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

Respiratory Infections in Children

Dr Basil Elnazir

PhD, FRCPI, FRCPCH, DCH

Respiratory Tract infections

• Upper

– Pharyngitis– Tonsillitis– Otitis media– Croup

• Lower

– Croup– Bronchitis– Bronchiolitis– Pneumonia

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

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

Common Cold

• Investigations– None

• Management– Antibiotics (not useful)– General measures

• Fever relief• Frequent fluid intake• Nasal obstruction/stuffiness relief• Avoidance of Environmental Tobacco smoke

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

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 !!

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)

CROUPAcute

Laryngotracheobronchitis

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

Pathology

Diagnosis

• History

• Examine Oropharynx ( DON’T)

• Xray (lateral neck)

• Laboratory work (generally unnecessary)

• D/D

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

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

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

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

Clinical Features of LTB (Croup) vs Epiglottitis

Croup

• Indications for Hospital admission

– Moderate – severe croup– Toxic looking– Poor oral intake– Age < 6 months– Family circumstances

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

Do Not

Bronchiolitis

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.

Bronchiolitis

• Viral Resp. Prodrome ( Runny nose, congestion, poor feeding)

• Increased work of breathing, diffuse wheezing, acc. muscles, diffuse crackles

• Generally mild and self limiting

• 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.

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.

Bronchiolitis

Bronchiolitis: High Risk

• Prematurity

• Chronic Lung disease

• Very young age (< 6 weeks)

• Congenital heart disease

• Underlying immune deficiency

Fever

Increased work of breathing

Wheezing

Cyanosis

Grunting

Noisy breathing

Vomiting, especially post-tussive

Irritability

Poor feeding or anorexia

Signs & Symptoms

Management

• O2 & fluids

• Steroids (no role)

• Bronchodilators (minimal effects)

• Racemic epinephrine (appears effective)

• 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

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

Management

Bronchiolitis (CXR)

• Hyperinflation of the Lungs with flattening of the diaphragm

• Horizontal ribs

• Hilar bronchial markings

• Occasional Collapse

• 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

Morbidity & Mortality

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

Pneumonia; LRTI

Pneumonia

• Acute respiratory disease accompanied by fever , tachypnoea, +/- cyanosis

• Definition– Bronchopneumonia

• febrile illness with cough, respiratory distress with evidence 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

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,

Pneumonia

• Tachypnoea

– <2 months >60/min

– 2-12 months >50/min

– 12mo- 5 yrs >40/min

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)

Pneumonia: Invest.

• Investigations– CXR– WBC & diff– CRP– Blood Cx ( +ve 10-30 %)– Resp. secretions C/S– BAL (P.carini in immune compromised)– Serological studies (M. pneumoniae)

Pneumonia

• Management

– Supportive

– Antibiotic therapy

– Chest Physiotherapy

Pneumonia: Summary

• Tachypnoea is the best single predictor of pneumonia in children of all ages.

• Bacterial pneumonia cannot be reliably distinguished from viral pneumonia

• The age of the child, local epidemiology of respiratory pathogens determine the choice of antibiotic therapy.

• 4. Anti-tussive remedies and chest physiotherapy should NOT be routinely prescribed for children with pneumonia

Pearls• Lobar consolidation is a feature of

pneumoccocal pneumonia.

• Multiple cavities containing fluid/air in staphyloccocal pneumonia.

• Common for children to start with viral pneumonia and get bacterial superinfection.

• Pertussis (whooping cough)… Leucocytosis with absolute Lymphocytes

Asthma

Asthma

• Chronic inflammatory pulmonary disorder,

characterised by

REVERSIBLE OBSTRUCTION

of the airways .

Asthma Burden

• ISAAC– Ireland 4th

– 15% children

• Asthma Society of Ireland– 5-11 yrs 3.5 school days/ yr– 12-18 yrs 2 school days/ yr– 79% suboptimal control

Prevalence of asthma in children

• estimated 1.4 million children

receiving treatment for asthma in the UK

• 29% of consultations for asthma in primary care are for children (aged 0–14 years)

Pathophysiology

• Chronic inflammation

• Bronchial Hyperresponsiveness

• Reversible bronchospasm

• Intermittent exacerbations

Causes of Asthma Exacerbations

• VRI

• Allergic exposure

• Air pollution/ tobacco smoke

• Bacterial infections

• Stress/ Emotional factors

• Excerise

• Cold Air

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Diagnosis of asthma in childrenDiagnosis of asthma in children

•• breathlessnessbreathlessness•• noisy breathingnoisy breathing

•• wheezewheeze•• dry coughdry cough

Presenting featuresPresenting features

Chronic Cough• Recurrent RTI• Asthma• Allergic Rhinitis/ Sinusitis/ PND• Infections (Pertussis, RSV, Mycoplasma)• Inhaled foreign body• Suppurative lung disease (CF, PCD)• GOR• TB• Cigarette smoking (Active /passive)• Habit cough / Psychogenic cough)

Recurrent Wheeze

• Asthma

• Post RSV bronchiolitis

• Recurrent aspiration of feeds

• CLD

• CF

• Pulmonary/ cardiac Congenital anomalies

• Maternal smoking

• Cow milk allergy/intolerance ( infants)

ASTHMA: DIAGNOSIS

• A clinical diagnosis

– symptoms / history – Signs– objective evidence

Asthma History• Nature of symptoms• Pattern of Symptoms

– (severity/frequency/seasonal & diurnal variation)

• Precipitating/aggravating factors• Profile of AAA (ER visit/ ICU)• Previous and current drug therapy

– Response, dosage, delivery, S/E

• Impact of disease on child and family– Exercise tolerance,sleep disturbance

• Atopic History• School performance & attendance• Environmental history (active/passive smoking)• General medical History of child• Family History

ASTHMA: DIAGNOSISSYMPTOMS: none are specific for asthma: wheeze, SOB, cough (esp: at night, exercise)

F.H. (+)ve

SIGNS wheeze, Harrison’s sulcus, AP diameter

OBJECTIVE : reduced FEV1 ( / FVC ) : PEFR variability >20% : exercise-induced bronchospasm : sputum eosinophils (research)

Asthma diagnosis: children Suspect asthma in any wheezing child:

ideally heard on auscultation

Δ Similar to adults - but can’t measure lung function• presence of KEY FEATURES• no alternative diagnosis• RESPONSE to Mx plan • RE-ASESSMENTS

HISTORY: ‘chesty’ with viral URTIs

: cough (esp. at night, on exercise )

: wheeze

Classification of Asthma Severity: Clinical Features Before Treatment

Days With Symptoms

Nights WithSymptoms

PEF orFEV 1 *

PEF Variability

Step 4SeverePersistent

Continual Frequent 60% >30%

Step 3ModeratePersistent

Daily -5/month >60%-<80% >30%

Step 2MildPersistent

3-6/week 3-4/month 80% 20-30%

Step 1MildIntermittent

2/week 2/month 80% <20%

What is Asthma Control?

• Standards for assessment of Control– Minimal symptoms day and night– Minimal need for reliever– No exacerbations– No limitation of physical activity– Normal Lung functions (FEV1and /or PEF

>80%

Asthma : Management

• Avoidance of triggers

• Prompt treatment of acute attacks

• Prevention of Asthma attacks and symptoms

Severe Acute Asthma

• Severe AAA– Increased Resp rate – Too breathless to talk or feed– Accessory muscle use – Pulsus paradoxus (older children)

• Potentially life –threatening features– Silent chest or feeble respiratory effort– Cyanosis– Reduced level of consciousness or fatigue– Pneumothorax / pneumomediatinum/ SC air

Severe Acute Asthma: Treatment

• Recognition• Close observation• Relieve Hypoxemia

– O2 via face mask– Aggressive use of bronchodilators

• Salbutamol 5mg/kg (2.5 mg/kg <5 yrs)• +/_ ipratropium bromide (125-250 micro grams)

– Systemic steroids• Oral prednisolone (1-2 mg/kg)• I/v Hydrocortisone (100 mg qid)

• Reassessment (monitor PEFR & O2 sats

Severe Acute Asthma: Treatment 2

• Aminophylline– 20 mg/kg over 20 min (omit if theophylline)– Continuous infusion 1 mg/kg

• CLOSE OBSERVATION & Reassessment

PROGNOSIS OF CHILDHOOD ASTHMA ‘Not all who wheeze will always do so’

FH asthma, rhinitis (esp. in mother )

- predict persistence to late childhood

not adulthood

Co-existent eczema / rhinitis

- predict persistence to late childhood

and adulthood

Markers e.g. (+)ve skin prick tests

- reflect current severity

- do not predict long-term outcome

PROGNOSIS OF CHILDHOOD ASTHMA

Gender

boys: early childhood asthma

: more likely to ‘outgrow’ asthma

girls : persistence to adulthood


SMOKING maternal smoking: infants wheeze (no evidence of persistence to adulthood)

PREMATURE / LBW infants more likely to wheeze in early childhood (but not adulthood)


SEVERITY

the more severe the asthma in childhood,

the more likely to persist into adulthood

LUNG FUNCTION

poor function in childhood predicts

persistence of asthma into adulthood

Asthma Drugs 1• Short acting Bronchodilator (Reliever, Blue) 2 bronchodilator

• Salbutamol (Ventolin/ Salamol etc.)• Terbutaline (Bricanyl)

– Anticholinergic Bronchodilator• Ipratropium Bromide (Atrovent )

• Preventative/ Prophylactic Treatment– Cromoglycates (DSCG…..Intal)– Methylxanthines (Theophylline)– Leukotriene Inhibitor (Montelukast (singulair),Zafirlukast)– Oral Prednisolone

Asthma Drugs 2• Inhaled Corticosteroids

– Budesonide (Pulmicort …Brown)– Beclomethasone (Becotide)– Fluticasone (Flixotide…..Orange)

• Long acting Bronchodilator (LABA)– Salmetrol– Formetrol

• Combination (ICS + LABA)– Seretide (Fluticasone + Salmetrol) (Purple)– Symbicort ( Budesonide + Formetrol) (Red)

Asthma Hx

• Pregnancy (smoking)• Birth Hx (prem?), hx of RSV etc• When did symptoms start?• Have you ever heard your child wheezing• Hx of infantile eczema, allergies• Problems with swallowing/GOR• Environment (smokers/pets/wooden floors, overcrowded

accommodation)• F Hx of atopy (asthma, eczema,hay fever, food allergy).• Nocturnal symptoms (cough, night time awakenings)• Exertional symptoms• GP/ER visits, Steroids• School absenteeism

Severe Acute Asthma

• Physiological features:– SaO2 < 91 % (R/A , before treatment)

– PEF < 50 % predicted or personal best

– PaCO2 > 5.3 Kpa (40mmhg) if measured

STEP 1Inhaled short-acting β2-agonist as required

STEP 2 Add inhaled corticosteroid*: 200-400 μg/day or leukotriene receptor antagonist if inhaled coticosteroid cannot be used.

STEP 4 Refer to respiratory paediatrician

Summary BTS/SIGN Asthma Guideline for

patients under 5 years

STEP 3 In children aged 2-5 years, consider trial of leukotriene receptor antagonist.

Adapted from BTS /SIGN Asthma Guideline

Thorax 2003; 58 (suppl I): i1 - i94 (*beclometasone or equivalent)

Patients should be regularly reviewed to ensure that the level of treatment they receive remains optimal.

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Stepwise management ofStepwise management ofasthma in children aged 5asthma in children aged 5--12 years12 years

Inhaled short acting Inhaled short acting ßß22 agonist as requiredagonist as required

Step 1: Mild intermittent asthmaStep 1: Mild intermittent asthma

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Add inhaled steroid 200Add inhaled steroid 200--400mcg/day *400mcg/day *(other(other preventerpreventer drug if inhaled steroid cannot be used)drug if inhaled steroid cannot be used)200mcg is an appropriate starting dose for many patients200mcg is an appropriate starting dose for many patients

Step 2: RegularStep 2: Regular preventerpreventer therapytherapy

Step 1: Mild intermittent asthma

Start at dose of inhaled Start at dose of inhaled steroid appropriate to steroid appropriate to severity of disease.severity of disease.

* BDP or equivalent* BDP or equivalent

9


Add inhaled steroid 200Add inhaled steroid 200--400mcg/day *400mcg/day *(other(other preventerpreventer drug if inhaled steroid cannot be used)drug if inhaled steroid cannot be used)200mcg is an appropriate starting dose for many patients200mcg is an appropriate starting dose for many patients

Step 2: RegularStep 2: Regular preventerpreventer therapytherapy


Start at dose of inhaled Start at dose of inhaled steroid appropriate to steroid appropriate to severity of disease.severity of disease.


10


1. Add inhaled long1. Add inhaled long--acting acting ßß22 agonist (LABA)agonist (LABA)2. Assess control of asthma:2. Assess control of asthma:

•• goodgood response to LABAresponse to LABA –– continue LABA.continue LABA.•• benefit from LABA but control still inadequatebenefit from LABA but control still inadequate –– continue LABA and continue LABA and

increase inhaled steroid dose to 400mcg/day * (if not already onincrease inhaled steroid dose to 400mcg/day * (if not already on this dose).this dose).•• no response to LABAno response to LABA –– stop LABA and increase inhaled steroid tostop LABA and increase inhaled steroid to

400mcg/day *. If control still inadequate, institute trial of o400mcg/day *. If control still inadequate, institute trial of other therapies ther therapies (e.g. leukotriene receptor antagonist or SR theophylline).(e.g. leukotriene receptor antagonist or SR theophylline).

Step 3: AddStep 3: Add--on therapyon therapy


Step 2: Regular preventer therapy Start at dose of inhaled Start at dose of inhaled steroid appropriate to steroid appropriate to severity of disease.severity of disease.


11


Increase inhaled steroid up to 800mcg/day *Increase inhaled steroid up to 800mcg/day *

Step 4: Persistent poor controlStep 4: Persistent poor control


Step 3: Add-on therapy



12


Use daily steroid tablet Use daily steroid tablet in lowest dose providing adequate controlin lowest dose providing adequate controlMaintain high dose inhaled steroid at 800mcg/day *Maintain high dose inhaled steroid at 800mcg/day *Refer patient to respiratory paediatricianRefer patient to respiratory paediatrician

Step 5: Continuous or frequent use of oral steroidsStep 5: Continuous or frequent use of oral steroids


Step 3: Add-on therapy



Step 4: Persistent poor control

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

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