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P82 Pediatrics
Respirology
Toronto Notes 2019
Table 39. Common Causes and Treatment of Pneumonia at Different Ages
Age
Neonates 1-3 mo
3 mo-5 yr
>5 yr
Bacterial
GBS
E. coli Listeria
S. aureus
H. influenzae S. pneumoniae B. pertussis
S. pneumoniae S. aureus
H. influenzae GAS
S. pneumoniae H. influenzae S. aureus
Viral
CMV Herpes virus Enterovirus
CMV, RSV Influenza Parainfluenza
RSV Adenovirus Influenza
Influenza Varicella Adenovirus
Atypical Bacteria
Mycoplasma hominis Ureaplasma urealyticum
Chlamydia trachomatis Ureaplasma urealyticum
Mycoplasma pneumoniae
TB
Mycoplasma pneumoniae Chlamydia pneumoniae TB
Legionella pneumophila
Treatment
Ampicillin + gentamicin / tobramycin (add erythromycin if suspect Chlamydia)
Cefuroxime OR ampicillin ± erythromycin OR clarithromycin
Amoxicillin (if mild) OR ampicillin OR cefuroxime
Erythromycin OR clarithromycin
(1st line) OR ampicillin OR cefuroxime
Respiratory Tract Diseases
LOWER RESPIRATORY TRACT DISEASE
• obstructionofairwaysbelowthoracicinlet,producesmoreexpiratorysounds • classicsymptom:wheezing
Differential Diagnosis of Wheezing
• common:asthma(recurrentwheezingepisodes,identifiabletriggers,typicallyover6yr),bronchiolitis (first episode of wheezing, usually under 1 yr), recurrent aspiration (often neurological impairment), pneumonia (fever, cough, malaise)
• uncommon:foreignbody(acuteunilateralwheezingandcoughing),CF(prolongedwheezing, unresponsive to therapy), bronchopulmonary dysplasia (often develops after prolonged ventilation in the newborn)
• rare:CHF,mediastinalmass,bronchiolitisobliterans,tracheobronchialanomalies
UPPER RESPIRATORY TRACT DISEASE
• diseasesabovethethoracicinletcharacterizedbyinspiratorystridor,hoarseness,andsuprasternalretractions • differentialdiagnosisofstridor:croup,bacterialtracheitis,epiglottitis,foreignbodyaspiration,subglottic
stenosis (congenital or iatrogenic), laryngomalacia/tracheomalacia (collapse of airway cartilage on inspiration)
Table 40. Common Upper Respiratory Tract Infections in Children
Anatomy Epidemiology
Etiology
Clinical Presentation
Investigations
Treatment
Croup (Laryngotracheobronchitis)
Subglottic laryngitis
Common in children <6 yr, with peak incidence between 7-36 mo Common in fall and early winter
Parainfluenza (75%) Influenza A and B RSV
Adenovirus
Common prodrome: rhinorrhea, pharyngitis, cough ± low-grade fever Hoarse voice
Barking cough
Stridor
Worse at night
Clinical diagnosis
CXR in atypical presentation: “steeple sign” from subglottic narrowing
Stridor at rest is an EMERGENCY No evidence for humidified O2 Dexamethasone: PO 1 dose Racemic epinephrine: nebulized, 1-3 doses, q1-2h
Intubation if unresponsive to treatment
Bacterial Tracheitis
Subglottic tracheitis
Rare
All age groups
S. aureus
H. influenzae α-hemolytic strep Pneumococcus M. catarrhalis
Similar symptoms as croup, but more rapid deterioration with high fever
Toxic appearance
Does not respond to croup treatments
Clinical diagnosis
Endoscopy: definitive diagnosis
Usually requires intubation IV antibiotics
Epiglottitis
Supraglottic laryngitis
Very rare – due to Hib vaccination
Usually older (2-6 yr)
H. influenzae
β-hemolytic strep Toxic appearance
Rapid progression
4 Ds – drooling, dysphagia, dysphonia, distress
Stridor
Tripod position
Sternal recession
Anxious
Fever (>39oC)
Clinical diagnosis
Avoid examining the throat to prevent further respiratory exacerbation
Intubation
Antibiotics
Prevented with Hib vaccine
Croup
Stridor at rest is an emergency