Upper respiratory tract infections and pneumonia

Dr Odeyemi A.O

Department of paediatrics

College of Health Sciences

Bowen university.

CORYZA , OTITIS EXTERNA, OTITIS MEDIA

Coryza

• Coryza is the inflammation of the mucous membrane in the nose. It is also referred to as common cold or rhinitis

• it is an acute, self limiting viral inflammation of the nose

Aetiology

• The most common pathogens associated with the common cold are the rhinoviruses(50-80%).

• The syndrome can occasionally be caused by corona, Respiratory syncytial viruses and Human metapneumovirus

• Influenza viruses, Parainfluenza viruses, Adenoviruses and Enteroviruses are uncommon causes of coryza.

Epidemiology

• Colds occur year-round

• Young children have an average of 6-8 colds per year, but 10-15% of children have at least 12 infections per year. The incidence of illness decreases with age

• Children in day-care centres during the 1st year of life have 50% more colds than children cared for only at home.

Transmission

• Inhalation of airborne respiratory droplets from infected people

• Direct contact with infectious secretion

• Young children are the main reservoir of viruses

Clinical manifestation

• symptoms typically occurs 1-3 days after viral infection.

• The 1st symptom noted is often sore or scratchy throat, followed closely by nasal obstruction and rhinorrhea.

• Cough is associated with ∼30% of colds and usually begins after the onset of nasal symptoms

• Examination of the nasal cavity might reveal swollen, erythematous nasal turbinates

Laboratory Findings

• Routine laboratory studies are not helpful .

• A nasal smear for eosinophils may be useful if allergic rhinitis is suspected

• The viral pathogens associated with the common cold can be detected by polymerase chain reaction (PCR), culture, antigen detection, or serologic methods.

Treatment

Symptomatic treatments are recommended:

• nasal obstruction: nasal decongestants

• Rhinorrhea; first-generation antihistamines reduce rhinorrhea by 25-30%

• Sore throat, myalgia or headache: treatment with mild analgesics is occasionally indicated

• Cough: Cough suppression is generally not necessary , expectorants are not effective

Complications

• The most common complication of a cold is otitis media in 5-30%

• Sinusitis

• Exacerbation of asthma

OTITIS EXTERNA

Otitis externa

• Otitis externa is also known as swimmer’s ear.

• It is defined by inflammation and exudation in the external auditory canal in the absence of other disorders such as otitis media or mastoditis.

aetiology

• External otitis results from chronic irritation and maceration from excessive moisture in the canal.

• Cleaning of the auditory canal(loss of protective cerumen), swimming, trauma may play a role

• Is caused most commonly by P. aeruginosa

• S. aureus, Enterobacter aerogenes, Proteus mirabilis, Klebsiella pneumoniae, streptococci, coagulase-negative staphylococci, fungi such as Candida and Aspergillus also may be isolated.

Clinical manifestation

Characteristic findings include: • Pain • Tenderness • aural discharge • palpable and tender lymph nodes in the periauricular

region • erythema and swelling of the pinna and periauricular skin. • Fever is notably absent • Tenderness with movement of the pinnae (tragus)

particularly with chewing. This is a valuable diagnostic criterion

Investigation

• Diagnosis of uncomplicated OE is established on the basis of the clinical symptoms & examination findings.

• Additional laboratory evaluation is not needed

• Culture are required to identify the aetiologic agent

Treatment

• Topical (otic) quinolone preparations containing ofloxacin, ciprofloxacin are preferable and do not cause potential ototoxicity. They are active against S. Aureus and most gram-negative bacteria including P.aeruginosa.

• Otic solution containing corticosteroid are used to reduce local inflammation

• A solution that combines antibiotic and corticosteroid are a good choice in severe cases

Prevention

• This may be necessary for individuals susceptible to recurrences, especially children who swim.

• The most effective prophylaxis is instillation of dilute alcohol or acetic acid (2%) immediately after swimming or bathing.

• During an acute episode of otitis externa, patients should not swim and the ears should be protected from excessive water during bathing.

• A hair dryer may be used to clear moisture from the ear after swimming as a method of prevention

OTITIS MEDIA

Otitis Media(OM)

• OM is a suppurative infection of the middle ear cavity.

• The definition of AOM includes

• (1) a history of acute onset of signs and symptoms, (2) the presence of Middle ear effusion(MEE) and (3) signs and symptoms of middle-ear inflammation.

The presence of MEE, indicated by any of the following: • Bulging of the TM • Limited or absent mobility of the TM • Air-fluid level behind the TM • Otorrhea Signs or symptoms of middle-ear inflammation, indicated by either • Erythema of the TM, or • Otalgia (discomfort clearly referable to the ear[s] that

results in interference with or precludes normal activity or sleep)

Aetiology

• Both bacterial and viruses can cause OM

• Three predominant bacteria in AOM: Streptococcus pneumoniae, nontypeable Haemophilus influenzae, and Moraxella catarrhalis.

• Other pathogens include group A streptococcus, Staphylococcus aureus, and gram-negative organisms.

Aetiology cont’d

• viruses including rhinovirus and respiratory syncytial virus (RSV) and influenza are found alone or as co-pathogens in some patients

Pathogenesis

• The peak incidence of OM is between 6 -15 months of life

• Incidence of OM increase when there is:

• Defect in anatomic structures e.g cleft palate, obstruction of eustachian tube( seen in adenoidal hypertrophy) The shorter and more horizontal orientation of the tube the greater the likelihood of reflux from the nasopharynx

• Defective immunity: IgA deficiency, HIV is found in some children with recurrent AOM

Pathogenesis cont’d

• Feeding practices: bottle feeding as opposed to breast feeding, drinking a bottle/ breastfeeding while lying down

• Exposure to tobacco smoke and increased exposure to infectious agent( day care) increases risk of OM.

Clinical Manifestations

• evidence of ear pain may be manifested by irritability or a change in sleeping or poor feeding and occasionally, holding or tugging at the ear .

• Fever may also be present.

• Rupture of the tympanic membrane with purulent otorrhea (discharge)

Investigation

• Complete blood count

• Tympanometry: is a simple, rapid, atraumatic test that, when performed correctly, offers objective evidence of the presence or absence of MEE.

Treatment

• Antibiotic therapy using Amoxicillin 80-90 mg/kg per day, Amoxicillin-clavulanate, cefuroxime, cefpodoxime, ceftriazone.

• Acetaminophen and ibuprofen are recommended for fever

• The duration of treatment of AOM is 10 days

• When AOM is recurrent, despite appropriate medical therapy, consideration of surgical management with tympanostomy tube insertion is warranted

Complications

• Acute mastoditis

• Persistent middle ear infection

• Intracranial Complications include:

• Meningitis epidural abscess,

• subdural abscess focal encephalitis,

• brain abscess,

• sigmoid sinus thrombosis (also called lateral sinus thrombosis)

LARYNGOTAECHEOBRONCHITIS

Laryngotracheobronchitis (Croup)

• the most common form of acute upper respiratory obstruction most commonly caused by viruses

• Inflammation involving the vocal cords and structures inferior to the cords is called laryngitis, laryngotracheitis, or laryngotracheobronchitis,

• The term croup refers to a heterogeneous group of acute and infectious processes that are characterized by a bark-like or brassy cough and may be associated with hoarseness, inspiratory stridor, and respiratory distress.

Aetiology

• Usually caused by viruses

• The parainfluenza viruses account for ∼75% of cases;

• other viruses associated with croup include influenza A and B, adenovirus, respiratory syncytial virus (RSV), and measles. Influenza A has been associated with severe laryngotracheobronchitis

Clinical Manifestations

• Most patients have an upper respiratory tract infection with some combination of rhinorrhea, pharyngitis, mild cough, and low-grade fever for 1-3 days before the signs and symptoms of upper airway obstruction become apparent.

• The child then develops the characteristic “barking” cough, hoarseness, and inspiratory stridor.

Physical examination

• can reveal a hoarse voice,

• coryza,

• normal to moderately inflamed pharynx,

• slightly increased respiratory rate.

• respiratory distress.

• upper airway obstruction and continuous stridor

N.B Croup is a disease of the upper airway, and alveolar gas exchange is usually normal.

Investigation

• Croup is a clinical diagnosis and does not require a radiograph of the neck.

• Radiographs of the neck can show the typical subglottic narrowing, or steeple sign, of croup on the posteroanterior view .

Radiographs of the neck (PA view)

Treatment(croup)

• The mainstay of treatment for children with croup is airway management

• Nebulized racemic epinephrine is an accepted treatment for moderate or severe croup. A dose of 0.25-0.5 mL of 2.25% racemic epinephrine in 3 mL of normal saline

• IM/ oral dexamethasone used at a dose of 0.15 mg/kg q 8hrly for 24-48 hours

Treatment cont’d

• Antibiotics are not indicated in croup.

• Over-the-counter cough and cold medications should not be used in children <4 yr of age.

• A helium-oxygen mixture (Heliox) may be effective in children with severe croup

ACUTE EPIGLOTTITIS

• potentially lethal condition is characterized by an acute rapidly progressive and potentially fulminating course of high fever, sore throat, dyspnea, and rapidly progressing respiratory obstruction.

• Commonly caused by Haemophilus influenzae type b, Streptococcus pyogenes, Streptococcus pneumoniae, and Staphylococcus aureus

Clinical manifestation

• Often, the otherwise healthy child suddenly develops a sore throat and fever.

• Within a matter of hours, the patient appears toxic • swallowing is difficult, • breathing is labored. • Drooling is usually present • the neck is hyperextended in an attempt to maintain

the airway. • The child may assume the tripod position, sitting

upright and leaning forward with the chin up and mouth open while bracing on the arms.

Diagnosis

• The diagnosis requires visualization of a large, cherry red, swollen epiglottis by laryngoscopy.

• Laryngoscopy should be performed in a controlled environment such as an operating room or intensive care unit

• Lateral radiographs of the upper airway of a child who has epiglottitis show the thumb sign

Lateral radiographs of the upper airway

Lateral radiographs of the upper airway

Treatment (epiglottitis)

• Epiglottitis is a medical emergency and warrants immediate treatment with an artificial airway placed under controlled conditions, either in an operating room or intensive care unit.

• Intranasal oxygen.

• Antibiotics: Ceftriaxone, cefotaxime, or meropenum should be given parenterally for 7-10 days

• Racemic epinephrine and corticosteroids are ineffective

BRONCHITIS

Bronchitis

• Nonspecific inflammation of the bronchial tube(bronchi)is termed bronchitis

• Acute bronchitis is usually viral in origin, with cough as a prominent feature.

Clinical Manifestations

• Rhinitis.

• Dry, hacking cough develops, which may or may not be productive.

• Chest pain may be a prominent complaint in older children and is exacerbated by coughing.

• Fever is unusual

physical examination

• absent or are low-grade fever

• Auscultation of the chest may be unremarkable at this early phase.

• As the syndrome progresses and cough worsens, breath sounds become coarse, with coarse and fine crackles

Investigation

• Chest radiographs are normal or can have increased bronchial markings.

• Complete blood count

Treatment

• There is no specific therapy for acute bronchitis. The disease is self-limited

• Antibiotics, although often prescribed, do not hasten improvement. Frequent shifts in position can facilitate pulmonary drainage in infants.

• Cough suppressants can relieve symptoms but can also increase the risk of inspissated secretions and, therefore, should be used judiciously.

PNEUMONIA

• Pneumonia—inflammation of the lung parenchyma caused by micro-organisms

• It is a substantial cause of morbidity among children less than 2 years old.

• leading cause of death in developing countries

Definition of pneumonia

• Presence of fever, respiratory symptoms, and evidence of parenchymal involvement, either by physical examination or the presence of infiltrates on chest radiograph.

Aetiology

• pneumonia are caused by microorganisms

• bacterial or viral cause of pneumonia can be identified in 40-80% of children with community-acquired pneumonia

• Streptococcus pneumoniae (pneumococcus) is the most common bacterial pathogen in children 3 wk to 4 yr of age,

• Mycoplasma pneumoniae and Chlamydophila pneumoniae are the most frequent pathogens in children 5 yr and older.

• In addition to pneumococcus, other bacterial causes Haemophilus influenza, include group A streptococcus (Streptococcus pyogenes) and Staphylococcus aureus

• S. pneumoniae, H. influenzae, and S. aureus are the major causes of hospitalization and death from bacterial pneumonia among children in developing countries

Viral causes include

• influenza virus and

• respiratory syncytial virus (RSV) are the major pathogens,

• Other common viruses causing pneumonia include parainfluenza viruses, adenoviruses, rhinoviruses, and human metapneumovirus

Risk factors

Definite Risk Factors

• malnutrition (weight–for–age <–2z)

• low birth weight (≤2500 g)

• non–exclusive breastfeeding

• Lack of measles immunization

• household air pollution(HAP)

• overcrowding (7 or more persons sharing the same household)

Likely risk factors:

• Parental smoking

• Concomitant disease, e.g. heart disease, sickle cell disease, immunodeficiency states

Classification

• Based on

• Source of Acquisition : community acquired pneumonia, nosocomial pneumonia

• Severity: pneumonia, severe pneumonia

• Aetiology: bacterial, viral, fungal

• Radiologic finding: lobar, bronchopneumonia, interstitial

Homogenous opacity(lobar pneumonia)

Patchy opacity (bronchopneumonia)

Clinical Manifestations

• Typically rhinitis and cough.

• fever is usually present; temperatures are generally lower in viral than in bacterial pneumonia

• Tachypnea is the most consistent clinical manifestation of pneumonia.

• Increased work of breathing (intercostal, subcostal, and suprasternal retractions, nasal flaring, and use of accessory muscles is common.

• chest pain.

• cyanosis is seen in severe infection

• Abdominal pain is common in lower lobe pneumonia.

Physical findings

Clinical diagnosis

• Clinical chest examination useful .

• the ‘gold standard’ is chest radiography, an infiltrate on chest radiograph supports the diagnosis of pneumonia

• Chest ultrasound

• Complete blood count, usu elevated

• The definitive diagnosis of a bacterial infection requires isolation of an organism from the blood, lung (bronchoalveolar) aspirate

Differential diagnosis

• Bronchiolitis • Foreign body aspiration • Congenital Heart Diseases • Tuberculosis • Pertussis

Treatment

• Antibiotics: (Duration of 10 days)

• high doses of amoxicillin (80-90 mg/kg/24 hr) alternatives include cefuroxime axetil and amoxicillin/clavulanate.

• For school-aged children and in children in whom infection with M. pneumoniae or C. pneumoniae is suggested, a macrolide antibiotic such as azithromycin is required

Treatment

• in a hospitalized child, parenteral cefotaxime or ceftriaxone is the mainstay of therapy

• Bed rest

• Intranasal oxygen

• Identify and treat complication

Indication for admission

• Age< 6 months

• Immunocompromised state

• Severe respiratory distress

• Need for supplemental oxygen( hypoxaemia)

• Vomiting and dehydration

• No response to appropriate oral antibiotics

• Presence of complications

Complications

• Parapneumonic effusion • Empyema • Pneumatocoele • Bronchiectasis • Lung abscess • Heart failure • pericarditis • Anaemia • Septicaemia • Meningitis

Prevention

• Vaccination is recommended for all children(influenza vac, HiB, Pneumococcal conjugate vac, measles BCG, )

• Hand washing

• Exclusive breastfeeding

QUESTIONS?