Important lecture notes on upper respiratory infections

1. Upper Respiratory
Infections
DR CHANDA KAPOMA

2. Case 1 : Tapelo
5- year-old preschool aged girl
Became ill within the last 6 hours
Severe sore throat
Muffled voice
Drooling of saliva
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3. On examination
Sitting upright
Toxic, ill looking
Febrile 39.50C
Soft, inspiratory stridor
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4. 22/01/2022 URI LECTURE 4
What is the most likely diagnosis?

5. Diagnosis: Acute Epiglotittis
DO NOT:
Examine the throat
Try to get IV access or bloods
Order lateral neck X-ray
DO:
Summon:
Paediatrician
ENT Surgeon
Anaesthetist
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6. 22/01/2022 URI LECTURE 6
How would you manage this child?

7. Management
To theatre/PICU
Intubation/tracheostomy
IV access
Blood culture
IV 3rd generation cephalosporin
Prophylaxis for household contacts
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8. Acute Epiglottitis
Caused by H. influenzae type B
The incidence has reduced by 99% due to Hib vaccine
Most common age group is 1-6 years
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9. Clinical presentation of Epiglottitis
There is sudden onset of sore throat, drooling, odynophagia or dysphagia
Muffled dysphonia or loss of voice
Dry cough or no cough
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10. More manifestations…
Dyspnoea
Fever and toxic appearance
Tripod or sniffing posture
Stridor is a late sign
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11. Tripod Position
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14. Case 2: Mutinta
3- year-old female toddler
Unwell for one day
Sudden onset of sore throat
No cough
Fever
Difficulty feeding
Vomiting
Abdominal pain
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15. On examination
Pulse rate: 140 beats/minute
Respiratory rate: 40 breaths/minute
Temperatureof 39oC
Tender anterior cervical lymph nodes
Erythematous pharynx with enlarged tonsils and yellowish exudate
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16. 22/01/2022 URI LECTURE 16
What is the most likely diagnosis?

17. Diagnosis: Pharyngotonsillitis
PLAN
Admit to ward
IV access
Crystalline Penicillin 50 000 IU/kg/dose QID IV
Maintenance IV fluids: Half strength darrows in 10 % dextrose
Paracetamol 15 mg/kg/dose
FBC/DC
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18. 22/01/2022 URI LECTURE 18
If the child has a weight of 20 kg, and continues to
refuse food, how much sour milk could you give the
child every 3 hours by nasogastric tube?

19. Pharyngitis
It is mostly caused by viruses and Group A β haemolytic streptococcus
The onset of streptococcal pharyngitis is sudden with prominent sore throat and
fever and absence of cough and rhinorrhoea
The pharynx is red, the tonsils are enlarged and covered with a yellow blood
tinged exudate
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20. Pharyngitis
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21. Clinical Manifestations of Pharyngitis
The soft palate may have petechiae and the uvula may be inflamed as well
The anterior cervical lymph nodes are enlarged and tender
The onset of viral pharyngitis is more gradual and characterised bycoryza,
conjunctivitis, hoarseness and cough
The aim of specific diagnosis is to identify Group A β haemolytic streptococcus
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22. Treatment of Pharyngitis
Phenoxymethylpenicillin orally 250 mg every 12 hours for 10 days in children
weighing less than 27 kg
Phenoxymethylpenicillin orally 500 mg every 12 hours for 10 days in children
weighing >27 kg
Benzathine penicillin given IM as a singular dose can be used as well in a hospital
setting: 1.2 MU in children > 27 kg and 600 000 IU in children < 27 kg
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23. Complications
Retropharyngeal abscess
Lateral pharyngeal abscess
Peritonsillar abscess or cellulitis
Rheumatic fever
APGN
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24. Indications for Tonsillectomy
More than 7 episodes in the previous year
More than 5 in each of the preceding 2 years
Peritonsillar abscess
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25. Case 3: Kalonga
2-year-old toddler
1 day history of barking cough and fever
Coryzal symptoms
Noisy breathing
SOB
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26. On examination
Alert
Temp 38oC
Hoarseness of voice
Barking cough
Harsh inspiratory stridor
Sub-costal recessions
Transmitted sounds on auscultation
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27. 22/01/2022 URI LECTURE 27
What is the diagnosis?

28. Diagnosis: Viral Croup
PLAN
Dexamethasone PO 600mcg/kg
Budesonide 2 mg nebulized if vomiting
Observe
Discharge if mild to moderate croup
For severe croup
Adrenaline 1: 1000 neb 5mls
Anaesthetist assessment
May need intubation and ventilation
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29. Laryngotracheobronchitis (Croup)
It is mostly caused by viruses
80% are caused by Parainfluenza viruses (1,2 or 3)
It causes upper airway obstruction
These signs are preceded by a low grade fever,rhinorrhea, cough and
pharyngitis
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30. Clinical Manifestations of LTB
Barking cough
Hoarseness
Stridor
High fevers
Hypoxia and low oxygen saturations are rare
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31. Diagnosis of LTB
The diagnosis is clinical
X-rays may show the typical subglottic narrowing
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33. Clinical Score
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Signs 0 1 2 3
Stridor none When agitated At rest Severe insp/exp
Recession none
Mild sub costal
-
Moderate tracheal Severe
Colour Pink Pink Dusky Central cyanosis
GCS 15/15
Restless when
disturbed
Anxious Agitated Lethargic Drowsy

34. Score < 3 Mild Croup
Can be allowed home
Advice to parents:
Increase oral fluids
Signs of increasing distress
Return to hospital or clinic
Easy access to the hospital
Consider oral dexamethasone 0.3mg/kg stat
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35. Score 4-5 (moderate croup)
Admit to the hospital
Oral dexamethasone 0.6mg/kg (max 4mg)
Budesonide Nebulization
1mg BD<1year
2mg BD>1year
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36. Score ≥ 6 (severe croup)
Initially
Minimal handling
Oral/IM dexamethasone 0.6mg/kg
Adrenaline 1:1000 Neb 5mls in 0.9% saline
Hourly assessments
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37. If score is still ≥ 6
Repeat epinephrine neb
Call anaesthetist and ENT surgeon
Prepare for intubation
Consider tracheostomy
IV fluids
IV dexamethasone
Check ABG
If scoring < 6, follow moderate croup protocol
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38. Case 4: Musonda
7-year-old male school age child
Coryzal symptoms for 2 weeks
Unable to smell
Has had dental pain for the last 4 days
Headache exacerbated by leaning forward
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39. On examination
Temperature: 39.5o C
Purulent discharge from the right nostril
RR: 24 breaths per minute
HR: 110 breaths per minute
Localized pain over the cheekbones
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40. 22/01/2022 URI LECTURE 40
What is the most likely diagnosis?

41. Diagnosis: Sinusitis
PLAN
Allow home
Paracetamol 15/kg/dose given QID
Amoxicillin-Clavulanate 80-90 mg/kg/day
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42. 22/01/2022 URI LECTURE 42
Is there any role for antihistamines in
the treatment?

43. Sinusitis
It is a common illness of childhood
It can be viral or bacterial
Bacteria include Streptococcus pneumoniae, nontypable Haemophilus influenza
and Moraxella catarrhalis
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44. Clinical Manifestations of Sinusitis
Nasal congestion, purulent nasal discharge, fever and cough
Pain or pressure exacerbated by bending forward
The symptoms tend to localize the affected sinus in older children
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45. Other manifestations…
Maxillary tooth pain (dental pain)
Hyposmia
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46. Diagnosis and treatment of Sinusitis
The diagnosis of bacterial sinusitis is based solely on the history
According to the American Academy of Paediatrics, any URTI with any of the
following:
1. Persistent nasal discharge of any type or cough lasting 10 days or more without improvement
2. Worsening course (new or worse nasal discharge, cough or fever) after initial improvement
3. Severe onset, fever of 390 C and above for at least 3 consecutive days
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47. Treatment of Sinusitis
Antimicrobial therapy:
Amoxicillin/Clavulanate for 10 -14 days
Analgesia
Antipyretics
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48. Complications of Sinusitis
Periorbital cellulitis
Orbital cellulitis
Epidural abscess
Meningitis
Cavernous sinus thrombosis
Subdural empyema
Brain abscess
Osteomyelitis of the frontal bone
(Pott’s Puffy Tumour)
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49. References
1. Nelson Textbook of Paediatrics 20th Edition
2. Rheumatic Fever-new diagnostic criteria. Izabela Szczygielska et al. Reumatologia 2018
3. Common Respiratory Infections Slides Dr Somwe wa somwe
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