Bark, Cough, WheezeKelly Ussery-Kronhaus, MD, FAAFP

Overview

• Respiratory disease:• 10% of pediatric

emergency department visits

• 20% of hospital admissions

• 3-5% of deaths in children

Separating upper from lower respiratory tract at the epiglottis

Upper Airway Obstruction

• Pediatric airways are intrinsically small- further narrowing or collapse can have a profound effect on airflow

• Etiologies of the edema leading to airway collapse include:

• Mechanical (i.e. Foreign body aspiration)• Infectious (i.e. Epiglottitis, Pertussis)• Traumatic

A Clinical Vignette A mother brings her 14 month old son,

Jimmy, into the urgent care clinic with complaints of choking and gagging after eating potato chips15-20 minutes ago at his grandmother's house. His mother is unsure if he had eaten anything else with the potato chips and does not think the child turned blue during the choking and gagging episode. He returned to his normal activity shortly after the episode occurred, but since then, he has had a few intermittent coughing spells. The patient has two older siblings who are still at the grandmother's house.

Physical Exam

• Vital Signs:• T 37.2, P 103, R 28, BP 98/55, O2

saturation 96% on RA• Height/weight/head circumference are all

25-50%ile

Physical Exam

• Physical Exam:• General: NAD• Chest: Occasional low pitched monophonic

expiratory wheeze best heard over the sternal notch

Diagnosis

Diagnosis 2

Foreign Body Aspiration

• Three Phases of foreign body aspiration:• Phase 1:

• The patient will usually experience:• choking, gagging, coughing, wheezing, and/or stridor • temporary cyanotic episode is possible, usually perioral

• Phase 2: • Asymptomatic period

• can last from minutes to months The duration of this period depends on the

• Phase 3:• The renewed symptomatic period. • Airway inflammation or infection from the foreign body will

cause:• Cough, wheezing, fever, sputum production, and

occasionally, hemoptysis

Management

• If the patient is stable (i.e., forcefully coughing, well oxygenated):

• Removal of the foreign body via bronchoscopy or laryngoscopy

• If there is complete airway obstruction:

• Percutaneous (needle) cricothyrotomy

EPIGLOTTITIS

A rapidly progressive cellulitis of the of the epiglottis and surrounding structures

Epiglottitis

• Clinical presentation: • Symptoms:

• Sore throat• high fever• dysphagia• Respiratory distress progresses in

<12hrs

Epiglottitis

• Infectious Etiologies:• H. influenzae B• Non-typeable H.

influenzae • Haemophilus

parainfluenzae• S. aureus• S. pneumoniae

Epiglottitis:Management

Hemophilus Influenza B (Hib)• 2 vaccines available

• 1 is 3-dose series (PedvaxHIB®)• 1 is 4-dose series (ActHIB®)

• Vaccines are interchangeable• If changed at 2 or 4 months of age, need a 6-

month dose of either vaccine• Either vaccine may be given for the

12-month booster dose

Hemophilus Influenza B (Hib)

• Cannot give any form of Hib to infants less than 6 weeks old

• Have decreased immune response to polysaccharide capsule (PRP) of Hib

• May also prevent future ability to develop antibodies

PedvaxHIB®• Hemophilus influenza type b vaccine• Antigen conjugated to Meningococcal

Group B outer membrane protein (PRP-OMP)

• 2-dose primary series plus booster• 2, 4 months and 12-15 month booster• Also comes in a combination vaccine

with Hepatitis B (Comvax®)

Act-HIB®• Hemophilus influenza type b vaccine• Conjugated to tetanus toxoid (PRP-T)• 3-dose primary series plus booster• 2, 4, 6 months and booster at 12-15

months• Also comes in 2 combination vaccines

• With DTaP, and IPV (Pentacel®) Primary series• With DTaP (TriHibIt®) Booster dose only

Prevnar® (PCV-7)• Pneumococcal conjugate 7 valent vaccine• 2, 4, 6 and 12 months• Recommended for all children 2-23 months• Give if 24-59 months old with risk factors• Not for children >5 years old• Replaced by PCV-13 Spring 2010

PCV-7 PCV-13 (Prevnar™13)

• ACIP voted 2/24/10 to replace PCV-7• Transition guidelines published• Protects against 13 instead of 7

strains • Expanded vaccination for high-risk

groups to 72 months• Same dosing interval as PCV-7 for

never vaccinated children

PCV-13

• High risk children include • Immunocompetent children with

• Cyanotic congenital heart defects• Chronic lung disease• Asthma needing oral steroid treatment• Diabetes• CSF leaks• Cochlear implants• Asplenia (congenital or acquired)• Sickle cell and other hemoglobinopathies

PCV-13

• High risk children include• Immunocompromised children

• HIV• Chronic renal failure• Nephrotic syndrome• Lymphoma and leukemia• Chemotherapy• Organ transplant• Congenital immunodeficiencies

New for PCV-13• Single dose for children 6-18 years old at

increased risk for invasive pneumococcal disease

• Give regardless of previous PCV-7 or PPSV-23 vaccination

• Includes:• Sickle cell disease• HIV (or other immunocompromised state)• Cochlear implant• CSF leaks

• croup

Croup management

PERTUSSIS

Pertussis

• 3 phases of illness (post-incubation):• Catarrhal• Paroxysmal• Convalescent

• Complications:• Pneumothorax, pneumomediastinum &

air in soft tissues

Pertussis• Clinical

presentation• Symptoms:

• Mild to severe paroxysmal cough with dyspnea

• Signs:• Paroxysms of cough• Inspiratory whoop• Apnea & cyanosis

(infants)

• Diagnosis• PCR or culture

DTaP• Capital letter denotes full dose

vaccine• Small “a” for acellular• Compared to Td or Tdap

• Small letter denotes half dose vaccine for booster effect

• Diphtheria and Pertussis vaccines only given as combination with Tetanus

DTaP • Diphtheria• Tetanus • Acellular pertussis• Primary series

• 2, 4, 6 months• 12-18 months (at least 6 months from the 3rd dose)• 4 years• 12-14 years Tdap • Then Td boosters every 10 years

DTaP• Contraindications

• Severe allergic reaction (e.g., anaphylaxis) after a previous vaccine dose or to a vaccine component

• Encephalopathy (e.g., coma, decreased level of consciousness; prolonged seizures)

• not attributable to another identifiable cause

• within 7 days of administration of previous dose of DTP or DTaP

• Progressive neurologic disorder

• including infantile spasms

• uncontrolled epilepsy

• progressive encephalopathy

• Defer DTaP until neurologic status clarified and stabilized

DTaP• Precautions

• Temperature of >104°F (>40.5°C) • For <48 hours after a previous dose of DTP or DTaP

• Collapse or shock-like state • Occurs <48 hours after a previous dose of DTP/DTaP

• Seizure • <3 days after a previous dose of DTP/DTaP

• Persistent, inconsolable crying • lasting >3 hours within 48 hours of a dose of DTP/DTaP

• Guillain-Barre syndrome (GBS) • <6 weeks after dose of tetanus toxoid-containing vaccine

• Moderate or severe acute illness with or without fever

Safe Situations to Administer DTaP

• Temperature of <105°F (<40.5°C) after dose• Fussiness after dose• Mild drowsiness after dose• Family history of seizures• Family history of sudden infant death syndrome• Family history of an adverse event after vaccine• Stable neurologic conditions

• cerebral palsy

• well-controlled seizure disorder

• developmental delay

Management: Pertussis

• Monitoring• Cardiorespiratory monitoring • Continuous pulse oximetry • Apnea monitor

• Treatment:• PRN oxygen• Stimulation/ suctioning • Avoidance of large volume feedings• Macrolides x 14 days

Clinical Vignette• Amy, a 10-week-old girl presents to her

physician's office in January because her mother feels her breathing is labored. She was born full-term; pregnancy, labor, and delivery were uncomplicated. The baby’s mother smoked during pregnancy and continues to do so. The family history is negative for asthma or allergy. She developed rhinitis and a tactile fever 3 days prior to presentation. Over the next few days she developed increasing cough, increased work of breathing, and decreased PO intake.

Clinical Vignette cont.

• Vital Signs:• T 100.4°F, R42, O2 saturation 93%

on RA, BP 85/55, P 180• Physical Exam:

• General: Mild distress 2° respiratory distress, + wet cough

• Chest: Mild intercostal retractions, scattered crackles bilaterally, and expiratory wheezes bilaterally

Diagnosis

• Diagnosis is often clinical during the RSV season

• Diagnostic testing can be done by:• Immunofluorescence• ELISA

Management

• Supportive care

• Consider hospitalization:

• <12 weeks

• History of prematurity

• Underlying cardiopulmonary disease

• Immunodeficiency

• Supplemental oxygen therapy/ Fluid Support

• A trial of bronchodilators

• Corticosteroids and antibiotics not routinely recommended

Clinical Vignette Cont.

• Due to her young age Amy is hospitalized and observed over the next 24 hours.

• With supplemental oxygen therapy and a trial of bronchodialators the infant demonstrates improvement.

• She is sent home and her mother is advised to refrain from smoking around her child.

Asthma

• Most frequent respiratory diagnosis for children admitted to hospitals

• Causes 5000 deaths annually in the United States

• It is a complex syndrome consisting of inflammation which leads to: bronchospasm

airway• hyperirritability

Asthma Triggers

• Respiratory Infections• Allergens• Airway Irritants• Exercise• Medications (NSAIDS and Beta Blockers)

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MAJOR RISK FACTORS(at least one must be present)

• parental history of asthma• atopic dermatitis• sensitization to aeroallergens

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MINOR RISK FACTORS(2 required)

• sensitization to foods• more than 4% eosinophilia• wheezing apart from colds

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Aeroallergen

• Indoor:• Dust mite

• Cockroach

• Animal dander

• Mold

– Immunotherapy for children with documented sensitivities and mild or moderate persistent asthma (LOE B for dust mite, animal dander, and pollen)

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Exercise Induced Asthma

• Can be the only manifestation of asthma

• Symptoms: cough, shortness of breath and rarely wheezing

» Onset: 5-10 min after stopping exercise » Resolution: 20-30 min later

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Classifying Severity an Initiating Treatment: Children 0-4 years

Severity category

Days and nights with symptoms

Interference with normal activity

exacerbation Preferred Treatment

Severe persistent Throughout (D)>1 night/wk (N)

Extremely limited See below Step 3:Med dose ICS and consider short course OCS

Moderate persistent

Daily (D)3-4 nights/month

Some limitation See below Step 3: med dose ICS and consider short course OCS

Mild persistent 3-6 D/wk1-2 N/month

Minor limitation 2 or more/6m or >= episodes of wheezing/yr with risk factor

Step 2: low dose ICS

Intermittent <=2 D/wk0 night/month

None 0-1/y Step 1: SABA prn

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Classifying Severity and Initiating Treatment: children 5-11

Severity category

Days and nights with symptoms

Interference with normal activities

Pulmonary function

Exacerbations Preferred treatment

Severe persistent Throughout (D)Often (N)

Extremely limited FEV1<60%FEV1/FVC<75%

2 or more/y Step 4: medium dose ICS+LABA and consider short –course OCS

Step 3: Medium dose ICS and consider short course OCS

Moderate persistent

Daily (D)>1 N/wk

Some limitations FEV1:60-80%FEV1/FVC: 75-80%

2 or more/y Step 3: medium dose ICS and consider short course OCS

Mild persistent 3-6 D/Wk3-4 N/Month

Minor limitation FEV1>80%FEV1/FVC>80%

2 or more/y Step 2: low dose ICS

Intermittent <=2 D/wk<= 2 N/month

None FEV1>80%FEV1/FVC>85%

0-1/y Step 1: SABA prn

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Classifying Severity and Initiating Treatment: youth 12 years of age and older

Severity category

Days and nights with symptoms

Interference with normal activities

Pulmonary function

Exacerbations Preferred treatment

Severe persistent Throughout (D)Often (N) 7x/wk

Extremely limited FEV1<60%FEV1/FVC:Reduced>5%

2 or more/y Step 5: high dose ICS +LABA and consider short course OCS

Step 4: medium dose ICS+LABA and consider short –course OCS

Moderate persistent Daily (D)>2-6 N/wk

Some limitations FEV1:60-80%FEV1/FVC: Reduced >5%

2 or more/y Step 3: low dose ICS +LABAOrmedium dose ICS and consider short course OCS

Mild persistent 3-6 D/Wk3-4 N/Month

Minor limitation FEV1>80%FEV1/FVC:normal

2 or more/y Step 2: low dose ICS

Intermittent <=2 D/wk<= 2 N/month

None FEV1>80%FEV1/FVC: normal

0-1/y Step 1: SABA prn

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Comorbid conditions• Infection• Obesity• Depression in child or parent• Gastroesophageal reflux• Allergies• OSA

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Summary

• Initial management of asthma includes:

1) assignment of severity category

2) identification of asthma “triggers”

3) development of a treatment plan based on severity

Inhaled corticosteroids are the medication choice for treatment of persistent (LOE A)

Environmental control is an important component of asthma management

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Patient education

• Including how to use a written asthma action plan is critical to the management of asthma (LOE A)

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