Respiratory: Toddlers and Preschoolers

Respiratory in Toddlers and Preschoolers: Foreign Body, Croup, Pneumonia, Pertussis

Most children who ingest foreign bodies are in what age range?
<5 Peak: 6mos to 3y

What is the most common esophageal foreign body?
coin

Foreign body: Chest x-ray PA and lateral & neck
Also would want expiratory or lateral decubitus chest

When ordering chest x ray for suspected foreign body, remember than most FBs are no radiopaque, like…However, ________ are radiopaque
Carrots (bronchoscopy)

Coins (radiopaque)

What will be part of history if there is foreign body aspiration?
History of choking in 80-90%
Chronic croupy coughing
Wheezing
Dyspnea
Decreased breath sounds
Sudden onset of coughing w/o produce or signs of respiratory infection
Fever – retain FB leading to 2nd pneumonia

What do carrots in the lung look like on x-ray?
Pneumonia

A child with pneumonia not responding to antibiotics or wheezing not responding to bronchodilators, consider ________.
Foreign body

What is on the differential in toddlers and preschoolers for pneumonia that you always want to consider?
FB

Neck up – ENT
Lung – Pulm
Esophagus – GI

What is the treatment for FB?
Teach Heimlich maneuver
Bronchoscopy
Direct laryngoscopy

How do you prevent FB aspiration?
Age and developmentally appropriate toys
No hotdogs <4 No hard candy, gum <5 No run or lying down while eating No carrots No raisins Cylinder shaped objects small enough to fit in airway

A toddler presents to you with runny nose and cold sx for the past couple of days. Mom reports a temperature between 100.8-101F and a slightly decreased appetite. At night time, he develops this barking cough. What is this?
Croup = acute, inflam dz of larynx, trachea, and bronchi due to subglottic narrowing

patient has history of URI for a day or two before characteristic cough dev

*A toddler/preschooler with croup will sound terrible and may have retractions. However, doesn’t look toxic. May have inspiratory stridor that may be biphasic.

Is most croup viral or bacterial?
Viral (in the fall: parainfluenza type 1 -3)

Parainfluenza is the most common viral agent for croup, which type causes severe croup?
Type 3

Describe bacterial croup (bacterial tracheitis) on PE
*Thick layers of pseudopus within trachea and lower airways
Acute illness with high fever
Toxic appearance
Stridor – inspiratory and expiratory
Better in middle of day, worse at night
May not have preceding URI (common cold)

What management technique will work on viral group but not bacterial croup?
Cold moist air (freezer)

What is the most common pathogen for bacterial tracheitis?
S. aureus

Most children with croup can be managed as outpatients with <15% requiring hospitalization, this is due to
dexamethasone

Children of what age are the primary targets of croup?
6mos – 36 months

60% <24 months

How long does croup usually last for? Peak?
5 days

Peaks day 2-3

What do you give to treat croup?
Dexamethasone give 1 dose that will last 3 days
-oral 0.6mg/kg
Racemic nebulized epinephrine (ER)

Often children with mild to mod croup can be managed at home with oral corticosteroids (dexamethasone) and supportive care. No need for racemic epinephrine

Parainfluenza in toddlers don’t cause bronchiolitis

Viral croup is a clinical diagnosis and no need to image. Cultures are done when?
Severe fever
Toxic presentation
Severe inspiratory stridor

Suspect S. aureus (bacterial tracheitis)

What will you find on x-ray if child has croup?
Steeple sign

What are the components that make up the croup score?
LOC
Cyanosis
Stridor
Air Entry
Retractions (mod to severe retractions –> ER)

The greater the score, the greater the need for ER

What is on the differential for viral croup?
Epiglottitis = supraglottitis
Bacterial tracheitis
Foreign body
Abscesses (peritonsillar, retropharyngeal)
Smoke inhalation

How do you manage croup using non-pharm methods?
Cold humidified air (freezer)
Cold air (car ride at night with windows down)

When is hospitalization warranted for child with croup?
< 6 mos Children with supplemental O2 requirement Increased work of breathing Lethargy Altered LOC Cyanosis Poor oral intake Suspect epiglottis Suspect acute bacterial tracheitis (looks SICKER than croup)

What you will find on x-ray for epiglottitis (more prevalent in older adolescent)?
Thumb sign

What is the difference between spasmodic croup and croup?
Spasmodic croup occurs 3-4 times a year and lasts much shorter (1-2 nights)

Minimal coryza (nasal d/c), no fever, no sore throat, very mild cold sx.

Mainly nighttime croup.

May be a/w allergies and reflux

What is the treatment for spasmodic croup?
Dexamethasone
Cool air

Will get worse even on dexamethasone on day 2-3, if much worse –> ER

Walking pneumonia is a type of CAP that affects primarily what age population?
School-aged
Young adults
Preschoolers if school aged children at home

What organisms are implicated in walking pneumonia?
Mycoplasma pneumoniae – sore throat
Chlamydophila pneumoniae – worser sore throat

Children with walking pneumonia are not so sick that they can’t make it around

What is pneumonia?
Lower respiratory tract infection a/w fever and respiratory sx

What are the three types of pneumonia?
Lobar
Interstitial
Bronchopneumonial

Lobar pneumonia involves infection of ____________ and is otherwise known as ____________ pneumonia.
Alveolar space
Typical pneumonia

What will you see on chest x-ray if there is lobar pneumonia?
consolidation

Walking pneumonia, otherwise known as ________ pneumonia, will appear like what on chest x-ray?
Atypical pneumonia
Smudgy

What will you see on chest x-ray if there is interstitial pneumonia?
Fine lace pattern

In toddlers and preschoolers, pneumonia is due mainly from viral or bacterial causes?
Viral

New guidelines say that since most pneumonia is viral, no need to prescribe antibiotics. However, this is debated among practitioners as secondary MRSA can develop. Not all children will get secondary MRSA. Close follow up is another option.

2+ episodes of pneumonia in a season should be a red flag for:
Immunodeficiency
CF

Pneumonia can cause ________ symptoms. Describe these symptoms with upper lobe pneumonias and lower lobe pneumonias
referred

upper: radiating neck pain –> look like meningitis
Lower: vague abdominal pain –> look like appendicitis

Describe early onset pneumonia and late onset pneumonia in neonates?
Early onset pneumonia (first 3 days)
-thru blood or infected amniotic fluid
-respiratory distress

Late onset pneumonia
-non specific signs

Need to image b/c nonspecific signs

Children with pneumonia may not have crackles upon auscultation. May have breath sounds in the wrong place. Where you would normally hear vesicular breath sounds (I > E), you may hear E > I.

What is the hallmark clinical presentation of pneumonia?
Fever and cough in all age groups

tachypnea and increased work of breathing may precede coughing. the greater number of respiratory sx, the increased likelihood it will buy child a bed

What lung sounds will you hear with pneumonia?
Crackles, absence doesn’t rule out pneumonia
Consolidation –> decreased breath sounds
Viral or atypical –> wheezing
Associated bacterial infection –> unilateral wheezing, fever, bronchial obstruction
Splinting, dullness to percussion, friction rub, distant breath sounds –> possible fluid –> image

Can empirically treat child with pneumonia. No need to image, CBC, blood cultures unless going to be admitted. Absence of chest x-ray findings doesn’t mean child doesn’t have clinical pneumonia, why?
1. Takes 24 hours to change
2. With dehydration, you may not see white consolidation on x-ray
3. Sometimes atelectasis and pneumonia will look alike
-atelectasis will resolve in 48-72 hours. Pneumonia will resolve in 1 month.

When do you want to re image a child who has recovered from pneumonia?
1 month

want to make sure child is better

r/o FB and mass

When do you choose to do a chest x-ray?
Severe disease, hypoxemia or significant respiratory distress that requires hospitalization

R/o other cases of respiratory distress (e.g, foreign body, heart disease, underlying cardiopulmonary conditions)

Not responding to abx

If unclear as to source of findings after done CBC and found leukocytosis

As part of workup of young infant with fever without a source and leukocytosis

Think urine
Fever + leukocytosis = UTI

Rapid tests for viruses are available in inpatient and outpatient may decrease the need for further testing or for starting abx therapy (e.g., RSV, influenza)

What is the most common implicated bacterial pathogen in pneumonia even though in most toddlers/preschoolers it is viral?
Strep pneumoniae

What do you use to treat S. pneumoniae when it is causing pneumonia?
Amoxicillin 90-100 mg/kg (daycare)

Augmentin (day care)
-use 7:1 ratio 400mg/5mL

What are the risk factors for TB infection?
Close contacts of persons known or suspected to have active TB

People living in/visiting area with high incidence

Residents/employees of congregate settings whose clients are at increased risk (e.g., LT care facilities, correctional, homeless)

Health care workers who serve clients at increased risk for active TB

Underserved, low income, persons who abuse drugs/alcohol may have increased incidence of latent or active

Who are persons at increased risk for progression of infection to active TB?
Immunocompromised

HIV

<5 years old See slide

What are the clinical sxs of TB?
Most of time asymptomatic

Lymphadenopathy

Cough

Wt loss

Night sweats

What will you see on chest x-ray if someone has TB?
snow storm appearance

For people who have immigrated within past 5 years from areas with high TB rates, induration greater than 10mm is considered positive

Who should get immediate TST?
Contacts of confirmed or suspected contagious TB
Radiographic or clinical findings
Immigrating or traveling from countries that are endemic

How do you document a negative PPD?
0mm

Give an example of how you would document a positive PPD?
4 x 3 mm

What happens if a patient’s PPD is not read in 48-72 hours?
Repeat in 6 weeks

PPD and MMR can be given simultaneously at 1 and 4 years OR 6 weeks apart so there isn’t a false negative

*Read induration form PPD, not erythema!

In places like Arizona, Utah, Nevada, you will get a false positive PPD reading with small induration due to:
Atypical mycobacterium –> cross reactivity

What can cause a false positive PPD reading?
BCG shot
Cross reactivity with non tuberculosis mycobacterium or M. Scrofulaceum
Allergic reaction disappears by 48-72 hours
Tape reaction
Injection with something else aside from BCG

What can cause a false negative PPD reading?
Infancy
Recent infection (Type 4 hypersensitivity takes 2-8 weeks for positive result)
Subq placement with increased absorption due to gauze or bandaid
Vaccination with live vaccine within past 6 weeks

*What are the degrees of induration, corresponding to different populations, that indicate positive PPD reading?
>5mm
HIV, household contact, suspicion of TB

>10mm
At risk for TB (<4y, endemic country, daily exposure to HIV) >15mm
Greater 4 years
No risk factors for TB

Incubation period from infection to development of positive TST is 2-10 weeks

Interferon Gamma Release Assay can be given only if child is at least 5 years old. What is an advantage of using this instead of TST to detect mycobacterium TB?
No false positive if received BCG

TST and IGRA does not differentiate between latent and active TB

Never repeat a PPD on someone who came back positive. Do a chest x-ray q5y to check

Positive result from IGRA means likely ___________.
Negative result from IGRA does not mean ________.
latent TB
absence of infection

Need to report cases of TB to department of health

How do you treat latent TB infection?
2-11 years
9 month regimen of INH

12+
6 month regimen
12-dose once weekly regimen of INH and Rifapentine

The 12-dose once weekly regimen of INH and Rifapentine is not recommended for:
Children <2 y/o People with HIV/AIDS taking antiretroviral therapy People presumed to be infected with INH or rifampin-resistant M. tuberculosis Pregnant women or women expecting to become pregnant

12-dose once weekly regimen of INH and Rifapentine: Dosage
INH:
15mg/kg rounded up to nearest 50 or 100mg
max: 900 mg

RPT:
10-14 kg 300mg
14.1-25 kg 450mg
25.1-32 kg 600mg
32.1 – 49.9 kg 750mg
At least 50kg 900mg max

9 month regimen of INH: Dosage
Children 10-20mg/kg
Max dose: 300mg

Routine monitoring of serum liver enzymes is not necessary unless child has risk factors for hepatotoxicity

What screening test are needed prior to starting INH in face of positive PPD?
Chest x-ray PA and Lateral

Active TB refer to ID specialist, it is not your role
12 months of multiple drugs (INH, PZA, Ethambutol)

Pertussis: shift to right. what will you find on labs?
Lymphocytosis
Leukocytosis

Normally with bacterial infections there will be leukocytosis or shift to the _____. What is the exception?
left
Pertussis

What are the 3 phases of pertussis?
Catarrhal
-cold like sx
Paroxysmal
-persistent cough
-no fever
-possible vomiting
-exhaustion
Convalescent
-waning of cough that lasts for months
-can take up to 6 months

CDC pertussis video of child coughing and turning blue

Young infants don’t cough. If child is <6w and has a cough, think:
BAD things

Pertussis is gram negative bacillus

Pertussis if persistent destructive disease of lung lining where infant has cough for months

What does the pertussis cough sound like?
High pitched inspiratory whoop following a cough

How do you dx pertussis?
*Culture with swab (curved wire with cotton at tip) in first 2 weeks

PCR

How do you treat pertussis?
Azithromycin
Clarithromycin
Erythromycin

Erythromycin cannot be used under what age for pertussis due to increased risk for pyloric stenosis? What ADE does it have?
< 1 mos GI and stomach pain (not well tolerated!)

Azithromycin dosage for pertussis
0-6months
10mg/kg/day single dose for 5 days

6 months +
Day 1 10mg/kg/day single dose (max: 500mg)
Days 2-5 5mg/kg/day single dose (max: 250mg)

Clarithromycin dosage for pertussis
1 month+
15mg/kg/day in two divided doses for 7 days (max: 1g daily)

Erythromycin dosage for pertussis
1 month+
40mg/kg/day divided 4 doses for 14 days (max: 2g daily)

Bactrim is contraindicated in patients with ______.
G6PD

How do you prevent pertussis?
Cocooning until 2-5 months where everyone around infant gets immunized with flu and pertussis

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General Upper Respiratory Infections Symptoms Pharyngitis – sore throat Laryngitis – swelling of the larynx (voice box) causing hoarseness Tonsillitis – inflammation of the tonsils, making it difficult to swallow Sinusitis – inflammation of the sinuses Otitis Media – swelling …

What is pneumonia? It can be one of three things, what are they? Inflammation of the parenchyma (membrane) of the lungs 1) bacterial, viral or mycoplasmal 2. Inhalation of toxic or caustics chemicals, smoke, dust or gases 3) aspiration of …

bronchitis: definition inflammation of the large airways that is frequently associated w a URI bronchitis: cause viral agents WE WILL WRITE A CUSTOM ESSAY SAMPLE ON ANY TOPIC SPECIFICALLY FOR YOU FOR ONLY $13.90/PAGE Write my sample bronchitis: S&S: cough …

Most common manifestation of pneumonia in older adult clients. Confusion from hypoxia Physical assessment findings for pneumonia fever, chills, flushed face, diaphoresis, SOB, crackles and wheezing, cough, o2 sat decrease WE WILL WRITE A CUSTOM ESSAY SAMPLE ON ANY TOPIC …

Pathophysiology of Pneumonia *Excess fluid in lungs resulting from inflammatory process (in interstitial space, alveoli,, and the bronchioles) *Inflammation of bronchioles triggered by infectious organisms, inhalation or irritants Types of Pneumonia *Community-acquired infectious pneumonia (CAP) *Hospital-acquired (HAP) *Health care-associated (HCAP) …

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