Pediatric Respiratory Infections

1. Pediatric Respiratory Infections Important because: -You will see numerous, numerous, numerous outpatient and inpatient cases on pediatrics, … and with family and friends -Shows up on USMLE 3, inservice exams, AND Pediatrics Boards But way too broad of a topic to be covered in one talk…. -Discussion of real clinical cases and handout to provide topic introduction and overview -Further study through inpatient and outpatient pediatric practice and further reading. Some reading suggestions included Marta King, MD Assistant Professor of Pediatrics Division of Inpatient Medicine University of Utah

2. How We’ll Play Group 1: On clinic “concerned parent” call Group 2: In continuity clinic Group 3: Working in the pediatric ED Group 4: On the hospital wards (yay!) Five of you volunteered to be patients/parents (one per case). You’ll know the ultimate diagnosis. Don’t share with others! Everyone (other than pt/parent) comes up w/ the initial differential diagnoses list based on HPI Someone from the group currently working w/ the patient is in charge of documenting encounter on the board. Pass the markers to the next person and the patient changes settings!

3. Objectives Describe the general phone, outpatient, and inpatient approach to pediatric patients presenting with respiratory complaints: • Apnea and cyanosis • Wheezing, ear pain, fever • Stridor • Cough and fever • Sore Throat and fever

4. Meet your patients with respiratory problems

5. CC: 1 mo old “stopped breathing, turned blue, went limp”

6. Concerned Parent Call CC: 1 mo old “stopped breathing, turned blue, went limp” HPI: Well until yesterday. Progressively more fatigued. Less interested in feeding. Sputtered and turned blue around the mouth yesterday evening after feeding. Recovered with burping. 2 more episodes today. Neither associated w/ feeding. One occurred after coughing. Child turned blue around the face and went limp and seemed unresponsive for ~30 secs. Recovered w/ stimulation. Then 2hrs later a similar episode not associated with coughing. Was laying in the crib, seemed to stop breathing, turned blue. Limp when picked up. Took a minute of stimulation (blowing on his face and rubbing his chest) to wake him up again. Seems okay now. Just a little bit tired.

7. Everyone: 1 mo old “stopped breathing, turned blue, went limp” What’s the differential?

8. “Concerned Parent Call” Docs: What else do you want to know? What do you think is going on? • Get more hx information from parent. If so what do you want to know? • What do you think is going on?

9. “Concerned Parent Call” Docs: What do you want to do? Tell the caller to continue to carefully watch the child at home. F/u in the office tomorrow Send the family to the ED Ask the family to come the office today to be evaluated Refer for direct admission to the hospital

10. ED Crew: what other information do you need? Any therapies you want to start? • Addition history information? • PE information? • Diagnostic Studies? If so, which ones? • Therapies? If so, which ones?

11. ED Crew: what do you recommend? What is your discharge or admitting dx? • D/c home. Follow up w/ PMD • Admit to observation (<24hr) • Admit to floor • Call a PICU consult • Admit to PICU

12. Ward Team: What is your admitting diagnosis? Anything else you want to do with the child? • Any additional history or exam questions? • Any additional labs or studies? • Monitors? • Medications? • Fluids and diet? • Isolation?

13. Ward team: call for apnea: seemed not to be breathing and turned blue. The nurse put oxygen by his face and stimulated him. He recovered after about 1 min and seemed like his nl self. What do you recommend now? • Continue monitoring on the floor • Obtain further studies (what) • Change floor management (how) • Call a code • Call a PICU consult

14. How the Story Ends… • 2 more apneic episodes on the floor. 1st required stimulation. 2nd required bag mask ventilation. • PICU transfer. Intubated for apnea within 2hrs of PICU stay • Pertussis PCR positive. All other cultures negative • 3d later passed spontaneous breathing trials and extubated to NC oxygen • Transferred to the floor. Hospitalized for 10 more days due to continued (though progressively milder) apneic episodes • Goes home and continues to do well

15. Infant with Pertussis: Key Points • ALTE (apparent life threatening event): acute, unexpected change in infant’s breathing that was frightening to the infant’s caretaker and included some of the following features: apnea, color change, muscle tone change, choking or gagging • Differential Dx Extremely Broad: range from benign (periodic breathing, GERD) to ominous: (sepsis, meningitis, intracranial bleed) • Evaluation based on hx and physical • Pertussis: an annoyance to adolescents and adults (cough of a 100 days). Life threatening to infants

16. 6 mo old “wheezing, pulling on ears, fever”

17. Clinic Sick Visit CC: 6 mo old “wheezing,” pulling on ears, fever. HPI: Previously healthy. 2d hx of congestion and cough and 1d hx of fever to 39.2, crying, poor appetite, pulling on ears, and wheezing. Tried sibling’s albuterol MDI, but did not seem to have an effect.

18. Everyone: 6 mo old “wheezing, pulling on ears, fever.” What’s your differential?

19. Clinic Crew: what other information do you need? Any therapies you want to start? • Addition history information? • PE information? • Diagnostic Studies? If so, which ones? • Therapies? If so, which ones

20. Clinic Crew: What is your diagnosis? What do you recommend? • D/c home. Follow up? • Send the family to the ED • Refer for direct admission

21. “Concerned Parent” Docs “ But my friend’s doctor told her that most ear infections are caused by viruses and that last time her 3yr old had an ear infection he did not get antibiotics and did very well. Are you sure my baby needs antibiotics?”

22. “Concerned Parent” Docs: how do you advise the parent? * Adapted from the American Academy of Pediatrics American Academy of Family Physicians Clinical Practice Guideline on the Diagnosis and Management of Acute Otitis Media 2004.

23. Two days later…. Fever is lower and she’s not pulling on her ears as much. But her cough and appetite are getting worse. She is breathing fast and seems to be struggling to breathe. It’s 5AM. She’s been up coughing all night and hasn’t had anything to drink and has not had a wet diaper in 12hrs. She pushes the bottle away and seems sleepy. Parents are worried and decide to bring her to the ED.

24. ED Crew: What do you think is going on? What other information do you need? Any therapies you want to start? • Addition history information? • PE information? • Diagnostic Studies? If so, which ones? • Therapies? If so, which ones?

25. ED Crew: what do you recommend? What is your discharge or admitting dx? • D/c home. Follow up w/ PMD • Admit to PICU. • Admit to RTU (24hr obs) • Call a PICU consult • Admit to floor

26. How the Story Ends… • Admitted on 1L NC oxygen, supplemental IVF, and frequent NP suctioning. Continued AOM Abx • 3d floor hospitalization: off of IVF on HD 2. Weaned to bulb suction and 1/8L NC oxygen • Discharged home on 1/8L NC oxygen • F/u in clinic in 2-3d. Clinically improved though still with mild cough. Taken off of oxygen.

27. Acute Otitis Media: Key Points • Risk Factors for AOM • Being a child! • Environmental: URI’s, daycare, tobacco exposure, allergies • Behavioral: formula (vs breast) feeding, bottle propping at bedtime • Craniofacial abnormalities: cleft palate, Down syndrome • Most AOM viralantibiotic treatment depends on child’s age, symptoms, and physical exam

28. Bronchiolitis: Key Points • Wheezing: LOWER airway problem. Moderate-sized and small airways narrowed ALMOST to the point of closure → long, musical sounds generally heard during expiration • Acute wheezing differential diagnosis • Reactive Airway Disease/Asthma • Infection: bronchiolitis (<2yrs), bronchitis • Foreign body aspiration: sx generally unilateral (classically on the R), BUT can trigger generalized response w/ acute wheezing • Anaphylaxis • Bronchiolitis diagnosis:clinical • Bronchiolitis course: clinical worsening ~ day 4-5 of sx b/f improvement. Warn families! • Bronchiolitis treatment:supportive • Airway clearance: suctioning • Supplemental oxygen • Supplemental IVF or NG/NJ feeds • Monitoring for apnea

29. 2 year old with barky cough and harsh breathing

30. Clinic Sick Visit CC: 2 year old with barky cough and harsh breathing HPI:Previously healthy. 1d hx of congestion. Then overnight developed a barky cough and harsh breathing. Dad called grandma who listened to the cough and breathing over the phone and said he had croup. Based on her advice dad took him to the bathroom with shower running and gave him Tylenol. That seemed to help for about an hour, but then he seemed worse. Dad called grandma again who recommended you take him to the doctor.

31. Everyone: 2 year old with barky cough and harsh breathing. What’s your differential?

32. Clinic Crew: what other information do you need? Any therapies you want to start? • Addition history information? • PE information? • Diagnostic Studies? If so, which ones? • Therapies? If so, which ones

33. Clinic: After Treatment Within few minutes of racemic epi, significantly improved. Tachypnea resolved. Stridor less harsh though still audible. 30 minutes after treatment done sounds exactly as he did when he came in.

34. Clinic Crew: what do you recommend now? • Additional history information? • Additional PE information? • Diagnostic Studies? • Interventions? • D/c home. Follow up tomorrow or if worse • Refer to the ED • Refer for direct admission

35. ED or Ward Team: What is your admitting diagnosis? Anything else you want to do with the child? • Any additional history or exam questions? • Any additional labs or studies? • Monitors? • Medications? • Fluids and diet? • Isolation?

36. Ward Team:  RN call. 1hr after racemic pt sleeping comfortably in no respiratory distress but still has mild audible stridor. What do you want to do now? • Any additional history or exam questions? • Any additional labs or studies? • Treatment?

37. Stridor

38. How the Story Ends… • Positive for parainfluenza 2 • CXR read as concerning for croup AND double aortic arch • CT angiography confirms double aortic arch • Referred to CT surgery after recovery from croup • Goes home after 2d hospitalization

39. Croup Key Points • Stridor:UPPER airway problem. Partial obstruction of the larynx or trachea → inspiratory sound • Stridor at rest:BAD. Sign of significant upper airway obstruction • General Management • Keep the child as comfortable and calm as possible • Corticosteroids • Nebulized epinephrine

40. Croup Key Points • Stridor Causes • Try to differentiate acute from chronic. Keep in mind these are not mutually exclusive! • Acute Stridor:croup, cervical lymphadenitis, tonsillitis, peritonsilar abscess, retropharyngeal abscess, bacterial tracheitis, epiglotitis, foreign body, anaphylaxis, inhalation/chemical injury • Chronic Stridor: • Congenital/anatomic • Trauma/ post-traumatic • Mass Effect/Outside Compression • Airway papillomas (acquired through birth canal)

41. Cough and Fever

42. Clinic Sick Visit CC: 8 yr old girl w/ cough and fever HPI: Previously healthy. 5d hx of progressively worsening wet cough and fevers Tmax: 102 axillary. Decreased activity and decreased appetite.

43. Everyone: 8yr old previously healthy with 5d hx of cough and fever. What’s the differential?

44. Clinic Crew: what do you recommend now? Additional history information? Additional PE information? Diagnostic Studies? Interventions? D/c home. Follow up tomorrow or if worse Refer to the ED Refer for direct admission

45. 8yr old with cough and fever

46. 2d Later Has been taking antibiotics as prescribed, but she seems to be getting worse instead of better. Her fevers are now higher up to 104, her cough, appetite and activity are even more decreased. Parent is calling to know if it is normal and whether they should do anything different.

47. “Concerned Parent Call” Docs: What else do you want to know? What do you think is going on? Get more hx information from parent. If so what do you want to know? What do you think is going on?

48. “Concerned Parent Call” Docs: What do you want to do? Tell the caller to continue to carefully watch the child at home. F/u in the office tomorrow Send the family to the ED Ask the family to come the office today to be evaluated Refer for direct admission to the hospital

49. ED or Clinic Team: What do you think is going on and what do you want to do about it? • Any additional history or exam questions? • Any additional labs or studies? • Interventions?

50. 8yr old with cough and fever