as blow by • Steroids • Nebulised Budesonide • Oral dexamethasone ( 0.15-0.6mg/Kg) • Racemic epinephrine • Potent vasoconstrictor effect which decrease airway oedema • rapid but short lived

22. D/D Acute upper Airway obstruction • Croup (v.common) • Recurrent spasmodic croup • Bacterial tracheitis • Foreign body • Rare causes • Epiglottitis • Inhalation of smoke & hot air in fires • Trauma to the throat • Retropharyngeal abscess • Angioedema • Prexisting (congenital) structural abnormality

23. Clinical Features of LTB (Croup) vs Epiglottitis Croup Epiglottitis Onset over days over hours Preceeding Coryza Yes No Cough Yes No Ability To drink Yes No Drooling saliva No Yes Appearance unwell Toxic, very ill Fever < 38.5o C > 38.5o C Stridor Harsh, rasping soft whispering Voice, cry Hoarse Muffled/reluctant

28. Croup • Indications for Hospital admission • Moderate – severe croup • Toxic looking • Poor oral intake • Age < 6 months • Family circumstances

29. Croup: Summary • Clinical syndrome • Barking cough, inspiratory stridor, hoarse voice and resp. distress of varying severity • Routine neck Xray and Oropharynx exam is not indicated (dangerous!!) • Steroid therapy is effective (routine in moderate – severe. • Nebulised adrenaline may be used to provide rapid relief

30. Do Not

31. Bronchiolitis

32. RSV • Site of infection • Characteristic syncitum formation found in cell culture and infected tissues • Possible links between severe bronchiolitis and asthma are still under investigation.

33. Bronchiolitis • Viral Resp. Prodrome ( Runny nose, congestion, poor feeding) • Increased work of breathing, diffuse wheezing, acc. muscles, diffuse crackles • Generally mild and self limiting

34. Bronchiolitis • acute infectious disease of the lower respiratory tract that occurs primarily in young infants, most often in those aged 2-24 months. • Edema and inflammatory infiltration of the bronchial walls • Infection is spread by direct contact with respiratory secretions.

35. Bronchiolitis • Epidemics last 2-4 months beginning in November and peaking in January or February • Previous infection with the common etiologic viruses does not confer immunity. • Re infection is common.

36. Bronchiolitis: High Risk • Prematurity • Chronic Lung disease • Very young age (< 6 weeks) • Congenital heart disease • Underlying immune deficiency

37. Signs & Symptoms Fever Increased work of breathing Wheezing Cyanosis Grunting Noisy breathing Vomiting, especially post-tussive Irritability Poor feeding or anorexia

39. Management • O2 & fluids • Steroids (no role) • Bronchodilators (minimal effects) • Racemic epinephrine (appears effective)

40. Management • Humidified oxygen (<94%). • Patients should be made as comfortable as possible (held in a parent's arms or sitting in the position of comfort). • Cardiorespiratory monitoring is essential • Pulse oximetery is helpful

41. Management • ?I/V fluids (difficulty taking bottles) • Isolation • ?Nebulised therapy • ?? steroids • Antibiotics :not indicated unless • Toxic/ recurrent apnoea & circulatory impairment • WBC > 15,000 • Progressive infiltrative changes in CXR • +ve bacterial Cultures/ Acute clinical deterioration

43. Bronchiolitis (CXR) • Hyperinflation of the Lungs with flattening of the diaphragm • Horizontal ribs • Hilar bronchial markings • Occasional Collapse

44. Morbidity & Mortality • Significant morbidity is rare. • 1% of cases (Hospitalisation). • Mechanical ventilation is required for 3-7% of admitted patients • Mortality rate is 1-2% of all hospitalized patients and 3-4% for patients with underlying cardiac or pulmonary disease. • The majority of deaths occur in infants younger than 6 months

45. Bronchiolitis: Summary • 1-6 months (rare > 2 years) • RSV is the commonest cause • Severe RD is likely in high risk infants • Supportive therapy & O2 • Trial of nebulised bronchodilator • Chest physio, routine antibiotic & ribavarin are not recommended

46. Pneumonia; LRTI

47. Pneumonia • Acute respiratory disease accompanied by fever , tachypnoea, +/- cyanosis • Definition • Bronchopneumonia • febrile illness with cough, respiratory distress withevidence of localised or generalised patchy infiltrates on chest x-ray • Lobar pneumonia : • similar to bronchopneumonia except that the physical findings and radiographs indicate lobar consolidation

48. Pneumonia • Majority are viral in origin • RSV, Influenza, adenovirus & parainfluenza • Bacterial causes • Newborns • GBS, E. coli, Klebsiella sp., Enterobacteriaceae • 1-3 months • Chlamydia trachomatis • Preschool • Strept. Pneumoniae, H. influenzae b, Staph. Aureus • GAS, M. catarrhalis, Pseudomonas!! • School • Mycoplasma pneumoniae, Chlamydia, Strept. Pneumoniae,

49. Pneumonia • Tachypnoea • <2 months >60/min • 2-12 months >50/min • 12mo- 5 yrs >40/min

50. Pneumonia • Hospital admission • Community acquired pneumonia can be treated at home. • Criteria for admission • Children < 3 months • Fever ( > 38.5o C) • Refusal to feed / vomiting • Rapid breathing +/- cyanosis • Systemic manifestation • Failure of previous antibiotic therapy • Recurrent peumonia • Severe underlying disorders (immunodef, CLD)