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Unit 1 – TBL: Stridor and Acute Respiratory Infections in Children – Drs Bromwich and Kovesi TBL: Acute Respiratory Distress and Acute Respiratory Infections.

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Presentation on theme: "Unit 1 – TBL: Stridor and Acute Respiratory Infections in Children – Drs Bromwich and Kovesi TBL: Acute Respiratory Distress and Acute Respiratory Infections."— Presentation transcript:

1 Unit 1 – TBL: Stridor and Acute Respiratory Infections in Children – Drs Bromwich and Kovesi TBL: Acute Respiratory Distress and Acute Respiratory Infections in Children Tom Kovesi M.D. F.R.C.P.(C), Pediatric Respirologist, Professor (Pediatrics), Children’s Hospital of Eastern Ontario, University of Ottawa Matthew Bromwich M.D. F.R.C.S.(C), Pediatric Otolaryngology - Head and Neck Surgery, Assistant Professor (Surgery), Children’s Hospital of Eastern Ontario, University of Ottawa

2 Unit 1 – TBL: Stridor and Acute Respiratory Infections in Children – Drs Vaccani and Kovesi Objectives Explain why respiratory infections are common, and serious, in children. List reasons why children are more susceptible to respiratory infections. Recognize underlying conditions that may predispose children to respiratory tract infections. Identify the causative organism(s), presentation of, diagnosis of, and treatment of common pediatric respiratory infections respiratory tract infections: Epiglottitis, Croup, Pertussis, and Bronchiolitis, Bacterial Pneumonia,Viral Pneumonia and Mycoplasma Pneumonia Describe the differences between sturtor, inspiratory stridor and expiratory wheezing. Develop an approach to determining the cause of respiratory distress associated with stridor or wheezing in children and recognize important non"infectious causes of stridor, such as laryngomalaica. Identify life"threatening pediatric airway emergencies based on history and physical examination.

3 Predisposing Factors for Respiratory Infections (1): Endogenous Factors Smaller airway size in infants – Develop more respiratory distress when airways narrowed during infections Less developed (and experienced) immune system (especially premature infants) Underlying diseases - cystic fibrosis, primary Ciliary dyskinesia, congenital & acquired immune deficiency, Gastroesophageal Reflux Congenital anomalies - cardiac (pulmonary edema), neurological handicaps (aspiration)

4 Predisposing Factors (2): Environmental Factors Crowding, poverty, poor access to health care & immunizations Malnutrition Day care Environmental tobacco smoke exposure – Smoking in older children & teens Air pollution Indoor Air Pollution – Biomass fuel heaters in developing world Aspirated foreign bodies – Pieces of toys, nuts, pieces of food, cut corners of plastic milk bags

5 From The Airway To The Airspace Epiglottitis Croup Pertussis Bronchiolitis Pneumonia Epiglottis Subglottis Bronchi Bronchioles Alveoli Supraglottis Laryngomalacia

6  Oropharynx  Peritonsillar cellulitis/abscess  Retropharyngeal abscess  Larynx  Epiglottitis  Croup  Lower Airway  Bronchiolitis  Pertussis  Pneumonia  Tuberculosis Anatomical locations for Respiratory Distress in Children Unit 1 – TBL: Stridor and Acute Respiratory Infections in Children – Drs Vaccani and Kovesi  Nasal Cavity o Anterior/Midnasal stenosis o Choanal atreasia o Adenoid Hypertrophy  Oral Cavity o Tonsillar Hypertrophy o Glossoptosis  Pierre-Robin Sequence  Larynx o Laryngomalacia o Vocal cord paralysis o Subglottic stenosis  Trachea o Tracheomalacia Infectious Anatomic

7 Assessing Respiratory Disease in Children (3) Assess: – Respiratory rate – Retractions Tracheal tug Intercostal retractions Subcostal retractions – Accessory muscle use Sternocleidomastoid Paradoxical respirations – Level of consciousness – Cyanosis – Pulsus paradoxicus

8 Bronchoscopy and Suspension

9 Anatomic: Bronchoscopy

10 Bronchoscopy

11  Most common congenital cause of stridor  Congenital collapse of tissue into airway from above vocal cords  Several potential causes:  Short aryepiglottic folds,  Arytenoid prolapse,  Omega-shaped epiglottis  Maybe… abnormal development of neural control of larynx in babies  Usually starts prior to 2 weeks of age  Progresses for first few months of life  Slow improvement after this time  Usually all symptoms have gone by 18 months of age  Very rarely – severe with apnea, failure to thrive, feeding difficulties  May need surgery Laryngomalacia: Unit 1 – TBL: Stridor and Acute Respiratory Infections in Children – Drs Vaccani and Kovesi

12 Symptoms of Laryngomalacia Inspiratory stridor Stridor is not constant –intermittent –variable intensity Increases with agitation and feeding Decreases with neck extension or prone Normal cry Noisier asleep

13 Arytenoid Prolapse

14 Omega Epiglottis

15 Treatment of Laryngomalacia Expectant – wait for it to get better! Medical: Treat GERD if present (commonly associated) Surgical-supraglottoplasty (excision of floppy supraglottic tissues) Pre-op Post-op

16 Other Causes of Stridor in Children Congenital –Airway Hemangioma –Airway Webs Acquired –Subglottic Stenosis Most often: Post- intubation –Laryngeal Papillomatosis –Foreign Body –Vocal Cord Paralysis Unilateral or bilateral Unit 1 – TBL: Stridor and Acute Respiratory Infections in Children – Drs Bromwich and Kovesi

17 Vocal cord paralysis Etiologies – most often, acquired: –Iatrogenic ( most common) Post cardiac surgery Prolonged neonatal intubation: scarring –Brainstem Disorders –Thoracic Masses and compression of recurrent laryngeal nerve –Idiopathic

18 Two types of vocal cord paralysis Unilateral: one cord paralyzed –Usually asymptomatic from respiratory point of view –Able to create adequate airway opening –Voice changes –Watch for aspiration Bilateral: both cords paralyzed –Unable to create adequate airway 80% require trach within first year 50% resolve after 1 year with no surgical intervention –Significant inspiratory stridor –Increased risk of aspiration –Marked respiratory distress is often seen –Permanent surgical correction an option after 1-2 years of age

19 Tracheomalacia Congenital Causes expiratory wheeze; biphasic wheeze if severe Severe cases can cause: Apnea Feeding Difficulties Failure to thrive Recurrent Pneumonias (reduced mucociliary clearance) Associated with: Other congenital anomalies (cardiac, vascular rings) GERD

20 Foreign Bodies in the Airway Most common in toddler and preschool children Most often (but not always) – witnessed history of choking on something, with facial duskiness Presentation Asphyxia – large airway Respiratory distress Persistent Pneumonia Chronic cough Persistent wheeze Asymptomatic Whenever significant suspicion, needs a rigid bronchoscopy! Peanut

21 Retropharyngeal Abscess Retropharyngeal lymph nodes drain adenoids and nasopharynx, and can get infected, resulting in abscess formation Usual cause: Group A, β-haemolytic Streptococci Generally children < 2 years of age, following upper respiratory tract infection, tonsillitis, otitis, adenitis Can occur in older children from penetrating injury posterior wall of pharynx (lollipop, fishbones) Symptoms: fever, sore throat, difficulty and/or pain swallowing, difficulty breathing, stridor, muffled voice, gurgling breathing Signs: mass in posterior wall of pharynx, (generally unilateral), hyperextended neck, enlarged cervical lymph nodes Diagnosis: enlarged retropharyngeal space on lateral neck X-ray; CT neck – Normal width retropharyngeal space in child < 15 years is < 7 mm Treatment: surgical incision & drainage of abscess, intravenous Penicillin

22 Rules (Length of Retropharyngeal Space) Normal: - 7mm at C-2 - 14mm C-6 kids - 22mm C-6 adults OR: >1/2 Vert Body Retropharyngeal Abscess


24 Epiglottitis Bacterial infection of supraglottic structures - epiglottis and aryepiglottic folds Age 2 - 12 years Caused by Hemophilus influenzae type b; Rare since HiB (Hemophilus influenza type b) vaccination. Symptoms progress rapidly: – severe pain in throat leads to difficulty and avoidance of swallowing, causing drooling – dyspnea, – muffled cough and voice, – high fever, – anxious expression, – child tends to sit leaning forward Risk for epiglottis sticking to laryngeal structures causing complete airway obstruction and asphyxia Similar symptoms caused by Bacterial Tracheitis (severe bacterial infection of the trachea with necrotic tissue & pus, caused by Staphylococcus aureus, and occasionally by Haemophilus influenzae)

25 Lateral Views of the Larynx Normal Epiglottitis Diagnosis: lateral neck X-ray under medical supervision (“thumb sign” epiglottis, thickened aryepiglottic folds) DO NOT examine throat with tongue depressor or upset the child

26 Epiglottitis

27 Treatment of Epiglottitis Controlled intubation by experienced physician (emergency tracheostomy set available) Then - culture epiglottis Treat with IV Cefuroxime – (2 nd generation Cephalosporin, covers Haemophilus influenzae) Note: Bacterial tracheitis is diagnosed by bronchoscopy. – Treatment: Intubation Intravenous Cloxacillin, Vancomycin, or Cefuroxime

28 Croup (Viral Laryngotracheobronchitis) Age 3 months - 5 years Causes: – Parainfluenza virus type III (most common) – Influenza virus, – Respiratory syncytial virus (RSV) Symptoms - dramatic! – Coryza, – Loud, barky cough – Lots of stridor – Hoarseness – Fever – Cyanosis if severe – Worse at night Seasonality: especially fall & spring

29 Anterior views of the Larynx

30 More on Croup Diagnosis: – Usually clinical – If X-ray done, AP film of neck (“steeple sign”) Normal child may have a “steeple sign” if X-ray done in full inspiration Treatment: – Oxygen if needed – Oral Steroids (occasionally, nebulized budesonide) – Nebulized epinephrine if stridor at rest (to reduce swollen tissues) Observe 2h afterwards for recurrence – Traditionally: Cool mist (but not effective in studies)

31 Pertussis (Whooping Cough) The only true “bronchial infection” in children – Children get “bad colds” or bronchopneumonia (visible on CXR); Otherwise, as children aren’t heavy smokers, “bronchitis symptoms” are invariably viral Caused by Bordetella pertussis (85% of cases; occasionally Bordetella parapertussis or Adenovirus can cause similar symptoms) Vaccine-preventable, but Pertussis vaccination about 90% effective – Older whole-cell vaccine was less effective, more side effects, and vaccine effectiveness wanes over time; Adults remain a reservoir, spreading infection back to children – New acellular vaccine now in widespread use Infection and toxin production assist bacterial adhesion and lead to cell necrosis, leads to severe dysfunction of cough receptors

32 Pertussis (Whooping Cough): Symptoms Catarrhal phase - coryza, mild cough - lasts about a week Paroxysmal phase - severe paroxysms of coughing, leading to facial plethora, vomiting – In older children, an inspiratory “whoop” at the end of a paroxysm of coughing. – Paroxysms of coughing can cause apnea in small infants. – Lasts 6 weeks Convalescent phase - cough gradually abates, but re-activates with viral colds (never as bad as the initial episode) for up to a year Severity Time Catarrhal Phase Paroxysmal Phase Convalescent Phase

33 Pertussis (Whooping Cough): Diagnosis and Treatment Diagnosis: – Nasopharyngeal aspirate (culture or PCR), serologic testing – Chest x-ray shows bronchopneumonia pattern – Occasionally, severe lymphocytosis (“leukemoid pattern”) Treatment: – Macrolide antibiotics shortens the period of infectivity, but affects the cough only when given during the catarrhal phase – Macrolides are also used to prophylax close contacts. – Cough remedies have no effect Casey PA. Altitude treatment for whooping cough. BMJ. 1991 May 18;302(6786):1212.

34 Bronchiolitis Viral infection of the bronchioles Causes: – RSV (most common) – Less often: Influenza Parainfluenza virus Rhinovirus Adenovirus, Metapneumovirus, Bocavirus Pathology: – Viral infection causes intense inflammation, edema, mucous production, and mucosal shedding of the bronchiolar epithelium – Small-airways narrowing or obstruction leads to hyperinflation due to gas-trapping and areas of atelectasis – Bronchospasm may occur – May have contiguous spread into interstitium, causing an interstitial pneumonia

35 Bronchiolitis: Symptoms and Diagnosis Symptoms: – coryza and fever, – followed by respiratory distress (tachypnea, retractions), wheezing, cough; – Cyanosis and lethargy if severe Diagnosis: – Nasopharyngeal aspirate for viral culture or rapid testing (immunofluoresence assay) – Chest radiograph shows: hyperinflation, bronchial wall thickening. If associated viral pneumonia: – atelectasis, – interstitial infiltrates

36 Bronchiolitis X-ray Note: Hyperinflation Bronchial wall thickening Patchy atelectasis

37 Bronchiolitis: Treatment Oxygen Extra fluids 30-50% respond to bronchodilators (  2 -agonists, nebulized epinephrine) Role of oral steroids controversial – most studies do not support their use

38 Bronchiolitis - Prognosis Lower respiratory tract involvement during RSV infection associated with anti-RSV IgE (as opposed to anti-RSV IgG) antibodies Infants genetically predisposed to producing anti-viral IgE antibodies likely to develop other atopic diseases, so 50% infants with RSV bronchiolitis will later have asthma Severe bronchiolitis (especially adenovirus) in aboriginal children may lead to permanent lung damage, including permanent scarring of the bronchioles (bronchiolitis obliterans) and bronchiectasis

39 Pneumonia (General) Typical – Lobar Pneumonia – Bronchopneumonia – Due to bacteria: most often Strep pneumoniae, Haemophilus influenzae Atypical – Interstitial Pneumonia – Due to: Viruses Mycoplasma Children also get: – Nosocomial Pneumonia – Opportunistic infections (immunocompromised children) – Tuberculosis Incidence (per 1000) Commonest in 1 st year of life

40 Diagnosing Pneumonia in Children Chest radiograph, CBC Blood culture Nasopharyngeal cultures for viruses, mycoplasma Serology: Mycoplasma, Chlamydia, viruses TB skin test In severe cases: Bronchoscopy, Pleural fluid culture CT Scan, Ultrasound Chest can identify and characterize complications (lung abscess, empyema)

41 Lobar Pneumonia Classic consolidation of one or more lobes, with alveolar spaces being filled with fluid, pus, and fibrin, with eventual organization and consolidation Symptoms: – Onset with URI in infants. May follow influenza, measles (developing world) – Rapid development high fever, – lethargy, – dyspnea, – hacking cough ± sputum production – headache, – abdominal pain Physical exam: classical signs pneumonia: – crackles, – reduced air entry, – dullness – ± meningismus – Signs pleural effusion (if present)

42 Lobar Bacterial Pneumonia: X-ray and Organisms CXR: – lobar consolidation occupying one or more lobes – +/- parapneumonic effusion, empyema Common organisms: – Streptococcus pneumoniae – Haemophilus influenzae – Group A Streptococcus – Staphylococcus aureus

43 Right Middle Lobe - Lobar Pneumonia - Chest X-ray

44 Bronchopneumonia Patchy areas of consolidation near bronchi, often throughout one or in multiple lobes Suppurative neutrophilic exudate fills bronchi, bronchioles, and adjacent alveolar spaces Chest X-ray shows patchy infiltrates next to major bronchi Typically follows URI. Symptoms: – Fever, chills – Cough – Chest Pain (older children) – Fatigue – Shortness of Breath, Rapid Shallow Breathing – Sputum (older children) Signs: difficulty breathing, productive cough, crackles Causes: Streptococcus pneumoniae, Hemophilus influenzae, β-haemolytic Strep Group A

45 Complicated Pneumonia Bacterial pneumonia can be complicated by: – Pleural Effusion Parapneumonic Effusion (Transudate) Empyema (Exudate) – suppurative material and bacteria accumulating in pleural space – Lung Abscess Necrosis and breakdown of lung tissue into cavities filled with pus and air (air-fluid level) – Pneumatocele Necrosis of breakdown of lung tissue producing air-filled cavity only – Necrotizing Pneumonia Combination of empyema, consolidation, and multiple lung abscesses within the consolidated lung Symptoms: rapid progression respiratory distress, cyanosis, shock

46 The Key Bacteria (1) Streptococcus pneumoniae (“Pneumococcus”) – Overwhelmingly the commonest cause of pneumonia in children – ½ of cases are lobar, ½ are bronchopneumonia – commonest cause of parapneumonic effusions, empyema, and necrotizing pneumonia in children Hemophilus influenzae – 3/4 of cases are lobar – 80% cases children < 2 years of age – typable Hemophilus influenzae less common since vaccination – 75% are complicated by pleural effusion – High extra-pulmonary complication rate: meningitis, epiglottitis, septic arthritis

47 The Key Bacteria (2) Group A Streptococcus – Generally children > 5 years of age 1/3 have antecedent strep throat. Often follows varicella, influenza, measles – ¾ of cases are bronchopneumonia, ¼ are lobar – Severe pneumonia; massive pleural effusion in at least 2/3 cases Staphylococcus aureus – Infants, malnourished children (developing world) – Lobar or segmental infiltrates – Severe pneumonia; massive pleural effusion & empyema (75%) pneumothorax (40%) pneumatoceles (45%) lung abscesses

48 Mycoplasma Pneumonia Cause: Mycoplasma pneumoniae Rare before 4 years of age; commoner in children over 5 years of age and very common in adolescents and young adults Symptoms: – Usually - gradual onset fever, headache, malaise, myalgias, dry cough, sore throat, abdominal pain – Occasionally - sudden onset, sputum production may occur – Crackles in 75%. Diagnosis: – CXR: peribronchial infiltrates, patchy atelectasis most common; interstitial infiltrates may be seen – Other diagnostic tests: serology PCR or culture of respiratory specimens Cold agglutinins fairly sensitive but not specific

49 Mycoplasma Interstitial Pneumonia - Chest X-ray

50 More on Mycoplasma Pneumonia Complications common: – Arthritis – Hemolytic anemia – Meningitis Treatment: – Macrolide antibiotic (erythromycin, clarithromycin, or azithromycin) Chlamydia pneumoniae causes a similar infection in children, associated with a single, subsegmental lesion

51 Viral Pneumonia Common organisms: RSV, Influenza, Parainfluenza, Adenovirus Pathology: – Organisms spread contiguously from upper respiratory tract to lower, causing epithelial necrosis, sloughing, and mucous hypersecretion, causing hyperinflation and areas atelectasis. – Alveolar involvement leads to interstitial mononuclear cell infiltrates & edema Symptoms: – URI – anorexia, – respiratory distress, – cough, – fever, – cyanosis – Wheezing is common Chest radiograph: – Hyperinflation – bronchopneumonic/peribronchial infiltrates, interstitial infiltrates, patchy areas of atelectasis, Treatment: fluids, oxygen

52 Pneumonia – an Ounce of Prevention Influenza – influenza vaccination available in Ontario for people 6 months and older – Overall, 30% reduction in influenza deaths in Ontario Strep Pneumoniae: – 90 serotypes, 23 account for 85-90% of invasive disease – 7-valent protein-conjugated pneumococcal vaccine given at 2, 4, 6, 15 months Use resulted in 35% reduction in hospitalization for pneumonia in American children 1997-2006 – 23-valent polysaccharide vaccine for children 2 years and over For high-risk children with underlying disease Re-vaccinate in about 5 years Haemophilus influenzae type b (HiB): – Protein-conjugated HiB vaccine given at 2, 4, 6, 18 momths – Use resulted in 99.7% reduction in invasive Haemophilus influenza disease (including epiglottitis) in American children – No effect on non-typable Haemophilus influenzae, Haemophilus species

53 Bacterial Pneumonia: Treatment Mild-Moderate Pneumonias (Outpatient therapy) – Children 1 – 4 years: amoxicillin +/-clavulinic Acid, 2 nd -generation cephalosporin (cefuroxime) – Children 5-18 years: macrolide (clarithromycin, azithromycin) if broncopneumonia, amoxicillin if lobar pneumonia Severe Pneumonia (Inpatient therapy) – IV 2 nd -generation cephalosporin (cefuroxime) IV Ceftriaxone or Vancomycin for Penicillin-resistant Pneumococci – IV cloxacillin for staphylococcus; vancomycin if Methicillin-resistant Pleural effusions or pneumothorax: – Drain with a chest tube if moderate-large – Video-assisted Thoracoscopic Surgery (VATS) or fibrinolytics (TPase) by chest tube if thick/loculated empyemas Pneumatoceles generally resolve on their own

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