PNEUMONIA WHO Definition : Pneumonia is a form of acute respiratory tract infection that affects the lungs. The lungs are made up of alveoli, which fill with air when a healthy person breathes. In pneumonia, the alveoli are filled with pus and fluid, which makes breathing painful and limits oxygen intake.
- Epidemiology Pneumonia is the leading cause of death in children worldwide. Pneumonia kills an estimated 1.6 million children every year – (accounting for 18% of all deaths of children <5 y/o worldwide) more than AIDS, malaria and tuberculosis combined. Most prevalent in South Asia and sub-Saharan Africa.
-Etiology Bacterial : Viral : RSV is the most common Fungal : Infants infected with HIV, Pneumocystis jiroveci is the most common.
- Risk factors Higher incidence in children whose immune systems are compromised Can be due to certain disease such as HIV and measles or even in malnutrition or undernourishment, especially in infants who are not exclusively breastfed. Following environmental factors also increase a child's susceptibility to pneumonia: indoor air pollution caused by cooking and heating with biomass fuels (such as wood or dung) living in crowded homes parental smoking.
- Clinical manifestations May be absent in infant
- Investigations Blood investigations FBC-particularly in WBC for evidence of infections. In bacterial pneumonia WBC elevated(>20 000/mm3)- neutrophils, in viral pneumonia WBC count is normal mildly elevated (lymphocytes) Blood C&S- for precise etiology detection especially in severe pneumonia and poor respond twds 1 st line antibiotics
Cont.. Chest radiograph Pleural fluid analysis If there is significant pleural effusion, pleural tap is helpful Serology test If atypical pneumonia is suspected. Normal Lung Lobar pneumonia Bronchopneumonia
- Complications Cx are > frequent in bacterial than viral pneumonia These includes : Respiratory failure Sepsis and septic shock Pleural effusion, empyema, and abscess
- Treatments It is difficult to diff. Between viral/bacterial pneumonia Tx consist of both supportive and pharmacological measurements : Supportive : Fluids, O 2 , temperature control, chest physioteraphy Pharmachological Mild : Oral antibiotics / oral erythromycin for atypical pneumonia Severe : i/v antibiotics
- Preventions Immunization against Hib, pneumococcus, measles and whooping cough (pertussis) is the most effective way to prevent pneumonia. Adequate nutrition to improving children's natural defences, starting with exclusive breastfeeding for the first six months of life, also helps to reduce the length of the illness if a child does become ill. Encouraging good hygiene in crowded homes Children infected with HIV, the antibiotic cotrimoxazole is given daily to decrease the risk of contracting pneumonia.
b) COMMON COLD Definition : a.k.a acute viral rhinopharyngitis/acute rhinitis /rhinosinusitis Is a viral infectious disease of the URT, caused primarily by rhinoviruses and less common by coronaviruses. Most frequent infectious disease in humans with on average 2-4 infections a year in adults and up to 6–12 in children
- Pathogenesis Inhalation of virus-laden aerosol generated when an infected person coughs or sneezes/by touching a contaminated surface and then touching the nose or eyes Viral infection of nasal epithelium Acute inflammatory response Development of symptoms
Clinical manifestations Typically develop 1-3 days after viral infections These include: Nasal congestion Rhinorrhea Sore throat Occasionally, non-productive cough Cold usually persist for 1 week Examination of nasal mucosa may reveal swollen and erythematous nasal turbinates
Complications Otitis media rhinovirus infection, commonly predisposes children to ear infections, possibly by obstructing the Eustachian tube. Sinusitis Lower respiratory tract infection E.g: bronchitis and pneumonia Aggravation of asthma
Preventions & treatments Currently no medications which have been demonstrated to shorten the duration of illness. Treatment comprises symptomatic support usually via analgesics for fever, headache, sore muscles, and sore throat. Preventions include: Avoid close contact with people who are infected Regular hand washing Face mask usage
c) PHARYNGITIS Def : Inflammation of pharynx. (sore throat) Etiology : GAS (most common) Adenoviruses Enteroviruses Rhinoviruses Streptococcal pharyngitis uncommon before 2-3 y/o but incidence increase in school age children
Clinical manifestation Raw, red, and swollen throat. Lymph node enlargement Fever, headache, or earache. Cough and runny nose. Problems talking, breathing, swallowing, and sleeping. Tender, swollen areas on the sides of child's neck. Whitish-yellow patches or blisters in the back of throat or on tonsils.
Investigations Aim: to distinguish between pharyngitis caused by group A strep. from nonstreptococcal (usually viral) organism. Throat culture is the diagnostic ‘ gold standard ’ for establishing the presence of streptococcal pharyngitis. Many rapid diagnostic technique for streptococcal pharyngitis are available, with specificity up to 99%. However, the sensitivity are varies.
Complications Cx of strep. pharyngitis : parapharyngeal abscess acute rheumatic fever acute postinfectious glumerulonephritis. Viral pharyngitis may predispose to bacterial middle ear infections
TONSILLITIS OTITIS MEDIA BRONCHIOLITIS By: Siti Aisyah Bt Ramli
TONSILLITIS Definition- infalammation of tonsil caused by viral or bacterial infection Aetiology- group A ß-hemolytic streptococci and Epstein Barr virus
Clinical manifestations Red and swollen tonsils White or yellow patches on tonsils Dysphagia Headache Sore throat Fever Abdominal pain Tonsillar exudate Cervical lymphadenopathy Enlarged, red tonsils with and exudative white patches
Treatments Pain relief- acetaminophen or ibuprofen Antibiotics- penicillin/erythromycin Amoxicillin avoided because it can cause widespread maculopapular rash if it is due to infectious mononucleosis Chronic-tonsillectomy
OTITIS MEDIA Definition-infection of the middle ear, between tympanic membrane and the inner ear including eustachian tubes Epidemiology: - common at age of 6 months until 12 months -infant and young children are prone to get otitis media because Eustachian tubes are short, horizontal and functioning poorly Aetiology: Virus- RSV, rhonivorus Bacteria- Streptococcus pneumoniae, pneumococcus, Haemophilus influenza, Moraxella catarrhalis
Clinical manifestations Pain in ear Fever Cold or sore throat
Signs Tympanic membrane-bright red and bulging with loss of normal light reflection Acute perforation of ear drum with pus visible in external canal
Complications Mastoiditis-rare Meningitis-rare Recurrent ear infections can lead to otitis media with effusion. Eardrum is seen to be dull and retracted often with a fluid level visible Common in children with peak incidence of 1 year and resolves spontaneously. Antibiotic improve the appearance of tympanic membrane in short term. The most common cause of conductive hearing loss in children and interfere normal speech and learning.
Treatments Pain- treated by paracetamol or ibuprofen Antibiotics- amoxicillin Mostly can resolve spontaneously
BRONCHIOLITIS Definition - inflammation of bronchioles that leads to the lungs. As these airways become inflammed, they swell and fill with mucus, making difficult to breathing. Epidemiology -common in children less than 24 months-peak between 1-6 months of age. Aetiology -Respiratory Syncytial Virus is the commonest cause in Malaysia
Clinical Manifestation- Children <2years old Mild coryza Low grade fever Dry cough and wheeze Tachypnea, chest wall recession Breathlessness Hyperinflation of the chest Fine crepitation, rhonci Rattly chest In neonates-apnea
Risk factors History of premature Age less than 6 months Chronic lung disease Congenital heart disease Underlying immunodeficiency
Investigations Chest X-ray Hyperinflated chest with bronchial thickening Flattened diaphragm Area of atelectasis Upper lobe consolidation due to mucous plugging
Managements Majority- self limiting 1% will be hospitalized Criteria: Age less than 1week Cyanosis and apnea Chest recession Poor feeding Oxygen saturation <93% High risk category
Treatments Vital physiological monitor-heart rate, respiratory rate, oxygen saturation, level of consciousness If poor feeding -feed in a small amount but frequent to prevent dehydration Suction of nasopharynx –to maintain clear airway If severe resp distress, cyanosis and apnea-kept nil by mouth and IV Specific treatments: -oxygen therapy -nabulizes bronchiodilator -corticosteroid -ribavirin(anti-viral agent) not in Malaysia -montelukast-leukotriane agonist
Preventions Hand washing Avoid exposed to cigarette smoke Passive immunisation-Palivizumab® monoclonal antibody-IM
It is characterized by episodic , reversible bronchospasm resulting from an exaggerated bronchoconstrictor response to various stimuli. Characterized by: Airway inflammation Airflow obstruction Airway hyperresponsiveness
Most common chronic resp. disorder in children 10-15% of schoolchildren In childhood, asthma is twice as common in males as in females 10-20% of all acute medical admissions to paeds wards in children aged 1-16 years.
What makes a child more likely to develop asthma? risk factors such as presence of allergies , family history of asthma and/or allergies, frequent respiratory infections and low birth weight children are being exposed to more and more allergens such as dust, air pollution, and second-hand smoke. Children are not exposed to enough childhood illnesses to build up their immune system body fails to make enough protective antibodies. decreasing rates of breastfeeding have prevented important substances of the immune system from being passed on to babies.
Extrinsic and intrinsic Extrinsic: atopic, occupational, and allergic bronchopulmonary aspergillosis. Intrinsic: triggering mechanisms are nonimmune (eg: aspirin, pulm. inf, cold, stress and exercise) Acute and chronic When external triggers are present, sufferers experience acute attacks of symptoms. Asthma attacks can last anywhere from a few minutes to over 24 hours. Some individuals will have stable asthma for weeks or months and then suddenly develop an episode of acute asthma (exacerbation). Chronic asthma is most often an inherited disorder that tends to clear up in late childhood or adolescence, though many people have lifelong symptoms.
Can be genetic or enviromental (triggers) Enviromental : tobacco smoke, air pollution, viral or bacterial resp. infection, psychological stress, cold air, exercise, some medications (aspirin), dust and pets. In young pre-school children and older children, viruses are the commonest cause of wheezing– Some people call this 'viral-induced wheeze' or 'wheezy bronchitis', whilst others call it asthma.
To acquire asthma- have been born with a predisposition to the disease. It may not reveal itself until they have been exposed to some asthma irritants.
Patient’s history of symptoms - should elicit frequency, severity and factors that may worsen the child’s symptom - nightime symptoms are common Supported by personal or family history of atopic disease . (but absence of them does not exclude the diagnosis) Physical examination Usually normal during attacks. during acute episodes it will may reveal tachypnea, tachycardia, cough, wheezing and a prolonged expiratory phase
As the attack progresses, cyanosis, diminished air movement (chest tightness), retractions, agitation, inability to speak, tripod sitting position, diaphoresis, and pulsus paradoxus ( decrease in blood pressure with inspiration of > 15mm Hg) may be observed.
Assess the severity: It can be difficult to assess the severity of an acute asthma - wheeze and RR are poor indicators - contraction of the SCM, chest recession and pulse rate are better guides. - pulsus paradoxus indicates significant airways obstruction in children but it is difficult to measure accurately. - If breathlessness interferes with talking, the attack is severe. - Cyanosis is a late sign, indicating life-threatening asthma. Arterial oxygen saturation should be measured with a pulse oximeter in all children presenting to hosp with acute asthma Measurement PEF should be routine in school-age children.
Features of severe and life-threatening severe 1) Too breathless to talk or feed 2) Respirations > 50/min 3) Pulse > 140/min 4) Peak flow < 50% predicted or best value life threatening 1) Peak flow <33% predicted or best value 2) Fatigue, agitation, drowsiness 3) Cyanosis, silent chest or poor resp. effort
Criteria for hospital admission: If after high-dose inhaled bronchodilator therapy, they: Have not responded adequately clinically Are exhausted Still have marked reduction in their predicted peak flow rate Have a reduced oxygen saturation (<92% in air)
CXR is indicated only if there is severe dyspnea or unusual features (eg. Asymmetry of chest signs suggesting pneumothorax, lobar collapse) or signs of severe infection. In children, arterial blood gases are only indicated in life-threatening or refractory cases.
High-dose inhaled bronchodilators, steroids, and oxygen form the foundation therapy of severe acute asthma. As soon as dx has been made give B 2 bronchodilator. For severe exacerbations, high dose ‘burst’ therapy should be given 3 doses given back-to-back. Addition of nebulised ipratropium to the initial therapy in severe asthma has been shown to be beneficial. Oxygen is given when there is any evidence of arterial oxygen desaturation.
A short course ( 2-5 days) of oral prednisolone expedites recovery from severe acute asthma. For children who fail to respond adequately to inhaled bronchodilator IV therapy (IV amynophilline, IV salbutamol Antibiotics if there is bact. Infection After an acute exacerbation, child’s maintenance treatment and inhaler technique should be reviewed.
Summary of the treatment of acute asthma or life-threatening asthma: Immediate treatment Oxygen via a face mask Salbutamol (5mg) or terbutaline via oxygen driven nebuliser (half dose if <5years)- three back-to-back nebuliser. Ipratropium nebulised Oral prednisolone (1-2 mg/kg, max dose 40 mg)
Life-threatening features IV aminophylline or salbutamol IV hydrocortisone Subsequent management Oxygen if SaO2 <94% Repeat B2 agonist 1-4 hourly Monitor peak flow and oxygen saturation.
CROUP- definition Acute partial obstruction of the upper respiratory airway, usually in young children -Dorlan’s pocket medical dictionary Condition that causes an inflammation of the upper respiratory airways — the voice box (larynx), windpipe (trachea) & bronchi. Also known as laryngotracheobronchitis - http://kidshealth.org
Epidemiology Most common in children 6 months to 3 years old but can also effect older kids Male-to-female ratio is approximately 1.4:1. Episodes typically follow a common cold Symptomatic re-infection is common, usually mild Peak in cold weather
Pathophysiology Inhalation of the viruses through nose to nasopharyngx Inflammation and edema of larynx, trachea swelling of the airways significantly reduce the diameter and limiting airflow narrowing results in the barky cough, turbulent airflow and stridor, and chest retractions Endothelial damage and loss of ciliary function fibrinous exudate partially occludes the lumen of the trachea Decreased mobility of the vocal cords due to edema hoarseness of voice viruses that cause croup can cause inflammation farther down the airway and affect the bronchi
Clinical manifestation Low grade fever, stuffy or runny nose, cough and coryza for 12-72h Followed by increasingly bark-like cough and hoarseness. Inspiratory stridor- harsh, high pitched respiratory sound produced by turbulent airflow (sign of upper airway obstruction); occur when excited, at rest or both Respiratory distress of varying degree may develop quickly or slowly +/- wheezing if involved lower airways
Assessment of severity Stages (severity) Characteristics Mild Occasional barking cough, no audible rest stridor, and either mild or no suprasternal or intercostal recession Moderate Frequent barking cough, easily audible rest stridor, and suprasternal and sternal recession at rest, with little or no agitation Severe Frequent barking cough; prominent inspiratory stridor; marked sternal recession, decrease air entry and altered level of consciousness
Diagnosis Physical examination >An examination of the throat may reveal a red epiglottis > chest recession with breathing > On auscultation may reveal prolonged inspiration or expiration,+/- wheezing, and decreased breath sounds
Neck Radiograph Not necessary-to exclude foreign body, epiglottitis > AP views of upper airways shows ‘steeple sign’ - the tapered narrowing of the immediate subglottic airway
Management Indications for hospital admission: Moderate and severe viral croup Poor oral intake Lives long distance from hospital, lacks reliable transport Toxic looking Age <6months Unreliable caregivers at home
Treatment Mild moderate severe outpatient inpatient inpatient
Antibiotic are not recommended unless bacterial super-infection is suspected or ptn very ill Indications for Oxygen therapy: Severe viral croup Percutaneous SaO2 < 93%
Prognosis Prognosis of croup is excellent Usually lasts 5days As children grow, they become less susceptible to the resp viral infection
Prevention Avoid contact with people who have respiratory infections Hand washing *No vaccine for parainfluenza or RSV
croup will be misdiagnosed with acute epiglottitis dt having similar symptoms with croup. However, the history and the severity of the symptoms will distinguish acute epiglottitis and viral croup
Acute epiglottitis Inflammation of the epiglottis and soft tissue surround epiglottis. Can be life threatening due to complete obstruction of URT Caused by H. influenza B
Viral croup Acute epiglotitis Onset Over days Over hours Preceding coryza Yes No Cough Severe, barking Absent or slight Able to drink Yes No Drooling saliva No Yes Appearance Unwell Toxic , very ill Fever <38.5ºC >38.5ºC Stridor Harsh, rasping Soft, whispering Voice, cry Hoarse Muffled, reluctant to speak